DUCTAL CARCINOMA BREAST ENCASING THICK CALCIFIC WALLED TORTUROUS ARTERY- an ultrasound scan

A 50 yr female with lump right breast.

US scan showed a large well defined lobulated inhomogenic hypoechoic solid mass in central & outer region of right breast distorting glandular plane . The mass was encasing a prominently appreciable thick echogenic calcific walled tram track like tortuous structure within it.The structure had echogenic  tortuous branches which showed arterial colour & spectral signals on doppler & , this was a special  & unusual imaging feature in this case. No significant cystic or calcific foci noted within mass . The mass was abutting retro mammary muscle plane & extending deep to nipple . 

 

Fig - US scan right breast shows hypoechoic mass with echogenic elongated tortuous structure in it .

Fig 2- one another echogenic tram track like prominent branch also noted within mass which shows color flow signals on  color doppler , & this suggests vascular nature of this structure .

Fig 3- Spectral doppler interrogation shows arterial signals  

PS - 1) Biopsy proved the mass to be ductal carcinoma.

2) The case is presented to highlight this special imaging finding observed .

3) It is intended for radiologists for academic purpose only . 

SEGMENTAL TESTICULAR INFARCT

Image Presentation

ACUTE SEGMENTAL TESTICULAR INFARCT -  mimic like a tumor on grayscale ultrasound , and color Doppler ultrasound  can clearly differentiate it from tumor .

Abstract

Segmental testicular infract is very uncommon pathology , & involves variable etiology , but commonly idiopathic . On grayscale ultrasound it appears as a focal inhomogenic mass which is difficult to be differentiated  from testicular tumor . However high resolution color Doppler ultrasound confidently diagnose it as an area of infarction & allows testis sparing surgery .

Introduction

Color Doppler ultrasound ( CDUS ) is very useful modality in evaluation of acute scrotum , and to  differentiate  between epididymoorchitis & torsion when symptoms may overlap  ( 2 ) .  The common conditions causing a painful scrotum  includes torsion & epididymoorchitis ,  and rarely tumor . Testicular tumor normally presents as a slow growing mass , rarely painful , and incidently discorved by the patient( 3 ) . On grayscale ultrasound tumor appears as an inhomogenic focal mass and CDUS demonstrates internal vascularity with malignant vascular pattern ( 4 ) . I present a case with painful testicular focal inhomogenic mass on grayscale ultrasound where CDUS allowed the diagnosis of segmental testicular infarction , rather than a testicular tumor , to be labelled .

Case report

A 46 years old man presented with a history of increasing right testicular pain for few days . The case was already  on antibiotics for presumed epididymoorchitis , however with no significant relief . On physical examination there was tenderness at the upper pole of right testis and epididymis , and a clinical diagnosis of epididymoorchitis was made.  In view of no relief in symptoms , the scrotal sonography was requested . Scrotal sonography was performed on GE – Logiq 400 pro  ultrasound system , using 8 to 11 MHZ. linear probe with small parts setting . The grayscale ultrasound examination revealed a focal enlarged inhomogenic area of  iso to hypoechoic echogenisity  at upper pole of right testis ( figure 1 ) . The CDUS failed to show any color flow signals within the mass but color flow signals were noted normal in rest of the testicular parenchyma ( figure 2 ) .  No any calcific focus or cystic change noted within lesion . No any other ultrasound evidence of epididymoorchitis was present . The possibility of an acute segmental testicular infract was made rather then a tumor because of absent color doppler signals in the focal abnormal area . The patient had normal complete blood count , and  was advised surgical exporation  by the referring doctor to exclude spermatic cord torsion as a cause for the abnormality . But  the patient  had refused for surgery , and  was  allowed to continue symptomatic medical treatment for some days .

After few weeks the referring doctor was contacted for follow up details of this case , and he ( referring doctor )  confirmed that the patient improved gradually and became symptom free with some residual testicular atrophy . The patient  was advised a review ultrasound  but he did not turn up .  

            

Discussion

Total testicular infarction is usually seen after torsion of spermatic cord , severe epididymoorchitis or trauma ( 2 ) . Segmental testicular infarction  is a rare entity and usually diagnosed by postorchidectomy histopathology  ( 5, 6 ) . The predisposing factors to segmental infarction  includes polycythemia ( 7 ) , intimal fibroplasia of spermatic artery ( 8 ) , sickle cell disease ( 9 ) , hypersensitivity angitits ( 10 ) and trauma , although most of the cases are idiopathic in origin ( 7 ) , as in this case . S. Sriprasad  et. al. reported a case  in BJR in 2001  with the same grayscale and CDUS  findings , which was proved to be a segmental testicular infarct histopathologically .  Scrotal sonography is valuable tool in differential diagnosis  of acute scrotum , & clearly differentiate  testicular torsion & infarct with high accuracy . In epididymoorchitis the testis and epididymis shows hyperemia , whereas absent or poor vascularity seen in torsion and infarct . The B- mode findings in acute testicular ischemia are enlarged and hypoechoic testis . CDUS helps to diagnose testicular torsion  where absent or poor blood flow noted in symptomatic testis  , and normal blood flow in contralateral  testis . The testicular tumors are usually seen as focal inhomogenic  or variable echotexture  masses with disordered / malignant internal vascularity on Doppler  ( 13 ) . On color Doppler , focal lesions larger than 16 mm , usually show raised and disordered blood flow ( 4 ) . Segmental testicular infarct also appears as focal mass of variable echogenicity with absent blood flow on Doppler ( 1 ) .  However cases with focal area of increased echogenicity  and poor or absent blood flow on CDUS were also reported and documented  in  segmental infarct ( 16 ) . This case showed  focal inhomogenic or variable echotexture mass at upper pole right testis with absent blood flow signals on CDUS , closely resembles the case reported by S. Sriprasad  et. al. . There was  focal enlargement of upper pole of testis , which may indicate acute nature of  the disease , because in chronic process the affected testis may appear small or shrunken ( 16 ) .  So with recent advances in probe technology and color Doppler sensitivity , it is  possible to document Intratesticular blood flow as well as vasculature pattern in a better way , which is  important particularly in differentiating a malignant mass from segmental infarction , as both appears identical on B – mode ultrasound , and thereby helpful in  suggesting a treatment  planning ( testis sparing & conservative management ) .

  

                   ( Figure 1 )    - Sagittal US image shows inhomogenic iso to hypoechoic mass like lesion 

                                         ( two small arrows ) involving upper pole of right testis    

   

               ( Figure 2 )  -  Color Doppler Us image of same testis shows absent color flow signals in the                                    abnormal area     s/o infarct , and normal blood flow signals in rest of the testis .

 PS ; The case study is based on imaging features & review literature , and intended for medical professionals & imaging specialists for academic purpose .

Referrences

1.      S .sriprasad  et al. Acute segmental testicular infarct : differentiation from tumour using high frequency colour Doppler ultrasound. BJR [74]2001,965-967

2.      Sidhu PS. Clinical and imaging features of testicular torsion: role of ultrasound. Clin Radiol 1999;54:343–52.[Medline]

3.      Morse MJ, Whitmore WF. Neoplasms of the testis. In: Walsh PC, Stamey TA, editors. Campbell's Urology (5th edn). Philadelphia, PA: WB Saunders Co., 1986:1535–82.

4.      Horstman WG, Melson GL, Middleton WD, Andriole GL. Testicular tumours: findings with color Doppler US. Radiology 1992;185:733–7.[Abstract/Free Full Text]

5.      Han DP, Dmochowski RR, Blasser MH, Auman JR. Segmental infarction of the testicle: atypical presentation of a testicular mass. J Urol 1994;151:159–60.[Medline]

6.      Costa M, Calleja R, Ball RY, Burgess N. Segmental testicular infarction. BJU Int 1999;83:525.[Medline]

7.      Jordan GH. Segmental hemorrhagic infarct of testicle. Urology 1987;29:60–3.[Medline]

8.      Brehmer-Andersson E, Andersson L, Johansson J. Hemorrhagic infarctions of testis due to intimal fibroplasia of spermatic artery. Urology 1985;25:379–82.[Medline]

9.      Holmes NM, Kane CJ. Testicular infarction associated with sickle cell disease. J Urol 1998;160:130.[Medline]

10.    Baer HM, Gerber WL, Kendall AR, Locke JL, Putong PB. Segmental infarct of the testis due to hypersensitivity angiitis. J Urol 1989;142:125–7.[Medline]

11.    Martin B, Conte J. Ultrasonography of the acute scrotum. J Clin Ultrasound 1987;15:37–44.[Medline]

12.    Middleton WD, Melson GL. Testicular ischemia: color Doppler sonographic findings in five patients. AJR 1989;152:1237–9.[Abstract/Free Full Text]

13.    Grantham JG, Charboneau JW, James EM, et al. Testicular neoplasms: 29 tumors studied by high-resolution US. Radiology 1985;157:775–80.[Abstract/Free Full Text]

14.    Gofrit ON, Rund D, Shapiro A, Pappo O, Landau EH, Pode D. Segmental testicular infarction due to sickle cell disease. J Ultrasound Med 1998;160:835–6.

15.    Flanagan JJ, Fowler RC. Testicular infarction mimicking tumour on scrotal ultrasound: a potential pitfall. Clin Radiol 1995;50:49–50.[Medline]

16.    Kramolowsky EV, Beauchamp RA, Milby WP. Color Doppler ultrasound for the diagnosis of segmental testicular infarction. J Urol 1993;150:972–3.[Medline]

17.    Bushby L, Sriprasad SI, Sidhu PS. Focal testicular abnormalities: evaluation of lesion vascularity using high frequency colour Doppler ultrasound. Eur J Ultrasound 2001;13:S30.

POSSIBLE INTRAABDOMINAL TESTICULAR TUMOUR WITH PARAAORTIC LYMPHADENOPATHY - An ultrasound evaluation

POSSIBLE  INTRAABDOMINAL TESTICULAR TUMOR WITH  PARAAORTIC LYMPHADENOPATHY  - AN ULTRASOUND EVALUATION

CASE DETAILS -  A 34 years old man presented with lump lower abdomen &  mild pain ,  was referred for ultrasound abdomen  . No H/O vomiting , pyrexia , urinary or GI sign & symptoms was present  . Routine blood & urine tests were also non contributory .
AT USG - A large well defined  subtle inhomogenically hypoechoic  round to oval solid mass of about 95 x 54 x 65 mm size noted in suprapubic location abutting bladder wall. The mass was slightly mobile & extending towards right . No significantly appreciable internal vascularity was present . No internal calcifications or cystic changes were seen . This mass was assumed to be a neoplastic lesion of omento-mesenteric origion [ as it was slightly mobile ] or  nodal [ fig 1& 2] . There was also evidence of a well defined oval hypoechoic mass of about 29 x 14 mm size noted in upper paraaortic location at aorto-caval window , & was assumed to be lymphadenopathy [ fig 3] . Trace ascites was also present .  Rest of the abdominal organs were normal . In view of paraaortic lymphadenopathy the study was extended for scrotum to evaluate testes. Surprisingly both testes were absent in scrotum. Now retrospective H/O infertility was given by the  patient . A thorough search for undescended testes was made , and left testis of 31 x 16 x 21 mm size was found in intraabdominal location in left iliac fassa with homogenous echotexture [ fig -4 ] . Now the suprapubic mass was assumed to be  tumor development in right intraabdominal testis , as right testis was not separately seen . So on the basis of ultrasound findings a possible diagnosis of bilateral undesended intraabdominal testes with right testicular tumor and paraaortic lymphadenopathy was made.

Fig 1 - Suprapubic sag & transverse US scans showing a well defined oval solid mass abutting bladder wall
 [ possible right undescended intraabdominal testicular tumor]

Fig 2 - Color doppler scan of suprapubic mass , the mass did not revealed significantly appreciable color flow signals [ may be scanty poor flow ]

Fig 3 - Color doppler scan upper abdomen showing oval paraaortic lymphadenopathy in aorto-caval window

Fig 4 - Left iliac fossa US scan showing left intraabdominal testis

P S - The case study suggests possible diagnosis & is intended for medical professionals & imaging specialists for academic purpose