CASE 12377 Published on 24.12.2014

Bilateral testicular epidermoid cysts

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

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

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

16 years, male

Categories
Area of Interest Genital / Reproductive system male, Genital / Reproductive system female ; Imaging Technique Ultrasound
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].
Differential Diagnosis List
Bilateral testicular epidermoid cysts
Bilateral mature teratomas
Bilateral germinal tumors
Metastatic lesions
Adrenal gland rest testicular lesions
Final Diagnosis
Bilateral testicular epidermoid cysts
Case information
URL: https://www.eurorad.org/case/12377
DOI: 10.1594/EURORAD/CASE.12377
ISSN: 1563-4086