\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{A one-year-old boy with cystic teratoma mimicking simple testicular cyst
: A rare case report from Syria.}



\author[1]{Hasan Alsmodi}%
\author[1]{Mouhammed Sleiay}%
\author[1]{Bilal  Sleiay}%
\author[2]{Abdulazez Sleiay}%
\author[3]{Abdalrahman Slaea}%
\author[4]{Gihad Allugamie}%
\affil[1]{University of Hama}%
\affil[2]{Hama University}%
\affil[3]{Veterinary medicine institute , Hama University}%
\affil[4]{Department of Urology ,National Hama Hospital, Hama University .}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{Key clinical message:}

In the differential diagnosis of testicular transilluminating masses in
babies, testicular teratoma should be considered even in cases when
ultrasonography reveals a completely cystic lesion.

\textbf{Abstract:}

\textbf{Background :} The first intraparenchymal testicular cyst in a
human being was recorded by Copper in 1845, but it was subsequently
shown to be a cystic teratoma, making simple testicular cysts an
uncommon ailment.

\textbf{Case presentation:} A pediatrist sent a one-year-old child to
the urology department with a diagnosis of right-sided

hydrocele.Under ultrasound guidance, we aspirated the cyst through the

scrotum. The aspiration was a 2 ml clear serum-like fluid. Everything
was

normal during the first year of follow-up. After two years, the boy was

brought back to the department due to recurrent testicular

enlargement.Then it was discovered that it was a cystic teratoma.

\textbf{Conclusion:} In the differential diagnosis of testicular
transilluminating masses in babies, testicular teratoma should be
considered even in cases when ultrasonography reveals a completely
cystic lesion. The initial tests that direct the subsequent course of
treatment include ultrasonography and serum markers such as
Alpha-1-Fetoprotein(AFP) and Human Chorionic Gonadotropin(HGC).

\textbf{Keywords:}

Cystic teratoma; testicular ; cyst; ultrasonography.

Introduction:

Simple testicular cysts are rare condition, as Copper reported the first

human intraparenchymal testicular cyst in 1845, but it was later

determined to be a cystic teratoma Less than 50 occurrences of simple

testicular cyst were recorded from 1966 to 2004. Prepubertal testicular

tumors are uncommon, making between 1\% 2\% of all pediatric tumors

and occurring in between 0.5 and 2.0 children per 100,000. Teratoma is

the second most frequent testicular tumor in children, after yolk sac

tumor, despite seminoma being the most common testicular tumor in

adults. Individuals may exhibit either painless or painful scrotal

enlargement ,particularly if the cyst's diameter is greater than 5 cm.

simple testicular cyst usually ranges from 0.2 to 2 cm .1Testicular

teratomas are often a firm mass in patients; however, occasionally they

may feel cystic upon palpation because some of the mass is made up of

cysts that are fluid or mucous-filled. At some point, it may

transilluminate and be mistaken for a hydrocele. Ultrasonic imaging can

rule out hydrocele and reveal a testicular tumor that is partly cystic
and

has patches of hypo- or anechoic tissue. Thus, even though testicular

teratomas have no specific ultrasonographic pattern, the most typical

feature is a nonhomogeneous echoic mass that frequently has

calcifications. Unilocular, entirely cystic teratomas have not yet been

documented in any patients .2the encysted hydrocele, which is loculated

fluid between the inner surface of the visceral tunica vaginalis and the

tunica albuginea that is not surrounded by a real wall.3 Children's

scrotums can include cystic testicular dysplasia .4 The selection of the

treatment plan should take into account the patient's age, symptoms,

compliance with the surveillance, cyst size, and dynamic

ultrasonographic changes. where, in prepubertal age patients with a

testicular tumor with a benign ultrasonographic appearance and no serum

markers, testis-sparing surgery by scrotal access is advised .2

\textbf{Case history:}

A one-year-old boy was brought by his parents to the urology departement
with a complaint of right testicular enlargement(fig.1).on physical
examination, He looks healthy, had no surgical, trauma history. The left
testis and epididymis were normal.Scrotal ultrasound exposed a 2 cm
simple testicular cyst(Video 1).Due to the low incidence of simple
testicular cysts in infants and the sensitivity of testiculectomy and
its psychological consequences especially at this age so we did an
aspiration to the cyst through the scrotum under ultrasound guidance.
The aspiration was clear serum like 2ml fluid. The simple testicular
cyst disappeared later, and with follow-up for months, no enlargement of
the right testicle or recurrence of the simple testicular cyst was
observed during this period. In the first year of following up
everything was normal. After two years,the boy was brought to the
department again because of the recurrence of the testicular
enlargement. \textbf{Differential diagnosis, investigations and
treatment:}

Physical examination shows a 1 cm in diameter solid irregular mass in
his right testis, as well as in ultrasonography(fig.2).Tumor markers
show normal beta-HCG, but alpha-fetoprotein higher than 1200ng/ml.
Surgical inguinal exploration

was performed because the non-malignant part of the testicle does not
exceed 5\% of the entire testicle . Frosen section revealed Teratoma, so
we did radical orchiectomy(fig.3A). The biopsy showed cystic formations
with

multilayered and keratinized epithelium, and beneath this epithelium

there are glandular formations, which confirms the diagnosis of Mature
Cystic

teratoma 1 cm not invading tunica albuginea(fig.3B).

\textbf{Outcome and follow-up:}

After resection, AFP values returned to normal values .On follow up
for two years later , no other masses were observed.

Discussion :

Copper reported the first intraparenchymal testicular cyst in humans in

1845, though it was later determined to be a cystic teratoma. In 1966,

Schmidt reported the first case of a simple testicular cyst in a child
under

the age of 5 months. Tosi and Richardson reported the first adult case
of a

simple testicular cyst in 1975, involving a 58-year-old male. Less than
50

instances of simple testicular cysts were documented overall between

1966 and 2004. This indicates that a simple testicular cyst is a rare

condition. Small testicular cysts can develop at any age, although the

majority affect males over the age of 40. G\selectlanguage{ngerman}üçer, Tanyel, and Calar
(2007)

found that 75\% of patients with the infant type had a simple cyst in
the

left testis. Simple testicular cysts often have diameters between 0.2
and

2cm. Simple cysts seldom produce symptoms and are typically not

palpable if they are modest in size. A cyst may show as suspected

testicular torsion if there is spontaneous bleeding into the cyst
cavity.

Moreover, individuals may exhibit either painless or painful scrotal

enlargement, particularly if the cyst's diameter is greater than 5 cm. 1
In

children, benign testicular masses including testicular teratomas,

epidermoid cysts, and tunica albuginea cysts are infrequently observed.

There have only been 48 cases of simple cysts in the testicular

parenchyma recorded in the literature, making them incredibly

uncommon. Eight of the patients in these situations were under the age
of

two.4 A one-year-old child was brought by his parents to the urology

department in our case with a right scrotal enlargement, which makes it
a

highly unusual case for the age and the location. Simple testicular cyst

etiology is still controversial, however in most cases, ectopic
epithelium

like that seen in the Wolffian duct is thought to be the cause. The

pathological findings of the cyst wall in this instance matched those of

the Wolffian duct. Testicular lymphoangiomas, dermoid and epidermoid

cysts, epididymal cysts, hydrocele, cyst of tunica albuginea, cystic

dysplasia, teratoma, and juvenile granulose cell tumor are among the

other possible diagnoses for a simple testicular cyst. This difference
is

pathologically conceivable. 1,4,5,6 In fact, the pathognomonic

ultrasonography characteristics described by Rifkin and Jacobs (1983)

enable the preoperative diagnosis of a simple testicular cyst. A simple

testicular cyst is distinguished on ultrasound by edge shadowing,

posterior wall enhancement, lack of internal echoes, and cleanly defined

walls. These preoperative ultrasonography requirements differentiate a

simple testicular cyst from other diseases. Epidermoid cysts look

uniformly solid. Lesions outside the testis are known as tunica
albuginea

cysts.5 The best way to identify a simple testicular cyst is through

pathology. The pathological requirements for a simple testicular cyst
are

as follows: When a cyst is considered to be normal, it meets the

following criteria: (a) it is located in the parenchyma of the testis,
(b) the

tunica albuginea is not involved, (c) it contains sperm-free clear fluid
and

is surrounded by a cyst wall lined entirely or partially by flat or
cuboidal

epithelial cells with a fibrous tissue wall, (d) it is free of
teratomatous

elements inside the cyst or testis , and (e) not having any fibrosis or

persistent inflammation outside of the cyst wall.1 Preoperative

ultrasonography was first introduced in 1988 by Alta-Donna et al, who

also promoted testis-sparing surgery. Following that study,

ultrasonography has been used to identify all cases of simple testicular

cysts, and the testes that were impacted have been saved.4 For simple

testicular cysts, inguinal or scrotal methods have been documented. Some

authors believe the inguinal method is unnecessary and the scrotal

approach is recommended if clinical, ultrasonographic, and serologic

criteria support a benign, entirely cystic mass.2 Clearly, individuals
with

asymptomatic cysts of both the infant and adult types should choose for

this ''watch and wait'' approach.1 This is why we first chose to monitor

the lesion using follow-up ultrasonography. Surgery intervention is
still

necessary if any of the following conditions exist: (a) the cyst
undergoes

any change in ultrasonography while under surveillance; (b) the patient

fails to respond to the surveillance program; (c) the cyst is painful,

though it may not be the only cause of the pain; and (d) the cyst's

diameter is greater than 3 cm for children or 5 cm for adults.1 Thus,
the

normal course of prepubertal testicular teratoma is very different from

that of adult testicular teratoma. Compared to approximately 90\% of

cases in the latter, the former is virtually invariably benign and
seldom

exhibits concomitant intratubular germ cell neoplasia. Because of this,

metastatic assessment can be delayed until a histopathologic diagnosis
is

made. According to Shukla et al., therapy was based on testicular lesion
ultrasonographic and intraoperative visual appearance, as well as
preoperative AFP levels.They avoided frozen analysis and underwent
testis-sparing surgery in the

case of a prepubertal child who had a testicular tumor that was mostly

cystic and had AFP levels that were appropriate for the child's age.
They

found that testicular cystic lesions, including epidermoid and dermoid

cysts as well as simple cysts and teratomas, were always benign.2 in our

case, Inguinal exploratory surgery was done. Radical orchiectomy was

performed after a frost section showed teratoma because the
non-malignant part did not exceed 5\% of the entire testicle. The biopsy
confirmed the diagnosis of Mature Cystic teratoma 1 cm not invading
tunica albuginea because it revealed glandular forms beneath the
multilayered, keratinized epithelium that covered the cystic
formations.Even when ultrasonography shows a fully cystic lesion,
testicular

teratoma should be included in the differential diagnosis of testicular

transilluminating masses in infants. Ultrasonography and serum

indicators like AFP and HGC are first-level tests that guide the
following

treatment.

\textbf{List of abbreviations:}

AFP: alpha-1-fetoprotein.

HCG: human chorionic gonadotropin.

\textbf{Authors' contributions}

MS was a major contributor in writing the manuscript and prepared all
figures.

BS wrote a part of the manuscript.

HA wrote a part of the manuscript.

GA performed the histological examination and was a major contributor in
writing the manuscript.

AS wrote a part of the manuscript.

AbdalrS wrote a part of the manuscript.

\textbf{Acknowledgements}

Not applicable

\textbf{Conflict of Interest Statement}

Not applicable.

\textbf{Key Clinical Message}

In the differential diagnosis of testicular transilluminating masses in
babies, testicular teratoma should be considered even in cases when
ultrasonography reveals a completely cystic lesion.

\textbf{References:}

1. Fang Y, Zhao L, Yan F, Cui X, Zhou F. Strategy for Treating Simple

Testicular Cyst in Adults. Am J Mens Health. 2011;5(3):193-197.

doi:10.1177/1557988310364055

2. Di Renzo D, Persico A, Sindici G, Lelli Chiesa P. Testicular

teratoma, mimicking a simple testicular cyst, in an infant. Urology.

2013;82(3):701-703. doi:10.1016/j.urology.2013.03.022

3. Rifkin MD, Jacobs JA. Simple testicular cyst diagnosed

preoperatively by ultrasound. J Urol. 1983;129(5):982-983.

doi:10.1016/S0022-5347(17)52498-2

4. Honjo O, Uemura S, Murakami I. Simple testicular cyst in infants: A

case report and review of the literature. Eur J Pediatr Surg.

2001;11(6):425-427. doi:10.1055/s-2001-19724

5. Upadhyay V, Holmes M, Kolbe A. Gonadal preservation in a simple

testicular cyst. Pediatr Surg Int. 1998;13(5-6):445-446.

doi:10.1007/s003830050365

6. Haber MM, Cohen MB. Simple cysts of testis. Urology.

1992;39(6):563-565. doi:10.1016/0090-4295(92)90019-S

\textbf{Figures legends:}

Figure1. : right testicular enlargement without hydrocele. The left
testis

and epididymis are normal.

Figure2.: Scrotal ultrasound exposes a 1 cm in diameter solid irregular
mass in his right testis.

\emph{Figure3.:} \textbf{A.} Radical orchiectomy was performed after a
frost section

showed teratoma. \textbf{B.} The biopsy shows cystic formations with

multilayered and keratinized epithelium, and beneath this epithelium

there are glandular formations, which confirms the diagnosis of Cystic

teratoma 1 cm not invading tunica albuginea.

\textbf{Video Legends :}

\textbf{Video1. :} Scrotal ultrasound exposes a 2 cm simple testicular
cyst.

\textbf{Hosted file}

\verb`Figure1.docx`  available at \url{https://authorea.com/users/674369/articles/686730-a-one-year-old-boy-with-cystic-teratoma-mimicking-simple-testicular-cyst-a-rare-case-report-from-syria}

\textbf{Hosted file}

\verb`Figure2.docx`  available at \url{https://authorea.com/users/674369/articles/686730-a-one-year-old-boy-with-cystic-teratoma-mimicking-simple-testicular-cyst-a-rare-case-report-from-syria}

\textbf{Hosted file}

\verb`Figure3.docx`  available at \url{https://authorea.com/users/674369/articles/686730-a-one-year-old-boy-with-cystic-teratoma-mimicking-simple-testicular-cyst-a-rare-case-report-from-syria}

\selectlanguage{english}
\FloatBarrier
\end{document}

