Bilateral testicular epidermoid cysts

Author(s)

Myroslav Gerasymchuk, Danny Ma, Rojanandham Samudrala, Ghassan Tranesh, Warda Ibrar

St. John Hospital & Medical Center,
22101 Moross, Detroit, MI 48236

Patient

male, 16 year(s)

Clinical History

The patient is a 16-year-old boy who presented to a primary care physician with a self-identified painless right testicular mass. The primary care physician referred the patient for ultrasound of the scrotum.

Imaging Findings

Ultrasound of right testicle demonstrated a 1.5 x 1.5 cm mass in the central portion of the testes. The lesion appeared as a heterogeneous solid mass with lamellar or onion-skin type echo-texture. Spectral Doppler flow was identified in the right testis, but not in the mass.

There was also a 0.9 x 1.0 cm similar-appearing mass in the left testicle. Blood flow was established on Doppler in the normal testes tissue, but not the mass.

There was no evidence for extratesticular masses, hydrocele, or varicocele.

Discussion

Epidermoid cysts are the most common cause of cutaneous cysts. The wall of the cyst consists of normal epidermis that produces keratin. While testicular epidermoid cysts are rare, they are still the most common benign tumour originating in the testicles [1].

Patients usually present with testicular enlargement without any other clinical symptoms. While epidermoid cysts are completely benign, the lesion may remain stable or progressively enlarge, leading to inflammation and possibly even rupture. There is no way to predict which lesions will become inflamed and which will remain quiescent.

The diagnostic modality of choice is ultrasound, with colour and spectral Doppler. It is important to recognize sonographic patterns associated with epidermoid cysts to accurately distinguish them from malignant intratesticular masses. Epidermoid cysts appear in the testicles as heterogeneous masses without any flow on colour Doppler [2]. The most common finding is usually mural calcifications and concentric rings of alternating echogenicity (onion-skinning). MR with and without contrast is also becoming more and more important for the diagnosis.

As mentioned above, epidermoid cysts are completely benign and resection is curative. However, care must be taken to preserve normal testicular tissue during surgery.

After informed consent was obtained, the patient underwent bilateral testicular exploration, and bilateral testicular mass enucleation was performed. Care was taken to preserve normal testicular tissue, and limit the amount of seminiferous tubules that were taken with the specimen. Both masses were surrounded in pseudocapsules, which were also removed. Pathologist confirmed both masses as epidermoid cysts by frozen section, after which both testicles were delivered back to the scrotum uneventfully.

Follow-up data from the patient is unavailable, however, literature suggests that testis-preserving surgery offers the best cosmetic results with preservation of fertility [3, 4].

Final Diagnosis

Differential Diagnosis List

References

[1]

Cho JH, Chang JC, Park BH, Lee JG, Son CH (2002) Sonographic and MR imaging findings of testicular epidermoid cysts.. American Journal of Roentgenology 178(3): 743-748
[2]

Manning MA & Woodward PJ (2010) Testicular epidermoid cysts sonographic features with clinicopathologic correlation.. Journal of Ultrasound in Medicine 29(5): 831-837
[3]

Ross JH, Kay R, & Elder J (1993) Testis sparing surgery for pediatric epidermoid cysts of the testis. Journal of Urology 149: 353-356
[4]

Eisenmenger M, Langs S, & Donner G (1993) Epidermoid cysts of the testis: Organ- preserving surgery following diagnosis by ultrasonography. British Journal of Urology 72: 955

Citation

Myroslav Gerasymchuk, Danny Ma, Rojanandham Samudrala, Ghassan Tranesh, Warda Ibrar (2014, Dec 24).

Bilateral testicular epidermoid cysts, {Online}.

URL: http://www.eurorad.org/case.php?id=12377

DOI: 10.1594/EURORAD/CASE.12377

ISSN: 1563-4086

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Published 24.12.2014
DOI 10.1594/EURORAD/CASE.12377
Section Uroradiology & Genital Male Imaging
Case Type Clinical Cases
Views 3518
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Figure 1
Ultrasound of scrotum

a

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

b

Department of Radiology, St. John Hospital & Medical Center, Detroit, MI

c

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

d

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

e

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

f

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

g

Department of Radiology, St. John Hospital & Medical Center, Detroit, Michigan.

Transverse view of right testicle. Note the onion-skin appearance of the mass.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Transverse view of right testicle with Doppler. Note lack of blood flow in the mass.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Long view of the right testicle with the mass.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Long view of right testicle with Doppler flow.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Long view of left testicle with the mass.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Long view of left testicle with Doppler.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;

Transverse view of both left & right testicles with the lesions.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Cysts;
Figure 2
Histology

a

Department of Pathology, St. John Hospital & Medical Center, Detroit, Michigan.

b

Department of Pathology, St. John Hospital & Medical Center, Detroit, Michigan.

c

Department of Pathology, St. John Hospital & Medical Center, Detroit, Michigan.

Rt. testicle - low power. Shows portion of relatively normal testicular tissue with adjacent epidermoid cystic wall and keratic contents.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Removal; Special Focus: Cysts;

Rt. testicle - high power. This figure shows the epidermoid cystic wall that is lined by stratified squamous epithelium possessing an inner granular layer. The orthokeratin fills the cystic cavity with loose and...

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Removal; Special Focus: Cysts;

Lt. testicle - low power. Figure shows orthokeratin filling the cystic cavity.

Area of Interest: Genital / Reproductive system female; Imaging Technique: Ultrasound; Procedure: Removal; Special Focus: Cysts;