The Egyptian Journal of Radiology and Nuclear Medicine (2014) 45, 949–958

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology andNuclearMedicine

www.elsevier.com/locate/ejrnmwww.sciencedirect.com

ORIGINAL ARTICLE

Value of diffusion weighted magnetic resonance

imaging in diagnosis and characterization of scrotal

abnormalities

* Corresponding author. Tel.: +20 01001534149.E-mail addresses: hazimtantawy68@hotmail.com, hazimtantawy@

yahoo.com (H.I. Tantawy).

Peer review under responsibility of Egyptian Society of Radiology and

Nuclear Medicine.

0378-603X � 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine.

http://dx.doi.org/10.1016/j.ejrnm.2014.05.008Open access under CC BY-NC-ND license.

Ahmed M. Algeballya, Hazim Ibrahim Tantawy

a,*,

Reda Ramadan Hussein Yousef b

a Faculty of Medicine, Zagazig University, Egyptb Faculty of Medicine, AlAzhar University, Egypt

Received 3 February 2014; accepted 13 May 2014

Available online 10 June 2014

KEYWORDS

DWI;

MRI;

Scrotal abnormalities;

Diagnosis

Abstract Background: MRI of scrotal lesions represents an important diagnostic tool in the eval-

uation of scrotal diseases. Diffusion weighted (DW) MR imaging is a promising technique which

proved to improve tissue characterization.

Aim: To assess the diagnostic value and role of DWMR imaging in the detection and characteriza-

tion of scrotal lesions.

Results: A prospective study included 50 scrotal lesions (35 intratesticular and 15 extra testicular)

with 50 normal testes used as control. DW sequences were obtained using a b factor of 0, 500 and

900 s/mm22. The accuracy of conventional sequences, DW images alone and DW imaging combined

with conventional images in differentiating benign from malignant scrotal lesions was calculated.

There was significant difference between apparent diffusion coefficient (ADC) values of testicular

malignancies, normal testis and benign intratesticular lesions, and the ADC values of benign extra

testicular lesions from those of normal epididymis. The overall accuracy of conventional imaging,

DW imaging alone and DWMR combined with conventional sequences in the characterization of

intratesticular lesions was 90%, 87% and 100%, respectively.

Conclusion: Our findings suggest that DWMR imaging and ADC values may provide valuable

information in the diagnosis and characterization of scrotal diseases.� 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear

Medicine. Open access under CC BY-NC-ND license.

1. Introduction

Correct diagnosis and characterization of scrotal and testicular

masses are important for optimal treatment, including resec-tion planning to avoid orchiectomy for some subtypes ofbenign tumors for which enucleation is an alternative. Aconfident preoperative characterization of the lesion in

950 A.M. Algebally et al.

question is needed to spare the patient from the drasticprocedure (1,2). Imaging has an important role in the investi-gation of testicular masses. Sonography, although the primary

imaging technique for the evaluation of scrotal contents, donot always allow confident characterization of the nature ofa testicular mass (3–6). Magnetic resonance (MR) imaging of

the scrotum provides valuable information in the detectionand characterization of various scrotal disorders and differen-tiating intratesticular and extratesticular lesions. The advanta-

ges of MRI are simultaneous imaging of both testicles andboth sides of the inguinal region, acquisition of adequate ana-tomic information, and satisfactory tissue contrast (7–14).

Recently, DWMR technique proved useful in the detection

of malignant neoplasms and the histological characterizationof focal lesions in the abdomen (15,16). Lesion detection andcharacterization largely depended on the extent of tissue cellu-

larity, and increased cellularity is associated with restricted dif-fusion and reduced apparent diffusion coefficient (ADC)values (15,16). The ADC values of malignancies are reported

lower than those of benign lesions or normal tissues (15–28).In this study we are aiming to rule out the value of DWIand the ADC values of normal scrotal contents and the path-

ological conditions and trying to certain a cut off value for pre-diction of malignancy.

2. Materials and methods

The study was performed on 50 patients, age ranged from 14to 65 years. 35 patients show intratesticular lesion; 15 weremalignant and 20 were benign, the remaining 15 patients show

extra-testicular lesions which were all benign.

2.1. MR imaging protocol

All patients were scanned in the supine position on a 1.5-T MRsystem (Intera; Philips Medical System), using a pelvic phased-array coil. The MR protocol used is illustrated in Table 1.

Axial spin echo T1-weighted sequences and axial, sagittaland coronal fast spin echo T2-weighted images were obtainedwithout and with fat suppression (FS). Axial fat-suppressed

T1-weighted sequences were repeated when a lesion with highT1 signal intensity was noted. DWI was performed in the axialplane, using a single shot, multislice spin echo planardiffusion pulse sequence and b values of 500 and 900 s/mm22.

The time required to acquire DW sequences was 29 s. Inpatients with scrotal pathology, gadolinium-DTPA (Omniscan

Table 1 The MR protocol used in our study.

Sequences SE T1 FSE T2 and FSE-FS

Plane Transverse Transverse, sagittal c

TR (ms) 500–650 4000

TE (ms) 13–15 100–120

Slice thickness (mm) 3–4 3–4

Gap (mm) 0.5 0.5

Matrix (mm) 180 · 256 180 · 256

FOV (cm) 24 · 27 24 · 27

b value (s/mm2) – –

IV CM – –

IV CM (intravenous contrast media).

0.2 mmol kg21; Amersham Health, Oslo, Norway) was admin-istered intravenously. Dynamic contrast-enhanced MRimaging in the coronal, transverse and sagittal plans in spin

echo contrast-enhanced, fat suppressed T1-weighted imageswere subsequently obtained.

2.2. MR imaging data interpretation

Three observers (radiologists) have read the MR imaging dataindependently, the three radiologists were blinded to the clini-

cal data and histopathological diagnosis. Every radiologistevaluated: (1) the signal intensity of the lesion on conventionaland contrast-enhanced MR images, and (2) the signal intensity

of the lesions on DWI and comparing it to that of the normaltesticular parenchyma and the epididymis. (3) DWI was readin conjunction with the axial T2-weighted images and createdADC maps. (4) For the quantitative analysis, a single radiolo-

gist defined a circular region of interest (ROI) within the scro-tal and/or extrascrotal lesions, excluding areas of hemorrhageor necrosis revealed by the corresponding conventional MR

images. Three measurements were obtained and their averagewas taken. Another ROI placed in the normal testicular paren-chyma to calculate the ADC values of the normal testis. Cal-

culations of the normal values of the epididymis wereobtained when the epididymal parts were readily identifiablein the corresponding transverse T2-weighted images. (5) MRimaging data were interpreted on the conventional sequences

and a possible diagnosis of benignity or malignancy wasobtained. (6) DWI and ADC map alone were interpreted. (7)DWI, ADC maps in conjunction with the plain and con-

trast-enhanced MR sequences were evaluated. The accuracyof conventional MR imaging data alone, DW imaging aloneand conventional sequences combined with DW sequences in

the characterization of scrotal lesions was calculated. The stan-dard included clinical diagnosis and imaging follow-up fornon-surgical cases, surgical and histopathological findings in

surgical cases. Statistical analysis was performed. A P valueof less than 0.05 was considered statistically significant. Thesensitivity, specificity and accuracy of conventional MRimages alone, DW images and DW imaging combined with

the conventional sequences were calculated.

3. Results

MR evaluation included 100 testicular units, of which 50 testes(50%) were characterized as normal and used as the control

T2 DW T1-FS dynamic post contrast

oronal Transverse Transverse, sagittal coronal

3900 500–650

115 13–15

3–4 3–4

0.5 0.5

180 · 256 180 · 256

24 · 27 24 · 27

500 and 900 –

– 0.2 mmol/kg

Table 2 Final pathological diagnoses of intratesticular and extratesticular diseases.

Pathological diagnosis of scrotal lesions (n= 50)

Intratesticular lesions (n = 35) Extratesticular lesions (n= 15)

Benign (N = 20) Benign (N= 15)

-Epididymorchitis 7 -Adenomatoid tumor of 4

-Post infective traumtic 4 Epididymis and tunica. 2

-Ectasia retitestis 3 -Fibrous tumor of 2

-Granuloma 3 Epididymis 3

-Testicular cyst 3 -Chronic granulomatous 2

Epididymitis 2

-Acute epididymitis

-Spermatocele

-Hematoma of epididymid

Malignant (n = 15) Malignant (N= 0)

-Seminoma 8

-Non seminoma (Embryonal carcinoma, choriocarcinoma,

yolk sac carcinoma and teratoma)

7

Value of DWMR imaging in diagnosis and characterization of scrotal abnormalities 951

group. Another 50 testes (50%) were abnormal with scrotal dis-orders, 35 intratesticular lesions (70%), of which 15 (43%) were

malignant and 20 (57%) benign, 15 extra testicular lesionswhichall (100%) proved benign (Table 2).We used 50 testes as controlwhere, normal testicular parenchyma appeared hyperintense on

Fig. 1 A case of seminoma showing a T2 WI hyperintense signal lesio

in DWI (c) and low signal in ADC map (d).

both T2-weighted and DW images, and slightly hypointense onthe ADC maps. The mean ± s.d. of ADC value of the normal

testis was (1.12 ± 0.67 · 10�3 mm2/s).Diagnosis of intratesticular malignancies was done using

the MR criteria known from previously published reports

n (a) with heterogeneous post contrast enhancement (b) restriction

952 A.M. Algebally et al.

(7,29,30) and correlated with pathology report. We had eightcases (n = 8) of seminoma (Fig. 1a–d) (53%) and seven(n = 7) non-seminoma cases (Figs. 2 and 3a–d) (47%). Testic-

ular malignancies were detected on T2-weighted images aseither low signal in nine cases (n= 9) or heterogeneous signalintensity in six cases (n = 6), with areas of hemorrhage in two

cases (n = 2) and necrosis in four cases (n= 4), all heteroge-neously enhancing after contrast material administrationexcept three cases with mainly cystic components that showed

peripheral enhancement (n= 3). Invasion of the testicular tun-icas by the neoplasm in five cases (n = 5), invasion of the epi-didymis in two cases (n = 2) and extension of the tumor to thespermatic cord in two cases (n= 2) were detected. The MR

features of tubular ectasia of retetestis (n = 3) and testicularcysts (n= 3) were typical in this series, in the form of the pres-ence of testicular cyst or the multicystic lesions involving the

mediastinum testis, with fluid signal intensity, not enhancedafter contrast material administration (31,32). Seven cases(n = 7) of epididymo-orchitis (Fig. 4a–d) were also correctly

characterized by conventional MR images. Enlargement andcontrast enhancement of the epididymis and the testis, com-bined with signal hyperintensity on T2-weighted images, were

findings proved to correspond to acute inflammation on clini-cal and sonographic follow-up in this study. This study alsoincluded four cases (n = 4) of post traumatic/post infective

Fig. 2 A case of embryonal carcinoma of the left testes showing globu

post contrast study (b) restricted DWI in b900 (c) with hypointense s

heterogeneity seen by ultrasound, the cases showed heteroge-neous T2 signal with no mass effect or post contrast enhance-ment. Three cases (n = 3) of pathologically proved testicular

granulomas were included in this study one (n = 1) showedlow signal in T2 and the other two (n= 2) lesions showedmixed hyperintense signals in T2, all three lesions (n= 3)

showed peripheral delayed enhancement.Conventional MR had a sensitivity of 100%, a specificity

of 80%, a positive predictive value of 86.5%, a negative

predictive value of 100% and an overall accuracy of 90% indifferentiating malignant from benign testicular lesions.

When assessed by DW imaging, twelve cases (n= 12)(80%) of all testicular malignancies including seminoma

(Fig. 1) and non-seminoma (Figs. 2 and 3), were depicted asareas of restricted diffusion appearing hyperintense when com-pared to the normal testicular parenchyma and hypointense on

the ADC maps, respectively. Three cases (n = 3) (20%) ofmalignancy with mainly cystic components and thin peripheralsoft tissue rim showed no restriction in cystic parts in DW

images appearing as hyperintense signal in ADC maps.All benign testicular lesions in this study (n = 20) (100%),

were detected without causing significant restricted diffusion,

therefore of low signal intensity on DW sequences. Themean ± s.d. of ADC values of intratesticular malignancieswas (0.79 ± 0.16 · 10�3 mm2/s) and benign intratesticular

lar shape hypointense lesion in T2-FS-WI (a) with enhancement in

ignal in ADC map (d).

Fig. 3 A case of rhabdomyosarcoma of the testes showing globular shape hyperintense lesion in T2-FS-WI (a) with peripheral

enhancement and central necrotic changes in post contrast study (b) restriction of solid component in DWI (c) with restricted parts

appearing hypointense in ADC map (d).

Value of DWMR imaging in diagnosis and characterization of scrotal abnormalities 953

lesions was (1.58 ± 0.63 · 10�3 mm2/s). ANOVA analysisbetween normal testis, benign and malignant intra testicularlesions showed that the mean ADC values were different (F

23.0, P 0.00) (Table 3). The least significance difference testshowed a difference between the ADC values of normal testic-ular parenchyma and testicular malignancies (P = 0.000), the

ADC values of benign and malignant intratesticular lesions(P = 0.000), and between the measurements of normal testisand benign intratesticular lesions (P = 0.004).

DW images and ADC map using a cut off value (60.99)

had a sensitivity of 93.3%, a specificity of 90%, a positive pre-dictive value of 87.5%, a negative predictive value of 94.7% inthe characterization of intratesticular masses (Table 4). The

interpretation of DW data combined with conventional imagesenabled the correct characterization of false negative cases inDWI, based on the interpretation of the conventional data

alone in this study. The combined evaluation of both conven-tional and DW images proved accurate in differentiatingmalignant from benign intratesticular mass lesions in all

(100%) cases in this series.This study included fifteen cases (n= 15) of paratesticular

lesions. MR imaging identified normal epididymis at T2-weighted and DW sequences in this study, as relatively hypo-

intense when compared to the normal testicular parenchyma.

Three cases (n= 3) of acute epididymitis showed enlarge-ment and post contrast enhancement of the epididymis com-bined with heterogeneous low signal intensity. Two cases

(n= 2) of chronic granulomatous epididymitis with enlargedheterogeneous epididymis, have T2 heterogeneous low signalpattern with delayed heterogeneous enhancement. Two sper-

matoceles (n = 2) with typical fluid signal and no post contrastenhancement was detected. The diagnosis of paratesticularhematoma was straightforward in two patients (n = 2), basedon the presence of a blood degradation product signal changes

of the lesion on both T1- and T2-weighted sequences and lackof contrast enhancement. The study included four cases(n= 4) of adenomatoid tumors of tunica and epididymis

(Fig. 5), which presented as isointense signal lesion inT2-weighted image with early post contrast enhancement. Alsotwo cases (n = 2) of epididymal fibrous tumors showed

hypointense signal in both T1 and T2 weighted images andpost contrast enhancement.

The mean ± s.d. of ADC values of normal epididymis was

(1.08 ± 0.033 · 10�3 mm2/s). The benign lesions showed signalhypointensity and hyperintensity on DW sequences and ADCmaps, respectively. The mean ± s.d. of ADC values of benignparatesticular lesions was (1.17 ± 0.48 · 10�3 mm2/s). A dif-

ference between the ADC values of the normal epididymis

Fig. 4 A case of acute epididymo-orchitis showing enlarged testes and epididymis with increased signal in T2-FSWI (a) homogenous

enhanced testes with no focal lesion in post contrast study (b) no restriction in DWI (c) with diffuse increased signal in ADC map (d).

Table 3 ADC values of normal testicular parenchyma, benign and malignant intra-testicular lesions.

Normal testes (n= 35) Benign lesions (n= 20) Malignant lesions (n = 15) F P

Mean ADC± s.d. 1.12 ± 0.067 · 10�3 mm2/sa 1.58 ± 0.63 · 10�3 mm2/sb 0.79 ± 0.16 · 10�3 mm2/s 23.0 0.000

ADC Range 1.02–1.29 · 10�3 mm2/s 0.82-2.88 · 10�3 mm2/s 0.40–1.02 · 10�3 mm2/s

a Normal patients (control group) are significantly difference from both benign and malignant lesions (P= 0.004 and 0.000 respectively).b Benign is significantly different from malignant lesions (P= 0.000).

Table 4 Validity of ADC in diagnosis of intra-testicular

lesions.

ADC Intra-testicular lesions Total

Malignant Benign

ADC 6 0.99 14 2 16

ADC> 0.99 1 18 19

Total 15 20 35

AUC 0.96 (0.90–1.02), cut off value for prediction of malig-

nancy 6 0.99, sensitivity = 93.3, specificity = 90.0, PPV= 87.5,

NPV= 94.7, Kappa 0.82, P = 0.000.

954 A.M. Algebally et al.

and those of benign paratesticular lesions was noted (P = 0.49)(Table 5). The benign neoplastic lesions and inflammatory

lesions; both showed signal hypointensity and hyperintensityon DW sequences and ADC maps, respectively The

mean ± s.d. of ADC values of benign paratesticular neoplasmwas (0.99 ± 1.53 · 10�3 mm2/s) and paratesticular inflamma-tory lesions was (1.29 ± 0.59 · 10�3 mm2/s). A difference

between the ADC values of the benign neoplastic and inflam-matory paratesticular lesions was noted (P = 0.25) (Table 6).

Two cases (n= 2) of false positive for malignancy based on

the DW data alone in two patients with epididymal hematoma(Fig. 6), were detected with restricted diffusion on DW imagesand very low ADC values, conventional MR sequences

enabled the correct characterization in these patients. Bothconventional and DW images proved accurate in characteriz-ing the benign nature of all (100%) paratesticular lesions inthis series.

Fig. 5 A case of adenomatoid tumor of epididymis showing hypointense signal in T2-FSWI (a) with post contrast enhancement (b)

showing no restriction in DWI (c) and low signal in ADC map (d).

Table 5 ADC values in diagnosis of extra-testicular normal epididymal parenchyma versus benign lesions using paired t test.

Normal epididymis (n = 15) Benign lesions, both neoplastic and non-neoplastic (n = 15) P

Mean ADC ± SD 1.08 ± 0.33 · 10�3mm2/s 1.17 ± 0.48 · 10�3mm2/s 0.49 Non-significant

ADC range 1.01-1.13 · 10�3mm2/s 0.56-2.30t · 10�3mm2/s

Table 6 ADC (apparent diffusion coefficient) values in diagnosis of extra-testicular lesions, neoplastic (n = 6) versus inflammatory

(n= 9).

Neoplastic lesions (n = 6) Inflammatory lesions (n= 9) P

Mean ADC value ± SD 0.99 ± 1.53 · 10�3mm2/s 1.29 ± 0.59 · 10�3mm2/s 0.25 Non-significant

Value of DWMR imaging in diagnosis and characterization of scrotal abnormalities 955

4. Discussion

Magnetic resonance (MR) imaging of the scrotum provides

valuable information in the detection and characterization ofvarious scrotal disorders and differentiating intratesticularand extratesticular lesions. The advantage of MRI are simulta-

neous imaging of both testicles and inguinal region due itswide field of view, multiplanar capabilities, high contrast andspatial resolution helping in the distinction between benign

from malignant intratesticular lesions and evaluation of local

extent of malignant lesions (7–14). MRI is used when sono-graphic findings are inconclusive or inconsistent with clinicalfindings (10,11). As radical orchiectomy is the treatment ofchoice in majority of intratesticular malignant masses, a confi-

dent preoperative characterization of the lesion in question isneeded to spare the patient from the drastic procedure(8,14). The MR criteria which we used in characterization of

testicular neoplasms were the presence of mainly hypointense

Fig. 6 A case of left epididymis hematoma, (a) axial T2WI shows low signal lesion in epididymis of left testes, (b) coronal T1WI shows

hyperintense lesion in left epididymis, (c and d) are DWI and ADC map showing no restriction and hyperintense signal in ADC map.

956 A.M. Algebally et al.

or a heterogeneous mass lesion on T2-weighted images andheterogeneous enhancement after contrast material adminis-tration (7,14). The current study has showed high accuracy

of conventional MR sequences in characterization of bothparatesticular and intratesticular lesions which is in agreementwith previous researches (7–14). Paratesticular tumors are

masses of slow and indolent growth and in most cases ofbenign nature (70%), being that the case, the treatment ofchoice is simple extirpation of the lesion and follow-up, based

on observation only. On those identified as malignant (30%),treatment is more complex, consisting in radical orchiectomywith adjuvant chemotherapy or radiotherapy (33). In thisstudy we had 15 cases of paratesticular lesion which were of

benign nature (100%) according to MRI criteria and clinico-laboratory data as well as follow up output. Absence of postcontrast enhancement is considered to be the most sensitive

sign in predicting benign intratesticular lesions. The presenceof hemorrhagic changes, invasion of tunicae, and extensionof the tumor to the paratesticular regions and/or the spermatic

cord are criteria which are used for the diagnosis of malig-nancy as proved by histopathological correlation (7–14). Inthe current study there were 35 cases of intratesticular lesions,

20 cases were benign (non-neoplastic) lesions (57%) and 15cases were malignant (43%) according to MRI criteria,clinicolaboratory data, follow up and histopathological findingin operated cases (malignant). There are three cases of

malignancy with large areas of necrotic non enhancingchanges, the lesions were associated with peripheral rim ofenhancement and other MRI sequences were helpful to iden-

tify these changes as necrotic origin. These three cases wereproved to be of malignant nature in post biopsy pathologicalresults. Sadly we had no neoplastic benign lesions to include

in this study. Diffusion weighted MR imaging depends onmotion of water molecules. The extent of tissue cellularityand the presence of intact cell membranes define the imped-

ance of water molecule diffusion (15,16). Normal testis ishyperintense on DW imaging referring to restriction of watermolecules movement within densely packed seminiferoustubules of normal testicular parenchyma, separated by thin

fibrous septa (8). The ADC value reflects the movement ofwater molecules. High-b-value DW imaging (b800 or b900)reflects high signal intensity for malignant tumors in compari-

son to normal tissues and benign lesions, which correspond tolow ADC values for the malignant tumors (15–28). In the pres-ent study, DWMR imaging proved valuable in differentiating

testicular malignancy from various scrotal lesions. Malignanttesticular carcinomas have higher signal intensity in compari-son to normal testis; hence, assessment of the signal intensity

on DW images was proved efficient in differentiating betweennormal testicular tissue and malignant tissues. All except threecases of testicular malignancies were hyperintense (restricted)on DW images at b value of 900, the three malignant cases that

Value of DWMR imaging in diagnosis and characterization of scrotal abnormalities 957

did not show restriction, show considerable areas of necroticchanges which showed no restriction at DWMR, apart fromrestricted peripheral thin rim corresponding to solid compo-

nent, which was not conclusive. Conventional MRI was ableto achieve diagnoses in these three cases and final diagnosisas malignancy was obtained. In this study, no benign neoplas-

tic intratesticular mass lesions were included, otherwise; allother benign intratesticular lesions show no restriction inDWMR. The ADC values of intratesticular malignancies were

lower than that of normal testis and benign lesions (P, 0.000).There was no significant difference in ADC value betweennormal testicular tissue and benign testicular lesions (P,0.004). A cut off value of ADC value for prediction of

malignancy for intratesticular lesions was calculated, using thisvalue we get a high sensitivity, specificity, positive predictivevalue and negative predictive value suggesting that lesion with

ADC value equal to or less than (60.99) is suggestive for thepossibility of malignancy. In agreement with previous studies(27–28), in this study the lower the ADC values the more the

possibility for malignancies. The decrease of ADC values intesticular neoplasms is related to the histopathologicalcharacteristics of neoplastic tissue that is, increased tissue

cellularity and densely packed malignant cells, enlargementof the nuclei, and angulations of the nuclear contour, allcausing reduced motility of water molecules. The ADC valuesof the normal epididymis were lower than that of

various benign paratesticular lesions (P, 0.49). Therefore,both DW imaging characteristics and ADC calculations ofthe scrotal contents proved valuable in differentiating

between normal and abnormal scrotum, and moreimportant in differentiating normal from cancerous tissue inthe testicles.

In this study we had two false positives in a patient withparatesticular hematoma, related to the low ADC values ofbloody products and three false negatives in patients with mul-

ticystic testicular malignancies. Correct diagnosis was possiblein these cases which can be attempted using routine MRsequences. On routine conventional MR study adenomatoidtumor of epididymis and tunica, and fibrous tumor of epidid-

ymis were displayed as enhancing paratesticular masses andrevealed no restriction in DWMR which reflects the benignnature of these lesions. In the present study we found that

DW imaging data when interpreted in conjunction with con-ventional images improve the characterization of the lesion.The addition of DW sequences to routine scanning data

improves the diagnostic accuracy with only minimal increasein examination time.

There were some limitations in the current study as somepathological types of scrotal abnormalities were not included.

Also there is a wide individual variation of ADC measure-ments, so it was difficult to suggest to the ADC cut off valueas an effective parameter for tissue characterization.

5. Conclusion

MRI is a reliable method in diagnosis of scrotal lesions, DW

imaging and ADC values are helpful in differentiation betweennormal, benign and malignant scrotal lesions and also improvedetection and characterization of scrotal diseases and hence

can reduce unnecessary radical surgical procedures in thesepatients.

Conflict of interest

We have no conflict of interest to declare.

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