Benign Intratesticular Cystic Lesions: US Features
- Vikram S. Dogra, MD,
- Ronald H. Gottlieb, MD,
- Deborah J. Rubens, MD and
- Lydia Liao, MD
+Author Affiliations
Figure 1. Normal testis in a 38-year-old man. Longitudinal US scan shows the mediastinum testis as an echogenic linear band running across the testis (arrow). If imaged at an angle, the mediastinum testis may resemble a testicular tumor. Most benign cystic testicular lesions occur adjacent to this structure.
Figure 2. Tunica albuginea cyst in a 34-year-old man. Longitudinal US scan shows a well-defined cystic lesion in the anterior and upper portion of the testis (arrow), a characteristic location for a tunica albuginea cyst. These cysts are usually palpable and seen in a younger population, as opposed to intratesticular simple cysts.
Figure 3. Tunica albuginea cyst in an asymptomatic 70-year-old man who had a palpable left testicular mass. Longitudinal US scan shows a well-defined cyst with an imperceptible wall, an anechoic center, and through transmission. A diagnosis of intratesticular cyst was advanced. Findings of tumor markers were negative, but because the mass was palpable, the urologist suspected a malignant tumor. The patient underwent radical orchiectomy, after which a tunica albuginea cyst was confirmed. When large, these cysts can compress the testicular parenchyma, making distinction from an intratesticular cyst difficult, as in this case.
Figure 4. Simple intratesticular cyst in a 61-year-old man. A testicular mass was found at an annual physical examination. Findings of tumor markers were negative. Longitudinal US scan of the left testis shows two intratesticular cysts that meet all the US criteria of a simple cyst. Testicular microliths surround the cysts. The case was followed on a yearly basis for 5 years, with no change.
Figure 5. Intratesticular epidermoid in a 22-year-old man. A preemployment physical examination revealed a palpable, nontender mass at the inferior pole of the left testis. Findings of tumor markers were negative. Longitudinal US scan shows a well-circumscribed heterogeneous mass with an echogenic rim (arrow). Color Doppler US examination revealed no vascularity within the mass. At histopathologic examination, the echogenic rim corresponded to keratin deposition.
Figure 6a. Intratesticular epidermoid in a 21-year-old man, who presented with a growing mass in the left testis of 2-3 months duration. Physical examination revealed a 2- to 3-mm-diameter, palpable, nontender, firm nodule on the surface of the left testicle. (a) Longitudinal US scan reveals a well-circumscribed hypoechoic mass with a concentric lamellar pattern of alternating hyper- and hypoechoic rings (arrow). This US pattern is referred to as the onion ring appearance and is characteristic of an epidermoid cyst. At US, these cysts appear solid because of the high acoustic impedance of their contents. (b) Photomicrograph (original magnification, ×40) of an epidermoid cyst shows concentric layers of keratin (arrow), which correspond to the concentric, lamellar pattern seen at US.
Figure 6b. Intratesticular epidermoid in a 21-year-old man, who presented with a growing mass in the left testis of 2-3 months duration. Physical examination revealed a 2- to 3-mm-diameter, palpable, nontender, firm nodule on the surface of the left testicle. (a) Longitudinal US scan reveals a well-circumscribed hypoechoic mass with a concentric lamellar pattern of alternating hyper- and hypoechoic rings (arrow). This US pattern is referred to as the onion ring appearance and is characteristic of an epidermoid cyst. At US, these cysts appear solid because of the high acoustic impedance of their contents. (b) Photomicrograph (original magnification, ×40) of an epidermoid cyst shows concentric layers of keratin (arrow), which correspond to the concentric, lamellar pattern seen at US.
Figure 7. Mild cystic transformation of the rete testis (tubular ectasia) in a 52-year-old man. Longitudinal US scan of the right testis shows multiple avascular circular structures of varying sizes in the posterolateral region. There was an associated spermatocele (not shown). The patient was uncomfortable from the spermatocele and underwent spermatocelectomy.
Figure 8a. Moderate (a) and severe (b)cystic transformation of the rete testis (tubular ectasia) in a 70-year-old man who presented with palpable masses in both testes. (a)Longitudinal US scan of the left testis shows anechoic, multiple tubular lesions in the superolateral region near the mediastinum testis, with no evidence of flow at Doppler US interrogation. An associated spermatocele was in the head of the epididymis. (b) Longitudinal US scan of the right testis reveals avascular, anechoic dilated channels in the posterolateral region of the testis. There was an associated spermatocele. Tubular ectasia is a benign condition usually associated with spermatoceles (as in this case), is commonly bilateral, and requires no follow-up.
Figure 8b. Moderate (a) and severe (b)cystic transformation of the rete testis (tubular ectasia) in a 70-year-old man who presented with palpable masses in both testes. (a)Longitudinal US scan of the left testis shows anechoic, multiple tubular lesions in the superolateral region near the mediastinum testis, with no evidence of flow at Doppler US interrogation. An associated spermatocele was in the head of the epididymis. (b) Longitudinal US scan of the right testis reveals avascular, anechoic dilated channels in the posterolateral region of the testis. There was an associated spermatocele. Tubular ectasia is a benign condition usually associated with spermatoceles (as in this case), is commonly bilateral, and requires no follow-up.
Figure 9. Testicular immature teratoma that manifested as a cystic mass in a 23-year-old man. Sagittal US scan of the left testis reveals multiple cystic areas within the testicle ranging from 2 mm to 15 mm in diameter. This process involves nearly the whole testis. The patient underwent radical orchiectomy, which confirmed the diagnosis of immature teratoma. These cystic changes can be easily differentiated from tubular ectasia, which is confined to the mediastinum and occurs in an older population.
Figure 10. Mixed nonseminomatous germ cell tumor that manifested as a cystic lesion in a 36-year-old man who presented with testicular enlargement and pain of 2 months duration. Sagittal US scan of the right testicle shows multiple cystic regions surrounded by a rim of hyperechoic testicular parenchyma distinct from the normal testicular parenchyma. Color and duplex Doppler US did not show any blood flow in the cystic areas but did show flow in the tumor stroma surrounding these cystic areas. The patient underwent orchiectomy, which confirmed the diagnosis.
Figure 11. Intratesticular spermatocele in a 38-year-old man with a palpable testicular mass found during evaluation for infertility. Transverse US scan shows a cystic lesion 1.3 cm in its greatest dimension that has all the features of a simple cyst except that its wall is slightly irregular. Findings of tumor markers were negative. Because the mass was palpable and the patient was older, inguinal exploration was performed. Examination of frozen sections helped confirm that the mass was an intratesticular spermatocele with mature spermatozoa as its contents. US features of such spermatoceles are usually indistinguishable from those of a simple cyst.
Figure 12a. Intratesticular varicocele in a 47-year-old man. (a) Longitudinal US scan of the left testis shows intratesticular tubular cystic structures of varying sizes.(b) Color Doppler US scan (shown in black and white) shows flow (arrow) within the tubular structures. (c) Pulse Doppler US scan shows increased flow (arrow) with the Valsalva maneuver, a finding characteristic of venous flow. The patient also had an associated extratesticular varicocele (not shown).
Figure 12b. Intratesticular varicocele in a 47-year-old man. (a) Longitudinal US scan of the left testis shows intratesticular tubular cystic structures of varying sizes.(b) Color Doppler US scan (shown in black and white) shows flow (arrow) within the tubular structures. (c) Pulse Doppler US scan shows increased flow (arrow) with the Valsalva maneuver, a finding characteristic of venous flow. The patient also had an associated extratesticular varicocele (not shown).
Figure 12c. Intratesticular varicocele in a 47-year-old man. (a) Longitudinal US scan of the left testis shows intratesticular tubular cystic structures of varying sizes.(b) Color Doppler US scan (shown in black and white) shows flow (arrow) within the tubular structures. (c) Pulse Doppler US scan shows increased flow (arrow) with the Valsalva maneuver, a finding characteristic of venous flow. The patient also had an associated extratesticular varicocele (not shown).
Figure 13a. Testicular abscess in a 38-year-old man. (a) Longitudinal US scan shows a complex hypoechoic mass with an irregular margin. There is no through transmission, but there is a small, associated, reactive hydrocele and skin thickening. (b) Color Doppler US scan (shown in black and white) reveals increased vascularity in the surrounding parenchyma. The patient had orchitis, which led to abscess formation.
Figure 13b. Testicular abscess in a 38-year-old man. (a) Longitudinal US scan shows a complex hypoechoic mass with an irregular margin. There is no through transmission, but there is a small, associated, reactive hydrocele and skin thickening. (b) Color Doppler US scan (shown in black and white) reveals increased vascularity in the surrounding parenchyma. The patient had orchitis, which led to abscess formation.
Figure 14a. Infarction and hemorrhage in a 31-year-old man. (a) Longitudinal US scan shows an oblong, intratesticular, complex cystic lesion with areas of central necrosis.(b) Transverse US scan shows irregular, shaggy walls with low-level internal echoes and no through transmission. At US, this lesion was believed to represent an abscess, but at orchiectomy, it was confirmed to be an area of infarction with central necrosis. No abscess was found.
Figure 14b. Infarction and hemorrhage in a 31-year-old man. (a) Longitudinal US scan shows an oblong, intratesticular, complex cystic lesion with areas of central necrosis.(b) Transverse US scan shows irregular, shaggy walls with low-level internal echoes and no through transmission. At US, this lesion was believed to represent an abscess, but at orchiectomy, it was confirmed to be an area of infarction with central necrosis. No abscess was found.
http://radiographics.rsna.org/content/21/suppl_1/S273/F9.expansION
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