Correspondence: Koon Ho Rha MD PhD, Department of Urology, Yonsei University College of Medicine, 134 Shinchon-dong Seodaemun-ku, Seoul, Korea 120–752. Email: firstname.lastname@example.org
Cystic testicular masses have been considered rare but due to advances in ultrasonographic technologies their incidence has risen. Many testicular cystic masses are benign but there is a chance of malignancy. Psammoma bodies are found in various malignancies that occur in the genital tract of women but rarely in men. We report a case of testicular tunica albuginea cyst with psammoma bodies.
Cysts of the tunica albuginea have been considered very rare. Although this condition is completely benign, it is difficult to differentiate this cyst from testicular malignancies. Psammoma bodies are laminated basophilic spherical structures that occur in the various malignancies of the female genital tract, but rarely in the male genital tract. We report a case of testicular tunica albuginea cyst with psammoma bodies that was treated with a testicular sparing operation.
The patient was a 20-year-old man who had a non-tender cystic mass in the right testis for 1 year. Physical examination revealed a 2 cm non-transilluminating, well-demarcated mass on the anterior portion of the right testicle. Biochemical tumor markers for germ cell tumor of the testis (α-fetoprotein, human chorionic gonadotrophin-β, lactate dehydrogenase) were within normal limits. Ultrasonic evaluation revealed a 1.5 × 1 cm echolucent cyst on the anterior portion of testis (Fig. 1). This cystic mass was well-demarcated from the adjacent testicular parenchyma.
The right spermatic cord was identified and clamped via right inguinal incision to prevent any spillage of tumor cells. On visual inspection there was a transparent smooth walled cyst on the mid-anterior portion of right testis. The cyst was excised and intraoperative presumptive pathological examination suggested a benign serous cyst. Histological examination revealed a benign cystic mass within the tunica albuginea protruding into the testis parenchyma. Ciliated tall columnar epithelium lined the inner wall of the cyst (Fig. 2a) and a portion of the cyst wall was thickened with several calcific spherules, typical of psammoma bodies (Fig. 2b). Final pathological diagnosis was tunica albuginea cyst with psammoma bodies. On 12 month follow up, the patient had no recurrence of the testicular lesion.
Our case was a typical tunica albuginea cyst located at the mid-anterior portion of the testis, discovered incidentally by the patient. Tunica albuginea cyst was first presumed to be due to local trauma or infection, but recently this cystic lesion is considered a form of inclusion cyst probably originating from a Mullerian or Wolffian duct remnant.1 Tunica albuginea cysts have been reported with increasing frequency since the widespread use of ultrasonography. Minakami et al. reviewed 12 Japanese cases.2
A high suspicion for these benign lesions along with modern diagnostic modalities including high resolution ultrasonography, testis tumor markers such as α-fetoprotein, human chorionic gonadotrophin-β and lactate dehydrogenase, can reduce the incidence of total removal of the testis.
Psammoma body is seen in both malignant and benign conditions and regarded as degenerating sequelae of malignant cells, vessels and connective tissues. In the genital tract, psammoma bodies are occasionally found in malignant tumors of the upper gynecological tract such as papillary adenocarcinoma of endometrium or endocervix, benign and malignant neoplasms of the ovary and malignant neoplasms of the fallopian tube. They are also seen in malignant tumors in the peritoneal cavity, such as, mesothelial neoplasms. Psammoma bodies are rarely found in benign conditions, such as, cervicovaginal smears and pose no threat to prognosis.3 A rare case of malignant serous papillary tumor of the ovarian type containing psammoma bodies has been reported in the testis,4 but this case is the first report of psammoma bodies in a benign non-neoplastic condition of the testis. It is presumed to be due to a degenerative change in the fibrous layers of the testis and spermatic cord. Differential diagnosis should be made from other rare testicular and paratesticular tumors, such as, carcinoma of the appendix testis, epididymis, or rete testis. However, the clinical course, physical and ultrasonic evaluations and the distinct microscopic findings can easily rule out these tumors.