Simple cyst of the testis: case report and review of the literature

Strategy for treating simple testicular cyst in adults

Simple testicular cyst is increasingly diagnosed because of the general availability of high-resolution ultrasound devices, although its management has been controversial. The authors report their experiences in managing large simple testicular cyst in two adults aged 56 and 68 years. The first patient was hospitalized with a presumptive diagnosis of left hydrocele, and the second patient was hospitalized with left simple testicular cyst. Both patients felt pain in the left scrotum. The maximum diameter of the cyst in both patients was more than 6 cm. The patients were successfully treated with orchiectomy with very good long-term results. The authors indicate that a careful study of the medical history, physical examination, and scrotal ultrasonography may facilitate an accurate preoperative diagnosis. Age, symptom, compliance with the surveillance of the patient, and the size and dynamic ultrasonographic changes of the cyst should all be considered in the selection of the treatment regimen. Such a study may be helpful in managing a simple testicular cyst.

[Benign space-occupying cysts in the testis. An overview]

Testicular cysts are increasingly diagnosed in the course of scrotal ultrasound examination. Among other things this is due to the general availability of modern high-resolution ultrasound devices. Benign and malignant diseases with testicular cyst formation need to be differentiated by differential diagnosis and by their aetiology. Benign diseases with cystic space-occupying lesions of the testicle are tubular ectasia of the rete testis, cystic dysplasia, epidermoid cysts, simple intraparenchymatous testicular cysts and cysts of the tunica albuginea. Testicular dermoid cyst was long misleadingly regarded as potentially malignant, but is now classified as benign. On diagnosis of a benign lesion of the testis an organ-conserving surgical therapy or an observational watch-and-wait strategy can be recommended in most cases.

PREPUBERTAL TESTIS TUMORS: ACTUAL PREVALENCE RATE OF HISTOLOGICAL TYPES

PURPOSE

Tumor registries, urological textbooks and literature surveys all assert that yolk sac tumors are the most common primary testicular tumors in boys 12 years and younger. In contrast, several individual institutions have reported that benign tumors are more common than malignant tumors. To clarify these discordant findings, we surveyed the primary pathology records from 4 major pediatric centers.

MATERIALS AND METHODS

The pathology records of the contributing centers were culled for primary testicular masses in boys 12 years and younger. Older boys and those with either paratesticular tumors or leukemia were excluded. The prevalence of each histological subtype was calculated from the pooled cases.

RESULTS

A total of 98 patients met our criteria. Only 15% had yolk sac tumors. Teratomas comprised 48% of the tumors (mature 44%, immature 4%). Epidermoid cysts were found in another 14% of patients. Gonadal stromal cell tumors represented 13% of the total, divided among granulosa cell (5%), Leydig cell (4%), Sertoli cell (3%) and mixed gonadal stromal cell (1%). Other pathology, including cystic dysplasia (2), lymphoma (4), inflammatory pseudotumor (1) and gonadoblastoma (2), made up 9% of the total number of cases.

CONCLUSIONS

We found that benign lesions represent the majority of primary testis tumors (74%), with the most common histological type being teratoma (48%). The reported high prevalence rates of prepubertal yolk sac tumors probably results from a reporting bias, since benign tumors are less likely to be submitted to tumor registries. Therefore, the primary operative approach to the majority of testis tumors in boys 12 years and younger should entail testis sparing surgery. Orchiectomy should be reserved for histologically confirmed malignancy based on increased preoperative alpha-fetoprotein and/or frozen section analysis of the tumor.

Benign intrascrotal lesions

PURPOSE

We summarize important clinical, pathological and diagnostic features of benign intrascrotal lesions, including paratesticular lesions (adenomatoid tumors, fibrous pseudotumors, cystadenomas, spermatoceles, hydroceles, varicoceles and hernias) and intratesticular lesions (tunica albuginea cysts, testicular simple cysts, epidermoid cysts, cystic ectasia of the rete testis, intratesticular varicocele, adrenal rest tumors and splenogonadal fusion). This review provides the reader with a better understanding of benign lesions that occur in the scrotum.

MATERIALS AND METHODS

A directed MEDLINE literature review of benign scrotal lesions and of each individual lesion was performed. This information was enhanced with relevant information from select journals and texts. Particular emphasis was placed on clinical, pathological and diagnostic features.

RESULTS

Intrascrotal lesions continue to provide a diagnostic challenge for physicians. A diagnosis can be made with a thorough history, physical examination and understanding of the pathophysiological processes of the structures contained within the scrotum. Lesions that are suspicious for malignancy should prompt urological consultation and radiological imaging. Ultrasound aids in the diagnosis in instances of uncertainty. Ultimately surgery may be necessary to make a histological diagnosis.

CONCLUSIONS

Clinical assessment, physical examination and an understanding of benign intrascrotal processes are key to making a diagnosis. Ultrasound has an important role and adds essential information. If surgery is necessary and a benign process is recognized, a testis sparing procedure should be performed.

Diagnosis and management of teratomas and epidermoid cysts

One can strongly suspect a benign lesion in a prepubertal child on the basis of preoperative sonographic, biochemical, and clinical evaluation; however, when considering a testis-sparing enucleation, the definitive diagnosis must be established by pathologic frozen section of the tumor. The high incidence of benign testicular lesions in the prepubertal patient, the absence of associated carcinoma in situ in prepubertal germ cell tumors, and the universally benign behavior of the specific tumors described in this article are supportive evidence for testis-sparing surgery versus orchiectomy, for these benign lesions.

Bilateral intratesticular cysts--a specific entity

A case of bilateral testicular simple cysts was seen in a 79-year-old Chinese man. The cysts contained clear fluid and were lined with simple cuboidal epithelia. The histochemical and immunohistochemical findings of this case were presented with an effort to clarify the nature of the cyst. In addition, the clinicopathological features, differential diagnosis and proposed histogenesis of the documented testicular simple cysts in the literature were also reviewed.

Case report: ultrasound and MRI findings in a scrotal epidermoid cyst

Intrascrotal masses in the adult are worrisome due to their possible malignancy. Most intratesticular masses are malignant whereas most extratesticular masses are benign. The differential diagnosis of intrascrotal cysts usually includes simple testicular cysts, intratesticular epidermoid and dermoid cysts, tunica albuginea cysts, epididymal cysts and spermatoceles [1-7]. This case report describes a large epidermoid cyst of the scrotum presenting as an enlarging scrotal tumour.

Simple cysts of testis

Three cases of benign intraparenchymal cysts of the testis are described. A nine-month-old infant and a forty-two-year-old man were seen with painless testicular enlargement and underwent orchiectomy and cyst excision, respectively. The third patient, a sixty-eight-year-old man, was asymptomatic with the cyst discovered following orchiectomy for prostatic carcinoma. In each case the cyst was multilocular and lined with a simple cuboidal epithelium. In 1 case special and immunohistochemical stains were performed. Review of the literature in conjunction with the cysts' staining characteristics are strongly supportive of its derivation from ectopic epithelium.

Spermatozoa-containing simple cysts of the rete testis

Simple cysts of the testis are rare benign lesions of uncertain etiology. We report 2 spermatozoa-containing cysts of the rete testis found incidentally in the left testicle of a 56-year-old man evaluated by ultrasound for hydrocele. The presence of spermatozoa in the cyst fluid has not been observed previously and confirms the connection of the cysts with the seminiferous tubular system.

Simple cyst of the testis

We report 5 cases of simple cyst of the testis, the largest series to date, and review the literature. Included are 2 autopsy cases, a case of a multilocular simple cyst and 1 case treated nonoperatively. Based on our experience, simple cyst of the testis should be suspected particularly in an enlarged but otherwise palpably normal testis. High resolution real-time scrotal sonography revealing an anechoic mass in the testis with well defined walls, and enhanced posterior through transmission and edge shadowing is diagnostic for a simple cyst. An asymptomatic simple cyst of the testis may be treated with observation alone. The symptomatic simple cyst should be treated ideally with local parenchyma-sparing excision.

Simple cysts of the testis in children: preoperative diagnosis by ultrasound and excision with testicular preservation

We report on 2 children with simple cysts of the testis who were treated with excision and testicular preservation. To our knowledge both cases represent the first report of conservative surgery for these lesions in children. In 1 case the diagnosis of a simple intratesticular cyst was made by ultrasound. This patient was followed conservatively until enlargement resulted in excision of the cyst with preservation of the gonad. In the other case the diagnosis was made intraoperatively and simple excision of the lesion with testicular sparing was performed. High resolution real-time ultrasound should be performed routinely for all suspected testicular masses in children. Benign testicular tumors are more common than in adults and ultrasound may permit identification of lesions that can be excised locally with testicular preservation. Should the diagnosis of a simple, small intratesticular cyst be made by ultrasound regular followup may be appropriate. Should enlargement occur surgical excision can be done with the possibility of gonadal preservation.

Simple cyst of the rete testis

We report a case of a simple cyst in the upper pole and connected to the mediastinum testis at the rete testis. The cyst appeared to arise from a dilated rete duct, and it was spherical, smooth-walled and filled with clear fluid. The epithelium was lined with a single layer of cuboidal or flattened cells, with no evidence of squamous differentiation.

Simple testicular cyst diagnosed preoperatively by ultrasound

While fluid collections within the scrotum are not uncommon, an uncomplicated cyst attached to or within the various components of the scrotum is unusual. We report a case of a rare simple cyst of the testicle, which was diagnosed accurately by preoperative ultrasound examination.