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Lymphedematous fibroepithelial polyps of the penis are lesions that have only recently been described and are frequently associated with condom-catheter use.
We report an additional case of lymphedematous fibroepithelial polyps of the penis in association with long-term condom catheter use in a 36 year-old man.
Local excision showed large polypoid nodules with compact orthohyperkeratosis and mild acanthosis. The stroma was hypercellular with spindled to stellate fibroblasts and occasional multinucleated cells. Proliferation of small linear to slightly arcuate vessels with some superficial dilatation was a prominent feature. Focal expression of smooth muscle actin and desmin was present in the stroma.
Lymphedematous fibroepithelial polyps of the penis are rare lesions with only 11 cases previously reported. We present here an additional example of this entity to highlight the differential diagnosis, the association with condom-catheter use and to raise awareness for this unusual diagnosis.
Lymphedematous fibroepithelial polyps have only been recently described in the pathology literature (1). Out of the seven cases reported in the initial series, five were associated with condom catheter use, one presented with paraphimosis and for the remaining seventh case no clinical information was available. Four additional single case reports have subsequently been published two of which were associated with long-term condom catheter use (2–5). The clinical differential diagnosis typically includes squamous cell carcinoma, condyloma acuminatum, polypoid urethothelial carcinoma and fibroepithelial polyp.
The patient was a 36 year-old quadriplegic African-American male status-post C6-cervical spine injury from a motor-vehicle accident 17 years ago. Consequently he developed neurogenic bladder and had used a condom-catheter for a duration greater than 10 years. The patient was followed-up routinely in the urology clinic for his neurogenic bladder. On one of his visits the patient presented with several polypoid, flesh-colored, non-tender nodules on the glans penis and along the frenulum that had been growing significantly in the past year. The patient was taken to the operating room and underwent surgical excision.
The pathology specimen was composed of four polypoid gray-tan fragments of skin and underlying subcutaneous tissue varying in size from 0.4 × 0.6 × 0.6 cm to 1.1 × 1.4 × 2.6 cm. The specimen was entirely submitted for histologic examination.
Examination of hematoxylin and eosin stained sections revealed polypoid lesions composed of an edematous stroma covered by keratinizing squamous epithelium with compact hyper-orthokeratosis and mild acanthosis (Figure 1). The underlying stroma was hypercellular, containing numerous fibroblasts with a slight fascicular arrangement (Figure 2). The morphology of the stromal fibroblasts varied from bland spindled to stellate-shaped cells. Occasional multi-nucleated cells, some resembling touton giant cells were also present (Figure 3). Within the stroma, a prominent vascular component was noted. This was composed of small arcuate-to-linear vessels with dilated lumens in the superficial region while towards the deeper aspect of the lesion the vessels were larger with thick, muscular walls (Figure 4). A lymphocytic infiltrate was focally present in the papillary dermis and around occasional vessels. Mast cells were increased in number and were scattered throughout the stroma. Foci of brown pigment consistent with hemosiderin deposition were also present.
The patient’s postoperative course was unremarkable and at the last follow up 7 months post-excision he was disease-free.
Lymphedematous fibroepithelial polyps of the penis have only recently been described and to our knowledge, only one series (7 cases) and four other individual case reports have been reported in the literature for a total of 11 cases (Table 1). These lesions are characterized histopathologically by large size, a loose, edematous, cellular stroma containing numerous small vessels with occasional luminal dilatation, and occasional multinucleated mesenchymal cells. An increased number of mast cells was noted in the current case throughout the stroma, a finding reported also by others (1,4). A history of chronic condom catheter use was noted in the majority of the published cases (7 out of 11 cases).
On clinical grounds, the differential diagnosis includes acrochordon, condyloma acuminatum and even squamous or urothelial carcinoma. Lymphedematous fibroepithelial polyps of the penis are histologically and clinically distinct from the standard cutaneous fibroepithelial polyps (acrochordons) commonly encountered in dermatopathology practice. In comparison to the cutaneous fibroepithelial polyps, lymphedematous fibroepithelial polyps of the penis are typically larger, show stromal hypercellularity with occasional multi-nucleated cells, stromal edema and have a prominent vascular pattern with dilatation and thickening of vessels. In addition, lymphedematous fibroepithelial polyps have only been described occurring on the penis whereas the typical locations for cutaneous fibroepithelial polyps are neck, axilla, eyelid and inframammary folds. The location and clinical appearance raise the clinical impression of condyloma acuminatum however, there are no features such as papillomatosis or koilocytosis to suggest this diagnosis. There are also no histologic features of a cutaneous or mucosal carcinoma present such as invasion of normal stuctures, cytologic atypia or mitoses. The stromal hypercellularity and occasional multi-nucleation may appear worrisome on low-power however, high power examination shows a bland cytology (Figure 3)
The precise pathogenesis of these lesions is not known however, considering the strong association with condom catheter use they are likely reactive in nature. It has been proposed that these lesions are secondary to the negative pressure of the condom catheter and the irritation and inflammation associated with its long-term use (1,3). In fact, generalized penile edema, irritation and maceration are well-known complications of condom catheter use. The irritation and inflammation may also be the cause for this lesion in the two reported cases not associated with condom catheter (1,4) one of which was associated with phimosis/paraphimosis (1). The reactive pathogenesis is less clear in the case by Yildirim et al occurring in the 4 year-old boy (5). However, this case has a limited discussion of the histologic findings and may in fact represent a regular fibroepithelial polyp occurring on the penis.
Treatment by local excision has been successful in all previously reported cases (1–5). In the series by Fetsch et al recurrences are described in two of the five patients that had clinical follow-up information available (1). Both patients underwent a second local excision and remained disease-free at intervals of 12 years eight months and three months, respectively. At the time of writing this case, our patient is 7 months post-excision and remains disease-free.
In conclusion, we present here our experience with an additional case of lymphedematous fibroepithelial polyps of the penis. We think that this rare entity is currently under-recognized by the pathologists or dermatopathologists. Because clinical information regarding the use of a condom catheter may not be readily available, recognizing the distinct histologic features of this lesion (edematous, hypercellular stroma with occasional multi-nucleated cells and prominent vasculature) is important for a correct diagnosis as they will likely be the dermatopathologist’s only diagnostic clues.
Stephen E. Mason, Dermatopathology Fellow, University of Alabama Birmingham, Department of Pathology, Dermatopathology.
Patricia DeVilliers, Assistant Professor, University of Alabama, Birmingham, Department of Pathology.
Aleodor A. Andea, Assistant Professor, University of Alabama Birmingham, Department of Pathology, Dermatopathology, PD6A 149, 619 19th Street South, Birmingham, AL 35249-6815, Phone 205-975-6941, Fax 205-975-6922, Email: ude.bau@aednaa.