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Epidermoid cyst in a solitary testis: A case for non-surgical management
M. A. Omar1 J. Ochai2 C. Natarajan3 J. Makunde2 P. Close2
1Department of Urology, Wexham Park Hospital, Slough, Berkshire UK
2Department of Urology, St Mary’s Hospital, Isle of Wight, UK
3Department of Urology, Nuneaton General Hospital, Warwickshire, UK
Correspondence to: J. Ochai, Department of Urology, St Mary’s Hospital, Isle of Wight, PO30 5TG, UK Email: john.ochai@iow.nhs.uk
Keywords: Testicular epidermoids, scrotal ultrasound, tumour markers Surg J R Coll Surg Edinb Irel., 1 December 2004, 352-353
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
Epidermoid cysts are rare tumours of the testis. Approximately 300 cases have been reported in the literature, since the original article by Dockerty and Priestley in 1942.1 All cases, to date, have been managed by either testis-sparing local excision or orchidectomy. We wish to report a case of an epidermoid cyst in a solitary testis, which has been managed non-operatively.
A 71-year-old man was referred to the general surgeons in December 2000 with the complaint of chronic intermittent diarrhoea. On clinical examination, a lump in the right testis was noticed incidentally, which was firm in consistency and non-tender. The patient himself had never noticed it. His left testis had been removed 25 years previously during emergency repair of a strangulated hernia. An urgent ultrasound of the scrotum showed a 2.6cm well defined lesion within the substance of the right testis with a heavily calcified periphery. The calcified capsule reduced visualisation of the internal structure of the mass. The features were highly suggestive of a testicular epidermoid cyst and no additional intratesticular lesions were demonstrated (see Figure 1). Serum tumour markers were not raised. His chronic diarrhoea was unrelated and resolved without specific treatment.
Figure 1: Ultrasound scan of right testis showing epidermoid cyst with calcified periphery.
Treatment options discussed with the patient were orchidectomy, enucleation or observation. He elected for nonoperative management. He was followed up at six monthly intervals, with scrotal ultrasonography and tumour markers, without any adverse changes being documented.
Testicular epidermoids represent less than 1% of testicular tumours and are invariably benign.2 The precise histogenesis of an epidermoid cyst is not known, though it is commonly considered to be the end result of monophasic ectodermal development of a teratoma.3,4 Younger et al (2003) evaluated eight cases of testicular epidermoids for loss of heterozygosity and found partial genetic similarity between an epidermoid and a teratoma.5 Despite this partial similarity, the clinical history supports the benign nature of the former and, thus, does not warrant aggressive management.5 The benign behaviour of ectodermal teratoma is supported by the fact that no case of loco-regional or distant metastasis has ever been reported in the literature. A case report by Woo et al (2001) of the development of a seminoma in the ipsilateral testis, five years after excision of a testicular epidermoid, in all probability represents a different pathological entity in the same testis.6 Manivel et al (1989) in their evaluation of 13 adult cases of testicular epidermoids found no evidence of intratubular germ cell neoplasia (ITGCN) and noted that all the neoplasms, devoid of ITGCN, behaved in a benign fashion.7
Tumour markers (alpha-foetoprotein, lactic dehydrogenase and beta-human chorionic gonadotrophins) offer good diagnostic and prognostic markers in testicular neoplasms. There is an increase in the level of tumour markers in 51% of patients with testicular carcinoma.8 Alpha-foetoprotein and betahuman chorionic gonadotrophins are raised in 50-70% and 40-60% of patients with non-seminomatous germ cell tumours, respectively.9 In testicular epidermoids, the tumour markers are in the normal range. A case of a testicular epidermoid cyst with an elevated beta-human chorionic gonadotrophin, has been reported in the literature.10
Scrotal ultrasound scan appearances of an epidermoid cyst varies with the maturation, compactness and the quality of keratin within the cyst.11 Four appearances have been described: (a) a target appearance, (b) a sharply defined mass with a rim of calcification, (c) a solid mass with an echogenic rim and (d) the classic appearance of an ‘onion ring’. This ‘onion ring’ pattern corresponds to its natural evolution and may lead to a confident diagnosis and appropriate management.12-14 In terms of diagnosing a testicular neoplasm, the scrotal ultrasound scan has a specificity of 57.9% and a sensitivity of 94.6%. The overall accuracy of ultrasonography is approximately
82.0%.15 The presence of typical clinical findings, supported by scrotal ultrasound scan appearances can help in making the diagnosis of this benign lesion.
The surgical management of this disease has come a long way from radical to conservative excision. In the past, radical orchidectomy has been recommended because of the fear of malignancy and, indeed, some patients have been subjected to retroperitoneal lymph node dissection.16 This was probably due in part to misdiagnosis of what is purely a benign condition.
Testicular epidermoids are rare benign tumours of the testis. The incidental finding of an asymptomatic lump in a testis, with normal tumour marker levels and characteristic radiological features, should lead to a confident diagnosis of a testicular epidermoid cyst. Adequate counselling of the patient, coupled with ultrasound scan followup, is required if non-operative management is employed. Length of follow-up depends on individual circumstances and a case can be made for no follow-up at all, if all the diagnostic criteria are fulfilled. On the basis of current evidence it is justifiable to employ non-operative management in patients with testicular epidermoids and, even more so, in those patients with a solitary testis.
Copyright 18 October 2004
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