A giant scrotal pendulous fibroma mimicking a supernumerary testis

Dear Editor,

Pendulous fibroma, also called acrochordon, is a benign skin neoplasm, originating from the dermis.1 Usually, small in size, it can arise from any point of the dermis (frequently from the axillary area, inguinal region, eyelid, or neck), and in some cases, it can be unesthetic. Pendulous fibromas are more frequent in obese subjects, and most of the time, they are sporadic, although sometimes, they can be observed in Birt–Hogg–Dubé syndrome. In some rare cases, they can reach considerable dimensions. Occasionally, they are associated with diabetes mellitus, obesity, and intestinal polyps. Often, the pedicle undergoes torsion, causing pain and ischemic necrosis of the fibroma, which requires rapid removal of the tumor. We present a case of giant pendulous fibroma of the scrotum. The patient has given his consent to the publication of his clinical information and photographic images in an anonymous form.

A 50-year-old patient of North African ethnicity, who went to Civitanova Marche Hospital (Civitanova Marche, Italy) for a urological examination, reported the appearance of a pedicle neoplasm with a rubbery, slight texture, hanging from the left hemiscrotum (Figure 1a). The skin of the scrotum showed no erythema or signs of infection. The lesion has been developing for about a year; it was initially small in size, rapidly increasing in diameter in the last month until it reached the size of 5 cm × 4 cm × 4 cm. The patient is of normal weight, not a smoker, not diabetic, and does not take medications at home; no scrotal trauma occurred in the last years. The scrotal ultrasound (Esaote MyLab™ X8 Platform, Genova, Italy) showed an uneven tissue mass with a vascular pattern composed of vascular peduncle trunk with ramifications; both testicles were in place and normal for size and eco-structure. He performed blood tests that showed normal lactate dehydrogenase, follicle-stimulating hormone, luteinizing hormone, beta-human chorionic gonadotropin, and alpha-fetoprotein. Furthermore, blood count, serum protein electrophoresis, and urine test were normal. The urine culture was negative. Ultrasound of the abdomen revealed hepatic steatosis and no other relevant findings were found. The patient underwent removal of the mass with ligature of the peduncle and suturing (Figure 1b). Local truncular anesthesia was performed using 2% lidocaine hydrochloride (two vials of 5 ml). Antibiotic prophylaxis was performed with 2 g cefuroxime (Sandoz S.p.A., Varese, Italy) and operating time was 16 min. The final histological examination showed a soft pendulous fibroma with a fibrovascular axis lined by squamous epithelium (Figure 1c). After 10 days, there was complete healing of the wound. The 3-month follow-up ultrasound was negative.

Figure 1.

Scrotal pendulous fibroma. (a) Neoplasm at the left side of the scrotum, (b) excised neoplasm, and (c) histological features of the pendulous fibroma.

Excluding lipomas, only 1.0%–13.7% of intrascrotal formations in the literature are benign lesions.1,2,3 Adenomatoid tumor, fibrous pseudotumor, fibroma of the testis, dermoid cyst, and others3 are more frequently found. Among the endoscrotal masses, those of testicular relevance are the most frequently found. The rarer paratesticular masses originate from the epididymis, the spermatic cord or the surrounding structures, containing connective tissue.4 Göğüş et al.5 in 1990 reported a rare case of a 3-cm fibrous pseudotumor of epididymis, a pediculated mass originating from the epididymal region. Fibroma of the scrotum is a rare benign neoplasm of mesenchymal origin; it occurs as pure or mixed fibroid (myxofibroma, myxoma, and lipomyxofibroma) based on the component of fibroblasts, collagen, and mucous tissue.6 Pendulous fibroma has slow, painless growth, and occasionally reaches size greater than 5 mm. Patients tend to delay treatments because of their embarrassment. The perineum could be a frequent site because of its rich wall vascularization; other locations of giant pendulous fibromas described in the literature are the mammary areola, the eyelid, the tonsils, and the vulva.7,8,9,10 Although the appearance was compatible with a benign neoplasm, the considerable dimensions reached by the case just described and the rapid growth that had been observed in the last month had raised some doubts and finally dispelled by the histological examination that ruled out malignity. Therefore, any scrotal formation showing clinical features of benignity should not be underestimated, both to exclude a possible malignant nature, and for a possible torsion in the case of a pendulous lesion as in the case just described.

AUTHOR CONTRIBUTIONS

LQ is the main creator of the paper and has full access to all the data in the study. DF drafted the manuscript. RFDF and GP carried out the acquisition of the data and helped draft the manuscript. WG carried out the critical revision of the manuscript. All authors read and approved the final manuscript.

COMPETING INTERESTS

All authors declare no competing interests.