Figure 1
Ultrasound of the scrotum transverse oblique view shows normal appearing right and left testes with homogenous echopattern. Left sided varicocele and the right sided epidermoid cyst can be seen.
Extratesticular intrascrotal epidermoid cyst.
SectionUroradiology & genital male imaging
Case TypeClinical Cases
Authors
Asaad Gamal Sorial, Ahmed Elsahhar,
Connected authors
54 years, male
Clinical History
A 54-year-old male patient presented with scrotal pain of long duration more on the left side. There is also intermittent sense of heaviness of the scrotum. He provided history of operated right inguinal hernia years ago.
On local examination there is a left sided varicocele and a right sided mobile small scrotal nodule firm in consistency and non-tender.
Imaging Findings
Scrotal ultrasound revealed normal appearing right and left testes with left sided varicocele and the right sided Extratesticular intrascrotal epidermoid cyst appearing well circumscribed having a whorled appearance with a central calcific focus, giving the lesion a "target" or "onion skin" appearance.
Discussion
Epidermoid cyst is benign tumor of testicles representing 1% of the testicular tumors, it has no malignant potential with no metastasis. [1] This tumor is true cyst full of cheesy laminated material that gives it the characteristic ultrasound feature called “onion-skin” appearance.[2] It usually presents in the second to the fourth decades of life and is presented as a palpable non tender nodule on physical examination.[2] Extra-testicular epidermoid cyst is extremely rare with less than 10 cases reported. There are cases showing attachment to the spermatic cord, prostate and seminal vesicles with few showing extension to the true pelvis. [3]
Ultrasound is the primary imaging modality and epidermoid cyst can present with multiple appearances: onion ring pattern, target appearance, solid mass with an echogenic rim or sharply defined mass with a rim of calcification. [4] Also, absence of internal vascular flow helps in differentiating epidermoid cyst from other solid intratesticular tumors. The MR appearance was described to have onion skin appearance with alternating high and low signal intensity rings on T1 and T2 weighted images. It also can show target appearance with central and peripheral regions showing low signal intensity and middle region showing high signal intensity on both T1 and T2 weighted images with no internal gadolinium enhancement. [5]
Written informed patient consent for publication has been obtained.
Differential Diagnosis List
Extratesticular intrascrotal epidermoid cyst.
Testicular germ cell tumor
Testicular teratoma
Adenomatoid tumors of the scrotum
Focal extratesticular granulomatous disease, e.g. tuberculosis
Calcified appendix testis/epididymis
Final Diagnosis
Extratesticular intrascrotal epidermoid cyst.
References
[1] Ulbright, T. M. (1999). Tumors of the testis, adnexa, spermatic cord and scrotum. Armed Forces Institute of Pathology (AFIP), 59–85.
[2] Fu, Y., Wang, H., Yang, T., Chang, S., & Ma, C. (1996). Epidermoid cysts of the testis: diagnosis by ultrasonography and magnetic resonance imaging resulting in organ‐preserving surgery. British Journal of Urology, 78(1), 116–118. (PMID: 8795413)
[3] Sağlam, H. S., Kumsar, S., Köse, O., & Adsan, O. (2013). A unique scrotal extratesticular epidermod cyst attached to the seminal vesicles. Canadian Urological Association Journal = Journal de l’Association Des Urologues Du Canada, 7(3–4), E244–E247. (PMID: 23671535)
[4] Dogra, V. S., Gottlieb, R. H., Rubens, D. J., Oka, M., & di Sant Agnese, A. P. (2001). Testicular epidermoid cysts: sonographic features with histopathologic correlation. Journal of Clinical Ultrasound : JCU, 29(3), 192–196. (PMID: 11329161)
[5] Langer, J. E., Ramchandani, P., Siegelman, E. S., & Banner, M. P. (1999). Epidermoid cysts of the testicle: sonographic and MR imaging features. American Journal of Roentgenology, 173(5), 1295–1299. (PMID: 10541108)
Case information
| URL: | https://www.eurorad.org/case/17022 |
| ISSN: | 1563-4086 |
License
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Figure 2
Ultrasound of right testicle longitudinal view shows normal right testicle with homogenous parenchyma with extratesticular epidermoid cyst.
Figure 3
Longitudinal view of upper part of right scrotal compartment showing Extratesticular intrascrotal epidermoid cyst appearing well circumscribed having a whorled appearance with a central calcific focus, giving the lesion a "target" or "onion skin" appearance.
Ultrasound of the scrotum transverse oblique view shows normal appearing right and left testes with homogenous echopattern. Left sided varicocele and the right sided epidermoid cyst can be seen.
© Department of Radiology, Ain Shams University, Egypt, 2020
© Department of Radiology, Ain Shams University, Egypt, 2020
Ultrasound of right testicle longitudinal view shows normal right testicle with homogenous parenchyma with extratesticular epidermoid cyst.
© Department of Radiology, Ain Shams University, Egypt, 2020
© Department of Radiology, Ain Shams University, Egypt, 2020
Longitudinal view of upper part of right scrotal compartment showing Extratesticular intrascrotal epidermoid cyst appearing well circumscribed having a whorled appearance with a central calcific focus, giving the lesion a "target" or "onion skin" appearance.
© Department of Radiology, Ain Shams University, Egypt, 2020
© Department of Radiology, Ain Shams University, Egypt, 2020