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  图3-12可见上皮有增生，不典型增生，除头节处可见外胚层及中胚层结构，其余囊壁大部分为粘液性上皮，有睾丸畸胎瘤合并囊腺瘤的吗？不够诊断恶性的吧？

 请教老师，我昨天刚遇到一例21岁，睾丸肿瘤，大体就是睾丸实质里界清结节，镜下鳞状上皮衬里，腔内只有层状角化物，睾丸，附睾结构都正常，直接报的表皮样囊肿，可以么？

 本例提供的患者信息是否有误，性别是女还是男？上传的图片无睾丸及附睾组织，考虑为成熟性畸胎瘤伴体细胞癌变（肠型腺癌）

这例很值得探讨。

60岁的老女人有阴囊本来就奇怪。

从提供的图片看，睾丸皮样囊肿并未能就一定排除。只是本例的内胚层（肠腺上皮）是有异型的，像腺癌结构。首先考虑（睾丸）

成熟性囊性畸胎瘤伴体细胞癌变（腺癌）。

 畸胎瘤恶变

那版主的意思就是睾丸皮样囊肿可以有头节吗？

 WHO  icd-O编码   睾丸皮样囊肿是  9084/0    可是多数人又认为 成人睾丸成熟性畸胎瘤可有转移，那么作为成熟性畸胎瘤的亚型的成人“睾丸皮样囊肿”预后到底怎样？临床如何处理？   我又糊涂了     请老师解答

 那么在睾丸畸胎瘤和皮样囊肿鉴别要点有哪些呢？睾丸畸胎瘤报告时还需要分 成熟性与非成熟性吗？

 学

学习。

 在下考虑睾丸皮样囊肿，但局灶见肠型腺上皮成分，并见腺癌。学识浅薄，请各位专家指导。

像描述的一样，鞘膜内只见到一囊，未见明显的睾丸及附睾结构，确定有毛发有头节

 大家都认为是畸胎瘤，我想是把卵巢畸胎瘤的概念想当然地应用于睾丸，但睾丸却比较特殊。楼主提的有毛发结构，现在所有的文献中均提到睾丸的畸胎瘤看不到，至少目前还没有存在毛发的病例报道。加之楼主描述似乎是单囊，有头节，所以这一例需要鉴别皮样囊肿。请大家注意的是，睾丸的皮样囊肿和我们的一般理解不同，它可以有内胚层成分如肠上皮，可以有中胚层成分如软骨，当然它一定有外胚层成分皮肤组织。

为什么一定区分?

正如很多网友提到的，成人睾丸的畸胎瘤都是恶性的，有转移能力。但皮样囊肿无转移能力，在皮样囊肿中发生的癌的情况如何？我们现在还不知道。这一例的有意思的地方就在这里。

Epidermoid cysts are relatively uncommon, and dermoid cysts are rare. Both need to be distinguished from the usual teratoma of the adult testis because they are uniformly benign, whereas the usual postpubertal teratoma may have associated metastases of either teratomatous or nonteratomatous germ cell tumors.43,44 We feel that dermoid cysts likely develop from benign germ cells with retained embryonic properties, probably similar to prepubertal testicular teratomas and ovarian teratomas. Epidermoid cysts either have a similar histogenesis or may possibly arise from displaced metaplastic mesothelial cells. Usual testicular teratoma of the postpubertal type, in contrast, develops from malignant germ cells (IGCNU), usually indirectly, by differentiation from other types of invasive germ cell tumors. It, therefore, represents a differentiated, malignant neoplasm that forms through a process of “maturation” from more primitive types of germ cell tumors.

Grossly, dermoid cysts and epidermoid cysts are unilocular cystic masses filled with keratinous material that may have a laminated appearance (Figure 3, A). Dermoid cyst may have a mural protuberance in the wall and contain hair. In comparison, teratoma often presents as a multilocular solid-cystic complex mass, and we have never grossly identified hair in a usual teratoma of the adult testis. Microscopically, a dermoid cyst is lined by squamous epithelium and skin adnexal structures (Figure 3, B). Prominent lipogranulomas may be seen in the testis, presumably as a reaction to sebaceous material leaked from the cyst contents (Figure 3, C). In addition to the cutaneous-type components, dermoids may have components of other tissues, including glandular elements, adipose tissue, cartilage (Figure 3, B), and bone, further mimicking postpubertal teratoma.45 An epidermoid cyst is a simple cyst lined by squamous epithelium, with no adnexal structures or other tissue types (Figure 3, D).46,47 In contrast, a teratoma often contains multiple cysts, lined by glandular or squamous epithelium, neuroectodermal tissue, noncystic glands, and mesenchymal tissues, such as adipose tissue and cartilage (Figure 3, E). A critical feature of both dermoid and epidermoid cysts, which distinguishes them from the usual teratoma, is the absence of IGCNU in the adjacent testis (Figures 3, C and D), whereas IGCNU occurs with a usual teratoma in 90% of the cases (Figure 3, F).48 Extreme care is needed when diagnosing dermoid cyst or epidermoid cyst in postpubertal testes. The presence of IGCNU (or other germ cell tumor elements) excludes a dermoid cyst and an epidermoid cyst and indicates that the lesion is a usual teratoma. Additional helpful features that aid in the distinction of the dermoid cyst from the usual teratoma include the presence in a usual teratoma of cytologic atypia of its elements and associated testicular atrophy with impaired spermatogenesis. Dermoid cysts lack cytologic atypia, and in most cases, the adjacent testis has a normal appearance with active spermatogenesis (Figure 3, C), although there may be compressive atrophy in the parenchyma immediately adjacent to the cyst. Isochromosome 12p by cytogenetic studies can be confirmatory in difficult cases. It is present in most postpubertal teratomas, but not epidermoid cysts.49 Based on light microscopic observations of dermoid cysts, we anticipate that they would also lack i(12p) or other forms of 12p amplification, but that has not, to our knowledge, been studied yet. As a general marker for TGCT, SALL4 is frequently expressed in teratoma,41 but its expression in dermoid and epidermoid cysts is, to our knowledge, unknown.

Figure3. A, The cut surface of an epidermoid cyst frequently shows laminatedwhite-yellow material. B, A dermoid cyst, by definition, forms skinlikestructures with adnexal elements. Other tissue types, however, may also beseen, including cartilage. C, Lipogranulomas (right) and normal spermatogenesiswithout intratubular germ cell neoplasia are seen adjacent to a dermoid cyst.D, An epidermoid cyst is lined by keratinizing squamous epithelium withoutadnexal structures (top). The adjacent tubules show normal spermatogenesiswithout intratubular germ cell neoplasia. E, Most usual teratomas show ahaphazard arrangement of various tissues, including glands, squamousepithelium, and cartilage. F, Intratubular germ cell neoplasia, unclassifiedtype, has a basilar arrangement of seminoma-like cells with Sertoli cells attheir luminal aspect in a tubule lacking spermatogenesis (hematoxylin-eosin,original magnifications ×40 [B and E], ×200 [C], ×100 [D], and ×600 [F]).

 病史中性别应该是男的吧。

根据图片，（右侧阴囊）伴有体细胞型恶性成分的生殖细胞肿瘤（成熟型畸胎瘤+肠型腺癌，两种成分各占百分比需要注明），又称畸胎瘤恶变。

成熟性囊性畸胎瘤伴体细胞癌变（腺癌）。

畸胎瘤恶变

（右侧阴囊）伴有体细胞型恶性成分的生殖细胞肿瘤（成熟型畸胎瘤+肠型腺癌，两种成分各占百分比需要注明），又称畸胎瘤恶变；

大家多诊断为畸胎瘤。这里我想询问楼主的是：1.真的是纯畸胎瘤样结构吗，或者有无其他生殖细胞肿瘤成分？2.如果无其他生殖细胞肿瘤成分，一定是畸胎瘤吗？3.病变是单囊还是多囊，是否类似于卵巢的畸胎瘤？有无确实毛发？4.周边一点睾丸实质成分也没有？如果有，有无管内生殖细胞肿瘤改变？ 这些问题很关键，因为这一例需要进行畸胎瘤与皮样囊肿之间的鉴别。

这一例的诊断还是存疑的。