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 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

Antonio Pio Masciotra Campobasso – Molise – Italy Website YouTube 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 Ill 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 Masciotra Campobasso- Molise - Italy

The social impact of the diseases of the testis in Italy

Testis disease clinical case Undescended 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 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?

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!)

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 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?

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%).

Sonoelastography of the testis…………. and more……….. Antonio Pio Masciotra Campobasso – Molise – Italy Website YouTube 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 MHz Dinamic 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 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.

High transparence Better visualization of the boundaries between the lesion and the surrounding tissues Low transparence Better visualization of the core of the focal lesion 28 Opacity Its adjustment from 0 to 100% gives less 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 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

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) 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 ratios 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 probes frequency or on other variables. When this requirement will be accomplished well can really establish the cutoff value between normal and abnormal tissues both in focal and in diffuse diseases. Therefore well 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 its responding to the treatment). Then lets 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 wants to 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 Masciotra Campobasso – Molise – Italy Website YouTube Channel annel/UCgCj21nKGAhR997I a3-QegQ Sonoelastography of the testis…………. and more………..