How to cite this article: Othmane Y, Mohammed A T, Tariq K, Khalid E K, Abdellatif K, et.al. Testicular Epidermoid Cyst: Case Report and Literature Review. Glob J Reprod Med. 2018; 5(1): 555655. DOI:10.19080/GJORM.2018.05.555655.
Introduction: Testicular epidermoid cysts are extremely uncommon. They are considered as benign tumors. Although an inguinal orchiectomy is the standard procedure for testicular tumors, if the presence of an epidermoid cyst is suspected, a conservative treatment may be attempted.
Presentation of case: We report here the case of a testicular epidermoid cyst in a 28-year-old man, who consulted for infertility. Physical examination shows the presence of a hard swelling on the left testicle surface, suggesting the presence of a mass. Enucleation was performed and no tumor recurrence was observed during the 6 months of follow-up.
Conclusion: Thus, we will expose, through this observation and the literature, the clinicopathological characteristics of this rare testicular tumor and the different therapeutic aspects. This work has been reported in line with the SCARE criteria .
Testicular epidermoid cysts (TEC) are extremely rare and account for less than 1% of all testicular tumors. Orchiectomy is the standard treatment for clinically suspected malignant testicular tumors. On the other hand, if an intra-testicular benign lesion is suspected, conservative treatment may be offered to the patient. We report a new observation whose interest lies in the benignity of the lesion, but also in its association with sterility of the couple.
A 28-year-old male patient, with no medical history, consulted for primary infertility after 3 years of marriage. His physical examination showed a hard swelling on the left testicle surface, suggesting the presence of a mass, without neither pain nor inflammatory signs. The contralateral testicle was normal. The patient does not report the presence of LUTS (lower urinary tract symptoms) or other associated signs, and in particular, tuberculosis signs. Two spermograms performed one month apart showed oligoasthenoteratospermia (OATS). The measurement of tumor markers was normal.Ultrasound showed a rounded, intra-parenchymal formation with a heterogeneous and hyperechogenic center, associated with peripheral calcifications (Figure 1). No anomaly was objectified in the contralateral testicle.Given the ultrasound appearance of the testicular lesion, conservative surgery has been proposed to the patient. Thus, exploration by left inguinal incision was performed with first clamping of the spermatic cord (Figure 2).
The testicular mass was palpated and enucleated with macroscopically healthy margins (Figure 3). The postoperative course was simple.Macroscopic anatomic and pathological examination showed, after opening of the cyst, a whitish, lumpy content arranged in concentric lamellae measuring 15 mm of long axis (Figure 4). The microscopic study confirmed the benign lesion and made the diagnosis of epidermoid cyst of the left testicle. At 24-month follow-up, no tumor recurrence, neither on clinical examination nor ultrasound has been found.
Testicular cancer is relatively rare, with only about 5,500
new cases reported per year in the United States . Epidermoid
cysts are benign lesions often located in the skin and very rarely
intra-testicular. Histologically, they have the same characteristics
as cutaneous lesions. Since the first description of Dockerty and
Priestley in 1942, about 300 cases of testicular epidermoid
cysts have been reported in the literature.These are generally
unique lesions affecting a young population between 20 and 40
years old . Rare cases of bilateral involvement and in children
have been reported.Clinically, the lesions are usually firm, well
circumscribed, small, single, painless, and sometimes difficult
to distinguish from a malignant lesion. The measurement of
testicular tumor markers is always normal .
Ultrasound shows a characteristic image of the TEC, a “target”
image. The cystic wall can be either hypoechoic or hyperechoic
due to focal calcifications. The center of the cyst is heterogeneous
with hyper or hypoechoic zones attributable to the density of the
keratin lamellae that compose it [5-7]. Since the advent of MRI,
the images are more characteristic of the TEC, which makes it
possible to differentiate from other solid intratesticular lesions.
The typical appearance is the “bull’s eye”. The wall and the centre
of the cyst are in hypo-signal in T1 and T2 weighting. Between
these two zones, there is in T1 and T2 weighting a hyper-signal
that corresponds to isolated and degenerated epithelial cells
(rich in water and fat) . There is no enhancement of the signal
after injection of contrast dye because it is an avascular structure.
The histological diagnosis was established by PRICE in 1969
, the tumoral mass must necessarily gather five anatomopathological
criteria so that one can speak of isolated TEC: the
TEC must be in the testicular parenchyma, it wall should be
constituted by fibrous tissue and contain squamous epithelium,
it should contain keratin lamellae or amorphous material, no
teratomatous elements or cutaneous appendages should be
found in the cyst wall or adjacent to testicular parenchyma, and
no hyaline element (remnant of a germ cell tumor) should be
found in the adjacent testicular parenchyma.The recommended
treatment is surgical with an inguinal approach. Conservative
surgery for TCE has all its place given the psychological and
reproductive consequences of total orchiectomy for a benign pathology. Recently, several authors have proposed partial
resection or enucleation as the treatment of choice in adults
and children [4,9]. Heidenreich and al. have, in a review of the
literature including 300 cases treated by a conservative approach,
objectified no case of local recurrence or distant metastasis .
Ross et al.  estimate that conservative surgery is more
appropriate in the pediatric population because of the higher
percentage of benign testicular tumors compared to adults and
the risk of contralateral testicular disease (eg, torsion) is much
higher in the child . Some authors report an improvement
in long-term fertility even in patients with oligospermia or
contralateral disease, after conservative testicular surgery.
However, we must keep in mind the risk of infertility induced by
testicular surgery secondary to the rupture of the blood-testis
barrier and the immunological consequences demonstrated on
the animal model [11,12]. However, recently, studies have shown
that anti-sperm antibodies, found in sperm after testicular biopsy
or surgical enucleation, do not affect reproductive outcomes
(fertilization and clinical pregnancy rates) . Postoperative
monitoring is not codified in TEC.
TEC are rare and benign testicular tumors. Currently, the
existing clinical examination and paraclinical tools can guide
the diagnosis preoperatively and thus attempt a conservative
surgery. Performing biopsy of the adjacent testicular parenchyma
is essential. Orchiectomy is mandatory if the extemporaneous
examination is not formal.