Penis and scrotum - Cutaneous verruciform xanthoma

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Penis and scrotum

Inflammatory lesions

Cutaneous verruciform xanthoma

Reviewers: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (see Author/Reviewers page)

Revised: 22 May 2010, last major update February 2010

Definition

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● Rare disorder of foam cell aggregates in vascularized submucosa or papillary dermis, associated with verrucous epithelial hyperplasia

Epidemiology

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● Mean age 52 years

Sites

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● Usually in oral mucosa, rarely in scrotum, penis

Etiology

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● Uncertain etiology, although probably a reactive process following epithelial damage

● Initial keratinocyte damage attracts neutrophils, then dermal dendrocytes phagocytosize necrotic keratinocyte debris (Am J Surg Pathol 1998;22:479)

● Foam cells most likely derived from CD68+ dermal dendritic cells

● Some cases are PUVA related (PUVA is Psoralen + UVA treatment for eczema, psoriasis, vitiligo and mycosis fungoides)

● Consistently HPV negative (Arch Pathol Lab Med 2005;129:e6)

Clinical features

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● Slow growing, painless, solitary exophytic tumors measuring 0.5 to 2.0 cm

Case reports

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● Associated with cutaneous trauma (J Cutan Pathol 2009 Dec 2 [Epub ahead of print])

● 57 year old man with palate lesions (Case of Week #82)

Treatment

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● Excision; does not recur (J Formos Med Assoc 2007;106:141)

Clinical images

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Granular, elevated tan-white mass of distal shaft and coronal sulcus (from Arch Dermatol 1981;117:516)

Gross description (Macroscopy)

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● Solitary, raised or polypoid with cup-shaped craters

● Can simulate a verruciform penile tumor such as condyloma (typical or giant) or warty or verrucous carcinoma

Micro description (Histopathology)

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● Foam cell aggregates in vascularized submucosa or papillary dermis, associated with verrucous epithelial hyperplasia with acanthosis, papillomatosis, hyperkeratosis with no granular layer and prominent parakeratosis between papillae (AJSP 1998;22:479)

● Cup shaped craters are filled with parakeratotic cells blending into keratinocytes

● Also variable neutrophilic infiltrate near surface of epidermis between plump parakeratotic cells and keratinocytes

● Bandlike plasma cell infiltrate at base of epidermis

● Absence of atypical epithelial changes

Micro images

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H&E and CD68 Papillary epithelial hyperplasia and stromal histiocytes with

foamy cytoplasm in papillary cores

Scrotum:

Crater-shaped verrucoid lesion Numerous foamy macrophages between

elongated rete ridges

Cervix / vulva / vagina:

Palate:

Tongue:

Focal parakeratosis, mild epithelial acanthosis CD68

with regularly elongated rete and xanthoma

cells within connective tissue papilla

Virtual slides

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Vulvar lesion

Positive stains

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● Factor VIIIa, CD68, Mac387

● Cytokeratin (weak)

Negative stains

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● S100

Electron microscopy descriptions

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● Xanthoma cells contain membrane bound lysosomes, myelin figures and fragmented desmosomes

Differential Diagnosis

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● Condyloma acuminatum: prominent koilocytotic atypia in upper epidermis, no prominent foamy macrophages

● Squamous cell carcinoma: marked atypia, no prominent foamy macrophages

● Verrucous carcinoma: ulcerating or fungating lobules of mature squamous epithelium, minimal atypia but no prominent foamy macrophages

Additional references

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● eMedicine

End of Penis and scrotum > Inflammatory Lesions > Cutaneous verruciform xanthoma

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