This is the slideshow of the presentation held at 3d International Meeting on Sono-Elastography in Pavia on Oct. 1st 2013 concerning both elastography of the testis and general considerations on elastography. Queste sono le slides presentate al Terzo Meeting Internazionale di Sonoelastografia tenutosi a Pavia il 01/10/2013. Vengono trattati sia l'elastografia del testicolo che gli aspetti più generali dell'elastografia con le sue prospettive di sviluppo.

2. PRESENTATION
The general experience with Sono-Elastography is growing with time, thus we have built the
meeting 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 to
help understanding which one is best suited for any given indication and which information
can be obtained when using it.
The Scientific Committee
Fabrizio Calliada,
Mario Canepari,
Giovanna Ferraioli,
Carlo Filice

3. Sonoelastography of the testis
Antonio Pio Masciotra
Campobasso – Molise – Italy
Email
antoniomasciotra@yahoo.it
Website
www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/
UCgCj21nKGAhR997Ia3-QegQ

4. 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.

5. Topics in clinical use of Sonoelastography
in non neoplastic diseases of the testis
dr. Antonio Pio Masciotra
Campobasso- Molise - Italy

6. The social impact of the diseases of the testis in Italy
New cases/Year
Cryptorchidism
5 Years survival
2.100
1/222
>95%
New cases/Year
Tumors
Relative death risk
Risk of infertility
Odd ratio for test. cancer
15.000 (2-8%)
>25%
3,5-17
New cases/Year Prevalence in males Preval. in infertile males
Varicocele
52.000
15-20%
40%

7. Testis disease clinical case
Undescended testis
 Man 35 years old
 Left testis undescended at birth
 Left orchiopexy at age of 14 years
 Then infertility

8. Right testis
• Volume 10,89 cc
• kPa : 2,2
Left testis
• Volume 04,26 cc
• kPa : 5,0

9. Key points and take home messages
 The left testis previously undescended and operated too
late 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?

10. Testis disease clinical case
Varicocele
 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!)

11. Left testis

12. Left testis

13. Right testis Mean Stiffness 3.0 kPa
Left testis Mean Stiffness 2.2 kPa

14. Key points and take home messages
 The left testis shows loss of volume, scant vessels and
inhomhogeneous texture as consequences both
of 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 still
fertile
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?

15. 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 treatment
2) 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 done
between 10 months and 2 years of age, without
the delay induced by hormonal therapy, too
often unsuccessfull or not resolutive
(efficacy <20%).

16. Sonoelastography of the testis………….
and more………..
Antonio Pio Masciotra
Campobasso – Molise – Italy
Email
antoniomasciotra@yahoo.it
Website
www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/
UCgCj21nKGAhR997Ia3-QegQ

18. The testis both at B scan and at strain elastography shows an almost uniform pattern,
with septa remaining not distinguishable.

19. Shear Wave elastography, instead, for the first time does show the septa
originating from the albuginea.

20. 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.

21.  The optimal highlighting and perception of the stiffness differences in an organ or
tissue at Shear Wave Elastography depend on the dynamic scale used………….
•Probe : 10-2 MHz
• Lower contrast
Dinamic scale
0-50 kPa
• Probe : 10-2 MHz
• Higher contrast
Dinamic scale
0-20 kPa
 ………. 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)

22.  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
•Probe : 10-2 MHz
Dinamic scale
0-30 kPa
• Probe : 15-4 MHz
Dinamic scale
0-50 kPa
 Very narrow Dinamic scale (0-10 kPa) well highlights that the ‘mirror artifact’
is possible also in Shear Wave Elastography

23. 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 a
smoother 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.

24. 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
• High transparence
• Low transparence
Better visualization of the boundaries between the
lesion and the surrounding tissues
Better visualization of the core of the focal lesion

25. 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 colors
2) your hand tells you its consistence, the characteristics of its surface and very
approximately the temperature, weight and lenght
3) your tongue tells you its taste, but also its consistence, the characteristics of its
surface and its temperature
4) 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 kg
b) the libra in scale of decigrams (more precise than the former) tells you that its weight is between
10 and 20 grams
c) 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 weight
2) cm or inches for the lenght
3) Centigrades or Kelvin or Fahrenheit grades for temperature

26. 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.

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

28. 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
• Bidimensional
• 3D

29.  But while the quantification of the feature ‘Weight’ of the testis with different libras
gives the same value……........
• 16 g with electronic libra
• 16 g with mechanical libra
 ………..The quantification of the feature ‘Stiffness’ of the testis with probes of
different frequencies gives very different values and…………….
• 1.7 kPa with Probe 10-2 MHz
• 3,3 kPa with Probe 15-4 MHz

30.  …….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
Fat 19.9 kPa
Lipoma 20.5 kPa SW Ratio 1.03
Time 10:07:09
Fat 8.0 kPa
Lipoma 7.8 kPa
Time 10:07:34
SW Ratio 1.03

31. 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.

32. Galileo Galilei
"Any problem that wants
to be solved
starts with curiosity."
Johann Wolfgang von Goethe
"Knowing is not enough,
we must apply.
Willing is not enough,
we must do."

33. Sonoelastography of the testis………….
and more………..
Antonio Pio
Masciotra
Campobasso – Molise – Italy
Email
antoniomasciotra@yahoo.it
Website
www.masciotra.net
YouTube Channel
https://www.youtube.com/ch
annel/UCgCj21nKGAhR997I
a3-QegQ