Comparative accuracy of imaging modalities for differentiating malignant small testicular masses

Abstract

Objectives To synthesise evidence comparing the diagnostic performance of imaging modalities in differentiating malignant from benign small testicular masses. Patients and Methods A Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA)‐compliant search of PubMed, Scopus, Cochrane and Web of Science databases up to 6 May 2026 identified 11 studies comprising 707 patients with small testicular masses (predominantly <2 cm) who underwent imaging prior to a histopathological or, where unavailable, a mixed clinical/radiological follow‐up reference standard. Diagnostic accuracy measures for six modalities (brightness‐mode [B‐Mode] ultrasonography [US], colour doppler US [CDUS], contrast‐enhanced US [CEUS], magnetic resonance imaging [MRI], strain elastography [SE] and strain ratio [SR]) were synthesised using a Bayesian bivariate hierarchical summary receiver operating characteristic model. Results The CEUS demonstrated the most reliable discriminatory ability with a pooled sensitivity of 91% and pooled specificity of 81%, yielding the highest diagnostic odds ratio of 46. B‐Mode US remains a valid screening test with the highest sensitivity of 96% but a specificity of only 39%. CDUS showed a pooled sensitivity of 69% and a specificity of 81%. MRI had a pooled sensitivity of 91% and a specificity of 38%. SE demonstrated a pooled sensitivity of 87% and a specificity of 56%. Finally, SR reported the lowest sensitivity at 74% and a specificity of 50%. CEUS demonstrated significantly higher specificity than B‐Mode US (ratio 1.9, 95% posterior interval [PI] 1.2–4.4) and MRI (ratio 1.8, 95% PI 1.0–5.2). Conclusion The CEUS demonstrates the highest combined sensitivity and specificity for differentiating benign from malignant testicular masses, significantly outperforming conventional B‐Mode US and MRI in specificity. CEUS represents a compelling decision‐making tool to support testis‐sparing strategies and reduce unnecessary orchidectomies for indeterminate small testicular masses.