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QUIZ No. 38
CASE 38
A young male presented with a painless testicular lump noted incidentally. No history of trauma, fever, or infertility. Tumour markers (β-hCG, AFP, LDH) were within normal limits. USG and MRI images are provided. What’s the diagnosis?
USG
MRI
Findings: Well-defined intratesticular lesion, predominantly avascular on doppler. Shows characteristic laminated/concentric rings (onion-skin appearance). Internal echogenic whorled pattern with no posterior acoustic shadowing. T1/T2: Well-circumscribed round heterogeneously hyperintense lesion. DWI: Mild restricted diffusion.
Diagnosis. Testicular epidermoid cyst.
Testicular epidermoid cyst is a rare benign testicular tumor (~1% of testicular neoplasms); typically occurs in young men (2nd–4th decade).
A true epidermal inclusion cyst; composed of keratin debris lined by squamous epithelium; no germ cell tumor component, hence tumor markers are normal.
Imaging Features: US: Onion skin appearance; avascularity; usually well-encapsulated. MRI: Concentric T2 rings (target sign), absence of enhancement — most specific sign.
Differentials: Mature teratoma (enhancing solid components, fat or calcification). Infarction (peripheral vascularity, irregular margins). Fungal orchitis (hypervascular, heterogeneous). Simple cyst (anechoic, no internal lamination)
Treatment: Testis-sparing enucleation preferred; radical orchiectomy only if diagnosis uncertain. Prognosis is excellent with no malignant potential.
Take home point:
Avascular laminated “onion-skin” lesion → think epidermoid cyst.
Tumor markers always normal.
Should be managed with testis-sparing excision, not orchiectomy.
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