P R E S E N T A T I O N

The general experience with Sono-Elastography is growing with time, thus we have built themeeting as an occasion to share current knowledge and advances in this field.Sono-Elastography adds valuable information to the study of all organs, potentially resulting in“a virtual biopsy”. Because different elastographic modalities are available, our aim is also tohelp understanding which one is best suited for any given indication and which informationcan be obtained when using it.

The Scientific Committee

Fabrizio Calliada,Mario Canepari,

Giovanna Ferraioli,Carlo Filice

Antonio Pio MasciotraCampobasso – Molise – Italy

Email

antoniomasciotra@yahoo.it

Website

www.masciotra.net

YouTube Channel

https://www.youtube.com/channel/

UCgCj21nKGAhR997Ia3-QegQ

Sonoelastography of the testis

EFSUMB Guidelines and Recommendations on clinical use of US Elastography

takes only five lines to pursue the testis issue, then limited to a very rare tumor.

Instead I’ll try to describe the use of US elastography in the most prevalent

diseases of the testis highlighting its distinctive contribution to their clinical

workup.

Topics in clinical use of Sonoelastography in non neoplastic diseases of the testis

dr. Antonio Pio MasciotraCampobasso- Molise - Italy

New cases/Year Relative death risk 5 Years survival

Tumors 2.100 1/222 >95%

New cases/Year Risk of infertility Odd ratio for test. cancer

Cryptorchidism 15.000 (2-8%) >25% 3,5-17

New cases/Year Prevalence in males Preval. in infertile males

Varicocele 52.000 15-20% 40%

The social impact of the diseases of the testis in Italy

Testis disease clinical caseUndescended testis

Man 35 years old Left testis undescended at birth Left orchiopexy at age of 14 years Then infertility

Right testis

• Volume 10,89 cc

• kPa : 2,2

Left testis

• Volume 04,26 cc

• kPa : 5,0

Key points and take home messages

The left testis previously undescended and operated toolate shows loss of volume and inhomhogeneous texture

These alterations correspond to increased stiffness(Left 5,0 kPa Vs Right 2,2 Kpa) and the patient is infertile

Final consideration and Question

Could SW Elastography with its tissue stiffness quantification be used as a reliable indicator of tissue viability and functionality in the undescended testis to

choose the optimal timing of orchiopexy?

Testis disease clinical caseVaricocele

Man 25 years old Normally descended testes at birth Three years before operated for left testis torsion

ten hours after the beginning of the symptoms Preserved fertility

(2.5 years after the operation he had a baby!)

Left testis

Left testis

Left testis Mean Stiffness 2.2 kPaRight testis Mean Stiffness 3.0 kPa

Key points and take home messages

The left testis shows loss of volume, scant vessels andinhomhogeneous texture as consequences bothof previoius torsion and of varicocele

Despite these alterations, it preserves normal stiffness(left 2.2 kPa Vs Right 3.0 Kpa) and the patient is stillfertile

Final consideration and Question

Could SW Elastography with its tissue stiffness quantification be used as a reliable indicator of tissue viability and functionality at least in the varicocele to

identify the cases to be treated usefully?

New topics in clinical use of Sonoelastography in non neoplastic diseases of the testis

It could be useful to explore its utility in :1) predicting if varicocele will have

favourable response to treatment2) predicting if and how much the testis

can 'rescue' after treatment.3) guiding the best timing in the surgery of

undescended or ascensus-retractile testes.

Personal comment : I've the impression that orchiopexy had to be donebetween 10 months and 2 years of age, without the delay induced by hormonal therapy, too often unsuccessfull or not resolutive (efficacy <20%).

Sonoelastography of the testis………….and more………..

Antonio Pio MasciotraCampobasso – Molise – Italy

Email

antoniomasciotra@yahoo.it

Website

www.masciotra.net

YouTube Channel

https://www.youtube.com/channel/

UCgCj21nKGAhR997Ia3-QegQ

The testis both at B scan and at strain elastography shows an almost uniform pattern,

with septa remaining not distinguishable.

Shear Wave elastography, instead, for the first time does show the septa

originating from the albuginea.

Then Shear Wave Elastography adds details in the representation

of the anatomy of the testis highlighting the septa………….

….. like nightvision tools highlight objects and living beings

otherwise hidden in the dark.

• Probe : 10-2 MHz

• Higher contrast

Dinamic scale

0-20 kPa

Dinamic scale

0-50 kPa

•Probe : 10-2 MHz

• Lower contrast

The optimal highlighting and perception of the stiffness differences in an organ or

tissue at Shear Wave Elastography depend on the dynamic scale used………….

………. like in CT scan the optimal visualization of the kidney or of the peritoneal fat

depends on the setting of the window (width and center on HU scale)

• Probe : 15-4 MHzDinamic scale

0-50 kPa

Dinamic scale

0-30 kPa•Probe : 10-2 MHz

Equivalent highlighting and perception of the stiffness differences in an organ or

tissue at Shear Wave Elastography using different frequencies probes require the

adoption of different widths on the dynamic scale

Very narrow Dinamic scale (0-10 kPa) well highlights that the ‘mirror artifact’

is possible also in Shear Wave Elastography

Optimization of SWE™ map

Resolution mode is for shallow and/or well

circumscribed lesions. Excellent axial resolution and less persistence is applied. Improves clearing of fluid-filled lesion.

Standard default setting, to be used for

evaluation of the elasticity within the ROI.More persistence is applied to create asmoother appearance.

Penetration mode for deep, and/or large,

and/or anechoic or hypoechoic lesions with posterior dropout. Improves penetration at the cost of axial resolution.

• High transparenceBetter visualization of the boundaries between the

lesion and the surrounding tissues

• Low transparenceBetter visualization of the core of the focal lesion

28

Opacity

Its adjustment from 0 to 100% gives more and more priority to the SWE map over the B-Mode image highlighting different features of focal lesions like in this case of breast cancer

In imaging it's like in every day's life.If you need to know the details of an object you can rely on the information given by different tools :

1) your eyes tell you its morphology and the colors2) your hand tells you its consistence, the characteristics of its surface and very

approximately the temperature, weight and lenght3) your tongue tells you its taste, but also its consistence, the characteristics of its

surface and its temperature4) your nose tells you its smell.

So is in imaging. Each modality and technique give us different kind of information.

Then you can have different grades of accuracy using different kind of the same tool.In example, if you need to know the weight of a pen of 16 g you can use different libras with different scales :

a) the libra in scale of kgs is not useful cause the pen's weight is less than 1 kgb) the libra in scale of decigrams (more precise than the former) tells you that its weight is between

10 and 20 gramsc) the libra in scale of grams gives you the precise weight : 16 gr.!

Then you can use different unit of measurement for the same characteristic :

1) grams or pounds for the weight2) cm or inches for the lenght3) Centigrades or Kelvin or Fahrenheit grades for temperature

In Shear Wave Sonoelastography you can use two different units of measurement for the same feature (elasticity) :

kPa and m/s

In fact elasticity (E in kPa) and shear wave propagation speed (c) are directly linked

through the simple formula:

E = 3ρc²

Where ρ is the density of tissue expressed in kg/m3 The density of tissue remains relatively constant in the body, i.e. very close to the density of water

(1000 kg/m3 +/- 8%) .

Therefore, since the density of tissues is well known (~ 1), if the shear wave propagation velocity c can be measured, the elasticity of the tissue can be determined.

Display forms of the units of measurement of elasticity (or stiffness)

• Bidimensional • 3D

On the SWE image are displayed different information on elasticity

(or stiffness) quantification for each ROI selected in the colored box:

• Mean value in kPa or m/s (mean elasticity or stiffness)

• Minimum value in kPa or m/s (softest)

• Maximum value in kPa or m/s (stiffest)

• Standard deviation in kPa or m/s (its an index of more or less homogeneity)

• Elasticity ratio (if are selected 2 ROIs) < or > than 1

• Diameter of the ROI selected in mm

• 3,3 kPa with Probe 15-4 MHz• 1.7 kPa with Probe 10-2 MHz

But while the quantification of the feature ‘Weight’ of the testis with different libras

gives the same value……........

………..The quantification of the feature ‘Stiffness’ of the testis with probes of

different frequencies gives very different values and…………….

• 16 g with electronic libra • 16 g with mechanical libra

Fat 19.9 kPa Lipoma 20.5 kPa SW Ratio 1.03

Time 10:07:09

Fat 8.0 kPa Lipoma 7.8 kPa SW Ratio 1.03

Time 10:07:34

…….even the quantification of the feature ‘Stiffness’ in this study of the breast

with the same probe can give very different values, but with costant SW ratio’s values

CONCLUSIONS

Sono-Elastography adds valuable information to the study of all organs, potentially resulting in “a

virtual biopsy” .

This final aim will be achieved when further improvement of Shear Wave Elastography technology

(the only actually capable to quantify elasticity or stiffness) will give us the right consistency of the

quantitative measurements of tissue elasticity that up todate is still lacking.

Hence the RSNA initiative of ‘Quantitative Imaging Biomarkers Alliance’ applied to

Sono-Elastography too.

This means that if the intrinsic elasticity of the testis is 2 kPa all the measurements have to give this

value, not depending on the probe’s frequency or on other variables.

When this requirement will be accomplished we’ll can really establish the cutoff value between

normal and abnormal tissues both in focal and in diffuse diseases.

Therefore we’ll can rely on it at same extent we actually rely on the use a thermometer to check

the behavior of the fever during an infection (if it’s responding to the treatment).

Then let’s go on!

Lessons need to be drawn from two great men of the past who had the

vision to preparing for the future.

Galileo Galilei

"Any problem that wantsto be solved

starts with curiosity."

"Knowing is not enough, we must apply.

Willing is not enough, we must do."

Johann Wolfgang von Goethe

Antonio Pio

MasciotraCampobasso – Molise – Italy

Email

antoniomasciotra@yahoo.it

Website

www.masciotra.net

YouTube Channel

https://www.youtube.com/ch

annel/UCgCj21nKGAhR997I

a3-QegQ

Sonoelastography of the testis………….and more………..