Background: Recent advances in ultrasonography (US) have produced new innovative techniques for the non-invasive assessment of testicular masses. The aim of this study was to investigate the diagnostic performance of multiparametric US, including gray-scale, Color-power Doppler and real-time elastography (RTE) analysis, in the characterization of testicular lesions. Methods: Fifty-four patients (median 42.2 years; range, 10-64 years) with testicular lesions detected with gray-scale US and power Doppler US were evaluated with RTE. The tissue elasticity was assessed in all lesions. Hard lesions were suspected of being malignant while testicular lesions with normal or decreased tissue stiffness (soft lesions) were considered benign. Intraoperative findings were the standard of reference. Sensitivity, specificity, negative predictive value, positive predictive value, and diagnostic accuracy were calculated for each US method and in combination. Results: Forty-six of the 54 lesions (85.2%) were testicular malignant tumors. Thirty-five out of 46 (76%) were ≥2 cm [seminomas (n = 18), mixed seminomatous and/or nonseminomatous tumors (n = 9), embryonal carcinomas (n = 2), immature teratomas (n = 3) and Leydig cell tumors (n = 3)] while the remaining 11 tumors were < 2 cm [seminomas (n = 5), mixed germinal cells tumors (n = 2), immature teratomas (n = 2) and Leydig cell tumors (n = 2)]. Eight out of 54 lesions (14.8%) were benign lesions (orchitis n = 2, dermoid cyst n = 1, adrenal rest n = 1, papillary cystadenoma n = 1, sclero-hyaline nodule n = 1, focal fibrosis n = 1 and post-traumatic focal fibrosis n = 1). RTE showed the presence of hard pattern in 40 out of 46 (87%) malignant tumors and in 2 out of 8 (25%) of benign lesions. The combination of gray-scale US, Color-power Doppler and RTE aided a sensitivity of 100%, a specificity of 83%, a negative predictive value of 100%, a positive predictive value of 91% and accuracy of 90%. Conclusions: RTE demonstrated to increase the diagnostic accuracy of conventional US in the characterization of testicular lesions providing additional information on tissue stiffness. The multiparametric US evaluation has proven to increase the diagnostic performance in the characterization of testicular lesions.
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