Testicular Epidermoid Cyst in a Paediatric Patient with Bilateral Testicular Microlithiasis

Testicular Epidermoid Cyst in a Paediatric Patient with Bilateral Testicular Microlithiasis

Clinical Radiology Extra (2002) 57: 40±42 doi:10.1053/crae.2002.0010, available online at http://www.idealibrary.com on Case Report Testicular Epider...

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Clinical Radiology Extra (2002) 57: 40±42 doi:10.1053/crae.2002.0010, available online at http://www.idealibrary.com on

Case Report Testicular Epidermoid Cyst in a Paediatric Patient with Bilateral Testicular Microlithiasis D . H U G H E S *, L . A B E R N E T HY{, G. KO KA I{ *Department of Radiology, {Department of Radiology and {Department of Pathology, Royal Liverpool Children's NHS Trust (Alder Hey), Alder Hey Eaton Road, West Derby, L12, 0151 228 4811, U.K.

CASE REPORT A 12-year-old male presented with a 6-year history of vague left testicular discomfort, weight loss and fatigue following a viral illness. Physical examination revealed an enlarged, ®rm, non-tender left testicular swelling. The right testicle was normal. Both testes were descended and normal lying. Ultrasound was performed using a Phillips (ATL) HDI5000 12.5 MHz linear array transducer. This demonstrated bilateral, di€use, small calci®c density foci consistent with testicular mircolithiasis (Fig. 1). In the lower pole of the left testicle there was a 1.3  1.1  1.1 cm hypoechoic mass that contained some low central cystic areas and some focal calci®c areas (Fig. 2). Serum tumour markers, b-human chorionic gonadotrophin and a-fetoprotein, were both normal. The ultrasonic ®ndings suggested a

testicular tumour with underlying testicular microlithiasis. On the basis of this the patient underwent an operative frozen section followed by excision of the mass and sparing of the testicle. Pathological examination revealed cysts containing keratin and a wall composed of ®brous tissue lined by squamous epithelium (Fig. 3). The pathology was diagnostic of testicular epidermoid cyst.

DISCUSSION

Epidermoid cyst of the testicle usually occurs in the adult population with a peak incidence between 20±40 years. It is rare for them to occur in children [3]. They are benign

Fig. 1 ± Testicular microlithiasis of the right testicle. Author for correspondence: Dr D. Hughes 296 Waterloo Quay, Waterloo road Liverpool L3 0BS, U.K. Tel.: 07881827919; Fax: 0151 529 3813; E-mail: [email protected] 1477-6804/02/$35

# 2002 The Royal College of Radiologists Published by Elsevier Science Ltd. All rights reserved.

CASE REPORT

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Fig. 2 ± B-mode ultrasound longitudinal section of the left testicle showing a hypoechoic mass containing cystic areas and calci®cations along with di€use testicular microlithiasis.

Fig. 3 ± Histopathology shows a thick walled cyst lined by hyperkeratic squamous epithelium.

epithelial tumours derived from epithelial rests or inclusions. Histologically, the lesion is a cyst containing keratinized debris and cleft spaces [4] contained within a ®brous capsule lined with simple squamous epithelium. Occasionally there is calci®cation within the tumour. The ultrasound appearances of epidermoid cysts are varied. Dewbury et al. [5] recently described four types of sonographic ®ndings in epidermoid cyst. Type 1 is the onionskin appearance of concentric rings. Type 2 is a densely calci®ed mass with no discernable cyst. Type 3 is a

cyst with peripheral or central calci®cations (as in this case) and type 4 is a mixed pattern with poorly de®ned heterogeneous texture. Management of epidermoid cyst is a contentious issue [2]. Some authors advocate testicle-sparing surgery [6,7] if histology can be con®rmed before excision. Others advise radical orchidectomy for all testicular masses [8]. Testicular mircoliths are discrete 1±3 mm echogenic foci scattered throughout the testicular parenchyme which form from degenerating cells in the seminiferous tubules. It is

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thought that the core is an accumulation of cellular debris that calci®es [9]. Testicular microlithiasis has been a source of much debate recently [10,11] in terms of management and follow-up because of its association with teratoma and seminoma [12]. There is no conclusive evidence that frequent ultrasound screening is of bene®t, although most radiologists would advise regular follow-up. There is a growing body of opinion that supports the use of ultrasound surveillance in patients with a combination of microlithiasis in association with cryptorchidism. With the increasing use of high-resolution ultrasound equipment, testicular microlithiasis is being diagnosed more in the paediatric population. To our knowledge, there have been no previous reports of epidermoid tumour occurring in association with bilateral testicular microlithiasis.

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3 Pinski JV, Green®eld SP, Siddiqui S, Fisher J. Epidermoid cyst of the testicle in children. J Surg Oncol 1991;48:277±281. 4 Price EB Jr. Epidermoid cysts of the testis: a clinical and pathological analysis of 69 cases from the testicular tumour registry. J Urol 1969;102:708±713. 5 Atchley JTM, Dewbury KC. Ultrasound appearances of testicular epidermoid cysts. Clin radiol 55:493±502. 6 Gonzalez BL, Ross LS. Epidermoid cysts of testis: rationale for conservative management. Urology 1977;9:456±458. 7 Schlecker BA, Siegel A, Weiss J, Wein AJ. Epidermoid cyst of the testis: a surgical approach for testicular preservation. J Urol 1985;13:610±611. 8 Brown RB. The management of testicular epidermoid cysts and other benign intra-tunica albuginea testicular tumours with particular reference to scrotal ultrasound studies. Aust N Z J Surg 1984;54:229±232. 9 Nistal M, Paniague R, D'ez-Pardo JA. Testicular microlithiasis in 2 children with bilateral cryptorchidism. J Urol 1979;121:535±537. 10 Peterson AC, Bauman JM, Light DE, McMann LP, Costabile RA. The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old. J Urol 2001;166:2061±2064. 11 Von Eckardstein S, Tsakmakidis G, Kamischke A, Rolf C, Nieschlag E. Sonographic testicular microlithiasis as an indicator of premalignant conditions in normal and infertile men. J Androl 2001;22:818±824. 12 Parra BL, Venable DD, Gonzalea E, Eastham JA. Testicular microlithiasis as a predictor of intratubular germ cell neoplasm. Urology 1996;48:797±799.