Vol. 114, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
CYSTS OF THE TUNICA ALBUGINEA. REPORT OF 4 CASES AND REVIEW OF THE LITERATURE RAUL MANCILLA-JIMENEZ*
AND
GORDON T. MATSUDA
From the Divisions of Surgical Pathology and Urology, Washington University School of Medicine, Barnes Hospital, St. Louis, Missouri
ABSTRACT
Four cases of benign testicular cysts arising from the tunica albuginea are reported. A review of the literature yielded only 4 more instances of such lesions. Clinically, these cysts may be manifested as a tumor or painful swelling, or are discovered incidentally. In 3 cases a diagnosis of testicular carcinoma was entertained and high inguinal orchiectomies were done. The possibility of a conservative surgical approach, as followed in 1 case, is discussed. These cysts appear in the anterior and lateral aspects of the testis, show ample connection to the albuginea and are lined by a cuboidal epithelium. Gland-like inclusions were found in the fibrous cystic walls and in the albuginea. The histogenesis of these lesions is discussed and evidence for a possible origin in mesothelial rests trapped during development is presented. The differential diagnosis of cystic lesions of the testis is reviewed briefly. The literature on cysts of the tunica albuginea is sparse. In 1929 Frater reported on a case found at autopsy and reviewed the literature on the subject. 1 The rarity of this lesion is assessed by the fact that Arcadi was able to find only 3 instances of such a lesion in more than 46,000 cases recorded at the Johns Hopkins Hospital. 2 The importance of the cysts involving the tunica albuginea involves the fact that a malignant process cannot be ruled out on clinical grounds and that a correct pathologic interpretation may pose some difficulties if one is not aware of the existence of these cysts. These facts prompted us to report the only 4 cases in the files of our hospital. CASE REPORTS
Case I. A 59-year-old black man was admitted to
the hospital for treatment of a right calf thrombophlebitis. The history was unremarkable and there was no record of trauma, gonorrhea or other urinary tract infection. On physical examination findings compatible with thrombophlebitis were noted. On the superior lateral aspect of the left testis a firm, non-tender, non-transmitting, 1.5 cm. mass was present. Routine laboratory studies were within normal limits. An excretory urogram (IVP) disclosed a non-visualized left kidney with multiple rim-like calcifications, which were believed to Accepted for publication June 6, 1975. Supported by United States Public Health Service Grant 5 TOl CA-05201-08. * Requests for reprints: Division of Surgical Pathology, Barnes Hospital, Barnes Hospital Plaza, St. Louis, Missouri 63110. 730
represent calcifications following infections in a dysplastic kidney. A radical orchiectomy was performed because a carcinoma of the testis was suspected. On gross examination the testis measured 4.5 by 2.5 by 2.5 cm. When the tunica vaginalis was opened 4 cysts were seen on the anterior and lateral aspects of the testis. On cut sections the cysts appeared to be in continuity with the tunica albuginea (fig. 1). The cysts measured from 0.5 to 2.3 cm. and were filled with a serous fluid. The epididymis was enlarged and displayed tubular dilatation. Case 2. A 52-year-old black man had a 3-year history of several episodes of epididymitis. The rest of the clinical history was non-contributory and there was no record of trauma or urinary tract infections. Ten days before hospitalization he noticed a mass in the right testicle. On physical examination the testicular mass was noted to be located on the upper pole. Routine laboratory studies and an IVP were within normal limits. Diagnosis of carcinoma of the testis was considered and right radical orchiectomy was performed. Gross examination disclosed a cystic 2.5 cm. lesion on the anterior surface of the upper pole. The cyst was multiloculated and displayed a complicated shape with many anfractuosities, some ending in cystic spaces that projected centrally into the substance of the testis (fig. 2). The cyst contained a moderate amount of serous fluid. Case 3. A 65-year-old man was admitted to the hospital with a 4-week history of suprapubic pain and urethral irritation. When he was 18 years old he apparently had gonorrhea and prostatitis. Four
CYSTS OF TUNICA ALBUG!NEA
FIG. 1. Case 1. Bisected testis shows 2 cysts widely connected to tunica albuginea and projecting into testicular parenchyma. contained serous fluid. Epididymis is enlarged tubular dilatation. Testicular parenchyma surrounding cysts is unremarkable.
years before a multiloculated cyst was removed from the left On examination the only finding of note was a small mass in the left testicle. Laboratory examination was non-contributory. Diagnosis of testicular carcinoma was considered and left radical orchiectomy was done. On cut sections a 4 cm. multiloculated lesion was found on the anterior surface of the lower pole of the testis. The cyst was widely connected to the albuginea but was also present in the testicular parenchyma. The cyst contained serous fluid and displayed smooth inner surfaces. The testicular parenchyma and epididymis were grossly unremarkable. Case 4. A 23-year-old white man had mild pain in the left testis a week to hospitalization. Clinical was completely negative. On physical examination the finding was a small mass in the testis next to the epididymis. examination was exploration was carried out. In the anterior surface cent to the epididymis there was a small yellowish firm 1 cm. cyst arising from the albuginea (fig. 3). The cyst was removed with a small of testicular tissue. A frozen section of the cyst cyst and no furtheY A small
731
FIG. 2. Case 2. Multiloculated is seen arising from tunica albuginea. exhibits complicated structure and fibrous ""'-~~"~'"' -No inflammatory changes are seen in & E, reduced from x9.
FIG. 30 C2se 4. A l cm. cyst tormed by thick fibrous present ·:overing segments ll E. ~eCuced from >
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
CYSTS OF THE TUNICA ALBUGINEA. REPORT OF 4 CASES AND REVIEW OF THE LITERATURE RAUL MANCILLA-JIMENEZ*
AND
GORDON T. MATSUDA
From the Divisions of Surgical Pathology and Urology, Washington University School of Medicine, Barnes Hospital, St. Louis, Missouri
ABSTRACT
Four cases of benign testicular cysts arising from the tunica albuginea are reported. A review of the literature yielded only 4 more instances of such lesions. Clinically, these cysts may be manifested as a tumor or painful swelling, or are discovered incidentally. In 3 cases a diagnosis of testicular carcinoma was entertained and high inguinal orchiectomies were done. The possibility of a conservative surgical approach, as followed in 1 case, is discussed. These cysts appear in the anterior and lateral aspects of the testis, show ample connection to the albuginea and are lined by a cuboidal epithelium. Gland-like inclusions were found in the fibrous cystic walls and in the albuginea. The histogenesis of these lesions is discussed and evidence for a possible origin in mesothelial rests trapped during development is presented. The differential diagnosis of cystic lesions of the testis is reviewed briefly. The literature on cysts of the tunica albuginea is sparse. In 1929 Frater reported on a case found at autopsy and reviewed the literature on the subject. 1 The rarity of this lesion is assessed by the fact that Arcadi was able to find only 3 instances of such a lesion in more than 46,000 cases recorded at the Johns Hopkins Hospital. 2 The importance of the cysts involving the tunica albuginea involves the fact that a malignant process cannot be ruled out on clinical grounds and that a correct pathologic interpretation may pose some difficulties if one is not aware of the existence of these cysts. These facts prompted us to report the only 4 cases in the files of our hospital. CASE REPORTS
Case I. A 59-year-old black man was admitted to
the hospital for treatment of a right calf thrombophlebitis. The history was unremarkable and there was no record of trauma, gonorrhea or other urinary tract infection. On physical examination findings compatible with thrombophlebitis were noted. On the superior lateral aspect of the left testis a firm, non-tender, non-transmitting, 1.5 cm. mass was present. Routine laboratory studies were within normal limits. An excretory urogram (IVP) disclosed a non-visualized left kidney with multiple rim-like calcifications, which were believed to Accepted for publication June 6, 1975. Supported by United States Public Health Service Grant 5 TOl CA-05201-08. * Requests for reprints: Division of Surgical Pathology, Barnes Hospital, Barnes Hospital Plaza, St. Louis, Missouri 63110. 730
represent calcifications following infections in a dysplastic kidney. A radical orchiectomy was performed because a carcinoma of the testis was suspected. On gross examination the testis measured 4.5 by 2.5 by 2.5 cm. When the tunica vaginalis was opened 4 cysts were seen on the anterior and lateral aspects of the testis. On cut sections the cysts appeared to be in continuity with the tunica albuginea (fig. 1). The cysts measured from 0.5 to 2.3 cm. and were filled with a serous fluid. The epididymis was enlarged and displayed tubular dilatation. Case 2. A 52-year-old black man had a 3-year history of several episodes of epididymitis. The rest of the clinical history was non-contributory and there was no record of trauma or urinary tract infections. Ten days before hospitalization he noticed a mass in the right testicle. On physical examination the testicular mass was noted to be located on the upper pole. Routine laboratory studies and an IVP were within normal limits. Diagnosis of carcinoma of the testis was considered and right radical orchiectomy was performed. Gross examination disclosed a cystic 2.5 cm. lesion on the anterior surface of the upper pole. The cyst was multiloculated and displayed a complicated shape with many anfractuosities, some ending in cystic spaces that projected centrally into the substance of the testis (fig. 2). The cyst contained a moderate amount of serous fluid. Case 3. A 65-year-old man was admitted to the hospital with a 4-week history of suprapubic pain and urethral irritation. When he was 18 years old he apparently had gonorrhea and prostatitis. Four
CYSTS OF TUNICA ALBUG!NEA
FIG. 1. Case 1. Bisected testis shows 2 cysts widely connected to tunica albuginea and projecting into testicular parenchyma. contained serous fluid. Epididymis is enlarged tubular dilatation. Testicular parenchyma surrounding cysts is unremarkable.
years before a multiloculated cyst was removed from the left On examination the only finding of note was a small mass in the left testicle. Laboratory examination was non-contributory. Diagnosis of testicular carcinoma was considered and left radical orchiectomy was done. On cut sections a 4 cm. multiloculated lesion was found on the anterior surface of the lower pole of the testis. The cyst was widely connected to the albuginea but was also present in the testicular parenchyma. The cyst contained serous fluid and displayed smooth inner surfaces. The testicular parenchyma and epididymis were grossly unremarkable. Case 4. A 23-year-old white man had mild pain in the left testis a week to hospitalization. Clinical was completely negative. On physical examination the finding was a small mass in the testis next to the epididymis. examination was exploration was carried out. In the anterior surface cent to the epididymis there was a small yellowish firm 1 cm. cyst arising from the albuginea (fig. 3). The cyst was removed with a small of testicular tissue. A frozen section of the cyst cyst and no furtheY A small
731
FIG. 2. Case 2. Multiloculated is seen arising from tunica albuginea. exhibits complicated structure and fibrous ""'-~~"~'"' -No inflammatory changes are seen in & E, reduced from x9.
FIG. 30 C2se 4. A l cm. cyst tormed by thick fibrous present ·:overing segments ll E. ~eCuced from >
