Original Report

Jae-Ho Cho 1
Jay-Chun Chang 1
Sonographic and MR Imaging
Bok-Hwan Park 1 Findings of Testicular
Jae-Gyo Lee 1
Chul-Ho Son 2 Epidermoid Cysts
American Journal of Roentgenology 2002.178:743-748.

OBJECTIVE. The purpose of this study is to analyze the sonographic and MR imaging
findings of testicular epidermoid cysts.
CONCLUSION. Sonographic findings of a markedly heterogeneous intratesticular mass
with or without alternating hypo- and hyperechoic layers surrounded by a hypoechoic or
echogenic rim and the absence of flow on color Doppler sonography suggest the preoperative
diagnosis of testicular epidermoid cysts. T2-weighted MR imaging findings of a high-signal-
intensity mass with or without low-signal-intensity foci surrounded by a low-signal-intensity
rim and the absence of enhancement on contrast-enhanced T1-weighted MR images can
strengthen the preoperative diagnosis. These imaging findings can offer a basis for surgeons
to attempt testis-sparing surgery instead of orchiectomy.

Received May 2, 2001; accepted after revision
September 12, 2001.
1 Department of Diagnostic Radiology, School of Medicine,
Yeungnam University, 317-1, Daemyungdong, Namgu,
Taegu, 705-717, South Korea. Address correspondence to
J-H. Cho.
2 echogenicity of the wall, internal echo texture, and
Department of Diagnostic Radiology, School of Medicine,
Keimyung University, 194, Dongsandong, Junggu, Taegu,
700-712, South Korea.
AJR 2002;178:743–748
0361–803X/02/1783–743
© American Roentgen Ray Society
T
esticular epidermoid cysts are
rare, benign masses accounting
for approximately 1–2% of all re-
sected testicular masses, but they are also the
most common benign tumors originating in
the testis [1]. Generally, most patients present
with testicular enlargement without any clini-
cal symptoms [2].
Epidermoid cysts are benign lesions with
no malignant potential [3] and can be cured
by orchiectomy or enucleation of the lesion
[3, 4]. However, many surgeons still favor or-
chiectomy rather than enucleation because
sonographic findings are not specific and can-
not accurately differentiate the lesions from
testicular malignancies. Therefore, if sonogra-
phy does not show specific findings compati-
ble with testicular epidermoid cysts, an
additional study is needed for confirmation of
the diagnosis.
We attempted to identify the findings nec-
essary to accurately diagnose a testicular epi-
dermoid cyst by analysis of sonographic and
MR imaging findings.
Materials and Methods
Between August 1997 and July 2000, five pa-
tients were included in this study who underwent
radical orchiectomy and were histopathologically
confirmed to have had epidermoid cysts. In two
patients, pathologic and radiologic reports were
retrospectively reviewed, and in three patients, tes-
ticular epidermoid cysts were strongly suspected
on sonography. In all patients, MR imaging was
performed after sonography.
All five patients underwent preoperative sonog-
raphy using 5- to 10-MHz linear transducers and
MR imaging examinations.
An Ultramark 9 HDI scanner (Advanced Tech-
nology Laboratories, Bothell, WA) was used in four
patients, and a Sequoia scanner (Acuson, Mountain
View, CA) was used in one patient. Color Doppler
sonography was performed in three of the five pa-
tients. On sonography, the sharpness of the margin,
flow signal of the mass were evaluated.
The MR imaging examinations were performed
using a 1.5-T scanner (Magnetom Vision; Sie-
mens, Erlangen, Germany) with a surface coil by a
standard scrotal imaging protocol [5]. Contrast-en-
hanced MR imaging was performed in all five pa-

AJR:178, March 2002 743

 Cho et al.

tients after IV administration of 0.1 mmol/kg of
gadopentetate dimeglumine. In one patient, a dy-
namic enhanced study was performed, and images
were obtained at 30, 90, 180, and 300 sec after IV
injection of the contrast material. The signal inten-
sities on the T1- and T2-weighted MR images,
margin of the mass, capsule, and contrast enhance-
ment pattern were evaluated.
Results
Clinical Features
The patients were 11–32 years old (aver-
age age, 22.4 years) and had no considerable
medical or surgical history. Patients pre-
American Journal of Roentgenology 2002.178:743-748.
sented with testicular pain or enlargement
over various periods (20 days to several
years). On physical examination, each pa-
tient had a nontender, firm testicular mass.
Serum β-human chorionic gonadotropin and
α-fetoprotein levels were normal, and there
were no other specific laboratory findings.
Pathologic Features
All lesions were intraparenchymal and
sharply demarcated. Adjacent testicular tis-
sue was compressed but otherwise unre-
markable in all patients. The cysts ranged
from 1.1 × 1.0 to 3.0 × 2.5 cm. All of the
cysts were unilocular masses lined by a ma-
ture squamous epithelium and filled with
laminated keratinous materials. In one pa-
tient, calcification and reactive osseous meta-
plasia were found focally.
Sonographic Features
On sonography, four lesions were sharply de-
marcated, and the fifth showed a focally indis-
tinct margin (Fig. 1A). Three lesions were
surrounded by a hypoechoic rim (Figs. 1A, 2A,
and 3A) and two by an echogenic rim (Fig. 4A).
All lesions showed a markedly heterogeneous
internal echotexture. One of the lesions con-

A B

C D

Fig. 1.—11-year-old boy with right testicular epidermoid cyst that showed partially indistinct margin and lobulated contour on sonography.
A, Sonogram shows heterogeneous solid-appearing lesion (arrows) surrounded by echolucent rim. Note that superior border (arrowheads) is partially indistinct.
B, T2-weighted MR image shows lobulated contour lesion of heterogeneous signal intensity intermixed with high, intermediate, and low signal intensities.
C, Unenhanced T1-weighted MR image shows lesion of heterogeneous signal intensity and partially indistinct margin (arrows).
D, Fat-suppressed contrast-enhanced T1-weighted MR image shows sharply marginated low-signal-intensity mass without enhancement. Suppression of signal intensity
in portions containing high lipid content is noted. Adjacent vessel (arrow) simulating enhancement is seen.

744 AJR:178, March 2002

 Sonography and MR Imaging of Testicular Epidermoid Cysts
Fig. 2.—20-year-old man with left testicular epidermoid cyst that contained calcifications.
A, Sonogram shows heterogeneous lesion (arrows) of laminated appearance. Several echogenic foci (arrowheads) with posterior sonic shadowing representing calcifi-
cations are seen.
American Journal of Roentgenology 2002.178:743-748.
B, T2-weighted MR image shows heterogeneous lesion containing low-signal-intensity foci.
tained a focal echogenic portion with posterior
sonic shadowing (Fig. 2A). Three lesions
showed an internal pattern of alternating hypo-
and hyperechoic layers. One lesion showed an
onionskin appearance (Fig. 3A), one showed a
target appearance (Fig. 4A), and one showed a
laminated appearance (Fig. 2A). The remaining
two lesions showed heterogeneous mixed
echogenicity with no alternating pattern (Fig.
1A). Vascular flow signal was not seen on color
Doppler sonography (Fig. 3A).
MR Imaging Features
On T2-weighted MR imaging, all lesions
were surrounded by a low-signal-intensity
rim and were sharply marginated. In one pa-
tient, a small part of the margin was indistinct
(Fig. 1B). Four lesions were heterogeneously
higher in signal intensity than that of normal
testicular parenchyma (Figs. 1B, 2B, and
4B), and one lesion was homogeneously high
in signal intensity (Fig. 3B). One out of five
lesions showed a typical target appearance
(Fig. 4B). (Fig. 3B). On T1-weighted MR im-
ages, four lesions were homogeneous or heter-
ogeneous, with low signal intensity containing
intermediate- or high-signal-intensity portions
(Fig. 4C); and in the remaining one lesion,
low, intermediate, and high signal intensities
were intermixed (Fig. 1C). On contrast-en-
hanced images, all lesions were sharply de-
marcated low-signal-intensity masses, and
contrast enhancement was not seen in any of
the cases (Figs. 1D and 3C).
AJR:178, March 2002
A B
Discussion
The histogenesis of testicular epidermoid
cysts has not been completely proved, but
most investigators suggest that these tumors
are a monodermal development of a teratoma
[1] or a squamous metaplasia of the seminif-
erous epithelium or rete testis.
Because testicular epidermoid cysts are
benign, a cure is possible if the mass is com-
pletely resected. Recently, organ-preserving
surgery has become favored over traditional
inguinal orchiectomy because it may offer
better psychologic and cosmetic results and
the preservation of fertility. Although organ-
preserving surgery has been widely advo-
cated, many surgeons still carry out an or-
chiectomy because of the relatively high
incidence of malignant testicular masses, the
potential for misdiagnosis on frozen sec-
tions, and the possible existence of concur-
rent malignant lesions. But the most
important problem is that the exact preopera-
tive differential diagnosis is difficult.
Sonography can suggest an epidermoid
cyst, but it is often not sufficient to convince
surgeons that the mass is an epidermoid cyst.
Heidenreich et al. [4] reported that the sono-
graphic appearance was not specific and in-
guinal testicular exploration was required.
However, if an exact preoperative imaging
diagnosis is possible, organ-preserving sur-
gery may be carried out more often.
Sonographic findings of epidermoid cysts
vary, but some suggestive findings have been
described, and these correlate well with the
gross pathologic findings [6–11]. Testicular
epidermoid cysts are well demarcated from
surrounding normal parenchyma by an echolu-
cent or echogenic rim. Pathologically, the cyst
is lined by a complete or incomplete inner lin-
ing of squamous epithelium. Also, a fibrous
capsule with or without calcification or ossifi-
cation may be present [7–10]. Langer et al.
[10] found that the lesions with an echogenic
rim had a fibrous capsule without calcification,
and the lesions without an echogenic rim had
an outer lining composed only of squamous
epithelium. However, other investigators [8, 9]
found that the echogenic rim represented calci-
fication. On pathologic correlation of our
study, two cases with an echogenic rim had fi-
brous capsules, and one of them showed a rim
of calcification. A focally indistinct margin
seen in one case was proved to have only a
squamous epithelium without a fibrous cap-
sule. The internal echogenicity may vary de-
pending on the complexity of the internal
contents. However, some cases show the spe-
cific finding of an onionskin [7, 10] or target
[11] appearance of concentric rings of alternat-
ing hypoechogenicity and hyperechogenicity.
The sonographic finding of alternating layers
is pathologically well correlated with alternat-
ing layers of compacted keratin and loosely
dispersed desquamated squamous cells [3, 7,
10]. Our cases also showed varying internal
echogenicity. This complexity seems to be
caused by the difference of arrangement in al-
ternating patterns. In the cases of regularly ar-
ranged alternating patterns, an onionskin or
745
 Cho et al.

A B
American Journal of Roentgenology 2002.178:743-748.

Fig. 3.—32-year-old man with right testicular epidermoid cyst that showed onion-
skin appearance on sonography.
A, Color Doppler sonogram shows heterogeneous lesion (arrows) of onionskin
appearance. Vascular flow signal is not noted.
B, T2-weighted MR image shows homogeneous high-signal-intensity lesion sur-
rounded by low-signal-intensity rim.
C, Fat-suppressed contrast-enhanced T1-weighted MR image shows sharply
marginated homogeneous low-signal-intensity mass without enhancement.
C

target appearance is present; in the cases of
somewhat irregularly arranged alternating pat-
terns, a laminated appearance is seen; and in
the cases of random arrangement with no or
few alternating patterns, the lesions appear as
merely heterogeneous masses.
Langer et al. [10] described a lack of in-
ternal vascularity as another feature that can
differentiate epidermoid cysts from most
solid intratesticular lesions. Our study corre-
lated well with the results of Langer et al.
All three lesions examined with color Dop-
pler sonography did not show any internal
flow signal.
Few reports have been published in En-
glish describing the MR imaging findings of
testicular epidermoid cysts [2, 5, 6, 10, 12].
Four of them were case reports, and another
study described the MR imaging findings of
only three cases [10]. In these reports, the re-
searchers found that testicular epidermoid
cyst showed a bull’s-eye or target appearance
or signal intensity characteristics more typi-
cal of a cystic lesion. The target appearance
was composed of a low-signal-intensity cen-
ter, a high-signal-intensity mid zone, and a
peripheral low-signal-intensity rim on both
T1- and T2-weighted MR images. The re-
searchers postulated that the outer fibrous
capsule, epithelial lining, and adjacent com-
pact keratin produced peripheral low signal
intensity; the dense debris and calcification
produced central low signal intensity; and
the desquamated cellular debris containing
both a high water content and a high lipid
content produced mid zone of high signal in-
tensity on both T1- and T2-weighted MR im-
ages. In our study, the high-signal-intensity
portion correlated with desquamated cellu-
lar debris containing both high water and
lipid contents, and the low-signal-intensity
focus correlated with dense keratin debris.
One case seen with an onionskin appearance
on sonography showed a homogeneous high-
signal-intensity mass on the T2-weighted
MR image. This result did not correlate with the
report of Langer et al. [10] that two out of three
cases showed an onionskin appearance on both
MR imaging and sonography. We believe this
difference was caused by the resolution of MR
imaging being insufficient to discriminate the
thin layers of laminated keratin debris. In addi-
tion, intervening water and lipid content were
relatively abundant in our case.
To our knowledge, only one report of con-
trast-enhanced MR imaging of epidermoid
cysts has been published in English [10]. In this
report, the researchers performed contrast stud-
ies that did not show enhancement in two pa-
tients. This is well correlated with our result that
showed no enhancement in all of the patients.
No enhancement on contrast-enhanced MR im-
aging was well correlated with the results of
color Doppler sonography. It may be a useful
finding to differentiate epidermoid cysts from
other solid intratesticular lesions.

746 AJR:178, March 2002

 Sonography and MR Imaging of Testicular Epidermoid Cysts

Fig. 4.—19-year-old man with left testicular epidermoid cyst that

showed target appearance on sonography and MR imaging.
A, Sonogram shows heterogeneous lesion (arrows) sur-
rounded by echogenic rim.
B, T2-weighted MR image shows high-signal-intensity lesion
with central intermediate-signal-intensity focus.
C, T1-weighted MR image shows low-signal-intensity lesion
with central intermediate-signal-intensity focus.

A
American Journal of Roentgenology 2002.178:743-748.

B C

We summarize the radiologic findings of
testicular epidermoid cyst as a lesion with a
typical onionskin or target appearance, a
markedly heterogeneous solid-appearing le-
sion surrounded by a hypo- or hyperechoic
rim with sharp margins on sonography, a
high-signal-intensity mass containing low- or
medium-signal-intensity foci surrounded by a
low-signal-intensity rim, and a lack of vascu-
larity on Doppler sonography or enhanced
MR imaging.
However, our study has several limitations.
The number of lesions in our study was not suf-
ficient to represent the entire spectrum of testic-
ular epidermoid cysts. Also, we could not
present the specific imaging findings able to dif-
ferentiate epidermoid cysts from other solid tes-
ticular tumors, including testicular malignancy.
In conclusion, sonographic and MR imaging
findings may suggest a testicular epidermoid
cyst. Although sonography shows strongly sug-
gestive findings of epidermoid cyst, sonogra-
phy is not completely diagnostic. In this
situation, MR imaging, including contrast en-
hancement, may provide more supportive find-
ings for the diagnosis of an epidermoid cyst,
and this may lead surgeons to perform organ-
preserving surgery instead of orchiectomy.
References
1. Price EB. Epidermoid cyst of the testis: a clinical
and pathological analysis of 69 cases from the tes-
ticular tumor registry. J Urol 1969;102:708–713

AJR:178, March 2002 747


2. Hricak H, Hamm B, Kim BH. Testicular tumors
and tumorlike lesions. In: Hricak H, Hamm B,
Kim BH, eds. Imaging of the scrotum: textbook
and atlas. New York: Raven, 1995:49–93
3. Dieckmann KP, Loy V. Epidermoid cyst of the
testis: a review of the clinical and histogenetic
considerations. Br J Urol 1994;73:436–441
4. Heidenreich A, Engelmann UH, Vietsch HV, Der-
schum W. Organ preserving surgery in testicular
epidermoid cysts. J Urol 1994;153:1147–1150
5. Schnall M. Magnetic resonance imaging of the
scrotum. Semin Roentgenol 1993;28:19–30
The full text and images from the American Journal of Roentgenology may also be viewed online at www.arrs.org
or www.ajronline.org.
American Journal of Roentgenology 2002.178:743-748.
748
Cho et al.
6. Fu YT, Wang HH, Yang TH, Chang SY, Ma CP.
Epidermoid cysts of the testis: diagnosis by ultra-
sonography and magnetic resonance imaging re-
sulting in organ-preserving surgery. Br J Urol
1996;78:116–118
7. Malvica RP. Epidermoid cyst of the testicle: an
unusual sonographic finding. AJR 1993;160:
1047–1048
8. Cohen EL, Carr L, Mandel E, Feigin G, Goodman
JD, Dikman S. Epidermoid cyst of testicle: ultra-
sonographic characteristics. Urology 1984; 24:79–81
9. Bahnson RR, Slasky BS, Ernstoff MS, Banner
BF. Sonographic characteristics of epidermoid
cyst of testicle. Urology 1990;35:508–510
10. Langer JE, Ramchandani P, Siegelman ES, Ban-
ner MP. Epidermoid cysts of the testicle: sono-
graphic and MR imaging features. AJR 1999;173:
1295–1299
11. Maxwell AJ, Mamtora H. Sonographic appear-
ance of epidermoid cyst of the testis. J Clin Ultra-
sound 1990;18:188–190
12. Brenner JS, Cumming WA, Ros PR. Testicular
epidermoid cyst: sonographic and MR findings.
(letter) AJR 1989;152:1344
AJR:178, March 2002