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Epidermoid Cyst of Testis: A Report of 3 Cases
0022-534 7/85/1332-0286$02.00/0 Vol. 133, February
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
EPIDERMOID CYST OF TESTIS: A REPORT OF 3 CASES JOHN NICHOLS,* STANLEY KANDZARI, MORTEZA K. ELYADERANI
AND
SATYA ROCHLANI
From the Departments of Urology, Radiology and Pathology, West Virginia University Medical School, Morgantown, West Virginia
ABSTRACT
We report 3 cases of simple epidermoid cyst of the testis. These tumors often are mistaken clinically for malignancy. Conservative surgical treatment with preservation of the testis is desirable when preoperative ultrasound reveals a well demarcated cystic nodule confirmed by histological frozen sections. Simple epidermoid cyst of the testis is a rare, benign disease, with an incidence of 2 per 100,000 male subjects and it occurs usually in early adult life. 1 Approximately 85 per cent of simple epidermoid cysts are removed by orchiectomy. 1 With better awareness of this condition an orchiectomy could be avoided in these young patients. 2 - 9 We report 3 cases of epidermoid cyst of the testis. Careful clinical, ultrasonographic, surgical and pathological evaluation is stressed, with particular emphasis on conservative surgical management and testicular salvage. CASE REPORTS
Case 1. An 18-year-old asymptomatic white man was evaluated for a right testicular mass discovered during routine physical examination. He had been in good health except for a recent aortic valve replacement. There was no history of trauma, torsion or infection. Physical examination revealed a 1 cm., hard, nontender mass in the right testicle. A chest roentgenogram was within normal limits. Preoperative ultrasound of the testes revealed "a sharply demarcated 1.3 cm. right testicular nodule with an echo complex in the central portion, suspicious of cystic trichoma" (fig. 1). Surgical exploration was performed by right inguinal incision. The nodule was excised, sent for frozen section and interpreted as "benign testicular cyst". Final histological interpretation was epidermoid cyst. Case 2. A 20-year-old white man was evaluated for a left testicular mass that he had noticed recently. There was no history of trauma, infection or torsion. Review of systems was remarkable for juvenile onset diabetes mellitus that was controlled well with diet and insulin. A chest roentgenogram was within normal limits. Physical examination revealed a 1.5 cm., hard nodule on the anteromedial aspect ef the left testicle. The patient was explored by a left inguinal incision. The biopsy specimen included a 1.8 cm. cystic mass obtained by wedge biopsy. Frozen section biopsy revealed benign testicular cyst and final histological interpretation was epidermoid cyst. Case 3. A 28-year-old white man was evaluated for a nontender right testicular lump that he had noticed 2 weeks previously. He denied trauma, torsion or infection. A chest roentgenogram was within normal limits. Physical examination revealed a 1 cm., firm, nontender nodule on the upper pole of the right testis separate from the epididymis. A right inguinal incision was performed with the patient under spinal anesthesia. Frozen section was histologically benign for the 1.0 cm. cystic structure that was excised. Final pathological diagnosis was "benign epidermoid cyst".
cysts. Since it has been advocated that any noninflammatory testicular lesion is malignant until proved otherwise, it is understandable why the diagnosis of epidermoid cysts was made after radical orchiectomy. In some cases even para-aortic lymph node dissection was performed. 10 Conservative surgical treatment with preservation of the testis is desirable when the diagnosis is reasonably certain, since the majority of epidermoid cysts of the testis occur in young people. Differentiation of epidermoid cysts from testicular malignancy by physical examination is unreliable. When used in conjunction with the clinical setting, ultrasound may be useful in determining whether to salvage the testicle. An analysis of 141 cases reported as of 1981 revealed that 50 per cent of epidermoid cysts of the testis occur in the third decade and 86 per cent between the second and fourth decades. In 41 per cent of the cases there is a painless enlargement of the testis for an average period of 2.25 years. Incidental detection on routine physical examination occurs in a third of the cases. A discrete testicular nodule can be palpated in 76 per cent of the cases. 11 With the advent of ultrasound of the testes, a reliable method is now available for determining if a testicular mass is composed of a cystic or solid component. Tumors generally reveal decreased echogenicity within the testicle, which usually is enlarged. Epididymal enlargement, marked increase in peritesticular fluid and skin thickening are hallmarks of nontumorous conditions. Figure 1 shows the characteristics of a simple benign cyst, including a cystic mass, a sharp wall and enhancement of the posterior wall. Arger and associates reported that ultrasound correlated reliably with testicular tumors in 13 testicular masses evaluated by the aforementioned criteria. 12 All intratesticular tumors ultimately showed an area of decreased echogenicity within the testicle. One false-negative diagnosis occurred during examination and one false-positive diagnosis occurred during surgery.
DISCUSSION
Salvage of the testicle in the young adult is a concerning matter. Until 1980 only 20 cases had been reported in "".hich simple cyst enucleation was performed for testicular epidermoid Accepted for publication October 10, 1984.
* Current address: Catholic Medical Center of Brooklyn and Queens,
Jamaica, New York 11432.
286
FIG. 1. Longitudinal ultrasonogram of testis demonstrates cystic mass that is sharply demarcated. Minute internal echoes make cyst suspicious of benign simple cyst. Posterior wall is below cystic mass.
287
EPIDERMOID CYST Of' TESTIS
FIG. 2. Case 1. A, epidermal cyst (arrow) embedded in testicular parenchyma (TP). B, cyst contains keratinized debris (KD) and is lined by fully matured stratified squamous epithelium (arrow).
These statistics represent an 8 per cent rate of false diagnosis in each category. Sample and associates reported that ultrasound diagnosis of a solid testicular abnormality correlated with the pathological anatomical diagnosis in 10 of 10 patients.13 When ultrasound is interpreted in light of history and physical examination, a preoperative diagnosis of simple testicular epidermoid cyst may be strongly suspected. After sufficient preoperative evaluation a relatively safe approach that would still preserve the principles of cancer surgery would be to perform an inguinal incision. The testis should not be handled before soft clamping the spermatic cord. After the tunica vaginalis is incised the epidermoid cyst should be apparent, pale and yellowish under the tunica albuginea. 14 The entire testis should be examined for evidence of any other tumor. Incision of the cyst wall will reveal an amorphous or laminated white cheesy-like substance. The cyst wall then is enucleated and sent for frozen section along with a biopsy of testicular parenchyma to rule out teratoma. It is at this juncture that knowledge of the preoperative ultrasound interpretation of the testicular mass may be useful. If the ultrasound revealed a cystic mass without tumor characteristics and the clinical setting is compatible with a presumed diagnosis of an epidermoid cyst of the testis, then testicular biopsy and salvage may be done. The histological interpretation of a simple epidermoid cyst of the testis has been well defined by Price.15 The cyst should be located within the testicular parenchyma (fig. 2, A). The contents of the cyst lumen should contain keratinized debris or amorphous material with spaces (fig. 2, B). The cyst lumen is encapsulated by a fibrous waU with a complete or incomplete lining of squamous epithelium. No teratomatous elements should be located within the cyst wall or testicular parenchyma. The pitfalls of pathological diagnosis are failure to recognize teratomatous elements or parenchymal scars 16 and receipt of inadequate tissue for diagnosis. The presence of scars or teratomatous elements may be diagnostic of teratoma and the treatment should be radical orchiectomy. To date, there has been no report in the literature describing the ultrasound appearance of testicular epidermoid cysts, nor has there been any report advocating ultrasound diagnosis and conservative management of epidermoid cysts of the testis. At our medical center we perform an inguinal approach to preserve the principles of cancer surgery and soft clamp the spermatic cord for testicular salvage in the event the diagnosis is an epidermoid cyst. Ultrasound should become an invaluable aid in determining the feasibility of testicular salvage.
In summary, a careful clinical, sonographic, surgical and pathological evaluation may save a testis without violating tumor principles. The limitations of a conservative surgical approach to a testicular lesion are dependent upon the expertise of those professionals who aid in making the diagnosis. The confidence of the sonographer and, more importantly, the pathologist must match the confidence of the surgeon. It is important to remember that with followup periods of up to 35 years no case of metastatic disease has been associated with a simple epidermoid cyst of the testis. 16 REFERENCES
l. Gonzales, B. L. and Ross, L. S.: Epidermoid cysts of testis: rationale
for conservative management. Urology, 9: 456, 1977. 2. Cook, F. E., Jr. and Kimbrough, J. C.: Epidermoid cysts of the testicle. J. Urol., 72: 236, 1954. 3. Gilbaugh, J. H., Jr., Kelalis, P. P. and Dockerty, M. B.: Epidermoid cysts of the testis. J. Urol., 97: 876, 1967. 4. Miller, E. V.: Benign testis tumor: epidermoid testicular cyst. J. Natl. Med. Ass., 67: 48, 1975. 5. Nowlin, P., Johnston, H. W. and Large, H. L., Jr.: Epidermoid cysts of the testicle. South. Med. J., 52: 473, 1959. 6. Olsen, J. G. and Calderin, V. 0.: Epidermoid cyst of the testis. U. S. Armed Forces Med. J., 6: 747, 1955. 7. Rotert, L. G.: Epidermoid cyst of the testis: case report and review of the literature. Proc. Kimbrough Urol. Sem., 6: 156, 1972. 8. Strahlberg, M. and Brown, J. S.: Concomitant bilateral epidermoid cysts of the testes. J. Urol., Hl9: 434, 1973. 9. Weitzner, S.: Epidermoid cyst of the testis. Texas State J. Med., 60: 495, 1964. 10. Goldstein, A. M. B., Mendez, R., Vargas, A. and Terry, R.: Epidermoid cysts of testis. Urology, 15: 186, 1980. 11. Shah, K. H., Maxted, W. C. and Chun, B.: Epidermoid cysts of the testis: a of three cases and an analysis of 141 cases from the world lltEffaicur,e. Cancer, 4 7: 577, 1981. 12. Arger, P. H., Mulhern, C. B., Jr., Coleman, B. G., Pollack, H. M., Wein, A., Koss, J., Arenson, R. and Banner, M.: Prospective analysis of the value of scrotal ultrasound. Radiology, 141: 763, 1981. 13. Sample, W. F., Gottesman, J. E., Skinner, D. G. and Ehriich, R. M.: Gray scale ultrasound of the scrotum. Radiology, 127: 225, 1978. 14. Rao, K. G. and Lorimer, A.: Epidermoid cyst of testis: benign intratesticular tumor. Urology, 19: 662, 1982. 15. Price, E. B., Jr.: Epidermoid cysts of the testis: a clinical and pathologic analysis of 69 cases from the testicular tumor registry. J. Urol., 102: 708, 1969. 16. Bates, R. J., Perrone, T. L. and Althausen, A.: Simple epidermoid cysts of testis. Urology, 17: 560, 1981.
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
EPIDERMOID CYST OF TESTIS: A REPORT OF 3 CASES JOHN NICHOLS,* STANLEY KANDZARI, MORTEZA K. ELYADERANI
AND
SATYA ROCHLANI
From the Departments of Urology, Radiology and Pathology, West Virginia University Medical School, Morgantown, West Virginia
ABSTRACT
We report 3 cases of simple epidermoid cyst of the testis. These tumors often are mistaken clinically for malignancy. Conservative surgical treatment with preservation of the testis is desirable when preoperative ultrasound reveals a well demarcated cystic nodule confirmed by histological frozen sections. Simple epidermoid cyst of the testis is a rare, benign disease, with an incidence of 2 per 100,000 male subjects and it occurs usually in early adult life. 1 Approximately 85 per cent of simple epidermoid cysts are removed by orchiectomy. 1 With better awareness of this condition an orchiectomy could be avoided in these young patients. 2 - 9 We report 3 cases of epidermoid cyst of the testis. Careful clinical, ultrasonographic, surgical and pathological evaluation is stressed, with particular emphasis on conservative surgical management and testicular salvage. CASE REPORTS
Case 1. An 18-year-old asymptomatic white man was evaluated for a right testicular mass discovered during routine physical examination. He had been in good health except for a recent aortic valve replacement. There was no history of trauma, torsion or infection. Physical examination revealed a 1 cm., hard, nontender mass in the right testicle. A chest roentgenogram was within normal limits. Preoperative ultrasound of the testes revealed "a sharply demarcated 1.3 cm. right testicular nodule with an echo complex in the central portion, suspicious of cystic trichoma" (fig. 1). Surgical exploration was performed by right inguinal incision. The nodule was excised, sent for frozen section and interpreted as "benign testicular cyst". Final histological interpretation was epidermoid cyst. Case 2. A 20-year-old white man was evaluated for a left testicular mass that he had noticed recently. There was no history of trauma, infection or torsion. Review of systems was remarkable for juvenile onset diabetes mellitus that was controlled well with diet and insulin. A chest roentgenogram was within normal limits. Physical examination revealed a 1.5 cm., hard nodule on the anteromedial aspect ef the left testicle. The patient was explored by a left inguinal incision. The biopsy specimen included a 1.8 cm. cystic mass obtained by wedge biopsy. Frozen section biopsy revealed benign testicular cyst and final histological interpretation was epidermoid cyst. Case 3. A 28-year-old white man was evaluated for a nontender right testicular lump that he had noticed 2 weeks previously. He denied trauma, torsion or infection. A chest roentgenogram was within normal limits. Physical examination revealed a 1 cm., firm, nontender nodule on the upper pole of the right testis separate from the epididymis. A right inguinal incision was performed with the patient under spinal anesthesia. Frozen section was histologically benign for the 1.0 cm. cystic structure that was excised. Final pathological diagnosis was "benign epidermoid cyst".
cysts. Since it has been advocated that any noninflammatory testicular lesion is malignant until proved otherwise, it is understandable why the diagnosis of epidermoid cysts was made after radical orchiectomy. In some cases even para-aortic lymph node dissection was performed. 10 Conservative surgical treatment with preservation of the testis is desirable when the diagnosis is reasonably certain, since the majority of epidermoid cysts of the testis occur in young people. Differentiation of epidermoid cysts from testicular malignancy by physical examination is unreliable. When used in conjunction with the clinical setting, ultrasound may be useful in determining whether to salvage the testicle. An analysis of 141 cases reported as of 1981 revealed that 50 per cent of epidermoid cysts of the testis occur in the third decade and 86 per cent between the second and fourth decades. In 41 per cent of the cases there is a painless enlargement of the testis for an average period of 2.25 years. Incidental detection on routine physical examination occurs in a third of the cases. A discrete testicular nodule can be palpated in 76 per cent of the cases. 11 With the advent of ultrasound of the testes, a reliable method is now available for determining if a testicular mass is composed of a cystic or solid component. Tumors generally reveal decreased echogenicity within the testicle, which usually is enlarged. Epididymal enlargement, marked increase in peritesticular fluid and skin thickening are hallmarks of nontumorous conditions. Figure 1 shows the characteristics of a simple benign cyst, including a cystic mass, a sharp wall and enhancement of the posterior wall. Arger and associates reported that ultrasound correlated reliably with testicular tumors in 13 testicular masses evaluated by the aforementioned criteria. 12 All intratesticular tumors ultimately showed an area of decreased echogenicity within the testicle. One false-negative diagnosis occurred during examination and one false-positive diagnosis occurred during surgery.
DISCUSSION
Salvage of the testicle in the young adult is a concerning matter. Until 1980 only 20 cases had been reported in "".hich simple cyst enucleation was performed for testicular epidermoid Accepted for publication October 10, 1984.
* Current address: Catholic Medical Center of Brooklyn and Queens,
Jamaica, New York 11432.
286
FIG. 1. Longitudinal ultrasonogram of testis demonstrates cystic mass that is sharply demarcated. Minute internal echoes make cyst suspicious of benign simple cyst. Posterior wall is below cystic mass.
287
EPIDERMOID CYST Of' TESTIS
FIG. 2. Case 1. A, epidermal cyst (arrow) embedded in testicular parenchyma (TP). B, cyst contains keratinized debris (KD) and is lined by fully matured stratified squamous epithelium (arrow).
These statistics represent an 8 per cent rate of false diagnosis in each category. Sample and associates reported that ultrasound diagnosis of a solid testicular abnormality correlated with the pathological anatomical diagnosis in 10 of 10 patients.13 When ultrasound is interpreted in light of history and physical examination, a preoperative diagnosis of simple testicular epidermoid cyst may be strongly suspected. After sufficient preoperative evaluation a relatively safe approach that would still preserve the principles of cancer surgery would be to perform an inguinal incision. The testis should not be handled before soft clamping the spermatic cord. After the tunica vaginalis is incised the epidermoid cyst should be apparent, pale and yellowish under the tunica albuginea. 14 The entire testis should be examined for evidence of any other tumor. Incision of the cyst wall will reveal an amorphous or laminated white cheesy-like substance. The cyst wall then is enucleated and sent for frozen section along with a biopsy of testicular parenchyma to rule out teratoma. It is at this juncture that knowledge of the preoperative ultrasound interpretation of the testicular mass may be useful. If the ultrasound revealed a cystic mass without tumor characteristics and the clinical setting is compatible with a presumed diagnosis of an epidermoid cyst of the testis, then testicular biopsy and salvage may be done. The histological interpretation of a simple epidermoid cyst of the testis has been well defined by Price.15 The cyst should be located within the testicular parenchyma (fig. 2, A). The contents of the cyst lumen should contain keratinized debris or amorphous material with spaces (fig. 2, B). The cyst lumen is encapsulated by a fibrous waU with a complete or incomplete lining of squamous epithelium. No teratomatous elements should be located within the cyst wall or testicular parenchyma. The pitfalls of pathological diagnosis are failure to recognize teratomatous elements or parenchymal scars 16 and receipt of inadequate tissue for diagnosis. The presence of scars or teratomatous elements may be diagnostic of teratoma and the treatment should be radical orchiectomy. To date, there has been no report in the literature describing the ultrasound appearance of testicular epidermoid cysts, nor has there been any report advocating ultrasound diagnosis and conservative management of epidermoid cysts of the testis. At our medical center we perform an inguinal approach to preserve the principles of cancer surgery and soft clamp the spermatic cord for testicular salvage in the event the diagnosis is an epidermoid cyst. Ultrasound should become an invaluable aid in determining the feasibility of testicular salvage.
In summary, a careful clinical, sonographic, surgical and pathological evaluation may save a testis without violating tumor principles. The limitations of a conservative surgical approach to a testicular lesion are dependent upon the expertise of those professionals who aid in making the diagnosis. The confidence of the sonographer and, more importantly, the pathologist must match the confidence of the surgeon. It is important to remember that with followup periods of up to 35 years no case of metastatic disease has been associated with a simple epidermoid cyst of the testis. 16 REFERENCES
l. Gonzales, B. L. and Ross, L. S.: Epidermoid cysts of testis: rationale
for conservative management. Urology, 9: 456, 1977. 2. Cook, F. E., Jr. and Kimbrough, J. C.: Epidermoid cysts of the testicle. J. Urol., 72: 236, 1954. 3. Gilbaugh, J. H., Jr., Kelalis, P. P. and Dockerty, M. B.: Epidermoid cysts of the testis. J. Urol., 97: 876, 1967. 4. Miller, E. V.: Benign testis tumor: epidermoid testicular cyst. J. Natl. Med. Ass., 67: 48, 1975. 5. Nowlin, P., Johnston, H. W. and Large, H. L., Jr.: Epidermoid cysts of the testicle. South. Med. J., 52: 473, 1959. 6. Olsen, J. G. and Calderin, V. 0.: Epidermoid cyst of the testis. U. S. Armed Forces Med. J., 6: 747, 1955. 7. Rotert, L. G.: Epidermoid cyst of the testis: case report and review of the literature. Proc. Kimbrough Urol. Sem., 6: 156, 1972. 8. Strahlberg, M. and Brown, J. S.: Concomitant bilateral epidermoid cysts of the testes. J. Urol., Hl9: 434, 1973. 9. Weitzner, S.: Epidermoid cyst of the testis. Texas State J. Med., 60: 495, 1964. 10. Goldstein, A. M. B., Mendez, R., Vargas, A. and Terry, R.: Epidermoid cysts of testis. Urology, 15: 186, 1980. 11. Shah, K. H., Maxted, W. C. and Chun, B.: Epidermoid cysts of the testis: a of three cases and an analysis of 141 cases from the world lltEffaicur,e. Cancer, 4 7: 577, 1981. 12. Arger, P. H., Mulhern, C. B., Jr., Coleman, B. G., Pollack, H. M., Wein, A., Koss, J., Arenson, R. and Banner, M.: Prospective analysis of the value of scrotal ultrasound. Radiology, 141: 763, 1981. 13. Sample, W. F., Gottesman, J. E., Skinner, D. G. and Ehriich, R. M.: Gray scale ultrasound of the scrotum. Radiology, 127: 225, 1978. 14. Rao, K. G. and Lorimer, A.: Epidermoid cyst of testis: benign intratesticular tumor. Urology, 19: 662, 1982. 15. Price, E. B., Jr.: Epidermoid cysts of the testis: a clinical and pathologic analysis of 69 cases from the testicular tumor registry. J. Urol., 102: 708, 1969. 16. Bates, R. J., Perrone, T. L. and Althausen, A.: Simple epidermoid cysts of testis. Urology, 17: 560, 1981.