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 1General 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: [email protected] Received: 17.12.2008, Accepted: 26.02.2009, DOI: 10.4103/0974-7796.56045

INTRODUCTION hernia having bowel contents. Preoperative tumor markers, serum α-fetoprotein (<10 IU/lit.) and human chorionic Dermoid cyst is the most common teratoma of the ovary, gonadotrophin (4.0 IU/lit.), were unremarkable. Subsequently, but is extremely rare in the testis. The incidence of dermoid the patient underwent right high inguinal orchidectomy and cyst is unknown, and its rarity may be due to lack of clinical bilateral inguinal hernia repair by mesh. Postoperative recovery criteria to establish a preoperative diagnosis and the fact that was uneventful. Macroscopically the testis was measuring some cases are grouped under mature teratomas.[1] We report 5.0 × 4.5 × 3.0 cm. On cut-section, there was near-total a case of dermoid cyst of the testis in a 72-year-old male who replacement of testicular architecture by a cystic mass presented with right testicular mass, bilateral inguinal hernia, containing flaky whitish keratinous material, hair follicles, and and grade-2 prostatomegaly. calcified foci [Figure 1a and b]. Histology revealed, fibrotic thickening of tunica vaginalis with obliterated testicular CASE REPORT architecture by the presence of a cystic lesion with inner stratified squamous epithelial lining, pilosebaceous apparatii, A 72-year-old male patient presented with painless right many hair follicles, luminal lamellar keratin, fibrofatty tissues, testicular mass and bilateral inguinal swellings of six months calcifications, and striking presence of nodular Leydig cell duration. There was no history of trauma or infection. clusters with lipochrome pigment within the lesional component Examination confirmed the presence of a right testicular [Figures 2–7]. Based on these findings a diagnosis of dermoid mass of approximately 4.0 × 3.5 cm, nontender, smooth cyst of the testis was made. surfaced, and varying in consistency (soft cystic, firm to hard). Left testis was normal except for the presence of mild DISCUSSION hydrocele. Bilateral direct inguinal hernia was present. Per-rectal examination revealed hard, nontender prostate without surface Teratomas represent 38% of testicular germ cell tumors in nodularity suggesting grade-2 prostatomegaly. Ultrasound infants and children and 47% in adults.[2] They are classified examination showed an enlarged right testis (4.3 × 3.9 × into three histological subtypes: mature teratoma, immature 2.9 cm) and epididymis (1.5 × 1.4 cm) with heterogeneous teratoma, and teratoma with malignant transformation.[3] echo texture comprising of both cystic and calcific foci (germ Mature teratomas are composed of benign well-differentiated cell tumor) and minimal left hydrocele with bilateral inguinal structures derived from the ectoderm, endoderm, or mesoderm.

Urology Annals | Jul - Dec 2009 | Vol 1 | Issue 2 61 Kinnera, et al.: Dermoid cyst of testis Although dermoid cysts are also referred to as mature cystic for testicular teratomas in postpubertal patients – the more teratomas or benign cystic teratomas, Mostofi et al, suggest that common being through intratubular germ cell neoplasia and they should be labeled as dermoid.[2] There are two pathways the less common one, taken by dermoid cyst, is by direct

a b Figure 1: (a) High orchidectomy specimen – Near-total replacement of testis by a cystic mass filled with flaky whitish debris and tuft of hair follicles; (b) Closer view of orchidectomy specimen – The cyst is filled with flaky whitish granular debris and hair follicles

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 Figure 5: Dermoid cyst of testis – lamellar keratin with hair follicles of fibrocollagen (H and E, x100) (H and E, x100)

62 Urology Annals | Jul - Dec 2009 | Vol 1 | Issue 2 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 investigations should have a frozen section performed first. If cyst of the testis should be suspected in a child or adult with the diagnosis is dermoid cyst, then testis-sparing surgery such as a painless testicular mass which has not shown progressive enucleation should be attempted if feasible, before considering enlargement. The differential diagnosis includes benign lesions orchidectomy.[1] such as epidermal cyst, simple cyst, and malignant tumors of the testis with secondary degenerative changes such as This case is being reported because of its rarity in the older age choriocarcinoma radiologically. group and interesting inclusions of nodular Leydig cell clusters within the contents of dermoid cyst of the testis. The tumor markers (α-fetoprotein and β-human chorionic gonadotrophin) which are done preoperatively to assess the REFERENCES presence of testicular neoplasm will be negative in a dermoid 1. Crankson J, Shabra S, Al Hawashim N. Dermoid cyst of the testis. Ann cyst. Dermoid cyst of the testis is filled with sebum and Saudi Med 1997;17:634-35. contains sweat and sebaceous glands and hair follicles in its 2. Mostofi FK, Sesterhenn IA, Davis CJ Jr. Developments in histopathology fibrous stroma. Bone, cartilage, teeth, and brain tissue may of testicular germ cell tumors. Semin Urol 1988;6:171-88. 3. Mostofi FK, Sobin LH. Histological typing of testis tumors. In: International be present. Dermoid cysts are less common than epidermoid Histological Classification of Tumors, No.16. Geneva: World Health cysts, with only scattered case reports in the urology Organisation; 1977. literature.[5-7] When dermoid cyst contains predominantly 4. Ulbright TM, Srigley JR. Dermoid cyst of testis: A study of five post pubertal ectodermal derivatives, it needs to be differentiated from cases, including a pilomatrixoma-like variant, with evidence supporting its separate classification from mature cystic teratoma. Am J Surg Pathol epidermoid cyst that contains only stratified squamous 2001;25:788-93. epithelial lining with luminal lamellar keratin without the 5. Upton JD, Das S. Benign intrascrotal neoplasms. J Urol 1986;135:504-6. presence of adnexe unlike that of dermoid cyst.[8] In all reported 6. Assaf G, Mosbah A, Homsy Y, Michaud J. Dermoid cyst of testis in five- year-old-child. Urology 1983;22:432-4. cases of testicular dermoid cysts, local excision, enucleation, 7. Eason AA, Spaulding JT. Dermoid cyst arising in testicular tunics. J Urol or orchiectomy have been curative, with no patient developing 1977;117:539 a metastatic germ cell tumor. Unlike that of present case, if 8. Peterson RO. Urologic pathology. Philadelphia: Lippincott; 1992. p. 450-1. prepubertal child or younger individuals in whom dermoid cyst is considered after clinical, ultrasound, and biochemical Source of Support: Nil, Conflict of Interest: None.

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