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Primary lipogranuloma of male genitalia
PRIMARY LIPOGRANULOMA
OF MALE GENITALIA
MASAHIRO
MASAHARU TAKANAMI,
MATSUSHIMA,
MASAHARU TAJIMA,
M.D.
M.D.
AK10 MAKI, M.D.
M.D.
KO ANDO, M.D. TOSHIHIKO
ATOBE,
M.D.
From the Departments of Urology and Pathology, Toho University School of Medicine, Tokyo, Japan
ABSTRACT-Lipogranulomas developing secondarily in the genitourinary system have been reported rather frequently, but primary lipogranulomas without any past history of etiologically related conditions are rare. We report on 2 cases recently encountered in which tumors were diagnosed as sclerosing lipogranuloma on histopathologic examination.
In 1950 Smetana and Bernhard’ used the term “sclerosing lipogranuloma” to describe a peculiar granulomatous reaction of adipose tissue and attributed it to trauma or subcutaneous injection of foreign bodies such as paraffin. Sclerosing lipogranulomas of the genitourinary system are rare. This report presents 2 cases we have recently encountered in which a painless tumor mass had developed in the right inguinal region of one and in the scrotal septum of the other. Neither patient had a past history of trauma nor an injection of any subcutaneous foreign body, yet both tumors were diagnosed as sclerosing lipogranuloma on histopathologic examination after surgical removal. Case Reports Case 1 A fifty-four-year-old man first noticed the presence of a thumb-sized mass in the right inguinal region early in June, 1982. He was seen at the outpatient clinic of our department on July 12, 1982. Palpation revealed a firm mass with an uneven surface, measuring approximately 4 by 2 by 2.5 cm and palpable along the spermatic cord in the right inguinal region. Both testicles and epididymides appeared to be normal. A right high orchidectomy was performed on July 22, 1982, with a suspicion of tumor of the right spermatic cord. The mass arose from the spermatic cord adjacent to the external inguinal
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JANUARY 1988
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VOLUME XxX1, NUMBER 1
ring. It was firm, sharply demarcated from and unrelated to the surrounding tissues, and measured 3 by 2.5 cm, with an uneven surface. Cut surface revealed solid, grayish white tissue. There was no miHistopathologic findings. croscopic evidence of malignant tumor cells. Sections showed a marked granulomatous growth, with adipose tissue appearing, rolllike, in the granulation tissue. Neither caseation necrosis nor epithelioid cells were noted; numerous foreign body giant cells and Langhans giant cells were seen in places. The tumor tissue generally showed a pronounced histiocytic reaction and a remarkable abundance of fibrous elements. Examination with acid fast and periodic acid-Schiff (PAS) stains resulted in negative findings (Fig. 1A). We interpreted the microscopic findings as corresponding to the term “sclerosing lipogranuloma,” or what should be referred to as a sort of pseudotumor. The patient had a satisfactory, uneventful postoperative course and was discharged on the tenth postoperative day. He has been without recurrence for fifty-six months. Case 2 A thirty-six-year-old man noticed a thumbsized painless mass in his scrotal septum. On examination, a firm mass measuring 5 by 2.5 cm with an uneven surface was palpated in the scrotal septum, adjacent to the corpus spongiosum penis.
75
FIGURE 1. Microscopic findings. (A) Case 1. Primary lipogranuloma of spermatic cord. (B) Case 2. Primary lipogranuloma of scrotum. (Hematorylin and eosin, x 100 and x 40, respectively. )
Excision of the mass was performed on June 29,1983, with a suspicion of intrascrotal tumor. The tumor was situated adjacent to the corpus spongiosum penis but distinctly demarcated from and unrelated to the surrounding tissues. The tumor was 5 by 3 by 2 cm with an uneven surface and a firm consistency. Sections revealed grayish white solid tissue. Histopathologic findings. There was no microscopic evidence of malignant tumor cells.
76
Sections showed a marked granulomatous growth, with adipose tissue appearing, rolllike, in the granulation tissue. Neither caseation nor epithelioid cells were noted; numerous foreign body giant cells and Langhans giant cells were seen in places. The tumor tissue generally showed a pronounced histiocytic reaction and a remarkable abundance of fibrous elements. Findings on examination with acid fast and PAS stains were normal (Fig. 1B).
UROLOGY
/ JANUARY1988 / VOLUMEXXXI,NUMBERl
Five cases of primary Eipogranuloma of male genitalia
TABLE I.
Histopathologic
Clinical
Symptom
Age
Takahashis
43 37 45
Scrotal septum Scrotal septum L-scrotum
Painless Painless Painless
mass mass mass
Malignant
54 36
R-inguinal area Scrotal septum
Painless Painless
mass mass
Spermatic Malignant
Inazumi and Suzuki6 Matsushima
et al.
Site
Diagnosis
Source
. . . .
The patient progressed satisfactorily, with an uneventful postoperative course, and was discharged on the tenth postoperative day. There has been no recurrence of the tumor for the past forty-five months. Comment Granulomas of adipose tissue have been described under various names since the report by Abrikossoff in 1926,2 (e.g., fat granuloma, lipophages granuloma, nodular panniculitis, and lipogranuloma) . The tumors are usually classified into three stages according to histopathologic finds: Stage I, characterized by degeneration and necrosis of fat cells and by cellular infiltration, predominantly by neutrophils and lymphocytes; Stage II, characterized by lipogranuloma formation with histiocyte, granular cells, and giant cells; and Stage III, characterized by atrophy of fat lobules accompanied by fibrosis. Subcutaneous injections of foreign bodies, such as oily drug preparations and corticosteroid medications, and the effects of trauma or heat have been incriminated in the etiology of lipogranuloma. However, no particular cause was found in the cases described herein. Lipogranulomas that develop secondarily in the genitourinary system have been frequently lipogranulomas reported, 3,4 but primary without any history of etiologically related conditions are rare. A perusal of the Japanese literature disclosed only 3 cases during the past decade.5*6 Table I summarizes the clinical features, diagnoses, treatment modalities, and histologic
UROLOGY
/ JANUARY 1988
/ VOLUME XxX1, NUMBER 1
Finding
Treatment
tumor
Resection Resection Orchidectomy
Sclerosing lipogranuloma Sclerosing lipogranuloma Lipogranuloma
cord tumor tumor
Orchidectomy Resection
Primary Primary
lipogranuloma lipogranuloma
findings of the 5 cases reported, including the present cases. The patients ranged in age from thirty-six to fifty-four years (mean age 42). Each patient had a painless mass in the scrotum or inguinal region and underwent radical treatment because of a suspicion of malignancy, though the final diagnoses are not given in 2 cases. Histopathologic findings were characteristic of sclerosing lipogranuloma in all 5 cases. The treatment undertaken with a presumptive diagnosis of malignant tumor was appropriate since it was extremely difficult, as pointed out by Inazumi and Suzuki,e to diagnostically distinguish the mass from other types of neoplastic growth. The use of fine needle aspiration prior to radical treatment may help establish the diagnoses in future cases. Department of Urology Toho University School of Medicine 6-11-1 Omori-Nishi, Ota-Ku Tokyo 143, Japan (DR. MATSUSHIMA) References 1. Smetana HF, and Bernhard W: Sclerosing lipogranuloma, Arch Path01 50: 296 (1950). 2. Abrikossoff A: Ueber die spontan auftretende Fettgewebsnekrose und Fettgranulome, Zbl Path01 38: 542 (1926). 3. Newcomer VD, Graham JH, Schaffert RR, and Kalpan L: Sclerosing lipogranuloma resulting from exogenous lipids, Arch Dermatol 73: 361 (1956). 4. Oertel YC, and Johnson FB: Sclerosing lipogranuloma of male genitalia, Arch Path01 Lab Med 101: 321 (1977). 5. Takahashi Y, Tobita S, Yamauchi T, and Sanada R: Two cases of sclerosing lipogranuloma of scrotum, Jpn J Urol71: 430 (1980). 6. Inazumi S, and Suzuki M: A case of sclerosing lipogranuloma of scrotum, ibid 71: 1111 (1986).
77
OF MALE GENITALIA
MASAHIRO
MASAHARU TAKANAMI,
MATSUSHIMA,
MASAHARU TAJIMA,
M.D.
M.D.
AK10 MAKI, M.D.
M.D.
KO ANDO, M.D. TOSHIHIKO
ATOBE,
M.D.
From the Departments of Urology and Pathology, Toho University School of Medicine, Tokyo, Japan
ABSTRACT-Lipogranulomas developing secondarily in the genitourinary system have been reported rather frequently, but primary lipogranulomas without any past history of etiologically related conditions are rare. We report on 2 cases recently encountered in which tumors were diagnosed as sclerosing lipogranuloma on histopathologic examination.
In 1950 Smetana and Bernhard’ used the term “sclerosing lipogranuloma” to describe a peculiar granulomatous reaction of adipose tissue and attributed it to trauma or subcutaneous injection of foreign bodies such as paraffin. Sclerosing lipogranulomas of the genitourinary system are rare. This report presents 2 cases we have recently encountered in which a painless tumor mass had developed in the right inguinal region of one and in the scrotal septum of the other. Neither patient had a past history of trauma nor an injection of any subcutaneous foreign body, yet both tumors were diagnosed as sclerosing lipogranuloma on histopathologic examination after surgical removal. Case Reports Case 1 A fifty-four-year-old man first noticed the presence of a thumb-sized mass in the right inguinal region early in June, 1982. He was seen at the outpatient clinic of our department on July 12, 1982. Palpation revealed a firm mass with an uneven surface, measuring approximately 4 by 2 by 2.5 cm and palpable along the spermatic cord in the right inguinal region. Both testicles and epididymides appeared to be normal. A right high orchidectomy was performed on July 22, 1982, with a suspicion of tumor of the right spermatic cord. The mass arose from the spermatic cord adjacent to the external inguinal
UROLOGY
/
JANUARY 1988
I
VOLUME XxX1, NUMBER 1
ring. It was firm, sharply demarcated from and unrelated to the surrounding tissues, and measured 3 by 2.5 cm, with an uneven surface. Cut surface revealed solid, grayish white tissue. There was no miHistopathologic findings. croscopic evidence of malignant tumor cells. Sections showed a marked granulomatous growth, with adipose tissue appearing, rolllike, in the granulation tissue. Neither caseation necrosis nor epithelioid cells were noted; numerous foreign body giant cells and Langhans giant cells were seen in places. The tumor tissue generally showed a pronounced histiocytic reaction and a remarkable abundance of fibrous elements. Examination with acid fast and periodic acid-Schiff (PAS) stains resulted in negative findings (Fig. 1A). We interpreted the microscopic findings as corresponding to the term “sclerosing lipogranuloma,” or what should be referred to as a sort of pseudotumor. The patient had a satisfactory, uneventful postoperative course and was discharged on the tenth postoperative day. He has been without recurrence for fifty-six months. Case 2 A thirty-six-year-old man noticed a thumbsized painless mass in his scrotal septum. On examination, a firm mass measuring 5 by 2.5 cm with an uneven surface was palpated in the scrotal septum, adjacent to the corpus spongiosum penis.
75
FIGURE 1. Microscopic findings. (A) Case 1. Primary lipogranuloma of spermatic cord. (B) Case 2. Primary lipogranuloma of scrotum. (Hematorylin and eosin, x 100 and x 40, respectively. )
Excision of the mass was performed on June 29,1983, with a suspicion of intrascrotal tumor. The tumor was situated adjacent to the corpus spongiosum penis but distinctly demarcated from and unrelated to the surrounding tissues. The tumor was 5 by 3 by 2 cm with an uneven surface and a firm consistency. Sections revealed grayish white solid tissue. Histopathologic findings. There was no microscopic evidence of malignant tumor cells.
76
Sections showed a marked granulomatous growth, with adipose tissue appearing, rolllike, in the granulation tissue. Neither caseation nor epithelioid cells were noted; numerous foreign body giant cells and Langhans giant cells were seen in places. The tumor tissue generally showed a pronounced histiocytic reaction and a remarkable abundance of fibrous elements. Findings on examination with acid fast and PAS stains were normal (Fig. 1B).
UROLOGY
/ JANUARY1988 / VOLUMEXXXI,NUMBERl
Five cases of primary Eipogranuloma of male genitalia
TABLE I.
Histopathologic
Clinical
Symptom
Age
Takahashis
43 37 45
Scrotal septum Scrotal septum L-scrotum
Painless Painless Painless
mass mass mass
Malignant
54 36
R-inguinal area Scrotal septum
Painless Painless
mass mass
Spermatic Malignant
Inazumi and Suzuki6 Matsushima
et al.
Site
Diagnosis
Source
. . . .
The patient progressed satisfactorily, with an uneventful postoperative course, and was discharged on the tenth postoperative day. There has been no recurrence of the tumor for the past forty-five months. Comment Granulomas of adipose tissue have been described under various names since the report by Abrikossoff in 1926,2 (e.g., fat granuloma, lipophages granuloma, nodular panniculitis, and lipogranuloma) . The tumors are usually classified into three stages according to histopathologic finds: Stage I, characterized by degeneration and necrosis of fat cells and by cellular infiltration, predominantly by neutrophils and lymphocytes; Stage II, characterized by lipogranuloma formation with histiocyte, granular cells, and giant cells; and Stage III, characterized by atrophy of fat lobules accompanied by fibrosis. Subcutaneous injections of foreign bodies, such as oily drug preparations and corticosteroid medications, and the effects of trauma or heat have been incriminated in the etiology of lipogranuloma. However, no particular cause was found in the cases described herein. Lipogranulomas that develop secondarily in the genitourinary system have been frequently lipogranulomas reported, 3,4 but primary without any history of etiologically related conditions are rare. A perusal of the Japanese literature disclosed only 3 cases during the past decade.5*6 Table I summarizes the clinical features, diagnoses, treatment modalities, and histologic
UROLOGY
/ JANUARY 1988
/ VOLUME XxX1, NUMBER 1
Finding
Treatment
tumor
Resection Resection Orchidectomy
Sclerosing lipogranuloma Sclerosing lipogranuloma Lipogranuloma
cord tumor tumor
Orchidectomy Resection
Primary Primary
lipogranuloma lipogranuloma
findings of the 5 cases reported, including the present cases. The patients ranged in age from thirty-six to fifty-four years (mean age 42). Each patient had a painless mass in the scrotum or inguinal region and underwent radical treatment because of a suspicion of malignancy, though the final diagnoses are not given in 2 cases. Histopathologic findings were characteristic of sclerosing lipogranuloma in all 5 cases. The treatment undertaken with a presumptive diagnosis of malignant tumor was appropriate since it was extremely difficult, as pointed out by Inazumi and Suzuki,e to diagnostically distinguish the mass from other types of neoplastic growth. The use of fine needle aspiration prior to radical treatment may help establish the diagnoses in future cases. Department of Urology Toho University School of Medicine 6-11-1 Omori-Nishi, Ota-Ku Tokyo 143, Japan (DR. MATSUSHIMA) References 1. Smetana HF, and Bernhard W: Sclerosing lipogranuloma, Arch Path01 50: 296 (1950). 2. Abrikossoff A: Ueber die spontan auftretende Fettgewebsnekrose und Fettgranulome, Zbl Path01 38: 542 (1926). 3. Newcomer VD, Graham JH, Schaffert RR, and Kalpan L: Sclerosing lipogranuloma resulting from exogenous lipids, Arch Dermatol 73: 361 (1956). 4. Oertel YC, and Johnson FB: Sclerosing lipogranuloma of male genitalia, Arch Path01 Lab Med 101: 321 (1977). 5. Takahashi Y, Tobita S, Yamauchi T, and Sanada R: Two cases of sclerosing lipogranuloma of scrotum, Jpn J Urol71: 430 (1980). 6. Inazumi S, and Suzuki M: A case of sclerosing lipogranuloma of scrotum, ibid 71: 1111 (1986).
77