Fibrolipoma of the Spermatic Cord: First Reported Case in Children and a Review of the Literature

Fibrolipoma of the Spermatic Cord: First Reported Case in Children and a Review of the Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fibrolipoma of the Spermatic Cord: First Reported Case in Children and a Review of the Literature Agah Koray Mansiroglu, Abdullah Duman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5619612/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Apr, 2025 Read the published version in BMC Urology → Version 1 posted 4 You are reading this latest preprint version Abstract Background Benign tumors of the spermatic cord constitute the majority of paratesticular tumors. While fibrolipoma is uncommon in adults, there are no recorded cases of fibrolipoma of the spermatic cord in children. Case Presentation: A male patient, aged 13, arrived at the emergency department complaining of right inguinoscrotal pain and nausea for the past four days. The Doppler scrotal ultrasound demonstrated a soft tissue structure measuring 48x19 mm with heterogeneity and absence of vascular activity, located along the spermatic cord in proximity to the right testicle. Right scrotal tenderness and absence of blood supply on Doppler ultrasound indicated emergency surgical intervention, considering the possibility of torsion in an accessory testicle, more frequently encountered in pediatrics. Surgical exploration of the inguinal region and mass excision were conducted. The pathology report determined a tumor exhibiting collagenized tissues surrounding fatty lobules, indicative of a fibrolipoma. Conclusions This case represents initial documentation of a pediatric paratesticular fibrolipoma. The mean age of the six cases reported thus far is 55.3 years. In the definitive diagnosis of paratesticular tumors, which are rarely seen and cannot be adequately evaluated through radiologic imaging, histopathologic sampling holds significant importance. Fibrolipoma paratesticular mass rare tumors Figures Figure 1 Figure 2 Figure 3 Introduction Paratesticular masses mostly originate in the spermatic cord [ 1 ], and lipomas are most prevalent [ 2 ]. Even though fibrolipoma/angiomyolipoma/spindle cell lipoma/angiofibrolipoma are subtypes of lipoma, they are rare [ 3 ]. It is impossible to diagnose these cases using preoperative radiologic imaging, requiring diagnostic immunohistochemistry. When radiologic imaging can only narrow differential diagnosis, clinicians and radiologists have a diagnostic dilemma. This article discusses a 13-year-old patient with right inguinoscrotal pain, subsequently diagnosed with fibrolipoma, carrying considerable significance as it constitutes the first documented pediatric fibrolipoma of the spermatic cord. Case Presentation A 13-year-old male patient presented to the emergency department complaining of right inguinoscrotal pain and nausea for four days. Genital examination indicated that both testes were intrascrotal, with symmetrical size and structure. An additional mass was identified in the right scrotum, demonstrating tenderness upon palpation and mobility. A Doppler scrotal USG revealed a 48x19mm heterogeneous soft tissue with no vascular activity at spermatic cord’s level in proximity to the right testicle (Fig. 1 a-b-c). β-HCG, AFP, LDH, and CEA levels were normal. Due to tenderness upon mass palpation and normal tumor marker levels, accessory testicular torsion was considered, since it did not demonstrate a blood supply on Doppler USG. An emergency surgical procedure was planned. A 5x2cm white solid mass was identified during inguinal exploration. The lesion, situated within the tunica vaginalis, was excised with relative ease after severing of its connections with vessels extending from the pampiniform plexus. (F A right herniotomy and high ligation were incorporated into surgical planning. The patient was discharged to follow-up with monthly/six-monthly visits. Pathology report identified fibrolipoma, characterized by collagenized stroma surrounding fatty lobules. Regarding macroscopic observation, fibrolipoma was characterized as a solid mass measuring 5x4x2cm, partially enclosed within a capsule, sections exhibiting a gray-yellow color with intermittent shiny gelatinous tissue fragments (Fig. 3 a). Microscopic examination revealed a diverse vascular structure featuring varying densities and interconnections. Spindle cells were observed in collagenized stroma, whereas mast cells and histiocytic cells were scarce. Adipose/collagenous structures surrounding the lesion showed no atypia (Figs. 3 b&c). Immunohistochemical analysis demonstrated positive staining with CD34 in some stromal areas and negative staining in other areas. Positive staining with CD117 was rare in mast cells, while positive staining with CD68 was rarely noted in histiocytes. Positive staining with SMA was observed exclusively in vascular walls, while positive staining with S-100 protein was observed in fatty tissues. Negative staining was observed with β-catenin-PanCK-MelanA-HMB-45-Desmin. Discussion Primary paratesticular tumors are detected in 7–10% of patients with intrascrotal neoplasms [ 2 ]. Spermatic cord tumors are exceedingly rare [ 4 ]. Clinicians’ primary differential diagnoses encompass incarcerated inguinoscrotal hernia/spermatic cord cyst/epididymal cyst. When encountering any incongruity in assessing these masses, clinicians opt for USG as initial imaging. Identifying paratesticular fibrolipoma through USG presents challenges. It, alongside MRI, plays a crucial role to narrow diagnostic possibilities [ 5 , 6 ]. It is crucial to exclude incarcerated hernia, spermatic cord cyst, cystic structures such as angiofibrolipoma [ 3 ], or solid structures like lipoma. Huben et al. employed scrotal ultrasound to exclude hydrocele/hernia during primary assessment of a scrotal fibrolipoma [ 7 ]. Moreover, ultrasonography/MRI offer valuable information, as 56% of spermatic cord masses are malignant when lipoma is excluded. The painful, hard, and mobile lesion in our case needed USG. Spermatic cord cysts can also be mobile and hard; however pain is not expected. On Doppler USG, we encountered a heterogeneous, solid mass with no circulation, suggesting incompatibility with fibrolipoma, which is well perfused on USG, as Hegele et al. noticed, but rather a finding that can be seen in lipoma [ 4 ]. However, pain and USG still did not describe lipoma [ 8 ]. In light of patient's clinical presentation, swift measures were taken for surgery. Tumor marker analysis displayed normal values, aligning with previous fibrolipoma cases as documented by Hegele, Mykoniatis, and Kacan [ 4 – 6 ]; tumor marker assessments were not conducted in other fibrolipoma case work-ups [ 1 , 7 , 9 ] (Table 1 ) Table 1. Comparative synopsis of the paratesticular fibrolipoma cases reported in the literature, together with the presented case PARATESTICULAR FIBROLIPOMA AGE SYMPTOMS PHYSICAL EXAMINATION FINDINGS RADIOLOGICAL AND LABORATORY FINDINGS TREATMENT MACROSCOPIC EXAMINATION FINDINGS MICROSCOPIC AND IMMUNOHISTOCHEMICAL EXAMINATION FINDINGS 1. Huben, 1983 [7] 68 2 years of increasing right scrotal swelling 20x25x30 cm non-tender mass; bilateral reducible inguinal hernias; normal lymph nodes A mass with diffuse irregular internal echoes in USG Mass excision An encapsulated fibrofatty tumor adherent to the scrotal wall but easily detachable A benign fibrolipoma without cellular atypia containing typical fat cells and fibrous tissue 2. Hegele, 2003 [4] 55 Palpable mass in the right inguinal region for the last 15 years; enlargement and pain extending to the scrotum for the last 6 months Firm, slightly painful mass; testes normal on palpation; no enlarged lymph nodes Well-perfused mass with low echogenicity on color Doppler USG; homogeneous soft tissue tumor measuring 4x3x2 cm on CT scan; tumor marker values within normal limits Intraoperative frozen section examination + mass excision A thinly encapsulated tumor composed of white tissue Mature fibrous connective tissue bundles crossing adipocytes; no atypia; Immunohistochemistry: fat cells positive for S100 protein - negative reaction to S-100 protein, actin, desmin and CD34 3. Terada, 2010 [9] 68 Right inguinal swelling for 2 years Mass excision + right orchiectomy 13x10x9 cm, round, hard tumor with a thin capsule; yellowish-white solid and lobulated tissue fragment with gelatinous consistency on the surface of the section Tumor consisting of mature adipose tissue (40% area) and mature collagenous fibrous tissue (60% area), which overlapped; lipoblasts not recognized; myxoid degeneration of mature adipose tissue in focal areas; smooth muscle not recognized with Azan stain; no vascular proliferation; tumor spindle cell clusters not recognized. Immunohistochemistry: Tumor cells negative for cytokeratins, epithelial membrane antigen, CD34, desmin, SMA, melanosome, p53 protein, MDM2, and CDK4; adipose tissue weakly positive for S-100 protein; %1 Ki-67 labeling 4. Mykoniatis, 2015 [5] 55 Slowly increasing painless swelling of left hemiscrotum for 6 years A painless, large, firm mass palpated in the left hemiscrotum, extending into the perineal region and not clearly distinguishable from the surrounding scrotal components; non-palpable inguinal lymph nodes On USG, a hyperechoic scrotal mass, 5x6 cm in size, separate from the left testicle; on MRI, a mass showing a high T1 signal intensity characteristic of fat-containing tumors (no benign/malignant differentiation could be made); tumor markers (β-HCG, AFP, LDH) within normal limits Mass excision A yellowish-white solid tumor measuring 19.5 x 7 x 5 cm, surrounded by a thin fibrous capsule Evident presence of mature fat cells between fibrous substrate; no cellular atypia, mitotic activity, lipoblasts, or necrosis; no smooth muscle recognized using Azan stain. Immunohistochemistry: Tumor cells negative for desmin, SMA, p53 protein, CD34, MDM2 and CDK4 Pathology report: fibrolipoma with diffuse mucoid degeneration 5. Kacan, 2016 [6] 56 Right scrotal swelling Painless, mobile mass posterolateral to the right testicle, distinct from the testicle; non-palpable inguinal lymph nodes On USG, a large, hyperechoic scrotal mass separate from the right testicle; laboratory tests normal; serum markers for testicular cancer (β-HCG, AFP, LDH) within normal limits Mass excision Yellowish, solid tumor with a thin capsule, with dimensions of 9.5x9.5x2 cm Microscopically, a tumor composed of mature adipose tissue and collagenous fibrous tissue; no lipoblasts recognized Tumor diagnosis: giant fibrolipoma of the right spermatic cord 6. Rohit, 2021 [1] 30 Left inguinoscrotal non-tender swelling for 2 years Left inguinoscrotal firm, elastic, non-tender swelling with a smooth surface and sized 8x6 cm on USG, heteroechoic mass measuring 7x6 cm with possible characteristics of a lipoma or desmoid Mass excision following fine needle aspiration biopsy Solid tumor measuring 7x6x5 cm with a smooth surface, smooth margins, and a gray-white stalk Mature adipose tissue with an encapsulated mass line of fibro-collagenous tissue, macrophages, calcifications, and areas of fat necrosis indicating fibrolipoma with secondary fat lysis; no atypia. 7. Mansiroglu, 2024 (presented case) 13 Four-day history of pain and swelling in the upper half of the right hemiscrotum An ellipsoid, firm, mobile lesion with a smooth surface, approximately 5 cm in length, tender to palpation; no inguinal LAP; no additional pathology on examination of the testes On Color Doppler USG, a 49x18 mm heterogeneous, solid, soft tissue structure with no vascular activity; tumor markers’ (β -HCG, AFP, LDH) values within normal limits Mass excision + inguinal hernia repair Partially encapsulated, solid tumor measuring 5x4x2 cm; solid tissue fragment, sections gray-yellow and occasionally glossy gelatinous. Fibrolipoma, characterized by collagenized and occasionally spindle cells surrounding fatty lobules; no atypia Immunohistochemistry: Positive staining with CD34 in some stromal parts (usually negative), positive staining with CD117 in rare mast cells, positive staining with CD68 in rare histiocyte cells, positive staining with S-100 in adipose tissue and negative staining in other areas, negative staining with B-catenin, PanCK, HMB-45, and Desmin Excision was deemed optimal due to mass's mobility and smooth surface. Torsion was not observed, and perfusion was provided by numerous thin vessels, contrary to USG findings. Possibility of spontaneous detorsion under anesthesia was also considered. However, it was impossible to perform a frozen-section pathological examination intraoperatively, like in Hegele's case, due to unavailability of a pathologist. The fact that the mass was not as large as that evaluated by Terada might have influenced us not to add orchiectomy. We considered a second operation, if deemed necessary, following the pathology report. Upon macroscopic examination, no significant variations were observed compared to other fibrolipoma cases, aside from its size. Lack of conclusive diagnosis of fibrolipoma through radiological imaging in our case, as well as in other fibrolipoma cases, emphasizes significance of microscopic examination and immunohistochemistry staining for obtaining a definitive diagnosis [ 10 ]. No evidence suggests any distinction in management and prognosis between spermatic cord fibrolipomas and other benign lipomatous tumors [ 5 ]. However, malignant lesions don’t fall into this category. Pathological assessment validated absence of rhabdomyosarcoma/liposarcoma, paratesticular region’s predominant malignant lesions. Angiomyolipomas, primarily renal and rarely in spermatic cord, showing strong staining with HMB-45 (80–100%) and almost complete staining with SMA, allowed us to deduce that angiomyolipoma was unlikely. Abundant mast cells in spindle cell lipomas, combined with strong positive CD34 staining, were observations that eliminated spindle cell lipoma [ 3 , 9 ]. Exclusive staining with S-100 in adipose tissue, as documented by Hegele and Terada [ 4 , 9 ], and encasement of fatty lobules with collagenous stroma in all remaining scenarios, constituted additional results affirming fibrolipoma, differentiating it from other subtypes. Pediatric paratesticular masses, ranging from non-neoplastic conditions such as spermatic cord cysts or polyorchidism to neoplastic masses such as rhabdomyosarcoma, represent a relatively uncommon group of disorders for clinicians. Histopathologic sampling is critical in precisely diagnosing paratesticular tumors, which are seldom seen and can be inadequately assessed through radiologic imaging. Preoperative/intraoperative histopathologic sampling could help avoid unnecessary orchiectomies. The youngest adult case of histopathologically diagnosed fibrolipoma was 30-year-old [ 1 ], indicating its occurrence in young adults, and six documented cases’ mean age was 55.3. Thus, this report signifies the initial documentation of a pediatric paratesticular fibrolipoma. Abbreviations USG: Ultrasonography β-HCG: Beta-Human Chorionic Gonadotropin AFP: Alpha Fetoprotein LDH: Lactate Dehydrogenase CEA: Carcinoembryonic Antigen SMA: Smooth Muscle Actin S-100: Soluble in 100% saturated solution of ammonium sulphate HMB-45: Human Melanoma Black-45 MRI: Magnetic Resonance Imaging Declarations Ethics approval and consent to participate: Ethics approval was not required as this is a single case report. Clinical trial number: not applicable. Informed consent was obtained from the parents of the patient who participated in the study. Consent for publication: Written informed consent was obtained from the parents of the case report for publication of the medical case details and accompanying images. Data Availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no competing interests. Funding: This study was not supported by any sponsor or funder. Authors’ Contributions: AKM contributed to Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft –, Writing – review & editing . AD contributed to Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Supervision, Visualization, Writing – review & editing . Acknowledgements: Not applicable. Authors’ information: AKM; Pediatric surgeon at Ministry of Health Sivas State Hospital, Sivas, Turkey AD; Radiologist at Ministry of Health Sivas State Hospital, Sivas, Turkey References Rohit G, Hariprasad CP, Bharti S, Kumar A, Paswan SS, Vikram S, et al. Astounding Fibro Lipoma of Spermatic Cord: A Diagnostic Dilemma. Case Rep Surg 2021;2021:7139109. doi: 10.1155/2021/7139109 Priemer DS, Trevino K, Chen S, Ulbright TM, Idrees MT. Paratesticular Soft-Tissue Masses in Orchiectomy Specimens: A 17-Year Survey of Primary and Incidental Cases From One Institution. Int J Surg Pathol 2017;25(6):480-7. doi: 10.1177/1066896917707040. Dagur G, Gandhi J, Kapadia K, Inam R, Smith NL, Joshi G, et al. Neoplastic diseases of the spermatic cord: an overview of pathological features, evaluation, and management. Transl Androl Urol 2017;6(1):101-10. doi: 10.21037/tau.2017.01.04. Hegele A, Olbert P, Roessler M, Heidenreich A, Hofmann R. Inguinal fibrolipoma of the spermatic cord: discrepancies between clinical and histopathological findings. Urol Int 2003;71(4):435-6. doi: 10.1159/000074102 Mykoniatis I, Metaxa L, Nikolaou V, Filintatzi C, Kikidakis D, Sountoulides P. Giant Scrotal Fibrolipoma. Rare Tumors 2015;7(4):6001. doi:10.4081/rt.2015.6001 Kacan T, Kilinc MF, Ayyildiz A. Giant fibrolipoma of the spermatic cord. 26th National Congress of Urology. Kyrenia, TRNC; 2017. http://file.uroturk.org.tr/files/cd/2017/CDDATA/CONTENTTR/PP-247.htm Huben RP, Scarff JE, Schellhammer PF. Massive intrascrotal fibrolipoma. J Urol 1983;129(1):154-5. doi: 10.1016/s0022-5347(17)51970-9. Ahmed HU, Arya M, Muneer A, Mushtaq I, Sebire NJ. Testicular and paratesticular tumours in the prepubertal population. Lancet Oncol 2010;11(5):476-83. doi: 10.1016/S1470-2045(10)70012-7. Terada T. Giant fibrolipoma of the spermatic cord. Pathol Int 2010;60(4):330-2. doi:10.1111/j.1440-1827.2010.02521.x Emerson RE, Ulbright TM. The use of immunohistochemistry in the differential diagnosis of tumors of the testis and paratestis. Semin Diagn Pathol 2005;22(1):33-50. doi:10.1053/j.semdp.2005.11.003 Hisamitsu I, Takashi N, Yutaka K, Satoru M, Tetsuo I, et al. Spindle cell lipoma of the spermatic cord. Int J Urol 2007: 14(11):1046-7 doi: 10.1111/j.1442-2042.2007.01892.x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Apr, 2025 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 24 Dec, 2024 Editor assigned by journal 17 Dec, 2024 Submission checks completed at journal 17 Dec, 2024 First submitted to journal 10 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5619612","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":391446907,"identity":"e4c354ec-5f4d-4a83-b25f-e2ff05e47f8f","order_by":0,"name":"Agah Koray Mansiroglu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYHACNhBhwMbefPDBBxCXnRgtB4Ba+HiOJRvOAHGZidUiJ5FjJswD4hPSwt+/+Nnjj233jNkk0tKYbX5tk+djZmD88DEHtxaJG8/MDQ62FZux8Tw+9ji377ZhGzMDs+TMbXisuXHATOJgW4ING3taunFuz21GoBY2Zl48WuRvHP8G0cKQYyZt2XPbnqAWg/M9YFvM2DiAWhh+3E4kqMXwBk+ZxJlzCcZsoEDubbid3MbM2IzXL3Lnj2+TqChLMJzfDozKH39u24IYHz7i875EAhKHsQ1MNuBRDwT8B5B5f/ArHgWjYBSMgpEJAPS6U163nx8wAAAAAElFTkSuQmCC","orcid":"","institution":"Sivas State Hospital","correspondingAuthor":true,"prefix":"","firstName":"Agah","middleName":"Koray","lastName":"Mansiroglu","suffix":""},{"id":391446908,"identity":"cf7572ea-65cb-4014-970b-2457ff38e513","order_by":1,"name":"Abdullah Duman","email":"","orcid":"","institution":"Sivas State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Duman","suffix":""}],"badges":[],"createdAt":"2024-12-10 22:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5619612/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5619612/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-025-01752-4","type":"published","date":"2025-04-02T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71894911,"identity":"786148da-56dc-4143-8601-bcf11a47d912","added_by":"auto","created_at":"2024-12-19 13:37:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":320791,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic and color Doppler imaging of the case a. Heterogeneous soft tissue structure (48x19 mm) at the right spermatic cord level; b. Paratesticular mass with no vascular activity on color Doppler USG; c. Ultrasonographic image of the patient's bilateral healthy testes\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5619612/v1/6b8a1233f8fe12f6b4b3725a.png"},{"id":71893913,"identity":"9b6f049b-bea2-41c9-bf2e-c49c4f8b5a3c","added_by":"auto","created_at":"2024-12-19 13:29:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":756566,"visible":true,"origin":"","legend":"\u003cp\u003ePhotographic imaging of the case a. Preoperatively; b \u0026amp; c. Intraoperatively\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5619612/v1/9fc6b267432da78a868da0bf.png"},{"id":71893927,"identity":"7c98f953-b90a-4912-ab03-90b861f8c832","added_by":"auto","created_at":"2024-12-19 13:29:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":610681,"visible":true,"origin":"","legend":"\u003cp\u003eImages of the case in pathological examination a. Macroscopic view - a solid mass measuring 5x4x2 cm, partially enclosed within a capsule; b \u0026amp; c. Microscopic views - collagenized connective tissue surrounding fatty lobules\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5619612/v1/40ddce15b734b8d0527576af.png"},{"id":80082101,"identity":"f536fba8-dc98-44de-89d0-c7f19b3e1621","added_by":"auto","created_at":"2025-04-07 16:07:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2712498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5619612/v1/6f7e0e70-f86b-48e1-8722-808d7aeb9f6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fibrolipoma of the Spermatic Cord: First Reported Case in Children and a Review of the Literature","fulltext":[{"header":"Introduction","content":"\u003cp\u003eParatesticular masses mostly originate in the spermatic cord [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and lipomas are most prevalent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Even though fibrolipoma/angiomyolipoma/spindle cell lipoma/angiofibrolipoma are subtypes of lipoma, they are rare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is impossible to diagnose these cases using preoperative radiologic imaging, requiring diagnostic immunohistochemistry. When radiologic imaging can only narrow differential diagnosis, clinicians and radiologists have a diagnostic dilemma.\u003c/p\u003e \u003cp\u003eThis article discusses a 13-year-old patient with right inguinoscrotal pain, subsequently diagnosed with fibrolipoma, carrying considerable significance as it constitutes the first documented pediatric fibrolipoma of the spermatic cord.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 13-year-old male patient presented to the emergency department complaining of right inguinoscrotal pain and nausea for four days. Genital examination indicated that both testes were intrascrotal, with symmetrical size and structure. An additional mass was identified in the right scrotum, demonstrating tenderness upon palpation and mobility.\u003c/p\u003e \u003cp\u003eA Doppler scrotal USG revealed a 48x19mm heterogeneous soft tissue with no vascular activity at spermatic cord\u0026rsquo;s level in proximity to the right testicle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003ea-b-c).\u003c/p\u003e \u003cp\u003eβ-HCG, AFP, LDH, and CEA levels were normal. Due to tenderness upon mass palpation and normal tumor marker levels, accessory testicular torsion was considered, since it did not demonstrate a blood supply on Doppler USG. An emergency surgical procedure was planned.\u003c/p\u003e \u003cp\u003eA 5x2cm white solid mass was identified during inguinal exploration. The lesion, situated within the tunica vaginalis, was excised with relative ease after severing of its connections with vessels extending from the pampiniform plexus. (F A right herniotomy and high ligation were incorporated into surgical planning. The patient was discharged to follow-up with monthly/six-monthly visits.\u003c/p\u003e \u003cp\u003ePathology report identified fibrolipoma, characterized by collagenized stroma surrounding fatty lobules. Regarding macroscopic observation, fibrolipoma was characterized as a solid mass measuring 5x4x2cm, partially enclosed within a capsule, sections exhibiting a gray-yellow color with intermittent shiny gelatinous tissue fragments (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003eMicroscopic examination revealed a diverse vascular structure featuring varying densities and interconnections. Spindle cells were observed in collagenized stroma, whereas mast cells and histiocytic cells were scarce. Adipose/collagenous structures surrounding the lesion showed no atypia (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003eb\u0026amp;c).\u003c/p\u003e \u003cp\u003eImmunohistochemical analysis demonstrated positive staining with CD34 in some stromal areas and negative staining in other areas. Positive staining with CD117 was rare in mast cells, while positive staining with CD68 was rarely noted in histiocytes. Positive staining with SMA was observed exclusively in vascular walls, while positive staining with S-100 protein was observed in fatty tissues. Negative staining was observed with β-catenin-PanCK-MelanA-HMB-45-Desmin.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrimary paratesticular tumors are detected in 7\u0026ndash;10% of patients with intrascrotal neoplasms [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Spermatic cord tumors are exceedingly rare [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. Clinicians\u0026rsquo; primary differential diagnoses encompass incarcerated inguinoscrotal hernia/spermatic cord cyst/epididymal cyst. When encountering any incongruity in assessing these masses, clinicians opt for USG as initial imaging.\u003c/p\u003e\n\u003cp\u003eIdentifying paratesticular fibrolipoma through USG presents challenges. It, alongside MRI, plays a crucial role to narrow diagnostic possibilities [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is crucial to exclude incarcerated hernia, spermatic cord cyst, cystic structures such as angiofibrolipoma [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e], or solid structures like lipoma. Huben et al. employed scrotal ultrasound to exclude hydrocele/hernia during primary assessment of a scrotal fibrolipoma [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, ultrasonography/MRI offer valuable information, as 56% of spermatic cord masses are malignant when lipoma is excluded.\u003c/p\u003e\n\u003cp\u003eThe painful, hard, and mobile lesion in our case needed USG. Spermatic cord cysts can also be mobile and hard; however pain is not expected. On Doppler USG, we encountered a heterogeneous, solid mass with no circulation, suggesting incompatibility with fibrolipoma, which is well perfused on USG, as Hegele et al. noticed, but rather a finding that can be seen in lipoma [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, pain and USG still did not describe lipoma [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn light of patient\u0026apos;s clinical presentation, swift measures were taken for surgery. Tumor marker analysis displayed normal values, aligning with previous fibrolipoma cases as documented by Hegele, Mykoniatis, and Kacan [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]; tumor marker assessments were not conducted in other fibrolipoma case work-ups [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e] (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eTable 1. Comparative synopsis of the paratesticular fibrolipoma cases reported in the literature, together with the presented case\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"982\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePARATESTICULAR FIBROLIPOMA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAGE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSYMPTOMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHYSICAL EXAMINATION FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRADIOLOGICAL AND LABORATORY FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTREATMENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMACROSCOPIC EXAMINATION FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMICROSCOPIC AND IMMUNOHISTOCHEMICAL EXAMINATION FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Huben, 1983\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003e2 years of increasing right scrotal swelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003e20x25x30 cm non-tender mass; bilateral reducible inguinal hernias; normal lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eA mass with diffuse irregular internal echoes in USG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003eAn encapsulated fibrofatty tumor adherent to the scrotal wall but easily detachable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eA benign fibrolipoma without cellular atypia containing typical fat cells and fibrous tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Hegele, 2003\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003ePalpable mass in the right inguinal region for the last 15 years; enlargement and pain extending to the scrotum for the last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003eFirm, slightly painful mass; testes normal on palpation; no enlarged lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eWell-perfused mass with low echogenicity on color Doppler USG; homogeneous soft tissue tumor measuring 4x3x2 cm on CT scan; tumor marker values within normal limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eIntraoperative frozen section examination + mass excision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003eA thinly encapsulated tumor composed of white tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eMature fibrous connective tissue bundles crossing adipocytes; no atypia;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eImmunohistochemistry: fat cells positive for S100 protein - negative reaction to S-100 protein, actin, desmin and CD34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Terada, 2010\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003eRight inguinal swelling for 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision + right orchiectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003e13x10x9 cm, round, hard tumor with a thin capsule; yellowish-white solid and lobulated tissue fragment with gelatinous consistency on the surface of the section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eTumor consisting of mature adipose tissue (40% area) and mature collagenous fibrous tissue (60% area), which overlapped; lipoblasts not recognized; myxoid degeneration of mature adipose tissue in focal areas; smooth muscle not recognized with Azan stain; no vascular proliferation; tumor spindle cell clusters not recognized.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eImmunohistochemistry: Tumor cells negative for cytokeratins, epithelial membrane antigen, CD34, desmin, SMA, melanosome, p53 protein, MDM2, and CDK4; adipose tissue weakly positive for S-100 protein; %1 Ki-67 labeling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Mykoniatis, 2015\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003eSlowly increasing painless swelling of left hemiscrotum for 6 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003eA painless, large, firm mass palpated in the left hemiscrotum, extending into the perineal region and not clearly distinguishable from the surrounding scrotal components; non-palpable inguinal lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eOn USG, a hyperechoic scrotal mass, 5x6 cm in size, separate from the left testicle; on MRI, a mass showing a high T1 signal intensity characteristic of fat-containing tumors (no benign/malignant differentiation could be made); tumor markers (\u0026beta;-HCG, AFP, LDH) within normal limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003eA yellowish-white solid tumor measuring 19.5 x 7 x 5 cm, surrounded by a thin fibrous capsule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eEvident presence of mature fat cells between fibrous substrate; no cellular atypia, mitotic activity, lipoblasts, or necrosis; no smooth muscle recognized using Azan stain.\u003c/p\u003e\n \u003cp\u003eImmunohistochemistry: Tumor cells negative for desmin, SMA, p53 protein, CD34, MDM2 and CDK4\u003c/p\u003e\n \u003cp\u003ePathology report: fibrolipoma with diffuse mucoid degeneration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Kacan, 2016\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[6]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003eRight scrotal swelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003ePainless, mobile mass posterolateral to the right testicle, distinct from the testicle; non-palpable inguinal lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eOn USG, a large, hyperechoic scrotal mass separate from the right testicle; laboratory tests normal; serum markers for testicular cancer (\u0026beta;-HCG, AFP, LDH) within normal limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003eYellowish, solid tumor with a thin capsule, with dimensions of 9.5x9.5x2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eMicroscopically, a tumor composed of mature adipose tissue and collagenous fibrous tissue; no lipoblasts recognized\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTumor diagnosis: giant fibrolipoma of the right spermatic cord\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Rohit, 2021\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003eLeft inguinoscrotal non-tender swelling for 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003eLeft inguinoscrotal firm, elastic, non-tender swelling with a smooth surface and sized 8x6 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eon USG, heteroechoic mass measuring 7x6 cm with possible characteristics of a lipoma or desmoid\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision following fine needle aspiration biopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003eSolid tumor measuring 7x6x5 cm with a smooth surface, smooth margins, and a gray-white stalk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eMature adipose tissue with an encapsulated mass line of fibro-collagenous tissue, macrophages, calcifications, and areas of fat necrosis indicating fibrolipoma with secondary fat lysis; no atypia.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0214%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Mansiroglu, 2024 (presented case)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4588%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6989%;\"\u003e\n \u003cp\u003eFour-day history of pain and swelling in the upper half of the right hemiscrotum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6317%;\"\u003e\n \u003cp\u003eAn ellipsoid, firm, mobile lesion with a smooth surface, approximately 5 cm in length, tender to palpation; no inguinal LAP; no additional pathology on examination of the testes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5473%;\"\u003e\n \u003cp\u003eOn Color Doppler USG, a 49x18 mm heterogeneous, solid, soft tissue structure with no vascular activity; tumor markers\u0026rsquo; (\u0026beta; -HCG, AFP, LDH) values within normal limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.74873%;\"\u003e\n \u003cp\u003eMass excision + inguinal hernia repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3438%;\"\u003e\n \u003cp\u003ePartially encapsulated, solid tumor measuring 5x4x2 cm; solid tissue fragment, sections gray-yellow and occasionally glossy gelatinous.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5493%;\"\u003e\n \u003cp\u003eFibrolipoma, characterized by collagenized and occasionally spindle cells surrounding fatty lobules; no atypia\u003c/p\u003e\n \u003cp\u003eImmunohistochemistry: Positive staining with CD34 in some stromal parts (usually negative), positive staining with CD117 in rare mast cells, positive staining with CD68 in rare histiocyte cells, positive staining with S-100 in adipose tissue and negative staining in other areas, negative staining with B-catenin, PanCK, HMB-45, and Desmin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eExcision was deemed optimal due to mass\u0026apos;s mobility and smooth surface. Torsion was not observed, and perfusion was provided by numerous thin vessels, contrary to USG findings. Possibility of spontaneous detorsion under anesthesia was also considered. However, it was impossible to perform a frozen-section pathological examination intraoperatively, like in Hegele\u0026apos;s case, due to unavailability of a pathologist. The fact that the mass was not as large as that evaluated by Terada might have influenced us not to add orchiectomy. We considered a second operation, if deemed necessary, following the pathology report.\u003c/p\u003e\n\u003cp\u003eUpon macroscopic examination, no significant variations were observed compared to other fibrolipoma cases, aside from its size. Lack of conclusive diagnosis of fibrolipoma through radiological imaging in our case, as well as in other fibrolipoma cases, emphasizes significance of microscopic examination and immunohistochemistry staining for obtaining a definitive diagnosis [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. No evidence suggests any distinction in management and prognosis between spermatic cord fibrolipomas and other benign lipomatous tumors [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, malignant lesions don\u0026rsquo;t fall into this category. Pathological assessment validated absence of rhabdomyosarcoma/liposarcoma, paratesticular region\u0026rsquo;s predominant malignant lesions.\u003c/p\u003e\n\u003cp\u003eAngiomyolipomas, primarily renal and rarely in spermatic cord, showing strong staining with HMB-45 (80\u0026ndash;100%) and almost complete staining with SMA, allowed us to deduce that angiomyolipoma was unlikely. Abundant mast cells in spindle cell lipomas, combined with strong positive CD34 staining, were observations that eliminated spindle cell lipoma [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Exclusive staining with S-100 in adipose tissue, as documented by Hegele and Terada [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e], and encasement of fatty lobules with collagenous stroma in all remaining scenarios, constituted additional results affirming fibrolipoma, differentiating it from other subtypes.\u003c/p\u003e\n\u003cp\u003ePediatric paratesticular masses, ranging from non-neoplastic conditions such as spermatic cord cysts or polyorchidism to neoplastic masses such as rhabdomyosarcoma, represent a relatively uncommon group of disorders for clinicians. Histopathologic sampling is critical in precisely diagnosing paratesticular tumors, which are seldom seen and can be inadequately assessed through radiologic imaging. Preoperative/intraoperative histopathologic sampling could help avoid unnecessary orchiectomies.\u003c/p\u003e\n\u003cp\u003eThe youngest adult case of histopathologically diagnosed fibrolipoma was 30-year-old [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e], indicating its occurrence in young adults, and six documented cases\u0026rsquo; mean age was 55.3. Thus, this report signifies the initial documentation of a pediatric paratesticular fibrolipoma.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUSG: Ultrasonography \u0026beta;-HCG: Beta-Human Chorionic Gonadotropin AFP: Alpha Fetoprotein LDH: Lactate Dehydrogenase CEA: Carcinoembryonic Antigen SMA: Smooth Muscle Actin S-100: Soluble in 100% saturated solution of ammonium sulphate HMB-45: Human Melanoma Black-45 MRI: Magnetic Resonance Imaging \u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was not required as this is a single case report.\u0026nbsp;Clinical trial number: not applicable.\u0026nbsp;Informed consent was obtained from the parents of the patient who participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents of the case report for publication of the medical case details and accompanying images.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAKM contributed to Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing \u0026ndash; original draft \u0026ndash;, Writing \u0026ndash; review \u0026amp; editing .\u003c/p\u003e\n\u003cp\u003eAD contributed to Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Supervision, Visualization, Writing \u0026ndash; review \u0026amp; editing .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAKM; Pediatric surgeon at Ministry of Health Sivas State Hospital, Sivas, Turkey\u003c/p\u003e\n\u003cp\u003eAD; \u0026nbsp;Radiologist at Ministry of Health Sivas State Hospital, Sivas, Turkey\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRohit G, Hariprasad CP, Bharti S, Kumar A, Paswan SS, Vikram S, et al. Astounding Fibro Lipoma of Spermatic Cord: A Diagnostic Dilemma. Case Rep Surg 2021;2021:7139109. doi: 10.1155/2021/7139109\u003c/li\u003e\n\u003cli\u003ePriemer DS, Trevino K, Chen S, Ulbright TM, Idrees MT. Paratesticular Soft-Tissue Masses in Orchiectomy Specimens: A 17-Year Survey of Primary and Incidental Cases From One Institution. Int J Surg Pathol 2017;25(6):480-7. doi: 10.1177/1066896917707040.\u003c/li\u003e\n\u003cli\u003eDagur G, Gandhi J, Kapadia K, Inam R, Smith NL, Joshi G, et al. Neoplastic diseases of the spermatic cord: an overview of pathological features, evaluation, and management. Transl Androl Urol 2017;6(1):101-10. doi: 10.21037/tau.2017.01.04.\u003c/li\u003e\n\u003cli\u003eHegele A, Olbert P, Roessler M, Heidenreich A, Hofmann R. Inguinal fibrolipoma of the spermatic cord: discrepancies between clinical and histopathological findings. Urol Int 2003;71(4):435-6. doi: 10.1159/000074102\u003c/li\u003e\n\u003cli\u003eMykoniatis I, Metaxa L, Nikolaou V, Filintatzi C, Kikidakis D, Sountoulides P. Giant Scrotal Fibrolipoma. Rare Tumors 2015;7(4):6001. doi:10.4081/rt.2015.6001\u003c/li\u003e\n\u003cli\u003eKacan T, Kilinc MF, Ayyildiz A. Giant fibrolipoma of the spermatic cord. \u003cem\u003e26th National Congress of Urology.\u003c/em\u003e Kyrenia, TRNC; 2017. http://file.uroturk.org.tr/files/cd/2017/CDDATA/CONTENTTR/PP-247.htm\u003c/li\u003e\n\u003cli\u003eHuben RP, Scarff JE, Schellhammer PF. Massive intrascrotal fibrolipoma. J Urol 1983;129(1):154-5. doi: 10.1016/s0022-5347(17)51970-9.\u003c/li\u003e\n\u003cli\u003eAhmed HU, Arya M, Muneer A, Mushtaq I, Sebire NJ. Testicular and paratesticular tumours in the prepubertal population. Lancet Oncol 2010;11(5):476-83. doi: 10.1016/S1470-2045(10)70012-7.\u003c/li\u003e\n\u003cli\u003eTerada T. Giant fibrolipoma of the spermatic cord. Pathol Int 2010;60(4):330-2. doi:10.1111/j.1440-1827.2010.02521.x\u003c/li\u003e\n\u003cli\u003eEmerson RE, Ulbright TM. The use of immunohistochemistry in the differential diagnosis of tumors of the testis and paratestis. Semin Diagn Pathol 2005;22(1):33-50. doi:10.1053/j.semdp.2005.11.003\u003c/li\u003e\n\u003cli\u003eHisamitsu I, Takashi N, Yutaka K, Satoru M, Tetsuo I, et al. Spindle cell lipoma of the spermatic cord. Int J Urol 2007: 14(11):1046-7 doi: 10.1111/j.1442-2042.2007.01892.x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fibrolipoma, paratesticular mass, rare tumors","lastPublishedDoi":"10.21203/rs.3.rs-5619612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5619612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBenign tumors of the spermatic cord constitute the majority of paratesticular tumors. While fibrolipoma is uncommon in adults, there are no recorded cases of fibrolipoma of the spermatic cord in children.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA male patient, aged 13, arrived at the emergency department complaining of right inguinoscrotal pain and nausea for the past four days. The Doppler scrotal ultrasound demonstrated a soft tissue structure measuring 48x19 mm with heterogeneity and absence of vascular activity, located along the spermatic cord in proximity to the right testicle. Right scrotal tenderness and absence of blood supply on Doppler ultrasound indicated emergency surgical intervention, considering the possibility of torsion in an accessory testicle, more frequently encountered in pediatrics. Surgical exploration of the inguinal region and mass excision were conducted. The pathology report determined a tumor exhibiting collagenized tissues surrounding fatty lobules, indicative of a fibrolipoma.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case represents initial documentation of a pediatric paratesticular fibrolipoma. The mean age of the six cases reported thus far is 55.3 years. In the definitive diagnosis of paratesticular tumors, which are rarely seen and cannot be adequately evaluated through radiologic imaging, histopathologic sampling holds significant importance.\u003c/p\u003e","manuscriptTitle":"Fibrolipoma of the Spermatic Cord: First Reported Case in Children and a Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 13:29:41","doi":"10.21203/rs.3.rs-5619612/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-24T16:32:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-17T14:08:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-17T14:05:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-12-10T21:56:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0135b254-b3c8-4947-b9f6-dadf9702131d","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T16:02:53+00:00","versionOfRecord":{"articleIdentity":"rs-5619612","link":"https://doi.org/10.1186/s12894-025-01752-4","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2025-04-02 15:57:54","publishedOnDateReadable":"April 2nd, 2025"},"versionCreatedAt":"2024-12-19 13:29:41","video":"","vorDoi":"10.1186/s12894-025-01752-4","vorDoiUrl":"https://doi.org/10.1186/s12894-025-01752-4","workflowStages":[]},"version":"v1","identity":"rs-5619612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5619612","identity":"rs-5619612","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}