2014, Volume 30, Number 1, Page(s) 078-080
A Giant Primary Sclerosing Lipogranuloma of the Scrotum
Sevdegül MUNGAN1, Ersagun KARAGÜZEL2, Celaleddin TURAN3, Abdulkadir REİS1
1Departments of Medical Pathology, Karadeniz Technical University, Faculty of Medicine, TRABZON, TURKEY
2Departments of Urology, Karadeniz Technical University, Faculty of Medicine, TRABZON, TURKEY
3Department of Urology, Akçaabat State Hospital, TRABZON, TURKEY
Keywords: Granuloma, Scrotum, Sclerosis, Adipose tissue
Sclerosing lipogranuloma is a rare, benign disease that can affect
several organs, particularly of genitourinary system in males. The
majority of the cases are secondary to exogenous foreign bodies.
The masses are composed of granulomatous tissue formed around
an either exogenous or endogenous lipomatous substance. We
describe a 47-year-old male patient who presented with a growing,
painless scrotal mass on physical examination. The mass was in 20
cm diameter and the laboratory findings were in normal limits.
Pathologic evaluation confirmed the diagnosis of scrotal sclerosing
lipogranuloma. To the best of our knowledge, this is the biggest
scrotal sclerosing lipogranuloma case in the literature. We aimed with
this presentation to keep in mind this benign lesion and also to assist
the algorithmic approach.
Sclerosing lipogranuloma (SLG) of the scrotum is relatively
uncommon granulomatous condition presenting with
subcutaneous mass. SLG was first reported by Smetana and
Bernhard in 19501
. This benign lesion has previously
been described as involving such structures as the scrotum,
perineum, penis, and spermatic cord2,3
. SLG is described
as primary when idiopathic in origin, and cases induced
by injection of pathogenic materials such as paraffin and
mineral oil are referred to as secondary4
. We report a
case of giant scrotal SLG treated surgically, together with a
review of the literature. Our case was a primary SLG with
no history of exogenous foreign bodies.
The patient was a 47-year-old man. He had a growing, painless
scrotal mass of 5 years duration. He did not have any
trauma or an exogenous material injection to the scrotum.
An irregular, painless, solid scrotal mass was revealed by the physical examination (Figure 1
). There were no lymphadenopathy
and also no lesion in bilateral testes, epididymis.
Laboratory findings (whole blood count, blood chemistry,
serum tumor markers) and roentgenologic examinations
(chest radiography and computed tomography of the abdomen)
were all within normal limits.
The scrotal mass was resected, and the testicles, all adjacent
structures were preserved. The mass was in the subcutaneous
fat tissue and had no connection to the adjacent structures
(testis, spermatic cord, epididymis, penis). At macroscopic examination, the mass was symmetrical, Y-shaped and
20 x 18 x 15 cm in size. The subsequent clinical course
of the patient was good and there was no recurrence
at 4-year follow-up. Histological evaluation revealed a
granulomatous reaction in fat tissue. Multinucleated giant
cells in epithelioid granulomas and inflammatory process
dominated by lymphocytes were present (Figure 2A, B).
Eosinophilic infiltrates were also present in the lesion
(Figure 2C). In large sclerotic areas there were many foci
of dystrophic calcification (Figure 2D), indicating that the
mass was an old lesion.
Click Here to Zoom
|Figure 2: A) Multinucleated giant cells in epithelioid granulomas
(H&E x400). B) Inflammatory process dominated by lymphocytes
(H&E x400). C) Eosinophils were present in the inflammatory
process (H&E x400). D) Dystrophic calcification (H&E x40).
E) CD45RO (x400). The majority of lymphocytes were CD45RO
(+) T lymphocytes.
An immunohistochemical examination was performed
using Dako’s ENVISION method. The primary antibodies
used were CD45RO (Neomarkers, UCHL–1, ready to use),
CD68 (Neomarkers, clone KP1, ready to use) and CD20
(Scytek, clone L26, ready to use). Most of lymphocytes (>
% 95) were CD45-positive T cells, and 5% of lymphocytes
were CD20-positive B ( Figure 2E) lymphocytes. CD 68
was strongly positive in epithelioid cells and multinucleated
giant cells. The result of polymerase chain reaction for
mycobacterium tuberculosis was negative. Acid-fast
bacteria were not identified by Ziehl-Neelsen stain. No
fungi or gram-positive bacteria were observed using
Grocott, gram, and PAS stains.
SLG was first reported by Smetana and Bernhard in 19501
SLG of the male genitalia is a tissue reaction to exogenous
foreign bodies such as paraffin, silicon (secondary SLG)
or endogenous lipids (primary SLG)3,4
. Our case was a
primary SLG with no history of exogenous foreign bodies.
Histologically, SLG is a granulomatous lesion containing
epithelioid cells, eosinophils, multinucleated giant cells,
lymphocytes and macrophages1,2,5
The term eosinophilic SLG has also been used for this lesion
because of marked eosinophilic infiltration and eosinophilia
in peripheral blood. It has been suggested that it is closely
related to the granulomas, although the mechanism remains
unclear6. Our case of primary SLG of the scrotum had mild
eosinophilic infiltration (10%-15%) and no eosinophilia in
peripheral blood. Immunohistochemically, the majority of
lymphocytes were CD45RO-positive T cells, compatible
with the hypothesis that degeneration of endogenous fat
due to some allergic mechanism might be involved in the
development of SLG6. Microscopic examination revealed
significant calcifications in the lesion. There has only been
one previous study regarding bilateral SLG of the gluteal
region with calcification, that by Iannello et al7. In our
case the dystrophic calcifications may be ascribed to the
aging of the lesion over a 5-year period. At macroscopic
examination the mass was symmetrical, Y-shaped and 20 x
18 x 15 cm in size. The SLG cases reported in the literature
have measured between 1.5 and 9 cm.7,8. Our case is
the largest scrotal SLG lesion in the literature. Tuberculosis,
fungal infection and foreign body granuloma should be
considered in cytological differential diagnosis of SLG.
A negative polymerase chain reaction for Mycobacterium
tuberculosis was seen. No acid-fast bacteria were identified
by Ziehl-Neelsen stain. No fungi or gram-positive bacteria
were observed using PAS, Grocott and gram stains. The presence of the granulomatous reaction and the
lymphocytic infiltration in particular led us to diagnose this
benign lesion as primary SLG of the scrotum.
Definitive diagnosis can be established by histological
examination of biopsied or resected specimens. Although
steroid therapy has been recommended as the first treatment
of choice, biopsy and surgical excision are frequently
performed in the treatment of SLG8,9. Surgery should
be the treatment of choice in patients with recurrence and
in whom steroids are ineffective8. SLG is a self-limited
condition after biopsy in many reported cases4,6,8,10.
In the case of incomplete resection, however, the mass
exhibits a rapid recurrence, thus mimicking a neoplastic
lesion6. No recurrence in our case was determined during
the 4-year follow-up. In summary, we describe a very rare
case of primary SLG of the scrotum. To the best of our
knowledge, this is the largest example of scrotal SLG in the
literature. Most of the reported cases in English literature
patients are Japanese. We didn’t have any knowledge about
the demographical distribution.
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