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Testicular Epidermoid Cysts

University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH 44106

I read with great interest the article by Jae-Ho Cho et al., entitled "Sonographic and MR Imaging Findings of Testicular Epidermoid Cysts" [1]. MR imaging and sonographic features of epidermoid cysts have previously been described in detail [2, 3].

I have a few points of concern regarding the epidermoid cyst depicted in figure 2A [1]. In this figure, the posterior acoustic shadow does not exactly correspond to the calcifications. Because these calcifications are within the hypoechoic rim, it appears that they are in the epidermoid cyst and not in the wall. The acoustic shadow appears to emanate from the keratinous debris and not from the calcifications. Keratinous debris can give rise to refraction artifact because of its high acoustic impedance [2]. Calcifications do occur in the wall of the epidermoid cyst, but not within the cyst itself [4]. The main internal content of the epidermoid cyst is keratin but occasionally a few desquamative epithelial cells may be present. The sonographic appearance of an epidermoid cyst is highly dependent on the maturation and compactness of the cyst and on the amount of keratin that is present [2]. In addition, contrary to the figure legend, no lamination is apparent on this sonogram.

Concerning MR imaging of epidermoid cysts, a study by Wantanabe et al. [3] was published in 2000. Their article describes imaging features of epidermoid cyst with dynamic gadolinium enhancement.

References

1. Cho J-H, Chang J-C, Park B-H, Lee J-G, Son C-H. Sonographic and MR imaging findings of testicular epidermoid cysts. AJR 2002;178:743 -748[Abstract/Free Full Text]
2. Dogra VS, Gottlieb RH, Rubens DJ, Oka M, Di Sant Agnese AP. Testicular epidermoid cysts: sonographic features with histopathologic correlation. J Clin Ultrasound 2001;29:192 -196[Medline]
3. Watanabe Y, Dohke M, Ohkubo K, et al. Scrotal disorders: evaluation of testicular enhancement patterns at dynamic contrast-enhanced subtraction MR imaging. Radiology 2000;217:219 -227[Abstract/Free Full Text]
4. Price EB Jr. Epidermoid cysts of the testis: a clinical and pathological analysis of 69 cases from the testicular tumor registry. J Urol 1969;102:708 -713[Medline]

Reply

Yeungnam University School of Medicine Taegu, 705-717, South Korea

We greatly appreciate Dr. Dogra's interest in our article [1]. We agree that calcifications do occur in the wall of the epidermoid cyst, but not within the cyst itself. However, epidermoid cysts may rarely contain calcification in the mass: Taghizadeh and Howlett [2] reported a case of epidermoid cyst containing prominent calcification, and Furuhata et al. [3] reported the calcification of keratinous debris in the cyst in a report of epidermoid cysts arising in the callosal region.

In our patient, unenhanced CT performed preoperatively (not shown in our article [1]) showed calcifications in the mass (Fig. 3), and this finding was confirmed histopathologically. We also agree that the lesion in figure 2A of our article does not show the typical laminated sonographic appearance of alternating hypoechoic and hyperechoic bands. However, we thought that the image showed a laminated pattern through the whole lesion, contrary to other cases that showed complex heterogeneous appearance in echo patterns.

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —20-year-old man with left testicular epidermoid cyst containing calcifications. Unenhanced CT scan shows hypodense mass (arrowheads) containing multiple calcifications.

We are sorry that we did not find the article written by Watanabe et al. [4] when we searched for references related to our article by using the index terms "epidermoid," "testis," and "testicular" in the Medline database.

References

1. Cho J-H, Chang J-C, Park B-H, Lee J-G, Son C-H. Sonographic and MR imaging findings of testicular epidermoid cysts. AJR 2002;178:743 -748
2. Taghizadeh AK, Howlett DC. Calcified epidermoid cyst in the testis: an unusual finding on ultrasound. Eur J Ultrasound 2000;11:199 -200[Medline]
3. Furuhata S, Yamada F, Fukuda S, Otani M, Toya S. Epidermoid cysts of the callosal region: three case reports. Neurol Med Chir 1993;33:697 -699
4. Watanabe Y, Dohke M, Ohkubo K, et al. Scrotal disorders: evaluation of testicular enhancement patterns at dynamic contrast-enhanced subtraction MR imaging. Radiology 2000;217:219 -227

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dogra, V. Articles by Park, B.-H. Search for Related Content PubMed PubMed Citation Articles by Dogra, V. Articles by Park, B.-H. Social Bookmarking                      What's this?