Simon Freeman

Increasingly small, non-palpable testicular incidentalomas 10x10-3 mm/day, and >5x10-3 mm/day for SGR, DT, ∆Dmax, ∆Dav, respectively. A conservative approach of non-growing small incidentalomas is safe. Malignant and non-malignant small incidentalomas can be effectively differentiated based on growing parameters, even though superimposition exists.

Introduction: It is a rare, but recognised phenomenon that malignant testicular germ cell tumours can ‘burn-out’, where the primary lesion spontaneously regresses and presents with no viable remaining malignant cells leaving only a residual ‘tumour scar’, frequently in the context of distant metastatic disease Case Report: We present a case report of a patient who underwent serial ultrasound scans documenting regression of a testicular lesion from a malignant appearance to a burned-out lesion, where subsequent resection and histology demonstrated features of a completely regressed seminomatous germ cell tumour with no residual viable tumour cells. Discussion: To the best of our knowledge, there are no previously documented cases where a tumour has been longitudinally followed from sonographic features of concern for malignancy to ‘burned-out’ appearances. Spontaneous testicular tumour regression has instead been inferred based on the presence of a ‘burned-out’ testicular lesion in patients presenting with distant metastatic disease. Conclusion: This case provides further evidence supporting the concept of spontaneous testicular germ cell tumour regression. Ultrasound practitioners should be aware of this rare phenomenon in men presenting with metastatic germ cell tumour and, additionally, that this condition may present with acute scrotal pain.

Introduction: This paper reports the results of a rolling audit of sonographer-performed non-obstetric ultrasound examinations undertaken between 2010 and 2020 in a large University Teaching Hospital Ultrasound Department in the United Kingdom. We believe that this represents the largest published audit of sonographer non-obstetric ultrasound examination quality. Methods: Random samples of sonographer ultrasound examinations were regularly and systematically audited by consultant-level ultrasound practitioners through review of soft copy images and reports. Examination and report quality were assessed against an internal audit standard in 3731 patients over an 11-year period and also against externally set audit standards in 3186 patients over a nine-year period. Results: Both image and report quality exceeded externally set audit standards in all nine years of audit. In the internal audit, the quality standard just failed to be met for the first five years of audit but was achieved in all the subsequent six years. Conclusion: This audit provides further information on the quality and safety of sonographer-led ultrasound service delivery within a service that has quality safeguards, readily available support and an active education programme. It is used not only to provide assurance to patients, clinicians, managers and commissioners of this service but also to direct individual professional development and drive an iterative process of quality improvement.

Purpose This study was devised to evaluate the imaging appearances of the interureteric crest (IUC) of the bladder on magnetic resonance imaging (MRI). The primary objective was to determine how commonly the IUC was observed on pelvic MRI examinations. The secondary objectives were to determine the average size of the IUC, its MRI signal characteristics and whether there is variation between men and women. By defining the imaging findings we hope to prevent misinterpretation of normal anatomy on MRI and, therefore, prevent unnecessary further investigations and procedures. Methods We retrospectively reviewed 114 adult patient’s magnetic resonance imaging examinations of the pelvis. Two readers independently recorded information about the presence and characteristics of the IUC with a third reader used to arbitrate in cases of disagreement. Results The IUC was demonstrated on MRI in 75% of patients. It was best observed on T2w sequences as a continual ridge of low signal intensity between the ureters. The mean AP diameter of the IUC at its mid-point on the sagittal images was 2.4 mm. Conclusions The IUC is often seen on MRI on T2w images of a non-collapsed bladder. Its characteristic appearance can be used to help the reporting radiologist confidently differentiate identify this normal structure from an area of focal bladder wall thickening that might be misinterpreted as a bladder tumor.

Varicoceles are relatively common particularly in asymptomatic men and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility. Ultrasound (US) is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification. In view of this uncertainty, the guideline writing group (WG) of the European Society of Urogenital Radiology (ESUR) Scrotal and Penile Imaging Working Group (ESUR-SPIWG) undertook a literature review and assessment of the quality of relevant evidence. The group then produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement. The results are presented in the form of 15 clinical questions with a brief summary of the relevant evidence and the authorised recommendations from the SPIWG. This paper provides a short summary of the evidence evaluation and the complete recommendations.Key Points• Varicocele is a common clinical problem; it is highly prevalent amongst subfertile men and the most common potentially correctable cause of male infertility. • Ultrasound is the imaging modality of choice for varicocele assessment, but there is no generally agreed consensus on the US examination technique or the criteria that should be used for diagnosis, grading, and classification. • This paper summarises the recommendations of the ESUR-SPIWG for standardising the US assessment of varicoceles. This includes examination technique, image interpretation, classification, and reporting.

Splenosis is an unusual condition representing auto‐transplantation of splenic tissue following splenic trauma or surgery. When detected on imaging studies, the splenosis deposits are usually misinterpreted as pathological masses. We present a case where a pelvic mass incidentally visualized on an MRI examination, was proven to represent a deposit of splenosis by contrast enhanced ultrasound (CEUS). CEUS demonstrated persistent late‐phase enhancement characteristic of splenic tissue. Ultrasound practitioners should be aware of this condition when an unusual abdominal or pelvic mass is encountered in a patient with a history of splenic trauma or surgery. CEUS is ideally suited to confirming the diagnosis.

Aim: The aim of the study was to evaluate whether the twinkle artefact is a valuable feature in the sonographic diagnosis of superficial epidermoid cysts. Materials and methods: A retrospective search was undertaken of our institution’s Radiology Information System and pathology database to identify cases of superficial masses showing the twinkle artefact that proceeded to surgical excision. Results: Eighteen superficial masses demonstrating the twinkle artefact were identified that were submitted for pathological analysis. Of these, 17 were confirmed to represent epidermoid cysts and only 1 case had an alternative diagnosis (proliferating trichilemmal cyst). Conclusion: The presence of the twinkle artefact appears to be a specific and valuable ancillary sonographic feature for the diagnosis of superficial epidermoid cysts.

Abnormalities in the spleen are less common than in most other abdominal organs. However, they will be regularly encountered by ultrasound practitioners, who carefully evaluate the spleen in their abdominal ultrasound studies. Conventional grey scale and Doppler ultrasound are frequently unable to characterise focal splenic abnormalities; even when clinical and laboratory information is added to the ultrasound findings, it is often not possible to make a definite diagnosis. Contrast-enhanced ultrasound (CEUS) is easy to perform, inexpensive, safe and will usually provide valuable additional information about splenic abnormalities, allowing a definitive or short differential diagnosis to be made. It also identifies those lesions that may require further imaging or biopsy, from those that can be safely dismissed or followed with interval ultrasound imaging. CEUS is also indicated in confirming the nature of suspected accessory splenic tissue and in selected patients with abdominal trauma. This article describes the CEUS examination technique, summarises the indications for CEUS and provides guidance on interpretation of the CEUS findings in splenic ultrasound.

The increasing detection of small testicular lesions by ultrasound (US) in adults can lead to unnecessary orchiectomies. This article describes their nature, reviews the available literature on this subject and illustrates some classical lesions. We also suggest recommendations to help characterization and management. The ESUR scrotal imaging subcommittee searched for original and review articles published before May 2015 using the Pubmed and Medline databases. Key words used were ‘testicular ultrasound’, ‘contrast-enhanced sonography’, ‘sonoelastography’, ‘magnetic resonance imaging’, ‘testis-sparing surgery’, ‘testis imaging’, ‘Leydig cell tumour’, ‘testicular cyst’. Consensus was obtained amongst the members of the subcommittee, urologist and medical oncologist. Simple cysts are frequent and benign, and do not require follow up or surgery. Incidentally discovered small solid testicular lesions detected are benign in up to 80 %, with Leydig cell tumours being the most frequent. However, the presence of microliths, macrocalcifications and hypoechoic areas surrounding the nodule are findings suggestive of malignant disease. Asymptomatic small testicular lesions found on ultrasound are mainly benign, but findings such as microliths or hypoechoic regions surrounding the nodules may indicate malignancy. Colour Doppler US remains the basic examination for characterization. The role of newer imaging modalities in characterization is evolving. • Characterization of testicular lesions is primarily based on US examination. • The role of MRI, sonoelastography, contrast-enhanced ultrasound is evolving. • Most small non-palpable testicular lesions seen on ultrasound are benign simple cysts. • Leydig cell tumours are the most frequent benign lesions. • Associated findings like microliths or hypoechoic regions may indicate malignancy.

The subcommittee on scrotal imaging, appointed by the board of the European Society of Urogenital Radiology (ESUR), have produced guidelines on imaging and follow-up in testicular microlithiasis (TML). The authors and a superintendent university librarian independently performed a computer-assisted literature search of medical databases: MEDLINE and EMBASE. A further parallel literature search was made for the genetic conditions Klinefelter’s syndrome and McCune-Albright syndrome. Proposed guidelines are: follow-up is not advised in patients with isolated TML in the absence of risk factors (see Key Points below); annual ultrasound (US) is advised for patients with risk factors, up to the age of 55; if TML is found with a testicular mass, urgent referral to a specialist centre is advised. Consensus opinion of the scrotal subcommittee of the ESUR is that the presence of TML alone in the absence of other risk factors is not an indication for regular scrotal US, further US screening or biopsy. US is recommended in the follow-up of patients at risk, where risk factors other than microlithiasis are present. Risk factors are discussed and the literature and recommended guidelines are presented in this article. • Follow up advised only in patients with TML and additional risk factors. • Annual US advised for patients with risk factors up to age 55. • If TML is found with testicular mass, urgent specialist referral advised. • Risk factors – personal/ family history of GCT, maldescent, orchidopexy, testicular atrophy.