Thursday, March 12, 2020

Digital Imaging of Testicular Cancer & Metastatic Recurrence

Written by: Dr. Robert L. Bard

Scan using a 3D Doppler Ultrasound identifying microlithiasis in testis























Fig 1- This image (above) is of a 28 year old newlywed with a biopsy proven high grade adenocarcinoma incidentally found for evaluation of a scrotal mass. The sonogram shows a black area indicating a 9mm focal vascular tumor. The digital scan maps the orange and red vessels feeding the testicular cancer. 

What makes for added concern are the numerous WHITE DOTS (calcific foci) surrounding the dark area which are micro-calcifications, otherwise called testicular microlithiasis (TM) or micro-stones. According to a 2018 study, this uncommon condition of micro-stones is linked to testicular cancer (as well as male infertility) possibly increasing one's risk as much as 1200%.

While not technically a precancerous condition, any man with these microcalculi should be checked periodically whereby small tumors could be treated focally if caught early. Since this 9mm tumor cannot be felt by itself, the simplest way to accurately identify the cause of the enlarged testis is with a high resolution sonogram. This non invasive screening may be also recommended for male family members.

 Using data from the most common cancer worldwide, basal cell skin cancer (BCC), we know the aggression of this cancer is proportional to the white dot number in the tumor volume (dot density-DD). With ultrasound computer analysis, the white dots are quantifiably measured providing a useful “risk” guideline. Another yardstick of tumor aggression comes from tumor vessel 3D analysis of both BCC and Prostate Cancers. The ability of both cancers to invade is evaluated by the type of feeding tumor arteries and the density of malignant arteries supplying the cancer (AD-arterial density)

FOCAL TREATMENT OPTIONS
Biopsy of a testicle tumor in the past meant an “orchiectomy”-surgically removing the entire testicle for the pathologist. As we have learned from 25 years of “digital biopsies” of prostate, lymph node, thyroid, breast and skin cancers, an accurate diagnosis may be obtained using the latest imaging modalities-CT, MRI, PET and 3D Doppler sonography to perform precision image guided biopsies thus sparing the removal of a valued piece of male real estate. From these same radiographic tools has evolved the paradigm of “focal” therapy and treatment verification showing reduction or total cessation of the malignant feeding vasculature.  For example, when a prostate cancers patient’s PSA dropped to 0, it was considered surgically successful treatment. Today, therapeutic effect may be quantitively measured by demonstration of absent vascular supply to the tumor or as the AD decreases in serial exams.

Aftermath: Standard treatment for this condition is typically surgery (cut off the entire testis). The patient refused this treatment solution and was instead treated focally with various nonsurgical options, later resulting in cancer remission followed by recurrence after therapy was discontinued and re-remission upon re-institution of the previously used modality. Avoiding the long list of serious side effects of the multitude of powerful onco-immunologic options is accomplished by ensuring that the treatment is effective by studying the DD or AD percentage decrease in order to timely discontinue an ineffective option. This non invasive evaluation is readily performed by 3D Doppler Histogram Arterial Density Analysis in minutes while the patient waits.
Progress tracking & comparative monitoring of testicular cancer under
treatment through the use of advanced ultrasound

Fig 2:  Treatment progress at 6 week intervals showing baseline at 32.9% AD followed by reduction to 4.9% after which treatment was stopped and recurrence of activity to 23.3% at which time therapy restarted.

RECURRENCE
Recurrence in the lymph glands is readily diagnosed by sonogram technology. Since the metastases usually spread around the abdominal aorta, the mass is commonly misdiagnosed as an aortic aneurysm. Periodic abdominal sonography screening is recommended. MRI is commonly used as an adjunct to ultrasound imaging.






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About the Author:



ROBERT L. BARD, MD, PC, DABR, FASLMS -
Advanced Imaging & Diagnostic Specialist
Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.



REFERENCES
Bard R DCE-MRI of Prostate Cancer   Springer 2009
Bard R Image Guided Prostate Treatment Springer 2013
Bard R Image Guided Dermatologic Treatment Springer 2019
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Images courtesy of: www.CancerScan.com





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