345Archivio Italiano di Urologia e Andrologia 2016; 88, 4 CASE REPORT An unusual case of primary intrascrotal lipoma Andrea Fabiani 1, Emanuele Principi 2, Alessandra Filosa 3, Tiziana Pieramici 3, Fabrizio Fioretti 1, Valentina Maurelli 1, Lucilla Servi 1, Gabriele Mammana 1 1 Urology Unit, Surgery Department, Macerata Civic Hospital, Area Vasta 3 ASUR Marche, Italy; 2 Urologic Clinic, Polytechnic University of Marche Region, Ancona, Italy; 3 Pathologic Unit ASUR Marche Area Vasta 3, Macerata Civic Hospital, Italy. In daily clinical practice, intrascrotal lesion are commonly detected, both by clinical examination either by ultrasound scan. While 95% of testicular lesions are malignant, most paratesticular lesions are benign. Among these, intrascrotal lipomas must be take into account in differential diagnosis. When they originate from scrotal wall, they named “primary scrotal lipoma”. We describe a case of a primary intrascrotal lipoma diagnosed after surgical excision in a young man presented at our Urological Department complaining a painful left scrotal mass. KEY WORDS: Scrotal lipoma; Paratesticular tumor; Scrotal ultrasound. Submitted 15 November 2016; Accepted 15 December 2016 Summary No conflict of interest declared. due to the difficult interpretation and to the symptoms complained, it was decided to perform a scrotal surgical exploration. After a local anesthesia with left funicular and median raphe infiltration (Lidocaine 2% 10 ml and Ropivacaine 7,5 mg 10 ml), a longitudinal median scro- tal incision was made. An ovoid intrascrotal mass was externalized (Figure 2). DOI: 10.4081/aiua.2016.4.345 Presented at 20th National Congress SIEUN, Sciacca 2016 Figure 1. Scrotal ultrasound shows a slightly hyperechoic homogeneous nodule without color signal expression. Figure 2. Nodule appearance at surgical exploration. INTRODUCTION Intrascrotal lipomas are lesions rarely observed in com- mon clinical practice. They are benign mesenchymal tumours that can arise from the paratesticular structures as the spermatic cord, epididymis, tunica vaginalis or from the subcutaneous adipose cell of the scrotum (1). In most cases it is not easy to identify the precise source site of these tumors . When lipomas originate from scro- tal wall they are named “primary scrotal lipomas” (2) such in the case reported herein. CASE PRESENTATION A 22-years-old patient presented to our Hospital with a painful nodule of a left scrotal region, that was first noticed about 3 months before but gradually and slowly became symptomatic. No others symptoms were report- ed in anamnesis. At palpation, the nodule showed an elastic non tender consistency and it resulted regularly shaped on the left side of the scrotum apart of the lower ipsilateral testicular pole. It was easily distinguishable from testicle and epidydimus that appeared normal for shape and size and not painful. The contralateral testicle and epidydimus were normal. The scrotal ultrasound, performed with a 7,5 Mhz linear probe, showed a slight- ly hyperechoic homogeneous nodule, that does not show any infiltrative character and was 3 x 2 cm in size (Figure 1). No echocolor signal was present. Therefore, Fabiani1_Stesura Seveso 09/01/17 10:51 Pagina 345 Archivio Italiano di Urologia e Andrologia 2016; 88, 4 A. Fabiani, E. Principi, A. Filosa, T. Pieramici, F. Fioretti, V. Maurelli, L. Servi, G. Mammana 346 The yellowish mass of about 3 cm in major diameter, was completely excised from the scrotal wall. The left testicle and epidydimus were normal. After excision and eversion of tunica vaginalis, scrotal wall was sutured with absorbable stiches. A drainage was placed in paratesticular space to avoid haematocele. The microscopic pathologic evaluation of the surgical specimen highlighted the pres- ence of mature adipocytes constituting the totality of the tissue examined in the absence of other types of connective tissue and an obvious abnormal vascular proliferation vas- cular with steatonecrosis areas and, at the periphery of the lesion, a reactive vascular proliferation like a granulation tissue (Figure 3a, b). The diagnosis of primary scrotal lipo- ma was made. DISCUSSION In daily clinical practice, intrascrotal lesion are commonly detected, both by clinical examination either by ultra- sound scan. While 95% of testicular lesions are malignant, most paratesticular lesions are benign. Among these, the intrascrotal lipomas are rare lesion. The region of origin are not always detectable and they may originate from the adipose tissue of spermatic cord, spermatic cord structures and the scrotal wall (3). The patient age may be a guide to clinical diagnosis (1). They may also be malignant and vary in size. Consequently symptoms are caused by growth. Ultrasound imaging play an important role in the initial evaluation of these lesions. providing information about localization, cystic or solid nature of the lesion (3). Then, these lesions can be distinguished from most other testicular lesions, such as fibrous pseudotumor, adenoma- toid tumor or cystic lesions, according to ultrasound find- ings, anatomic location, and negative tumor markers. However, even using these findings it is difficult to radio- logically determinate the nature of these lesions (benign or malignant). Although the majority of solid extratesticular masses are benign, it is hard to distinguish malignancy (4). In conditions like these, Magnetic Resonance Imaging may be of use. The histopathology of primary scrotal lipoma may be confused with lipomatosis, lipoblastoma and liposarcoma. Being the mass encapsulated and not infil- trated to the surrounding tissues helped us to differentiate it from lipomatosis, and the presence of mitosis and atyp- ia to differentiate it from liposarcoma. No malignancy was present in the case reported. On the third and sixth month follow-up no local relapse was seen. CONCLUSION Scrotal lipomas are rare, benign paratesticular tumors. Surgical excision is the treatment of choice. There is no evidence that scrotal lipomas differ in terms of manage- ment and prognosis from other variants of lipoma. Although the sonographic appearance of these tumors is variable and non-specific, ultrasound is the first exam in the clinical management as for all scrotal masses and it has a key role in the initial management. AUTHORS’ CONTRIBUTIONS All Authors participated in the design and conduct of the study. All Authors reviewed and approved the final ver- sion of the manuscript. REFERENCES 1. Algaba F, Mikuz G, Boccon-Gibod L, et al. Pseudoneoplastic lesions of the testis and paratesticular structures. Virchows Arch. 2007; 451:987-97. 2. Fujimura N, Kurokawa K. Primary lipoma of the scrotum. Eur Urol. 1979; 5:182-183. 3. Galosi AB, Scarpelli M, Mazzucchelli R, et al. Adult paratesticu- lar mesenchymal tumors with emphasis on a case presentation and discussion of spermatic cord leiomyosarcoma. Diagnostic Pathology. 2014; 9:90. 4. Basal S, Malkoç E, Aydur E, et al. Fibrous pseudotumors of the testis: The balance between sparing the testis and preoperative diagnostic difficulty. Turkish Journal of Urology. 2014; 40:125-9. Correspondence Andrea Fabiani, MD (Corresponding Author) - andreadoc1@libero.it Fabrizio Fioretti, MD PhD - fa.fioretti@libero.it Valentina Maurelli, MD - valentinamaurelli@hotmail.it Lucilla Servi, MD - lucilla.servi@sanita.marche.it Surgery Dpt, Section of Urology, ASUR Marche Area Vasta 3 Macerata Hospital, Macerata, Italy Emanuele Principi, MD, Urology Resident - principie@tiscali.it Urologic Clinic, Polytechnic University of Marche Region, Ancona, Italy Alessandra Filosa, MD, PhD - alessandrafilosa@yahoo.it Tiziana Pieramici, MD - t.pieramici@libero.it Section of Pathological Anatomy, Department of Clinical Pathology, Area Vasta 3, ASUR Marche, Macerata Hospital, Macerata, Italy Gabriele Mammana, MD - gabriele.mammana@sanita.marche.it Head Surgery Dpt, Chief of Section of Urology ASUR Marche Area Vasta 3, Macerata Hospital, Macerata, Italy Figure 3. Hystological features of the nodule. A. B. Fabiani1_Stesura Seveso 09/01/17 10:51 Pagina 346