==inizio objective==

Sonoelastography is a novel and promising imaging tool, which has been applied to breast, thyroid, and prostate tissues. The aim of this study was to evaluate focal lesions of the testes with diameters of <10 mm using sonoelastography, B-mode sonography (US), and colour Doppler ultrasonography (CDU). This study compared US, which is a widely used diagnostic sonographic method, with semiquantitative sonoelastography, which is a new method for visualizing the elastic characteristics of tissues, in the evaluation of testicular nodules with diameters of <10 mm. To explore the outcomes generated by this tool in greater depth, we tested the relationship between the strain ratio data obtained using sonoelastography, and the vascular indices (VI) that were determined from the immunohistochemical analysis of the testicular lesions. ==fine objective== ==inizio methodsresults== Thirty patients who were referred to our outpatient clinics for varicocoeles, scrotal pain, scrotal enlargements, epididymitis, palpable testicular nodules, or infertility, were prospectively enrolled into this study. Ultrasound evaluations had revealed that 27 subjects had focal testicular lesions with diameters of <10 mm and 3 subjects had 10-mm spherical non-homogeneous testicular nodules. All lesions were evaluated using semiquantitative sonoelastography, and the patients underwent orchifunicolectomies. The testicular lesions were examined histopathologically. The vascularization of the lesions and the surrounding testicular parenchyma was evaluated by analysing the immunohistochemical distribution of the cluster of differentiation 31 and by calculating the vascular indices (VI). Potential associations between the strain ratios (stiffness of the lesions) and the VI were tested. ==fine methodsresults== ==inizio results== Analyses of the strain fields obtained using the semiquantitative sonoelastography yielded different values for the masses and the surrounding tissues, which led to significant increases in the strain ratios. Semiquantitative sonoelastography provided data that supplemented those generated by US and CDU. Specifically, this tool demonstrated that the normal testicular tissue and nodules had different elastographic patterns, with the latter showing stiffer sonoelastographic signals, particularly at the perimeters of the masses, which was suggestive of pathological tissue, and has been described in previous reports. Sonoelastography upheld all of the diagnoses that were suspected when the patients were physically examined, when the serum markers were analysed, and after the patients had undergone US and CDU. Histopathological examinations confirmed the neoplastic characteristics of these masses. A significant inverse correlation was determined between the sonoelastographic strain ratio and the VI (Pearson correlation coefficient, r, = - 0.93; p < 0.001). ==fine results== ==inizio discussions== Testicular masses can be difficult to diagnose, particularly when they have a diameter of <1 cm and/or are not palpable. Palpation provides subjective data, but physicians need instrumental support to make informed decisions about therapy when the lesion is small. Evaluations using US combined with CDU are commonly used to characterize testicular lesions, but these evaluations do not provide any information about the internal consistency of the masses. This information might help to corroborate diagnostic assessments, especially when masses with small diameters are found incidentally. Sonoelastography can be used to evaluate the mechanical elastic properties of soft tissues, which are determined by their macromolecules and structural organization. This is the first report describing the use of semiquantitative sonoelastography to investigate subcentimetre testicular masses, which could be promising potential targets for this new imaging technology. Indeed, the information obtained through sonoelastography in this study has contributed to the diagnostic evaluation of testicular lesions, because it has given an insight into their atypical compositions and it has emphasized the need for a high level of clinical suspicion about malignancy in the context of subcentimetre testicular tumours. Our data concur with those from previously reported studies and they ratify the potential role of sonoelastography in the evaluation of testicular nodules. In our study, we sought to substantially reduce the subjectivity associated with evaluating the colour maps in real time by replacing the classification system with a numerical parameter, that is, the strain ratio, which is not operator dependent, is reproducible, and enables the elasticity of lesions to be given unique classifications. To ensure the objectivity of the assessment, we also attempted to define a cut-off value that would differentiate between likely benign nodular lesions and likely malignant lesions, and to add a numerical parameter that would help guide the next clinical step, for example, clinical monitoring with or without treatment, or surgical excision. This was possible with the semiquantitative sonoelastography system, because it expresses the deformation capacity of the structure under investigation relative to the normal (reference) tissue as an absolute value or as a strain ratio. Therefore, semiquantitative sonoelastography represents a modification of the real-time method and enables the off-line analysis of a nodule’s strain values by analysing variations in radiofrequencies using the raw data. The calculation is performed by selecting an ROI within the nodular formation and a reference region in an area of normal parenchymal elasticity. The result is an index of deformation (i.e. a strain index or a coefficient of elasticity) that can be compared with the organ’s reference values, and that rises as the rigidity of the structure being examined increases. Using this method, the coefficient of echogenicity can also be determined by comparing the echogenicity of the lesion with that of nearby normal structures, while taking into account the absolute values of echogenicity expressed in the raw data. ==fine discussions== ==inizio conclusion== The data generated by semiquantitative sonoelastography provide further evidence that the lesions discovered during the physical examinations, US, and CDU were pathological, which prompted surgical treatment. Furthermore, the immunohistochemical analysis undertaken in our study demonstrated a linear inverse correlation between the strain ratio values and the VI. It could be postulated that this inverse correlation is an expression of the lesions’ diminished consistencies and greater intralesional vascularity. This finding could be further interpreted as hypervascular tumours having lower levels of consistency than hypovascular tumours. Hence, sonoelastography could quantify the magnitude of intralesional microcirculation or neoangiogenesis, and substantiate the consistency of testicular masses. Together, these add important elements to diagnostic and prognostic assessments. Given that the main limitation of the present study was the small number of patients, further investigations with larger numbers of patients are required to corroborate these data and to support the use of semiquantitative sonoelastography in the evaluation of testicular lesions. ==fine conclusion== ==inizio references== 1. Garra BS: Imaging and estimation of tissue elasticity by ultrasound. Ultrasound Q 2007, 23(4):255–268. 2. Goddi A, Sacchi A, Magistretti G, Almolla J, Salvadore M: Real-time tissue elastography for testicular lesion assessment. Eur Radiol 2012, 22(4):721–730. 3. Magarelli N, Carducci C, Bucalo C, Filograna L, Rapisarda S, De Waure C, Dell'Atti C, Maccauro G, Leone A, Bonomo L: Sonoelastography for qualitative and quantitative evaluation of superficial soft tissue lesions: a feasibility study. Eur Radiol 2014, 24(3):566–573. ==fine references==