International Journal of Urology
Volume 13 Issue 1 Page 95 - January 2006
To cite this article: VAGELOGIANNIS KATERGIANNAKIS EMMANUEL
E LAGOUDIANAKIS HARIDIMOS MARKOGIANNAKIS ANDREAS MANOURAS (2006)
Huge epidermoid cyst of the spermatic cord in an adult patient
International Journal of Urology 13 (1) 95?97.
Huge epidermoid cyst of the spermatic cord in an adult patientAndreas Manouras md phd First Department of Propaedeutic Surgery Hippocrateion Hospital University of Athens Athens Medical School Q. Sophia 114 11527 Athens Greece. Email: email@example.com
AbstractTumors arng in the spermatic cord are uncommon and form a heterogeneous group of neoplasms. A variety of both benign and malignant lesions have been demonstrated. Benign tumors represent 80% of the total but unfortunately clinical and sonographic features are not specific and they cannot safely differentiate a teratomatous or a malignant neoplasm from benign tumors. We report a case of a huge epidermoid cyst of the spermatic cord in an adult patient confirmed after local excon. The etiology differential diagnosis and management alternatives are discussed.
Epidermoid cysts of the spermatic cord are very rare and to our best knowledge only three cases have been reported in the literature.13 Several criteria compose the definition of benign epidermoid cyst: (i) the wall of the cyst is composed of fibrous tissue with a complete or incomplete inner lining of squamous epithelium; (ii) the lumen of the cyst contains keratinized debris or amorphous material with cleft-like spaces; and (iii) no teratomatous elements or adnexal structures such as sebaceous glands or hair follicles are present within the cyst wall.
Most lesions in this area concern adult men who have detected a painless growing mass in the lower quadrant while others have a history of pain and tenderness. Routine physical examination can reveal the majority of such tumors but very few have been found incidentally during groin hernioplasty. Pathologic examination of the specimen is crucial for further prognosis and treatment.
We report the case of an adult patient with a huge epidermoid cyst of the spermatic cord who was successfully treated with organ-preserving surgery in our department.
A 45-year-old man presented with a mass that was located in his left inguinal region. According to his history he remembered having this mass for the last five years but during the last year it had grown steadily. No other symptoms apart from a progressively worsening diffuse discomfort in the left iliac fossa were noted. A complete review of systems as well as his medical and family history was unremarkable. Furthermore there was no history of trauma.
On physical examination a painless tender mass not bulging when the abdominal pressure increased was found in coexistence with a left varicocele. Routine laboratory tests and tumor markers including human chorionic gonadotropin embryonic globulin alpha-1-fetoprotein and carcinoembryonic antigen were within normal limits. A preoperative ultrasound (US) revealed a hyperechoic regular mass (Fig. 1).
The patient was operated on under epidural anesthesia. Surgically a left inguinal incon was performed and the spermatic cord was temporarily occluded. A well-defined lesion measuring 18 cm ?nbsp;7 cm and weighting 600 g was easily excised and the specimen was submitted for frozen section (Fig. 2). The pathology showed the lesion to be a dermoid cyst and after this interpretation organ-sparing surgery was decided.
Microscopic evaluation demonstrated a discrete cyst lined by mature stratified squamous epithelium and filled with laminated keratin. No evidence of malignancy was present. At 2 years following surgery there has been no recurrence of the tumor.
Tumors of the spermatic cord are histogenetically composed of a variety of epithelial mesothelial and mesenchymal agents with different behavioral patterns and hence have a wide differential diagnosis. Benign neoplasms constitute approximately 80% of these tumors; with adenomatoid and lipoma being the most frequent benign tumors of the spermatic cord.4 A close review of the world literature revealed that only three cases of an epidermoid cyst of the spermatic cord have been previously described while this lesion seems to be more often found in the testicle and scrotum where it accounts for 1% of all testicular masses.25
Preoperative diagnosis although desirable for facilitating the planning of surgery is not always feasible as symptoms are not specific and the sonographic findings vary. Epidermoid cysts have been described as hyperechoic echogenic or mixed echogenic masses with a central hypoechoic component and peripheral calcification. They have also been reported as homogeneous lesions with an echogenic rim or as masses of mixed echogenity with multiple hypoechoic foci. Although ultrasound findings can be suggestive of the diagnosis ultrasound is not completely diagnostic.6 Recently magnetic resonance imaging (MRI) has been used for preoperative diagnosis of epidermoid cysts of the testis6 and spermatic cord.1 Magnetic resonance imaging with contrast enhancement may provide supportive findings for the diagnosis thus permitting organ-preserving surgery.6 Even though US followed by MRI is useful for preoperative assessment of these tumors definite diagnosis can only be based on frozen and permanent sections. Frozen section examination (FSE) of the mass appears to be sufficient to differentiate benign from malignant lesions.7 Accurate pathological diagnosis requires permanent sections but there is no clinical impact of any discordance.7
Epidermoid cysts are characterized by a lining of stratified squamous cells without skin appendages in the stromal tissue containing only keratin. If there is no doubt about the diagnosis epidermoid cysts of the spermatic cord can be managed with local excon since malignant degeneration has never been observed.8 Furthermore there has never been a reported malignant epidermoid cyst of the testis where epidermoid cysts occur relatively often. Due to its benign course complete excon of the cyst is considered a safe and efficient treatment with no subsequent follow up needed.
Dermoid cysts of the spermatic cord should be differentiated from epidermoid cysts because they are potentially malignant in accordance with their ovarian variant. Dermoid cysts have almost the same histological and sonographic features but skin appendages such as sebaceous glands hair follicles and sweat glands are always present. However no dermoid cyst of the testis with a malignant course has ever been reported therefore these rare tumors may be applicable to organ-preserving surgery as well. Furthermore there are no important clinical consequences of FSE distinction of dermoid and epidermoid cysts.9 Still accurate pathological diagnosis after permanent sections will be necessary for planning subsequent follow up. Teratomas another lesion with potential malignancy should be ruled out. Histologically they are derived from all of the three embryonic germ layers and therefore contain ectodermal mesodermal and endodermal elements.
In our case the surgeon performed a testis-sparing excon of the cyst based on the preoperative evaluation the intraoperative findings of a smooth cystic mass readily separated from the layers of the spermatic cord and the FSE diagnosis of benign tumor. Furthermore testicular preservation was deemed essential in our patient because of his age.
One should ever have in mind the widely mentioned comment 'when in doubt take it out' especially in such rare lesions when differential diagnosis in frozen sections is not well established. In such a case testicular-sparing surgery cannot be performed and we suggest orchiectomy with high ligation of the spermatic cord.