Epidermoid cyst of the testis: a critical analysis

MRI findings of an atypical testicular epidermoid cyst: A case report

INTRODUCTION

Typical testicular epidermoid cysts (TECs) manifestate as a target sign or onion skin sign on ultrasonography and magnetic resonance (MR) imaging. Clinicians are increasingly aware of the imaging characteristics of typical TECs, which allow accurate diagnosis and successful treatment while preserving the testicle, but atypical TECs are likely to be misdiagnosed as a malignant intratesticular neoplasm, leading to complete testicular resection.

PATIENT CONCERNS

A 26 year-old male patient complained of a painless enlargement of the left testicle that had been present for 1 month. The patient had no recent medical history of scrotal trauma or systemic infection.

DIAGNOSIS

A round 48 mm × 45 mm × 43 mm mass was seen inside the left testicle. T2-weighted images of the lesion showed a thin hypointense capsule. T1-weighted images of the lesion showed a hyperintense nodule on the cyst wall, which appeared hypointense on T2-weighted and SPAIR images. After Gd-DTPA injection, the lesion was not enhanced; however, the nodule was enhanced on THRIVE images. These manifestations were consistent with a benign intratesticular lesion, and MR imaging diagnosed atypical TEC, which was confirmed by pathology after surgery.

INTERVENTIONS

The patient was treated with organ-sparing surgery with testicular enucleation.

OUTCOMES

The patient was re-examined with ultrasonography 3 months after surgery. The left residual testicular tissue appeared normal, and reproductive function was preserved.

CONCLUSION

Urologists must be aware of the clinical and MR imaging characteristics of atypical TECs and the utility of preoperative MR imaging for the diagnosis of testicular lesions to ensure that organ-sparing surgery is performed rather than unnecessary orchiectomy.

Epidermoid Cyst of the Testis: Sonographic Characteristic Appearance

Intratesticular epidermoid cysts are rare, benign, well-defined, and solitary keratinized intratesticular lesions. They usually present as a painless, discrete, and firm swollen area before being diagnosed. Preoperative diagnosis of epidermoid cysts is often difficult. Sonography is a useful imaging modality in the preoperative assessment of testicular lesions. Although it is difficult to distinguish epidermoid cysts from germ cell tumors, certain sonographic characteristics such as the classical “onion-peel” appearance, the negative tumor markers, and the underlying symptoms should raise the suspicion of epidermoid cysts.

High orchiectomy and ipsilateral testicular sperm extraction in a man with a testicular tumor and Klinefelter syndrome: A case report

Introduction

Testicular epidermal cysts in Klinefelter syndrome are very rare. We report a case of Klinefelter syndrome associated with a testicular epidermal cyst. To our knowledge, this is the first report showing successful spermatozoa retrieval from the affected testis.

Case presentation

A 25-year-old married man was referred to our hospital with right scrotal induration, which was in lower pole of the right testis. Testicular cancer tumor markers were normal; endocrinological findings indicated hypergonadotropic hypogonadism. Semen analyses revealed azoospermia. Preoperative chromosome test result: 47, XXY karyotype; ultrasonography report: 1.9-cm internal heterogeneous echoic mass in the right testis (malignancy not discarded). Because the patient hoped for children, he underwent high orchiectomy with ipsilateral testicular sperm extraction (200 spermatozoa from normal testicular tissue) for future fertilization procedures. Tumor pathology was an epidermal cyst.

Conclusion

While performing orchiectomy for testicular tumors, sperm retrieval should be attempted from normal tissues in patients planning for children.

Painless Benign Epidermoid Cyst of the Testis

Benign intratesticular lesions such as epidermoid cyst are rare, but recognition is important to avoid unnecessary surgical intervention (orchiectomy). The combination of ultrasonographic findings and negative tumour markers can help differentiate benign from malignant intratesticular lesions. At surgery, the lesion can be enucleated and frozen sections obtained to confirm the diagnosis, thus avoiding the need for orchiectomy.

Testicular microlithiasis and epidermoid cysts: a common pathway?

We present the case of a boy with antenatally diagnosed bilateral testicular microlithiasis. Following annual surveillance the child developed metachronous bilateral epidermoid cysts. These were subsequently excised with testicular sparing surgery. Currently, there are only three cases of bilateral epidermoid cysts in the paediatric population, and none have been associated with testicular microlithiasis. This reignites the discussion regarding the histogenesis of epidermoid cysts and how its pathophysiology might relate to testicular microlithiasis.

Multiple epidermoid cysts in the testis of a New Zealand White rabbit: a case report

Multiple epidermoid cysts were observed microscopically in the testis of a New Zealand White rabbit. The cysts were lined by stratified squamous keratinizing epithelium and filled with concentric layers of keratin. Testicular epidermoid cysts have been described in men but are very rare in animals.

Testicular epidermoid cysts: sonographic features with clinicopathologic correlation

OBJECTIVE

The purpose of this series was to describe the sonographic features of intratesticular epidermoid cysts with clinicopathologic correlation.

METHODS

A retrospective review of the sonographic features of all intratesticular epidermoid cysts within the radiologic pathology archive of the Armed Forces Institute of Pathology with correlation with clinical, surgical, and pathologic data was performed. On sonograms, intratesticular epidermoid cysts were evaluated for shape, borders, and the presence of characteristic features, including alternating hypoechoic and hyperechoic rings, mural calcifications, and echogenic central core. Color Doppler imaging was evaluated for the presence of internal flow.

RESULTS

Of 21 cysts seen in 20 male patients (mean age, 24 years; range, 11-52 years), the most common finding was mural calcifications, which were seen in 18 lesions (86%). Concentric rings of alternating echogenicity were shown in 13 lesions (62%), and 7 cysts (33%) had an echogenic central core. No cysts showed internal vascularity.

CONCLUSIONS

Testicular epidermoid cysts are uncommon solid-appearing testicular masses that usually present as palpable masses and are benign. Knowledge of the sonographic and pathologic features may help differentiate these lesions from malignancy and possibly prevent unnecessary orchiectomy.

Case report of a testicular epidermoid cyst and review of its typical sonographic features

A case of testicular epidermoid cyst, demonstrating multiple characteristic sonographic patterns in a single lesion, is presented with a brief review of the distinctive ultrasound features. It is important to remember that the sonographic patterns describing testicular epidermoids represent the varied amounts and arrangements of keratin of a particular lesion. A given lesion may demonstrate subtle variability or more than one characteristic pattern at any given time. With this in mind, preoperative characterization of testicular epidermoids should allow for increasing utilization of testicular sparring surgery in the management of this benign lesion.

Epidermoid Cyst of the Testicle

We describe the case of a 13-year-old boy with testicular epidermoid cyst who presented with a painless testicular mass. Epidermoid cyst of the testis is a benign, non-teratomatous tumor. It is often possible to make the diagnosis preoperatively, combining typical sonographic features with normal biochemical tumor markers. Preoperative diagnosis will allow for testis-sparing surgery and prevent unnecessary orchiectomy.

Epidermoid cyst of the ureter: a case report

Epidermal cysts of the upper urinary tract are extremely rare. Only three cases have been reported in the published work written in English, Italian or German. We encountered a case of an epidermoid cyst in the ureter of a 72-year-old male. Findings on urine analysis and radiological examination were useful for establishing a correct diagnosis of epidermoid cyst of the urinary tract.

Interphase fluorescence in situ hybridization analysis of chromosome 12p abnormalities is useful for distinguishing epidermoid cysts of the testis from pure mature teratoma

PURPOSE

The distinction of epidermoid cyst of the testis from teratoma is of critical importance because the former is benign and the latter is a malignant tumor that may have associated metastasis of either teratomatous or non-teratomatous germ cell tumor types. Chromosome 12p abnormalities are seen in the vast majority of testicular germ cell tumors of adults and are present in all histologic subtypes. In this study, we investigated the clinical utility of interphase fluorescence in situ hybridization (FISH) analysis of chromosome 12p abnormalities for distinguishing epidermoid cysts of the testis from pure mature teratoma.

EXPERIMENTAL DESIGN

Sixteen testicular epidermoid cysts and 17 testicular teratomas were investigated for isochromosome 12p [i(12p)] and 12p overrepresentation using interphase FISH analysis.

RESULTS

Neither i(12p) nor 12p overrepresentation were observed in 16 epidermoid cyst cases, whereas i(12p) was detected in 76% of teratomas and 12p overrepresentation was identified in 29% of teratomas. Overall, 88% of testicular teratomas had chromosome 12p abnormalities.

CONCLUSIONS

FISH identification of i(12p) and/or 12p overrepresentation in routinely processed surgical specimens is a useful ancillary diagnostic tool in distinguishing testicular epidermoid cysts from teratoma.

Sonography of Benign Intrascrotal Lesions

Ultrasound plays an important role and adds essential information in diagnosing benign intrascrotal lesions. Characterization of benign intrascrotal lesions with sonography, in combination with clinical assessment, can lead to nonsurgical management or testicular sparing surgery. We present important sonographic features of benign intrascrotal lesions, including extratesticular lesions: adenomatoid tumors, papillary cystadenomas, spermatoceles, hydroceles, varicoceles, hernias; and intratesticular lesions: tunica albuginea cysts, testicular simple cysts, epidermoid cysts, tubular ectasia of the rete testis, intratesticular varicoceles, adrenal rest tumors, and splenogonadal fusion. The goal of this review is to provide the radiologist with a better understanding of benign lesions that occur in the scrotum.

Testicular epidermoid cyst in Klinefelter's syndrome

A 38-year-old Japanese man was referred to our outpatient clinic for treatment of infertility. Semen analysis showed azoospermia. Chromosome analysis revealed a 47XXY karyotype, and non-mosaic Klinefelter's syndrome (KFS) was diagnosed. Upon physical examination, the patient's right testicular volume was 30 mL and the left testicular volume was 3 mL. Laboratory tests showed normal levels of lactate dehydrogenase, alpha-fetoprotein, and human chorionic gonadotropin beta-subunit. The plasma luteinizing hormone and follicle-stimulating hormone levels were increased to 15.7 mIU/mL and 45.9 mIU/mL, respectively. The plasma testosterone was decreased to 0.25 ng/mL. Magnetic resonance imaging showed a right testicular mass of low-signal intensity on the T1-weighted image and of high-signal intensity on the T2-weighted image. Therefore, the final diagnosis was KFS with a right testicular tumor. Thus, a right high orchiectomy was performed. Histological examination revealed an epidermoid cyst of the right testis. Epidermoid cysts in cases of KFS are rare. To our knowledge, only seven cases, including ours, have been reported in the literature.

Epidermoid cyst and teratoma of the testis: sonographic and histologic similarities

OBJECTIVE

The classic sonographic description of an epidermoid cyst is a mass with a target or onion ring appearance of alternating rings of hyperechogenicity and hypoechogenicity. This study presents a pathologic-sonographic assessment of classic and nonclassic appearances of an epidermoid cyst of the testis and reports the possible similarity between a classic epidermoid cyst and a teratoma on sonography.

METHODS

We reviewed the sonographic and histologic features of 8 testicular tumors that either had a classic onion ring pattern or were found at pathologic examination to be epidermoid cysts but did not have the classic sonographic pattern.

RESULTS

Three epidermoid cysts had a typical onion ring appearance. Histologic sections of these tumors revealed a squamous epithelial layer lining the cyst and multiple concentric laminated layers of keratin. Two tumors did not have a typical sonographic appearance of epidermoid cysts but were found to be epidermoid cysts at pathologic examination. One was homogeneously hypoechoic, and the other had irregular cystic and solid components, but neither had a target or onion ring appearance. Histologically, both of these tumors consisted of cystic cavities lined by squamous epithelium and contained desquamated keratinized epithelium. Notably, 3 other tumors pathologically diagnosed as teratomas had a sonographic appearance of classic epidermoid cysts. These tumors contained layers of keratin, but the cyst was lined by both squamous cells (ectodermal origin) and cylindrical epithelium (endodermal origin), thereby precluding the diagnosis of epidermoid cysts.

CONCLUSIONS

There is considerable overlapping of the sonographic appearances of teratomas and epidermoid cysts of the testis. Although the onion ring appearance of an intratesticular tumor is suggestive of an epidermoid cyst, this appearance may also be found in cases of a teratoma. Whereas the former condition can be treated by local enucleation, the latter requires radical orchiectomy.

Ultrasound of the scrotum

Ultrasound plays an important role in the diagnostic workup of scrotal diseases. It can differentiate a testicular mass from an extratesticular mass and determine whether the mass is cystic, solid, or complex. Using this information a likely diagnosis can be ascertained. In the acute scrotum, acute epididymitis/epididymo-orchitis can in most cases be distinguished from testicular torsion. Following scrotal trauma, surgery is needed to salvage the testis if there is testicular disruption and ultrasound can help with this diagnostic dilemma. When a large hydrocele is present, ultrasound allows evaluation of the underlying testis and epididymis and it can detect varicoceles, especially in the infertile male. In patients at risk for a testicular tumor (cryptorchid testis, testicular microlithiasis), ultrasound is the best imaging modality for follow-up. CT, MRI, and nuclear medicine scanning may be necessary for further evaluation of scrotal diseases and this will be briefly addressed.

Epidermoid cyst in a solitary testis: A case for non-surgical management

This is a case report of a 71-year-old man who presented with an incidental finding of a mass in a solitary right testis. A scrotal ultrasound scan showed the typical features of a testicular epidermoid cyst. Tumour markers were not elevated and the patient was managed non-operatively. On reviewing the literature, we found no previous report on the non-operative management of testicular epidermoid cysts

Testicular sparing surgery for bilateral epidermoid cysts of the testes: a case report

We report the case of a 12-year-old boy with bilateral epidermoid cysts of the testes diagnosed preoperatively from ultrasonography, magnetic resonance imaging, and negative tumor markers. The cysts were treated using bilateral testicular sparing surgery through a scrotal approach after intraoperative frozen section. We also discuss the diagnosis and management of epidermoid cyst of the testis and briefly review the literature.

Epidermoid cyst in the renal pelvis

Epidermoid cysts are benign cysts localizing rarely in solid organs with an unclear pathogenesis. A 55 years old woman having an epidermoid cyst in the renal pelvis was evaluated according to the literature.

Testicular epidermoid cysts: sonographic features with histopathologic correlation

Testicular epidermoid cysts are rare, accounting for 1% of all testicular tumors. We present the sonographic appearances of epidermoid cysts in 3 cases, together with the histopathologic correlation. In case 1, sonography showed an intratesticular hypoechoic mass with a well-defined echogenic rim; the mass measured 1.8 x 1.5 x 1.5 cm, and there was no evidence of calcification. In case 2, sonography showed a well-circumscribed mass measuring 1.3 x 1.3 x 1.0 cm, with alternating hypoechoic and hyperechoic rings (onion-ring appearance) and no calcifications. In case 3, sonography showed a 2.4- x 2.3- x 2.3-cm, well-circumscribed, oval mass with a heterogeneous echotexture and an outer hypoechoic halo. The mass contained plaque-like regions of increased echogenicity, with peripheral acoustic shadowing from refraction artifact. Hypoechoic clefts were visualized posterior to the plaque-like areas. The triad of findings-sonographic appearance of an onion ring, avascularity on Doppler sonography, and negative results of tumor marker studies-is highly suggestive of an epidermoid cyst.

Ultrasound appearances of testicular epidermoid cysts

Benign testicular tumours are uncommon but if recognized can enable a conservative approach to surgery to be recommended. This pictorial review demonstrates the variety of sonographic appearances of testicular epidermoid cysts correlating them with pathological findings in 19 lesions, the largest reported imaged series to date. Atchley, J. T. M., Dewbury, K. C. (2000). Clinical Radiology 55, 493-502.

Calcified epidermoid cyst in the testis: an unusual finding on ultrasound

Epidermoid cysts of the testis are uncommon, benign testicular tumours. They are often seen on ultrasound as rounded, hypoechoic lesions due to high keratin contents. Calcification within epidermoid cysts is rare. We report a case of prominent calcifications within an epidermoid cyst. If a possible epidermoid cyst is identified with ultrasound, testis-sparing surgery should be considered.

Ultrasound of testicular epidermoid cysts

The ultrasound findings of focal intratesticular lesions may sometimes be characteristic of benign pathology, which accounts for approximately 5% of all testicular tumours. Three cases of epidermoid cysts of the testis are presented along with a review of the literature. Recognition of the typical ultrasound appearances of this entity in a clinical situation of painless testicular swelling in the absence of a history of trauma and signs of inflammation can make testis-sparing surgery feasible.

Intratesticular spermatocele

High resolution ultrasound has increased our awareness of benign testicular cysts that appear to arise from the intratesticular sperm conduit system of the intratesticular ducts of the mediastinum and rete testis. The location of these benign cysts in the area of the mediastinum and rete testis and the absence of signs of a germ cell tumor may permit testicle preservation. These benign cysts may contain sperm. We present a case of a benign sperm-containing cyst with visible communication to the rete testis, designated an intratesticular spermatocele and managed with testicle preservation.

Testicular epidermoid cysts in prepubertal children: case report and review of the world literature

Epidermoid cysts of the testes are rare, benign lesions that account for approximately 1% of all testicular tumors. They present most often between the second and fourth decade of life, and have been reported in prepubertal children rarely. The authors report the clinical and sonographic findings in a 4 1/2-year-old child with a testicular epidermoid cyst, and they analyze the 22 prepubertal cases found in the world literature. As described below, the clinical and sonographic features of this tumor are not specific for an epidermoid cyst and do not preclude a teratomatous or malignant neoplasm. This case adds to the varied sonographic appearance of prepubertal testicular epidermoid cysts. The lack of either unique clinical or sonographic features would suggest that extreme caution be used if local excision is considered for a patient with presumed epidermoid cyst of the testicle.

Extratesticular epidermoid cyst with extension into the pelvis

We report a case of simple epidermoid cyst of the scrotum with extension into the pelvis. Complete excision was performed transcrotally and the presence of epidermoid cyst confirmed by histopathological examination. Simple excision was sufficient for treatment of this very rare lesion. The patient is now in the follow-up period.

Differential diagnosis of scrotal masses by ultrasound

Ultrasound is the mainstay for imaging of the scrotum. It is used primarily for determining the location and nature of palpable lesions and to demonstrate nonpalpable lesions. Scrotal US is characterized by high sensitivity in the detection of intrascrotal abnormalities and is a very good mode for differentiating testicular from paratesticular lesions. However, scrotal US is limited in determining whether a focal testicular lesion is benign or malignant. The limitations of gray-scale US in the assessment of an acute scrotum and in particular of testicular torsion have now been overcome by color-coded duplex sonography and power Doppler.

Sonography of the testis and epididymis

Sonography (ultrasound) is the mainstay for imaging morphologic abnormalities of the scrotum and testis. It is used primarily for determining the location and nature of palpable lesions and to demonstrate clinically occult, non-palpable lesions. This article describes the state of the art of scrotal sonography. After an initial presentation of the normal sonographic appearance of the testis and epididymis, the diagnostic evaluation of the most common scrotal disorders is described. Scrotal sonography is characterized by high sensitivity in the detection of intrascrotal abnormalities and is a very good mode for differentiating testicular from paratesticular lesions. However, scrotal sonography is limited in determining whether a focal testicular lesion is benign or malignant. Unsatisfactory results are obtained by conventional sonography in the evaluation of testicular torsion. This gap in the diagnosis of scrotal pathologies is now being reliably filled by colour-coded duplex sonography.

Epidermoid cyst of the testis: a review of clinical and histogenetic considerations

OBJECTIVE

To review the records of patients with epidermoid cysts and those with germ cell tumours to determine the most appropriate method of treatment.

PATIENTS AND METHODS

The records of the patients treated for epidermoid cysts and testicular germ-cell tumours in a period covering 22 years were analysed retrospectively. Nine specimens with an epidermoid cyst were examined by immunohistology for the presence of testicular intraepithelial neoplasia (TIN) (or carcinoma in situ of the testis).

RESULTS

Ten patients with a simple epidermoid cyst and 481 patients with testicular germ-cell tumour were treated during the observation period. The relative incidence of epidermoid cysts in relation to the number of patients with testicular germ-cell tumours was 2.1% (95% confidence interval 0.8-3.35%). The mean age of the 10 patients with an epidermoid cyst was 24.1 years. The right testis was affected in seven patients and the left in three. Six of these patients received conservative surgery with excellent cosmetic results. No relapse had occurred after a median observation period of 30 months. Immunohistological staining for placental alkaline phosphatase disclosed the absence of TIN in the parenchyma surrounding the cysts.

CONCLUSION

The absence of TIN calls into question the common assumption that an epidermoid cyst constitutes a monodermal teratoma. Two distinct entities of epidermoid cyst are proposed--one occurring in conjunction with a teratoma or a germ cell tumour (a 'complex' or 'mixed' epidermoid cyst) and the other a 'simple' epidermoid cyst without TIN in the adjacent tissue and thus representing a benign neoplasm that is not a teratoma. The absence of TIN near a simple epidermoid cyst justifies testis-sparing surgery.

Epidermoid cysts of testes and role of sonography

Four patients with histologically proved epidermoid cysts of the testicle were managed with radical orchiectomy. High-resolution testicular sonography demonstrated similar findings in all cases, but these findings were not specific and did not preclude other malignant or teratomatous lesions. The lack of both unique clinical features and specific sonographic findings would suggest that extreme caution must be used if wedge resection or enucleation is contemplated for a patient with presumed epidermoid cyst.

Cysts of the tunica albuginea--more common testicular masses than previously thought?

Cysts of the tunica albuginea have been considered very rare. Their clinical significance lies in their presentation as discrete testicular masses often diagnosed as malignancies prior to removal. We report our experience with 6 cases of cysts of the tunica albuginea over a 12-year period and review the relevant literature. It is obvious that these cysts can be both of epithelial and of mesothelial origin. Our material includes a cyst lined by a transitional-like epithelium, of a kind to our knowledge not reported previously. All of the cysts were found by palpation and they constituted 6% of the testicular tumours examined over the same period. High-resolution ultrasound examination can distinguish them from solid testicular masses, as in 2 cases here, thus enabling unnecessary operations to be avoided.

Intrascrotal adenomatoid tumors

Adenomatoid tumors are regarded as uncommon neoplasms of the paratesticular tissues, probably of mesothelial origin. The majority of cases reported have involved the epididymis. We report our experience with 8 cases of testicular tumors and 11 of epididymal adenomatoid tumors during a 13-year period, and review the relevant literature. The incidence of adenomatoid tumors relative to all tumors in the testis was 6.9% (8 of 116), exceeding that of Leydig cell tumors, which were previously believed to be the most common benign testicular neoplasms. The adenomatoid tumors included 38% epididymal tumors (11 of 29). The clinical course of the tumors was benign, without recurrences. Local excision is regarded as the treatment of choice for epididymal and testicular adenomatoid tumors.

Non-germ cell tumors of testis

Testicular tumors of non-germ cell origin represent from 5 percent to 10 percent of all testicular neoplasms. Included in this group are sex cord/gonadal stromal tumors, most originating from Leydig or Sertoli cells, mixed tumors, and tumors of mesenchymal or hematopoietic origin. In addition, various miscellaneous lesions, tumor-like conditions, and secondary testicular tumors may be classified as non-germ cell tumors. This review covers the presentation, diagnosis, and treatment of these rare lesions.

Sonographic characteristics of epidermoid cyst of testicle

The ultrasonographic characteristics of an epidermoid cyst of the testicle are presented. Since these findings are similar to other published case reports, preoperative sonographic diagnosis of this lesion may be possible.

Hormone profiles in Klinefelter's syndrome with and without testicular epidermoid cyst

Hormonal studies were performed in patients of Klinefelter's syndrome with and without testicular epidermoid cyst. Mean levels of plasma gonadotropins were elevated above normal ranges. The mean testosterone level in plasma was abnormally low. The mean prolactin level in plasma was within the normal limit. However, mean plasma levels of these hormones were not significantly different between the two groups. The administration of LH-RH resulted in low response of plasma gonadotropins. The response of plasma testosterone to the administration of hCG was also abnormally low. However, in the LH-RH and hCG tests there were no significant differences between the two groups. These data suggested that the hormonal disturbance in Klinefelter's syndrome is unrelated to the occurrence of testicular epidermoid cyst.