Scholarly article on topic 'Dermoid cyst of testis in a 72-year-old man: A rare entity'

Dermoid cyst of testis in a 72-year-old man: A rare entity Academic research paper on "Clinical medicine"

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Academic research paper on topic "Dermoid cyst of testis in a 72-year-old man: A rare entity"

Case Report

Dermoid cyst of testis in a 72-year-old man: A rare entity

Vijay Sreedhar Babu Kinnera, Kumaraswamy Reddy Mandyam, Mutheeswaraiah Yootla1, Venkatarami Reddy Vutukuru1

Departments of Pathology and 'General Surgery, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, India

Abstract Dermoid cyst is a mature-type teratoma containing sebaceous material and predominantly tufts of hair or teeth along with skin appendages. It is most commonly observed in the ovary but is rare in the testis, and only a few cases have been reported so far. In most of the reports, the cyst tended to be diagnosed in a younger age group. Here, we report a dermoid cyst of the testis in a 72-year-old man.

Key Words: Dermoid cyst, mature teratoma, testis

Address for correspondence:

Dr. Vijay Sreedhar Babu Kinnera, Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, India. E-mail: kinneravsb@rediffmail.com

Received: 17.12.2008, Accepted: 26.02.2009, DOI: 10.4103/0974-7796.56045

INTRODUCTION

Dermoid cyst is the most common teratoma of the ovary, but is extremely rare in the testis. The incidence of dermoid cyst is unknown, and its rarity may be due to lack of clinical criteria to establish a preoperative diagnosis and the fact that some cases are grouped under mature teratomas.[1] We report a case of dermoid cyst of the testis in a 72-year-old male who presented with right testicular mass, bilateral inguinal hernia, and grade-2 prostatomegaly.

CASE REPORT

A 72-year-old male patient presented with painless right testicular mass and bilateral inguinal swellings of six months duration. There was no history of trauma or infection. Examination confirmed the presence of a right testicular mass of approximately 4.0 X 3.5 cm, nontender, smooth surfaced, and varying in consistency (soft cystic, firm to hard). Left testis was normal except for the presence of mild hydrocele. Bilateral direct inguinal hernia was present. Per-rectal examination revealed hard, nontender prostate without surface nodularity suggesting grade-2 prostatomegaly. Ultrasound examination showed an enlarged right testis (4.3 X 3.9 X 2.9 cm) and epididymis (1.5 X 1.4 cm) with heterogeneous echo texture comprising of both cystic and calcific foci (germ cell tumor) and minimal left hydrocele with bilateral inguinal

hernia having bowel contents. Preoperative tumor markers, serum a-fetoprotein (<10 IU/lit.) and human chorionic gonadotrophin (4.0 IU/lit.), were unremarkable. Subsequently, the patient underwent right high inguinal orchidectomy and bilateral inguinal hernia repair by mesh. Postoperative recovery was uneventful. Macroscopically the testis was measuring 5.0 X 4.5 X 3.0 cm. On cut-section, there was near-total replacement of testicular architecture by a cystic mass containing flaky whitish keratinous material, hair follicles, and calcified foci [Figure 1a and b]. Histology revealed, fibrotic thickening of tunica vaginalis with obliterated testicular architecture by the presence of a cystic lesion with inner stratified squamous epithelial lining, pilosebaceous apparatii, many hair follicles, luminal lamellar keratin, fibrofatty tissues, calcifications, and striking presence of nodular Leydig cell clusters with lipochrome pigment within the lesional component [Figures 2—7]. Based on these findings a diagnosis of dermoid cyst of the testis was made.

DIsCUssION

Teratomas represent 38% of testicular germ cell tumors in infants and children and 47% in adults.[2] They are classified into three histological subtypes: mature teratoma, immature teratoma, and teratoma with malignant transformation.[3-Mature teratomas are composed of benign well-differentiated structures derived from the ectoderm, endoderm, or mesoderm.

Kinnera, et a!:. Dermoid cyst of testis

Although dermoid cysts are also referred to as mature cystic teratomas or benign cystic teratomas, Mostofi et al, suggest that they should be labeled as dermoid.[2] There are two pathways

for testicular teratomas in postpubertal patients — the more common being through intratubular germ cell neoplasia and the less common one, taken by dermoid cyst, is by direct

Figure 2: Dermoid cyst of testis - Thickened tunica with remnants of Figure 3: Dermoid cyst of testis - Luminal stratified squamous epithelial atrophic seminiferous tubules (H and E, x100) lining and dense fibrocollagen (H and E, x100)

Figure 4: Dermoid cyst of testis - Pilosebaceous apparatii in the midst of fibrocollagen (H and E, x100)

Figure 5: Dermoid cyst of testis - Lamellar keratin with hair follicles (H and E, x100)

Kinnera, et al.: Dermoid cyst of testis

Figure 6: Dermoid cyst of testis - Dense sclerosed and hyalinized Figure 7: Dermoid cyst of testis - Striking presence of nodular Leydig fibrocollagen with calcifications and many hair follicles (H and E, x200) cell clusters in the midst of lesional component (H and E, x200)

transformation from a nonmalignant germ cell line.[4] Dermoid cyst of the testis should be suspected in a child or adult with a painless testicular mass which has not shown progressive enlargement. The differential diagnosis includes benign lesions such as epidermal cyst, simple cyst, and malignant tumors of the testis with secondary degenerative changes such as choriocarcinoma radiologically.

The tumor markers (a-fetoprotein and P-human chorionic gonadotrophin) which are done preoperatively to assess the presence of testicular neoplasm will be negative in a dermoid cyst. Dermoid cyst of the testis is filled with sebum and contains sweat and sebaceous glands and hair follicles in its fibrous stroma. Bone, cartilage, teeth, and brain tissue may be present. Dermoid cysts are less common than epidermoid cysts, with only scattered case reports in the urology literature.[5-7] When dermoid cyst contains predominantly ectodermal derivatives, it needs to be differentiated from epidermoid cyst that contains only stratified squamous epithelial lining with luminal lamellar keratin without the presence of adnexe unlike that of dermoid cyst.[8] In all reported cases of testicular dermoid cysts, local excision, enucleation, or orchiectomy have been curative, with no patient developing a metastatic germ cell tumor. Unlike that of present case, if prepubertal child or younger individuals in whom dermoid cyst is considered after clinical, ultrasound, and biochemical

investigations should have a frozen section performed first. If the diagnosis is dermoid cyst, then testis-sparing surgery such as enucleation should be attempted if feasible, before considering orchidectomy.P]

This case is being reported because of its rarity in the older age group and interesting inclusions of nodular Leydig cell clusters within the contents of dermoid cyst of the testis.

REFERENCES

1. Crankson J, Shabra S, Al Hawashim N. Dermoid cyst of the testis. Ann Saudi Med 1997;17:634-35.

2. Mostofi FK, Sesterhenn IA, Davis CJ Jr. Developments in histopathology of testicular germ cell tumors. Semin Urol 1988;6:171-88.

3. Mostofi FK, Sobin LH. Histological typing of testis tumors. In: International Histological Classification of Tumors, No.16. Geneva: World Health Organisation; 1977.

4. Ulbright TM, Srigley JR. Dermoid cyst of testis: A study of five post pubertal cases, including a pilomatrixoma-like variant, with evidence supporting its separate classification from mature cystic teratoma. Am J Surg Pathol 2001;25:788-93.

5. Upton JD, Das S. Benign intrascrotal neoplasms. J Urol 1986;135:504-6.

6. Assaf G, Mosbah A, Homsy Y, Michaud J. Dermoid cyst of testis in five-year-old-child. Urology 1983;22:432-4.

7. Eason AA, Spaulding JT. Dermoid cyst arising in testicular tunics. J Urol 1977;117:539

8. Peterson RO. Urologic pathology. Philadelphia: Lippincott; 1992. p. 450-1.

Source of Support: Nil, Conflict of Interest: None.

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