Hemangioma of the scrotal septum: a rare entity in infants with review of the literature.
Abstract: Hemagiomas are most common tumors in infancy; however, scrotal septum hemangiomas are very rare with only 45 cases reported in the literature. We report a case of a 6 month old child who presented with a scrotal mass at birth which had increased in size with age.

A scrotal ultrasound with color doppler analysis, revealed a soft tissue mass with diffusely increased blood flow. Scrotal mass excision was performed and the pathology confirmed a capillary hemangioma.
Article Type: Case study
Subject: Hemangioma (Diagnosis)
Hemangioma (Case studies)
Hemangioma (Care and treatment)
Hemangioma (Risk factors)
Scrotum (Diseases)
Doppler ultrasonography (Usage)
Doppler ultrasonography (Health aspects)
Genital diseases, Male (Care and treatment)
Genital diseases, Male (Patient outcomes)
Genitourinary organs (Surgery)
Genitourinary organs (Usage)
Genitourinary organs (Complications and side effects)
Authors: Kumar, Tarun
Vaughan, Richard
Dangle, Pankaj P.
Pub Date: 07/01/2012
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: July-August, 2012 Source Volume: 108 Source Issue: 4
Accession Number: 310150682
Full Text: Introduction

Hemangiomas of the scrotum are rare with fewer than 45 cases reported previously in the literature. Due to the clinical similarity with varicoceles, scrotal hemangiomas can be challenging diagnostically as well as therapeutically. Of the cases of scrotal hemangiomas reviewed, hemangioma of the septum has been described only once as a case report in 1956. Ultrasound with color doppler is recommended as a part of the preoperative assessment delineating the extent of a scrotal hemangioma. The condition could be dealt with conservative approach with occasional spontaneous resolution; surgical excision is offered for those with increasing size.

Case history

A 6-month-old child was referred to rule out a varicocele. A scrotal mass was present since birth and had increased in size with age. On examination; a 1x2cm mass was situated over the median raphe of the scrotum suggestive of a typical hemangioma

A scrotal ultrasound with color doppler analysis revealed a focal, well circumscribed hypoechoic soft tissue mass along the median raphe with increased blood flow.

Due to increasing in size, surgical excision was performed; the final pathology confirmed the diagnosis of capillary hemangioma.

Discussion

Hemangiomas are the most common benign tumor of infancy occurring in 1-2.6% of all children. In 1937, Gibson classified hemangiomas of the genitalia into two types: cutaneous and subcutaneous. (3) Genital hemangiomas are extremely rare and can be divided into three types: 1) capillary 2) cavernous and 3) histiocytoid.

[FIGURE 1 OMITTED]

Capillary and cavernous hemangiomas are usually well-circumscribed, unencapsulated lesions with groups of mature and immature capillary vessels lined by well-defined endothelial cells. Cavernous hemangiomas have large, blood-filled spaces of variable diameter and thickness with areas of infarction and thrombosis. Histiocytoid (epitheloid) hemangiomas have proliferations of large, atypical histiocyte-like endothelial cells almost always accompanied by a mixed inflammatory infiltrate. A history of other hemangiomas, scrotal trauma, or family members with hemangiomas may be elicited in some patients. Genitourinary hemangiomas have been described in Klippel-Trenaunay syndrome (cutaneous port-wine hemangiomas, varicose veins, and ipsilateral soft tissue and bony hypertrophy of the involved extremities).

Scrotal hemangiomas are extremely rare lesions and less than 45 cases have been reported in the literature since the first case was reported by Boullay in 1851. (3) Many cases prior to definitive diagnosis may be misinterpreted as other soft tissue masses of the scrotum. Various conditions such as sebaceous cyst, midline epidemoid cyst, angiomyolipoma , varicocele, hematoma, hamartomas of the scrotum could be confused with hemangioma. Patients with scrotal hemangiomas usually present with scrotal enlargement, with or without tenderness. Clinical examination and radiological imaging in the form of ultrasound with doppler are valuable tools used to arrive at a definitive diagnosis. Typically most of the above mentioned clinical conditions have subtle clinical findings that differentiate them from hemangioma. Diagnosis is confirmed on ultrasound with doppler examination which reveals the vascular component with its flow patterns. It is important to rule out coexisting hemagiomas of the other system. Wide age range has been reported with respect to patients presenting with the scrotal hemangioma ranging from one month to sixth decade of life. (3,4) These patients are either asymptomatic or may present with sensation of heaviness, dragging pain and occasionally hemorrhage. (3,5,6) Though wide excision is a treatment of choice various other treatment options such as steroid, fulguration with either carbon dioxide or electrocautery has minimal to zero success. (3,5,6) Most patients when treated do not mandate long term follow-up as the likely risk of malignant transformation is not reported but may recur from its associated systemic nature.

Conclusion

Scrotal septal hemangiomas are rare, thought it should be considered in the differential diagnosis of all the other midline masses. Diagnosis is confirmed on doppler ultrasound with its characteristic findings. For growing hemangiomas early intervention in the form of surgical excision is valuable and long term follow-up is generally not required.

References

(1.) Ray B, Clark SS: Hemangioma of scrotum. Urology. 1976; 8(5): 502-505

(2.) Pratt AG: Birthmarks in infants. Arch Dermatol 1972; 67: 302-305

(3.) Gibson TE. Hemangioma of the scrotum. Urol Cutan Rev 1937; 41: 843

(4.) Mahoney MT: Cavernous hemangioma of scrotal septum. J Pediatr 1956; 49:744

(5.) Winslow ,N: Cavernous hemangioma of the scrotum, report of case, Arch. Surg. 9:829 (1929)

(6.) Cooper, T.P, Anderson RG, Chapman WH: Hemangioma of the scrotum; a case report, review and comparison with varicocele, ibid.112;623 (1974).

Tarun Kumar, MD, MCh

Department of Surgery, School of Medicine, St. Louis

University, St. Louis, MO

Richard Vaughan, MD

Section of Pediatric Surgery, Department of General

Surgery, WVU, Morgantown

Pankaj P. Dangle, MD, MCh

Department of Surgery, School of Medicine, St. Louis

University, St. Louis, MO
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