Journal of Surgical Oncology 27:76-79 (1984)

Scrota1 Calcinosis: Calcification of Epidermal Cysts

DEBA P. SARMA, MD AND THOMAS G. WEILBAECHER MD

From the Department of Pathology, VA Medical Center and Louisiana State University Medical School, New Orleans

The so-called idiopathic scrotal calcinosis does not appear to be idiopathic, but rather a process of dystrophic calcification of epidermal cysts. We report a case that would be otherwise called “idiopathic” where we found squamous epithelial lining around the calcified masses. Literature is re- viewed in support of the view that the calcified scrotal nodules are related to epidermal cysts.

KEY WORDS: idiopathic scrotal calcinosis, scrotal cyst, calcified scrotal cyst, scrotal calcification, scrotal calcinosis

INTRODUCTION nodules were deposits of calcium in the form of amor- Scrota] calcinosis, c o m m o ~ y known as ‘‘idiopathic phous basophilic masses (Fig. 2). The calcified masses

scrota1 calcinosis,” is a rare condition characterized by were surrounded by layers of collagen, Some macro- the presence of single or multiple painless calcified nod- Phages, and a few mononuclear (Fig, 3). In One

ules of various sizes in the scrota1 wall. Although various nodule, the calcified material was partially lined by a theories regarding the etiology and pathogenesis of the well-differentiated squamous epithelial lining showing a condition have been proposed, none has been widely maturation like that ofthe epidermis (Fig. 4). accepted; hence “idiopathic scrota1 calcinosis” is the Several nodules, on crystallographic analysis, were most commonly used term. composed of hydroxyapatite, Ca 10(P04)6(OH)2.

DISCUSSION We report a typical case of scrotal calcinosis in which we have seen a definite squamous cell lining around the calcific deposits. In light of our observation we, in agree- ShaPiro and associates in 1970, reported 13 cases of merit with the idea of a few other authors, propose that histologically studied idiopathic CalCinOSiS of the SCrOtUm the so-called idiopathic calcinosis of the scrotum is and critically reviewed nine other cases from the Iitera- probably a process of dystrophic calcification of the epi- ture [I]. They summarized that the lesions of the scrotal dermal cysts. skin were usually multiple and asymptomatic, began in

childhood or young adulthood, gradually increased in CASE REPORT size and number, and sometimes broke down to discharge

A 31-year-old Caucasian man presented with a several- chalky contents. Histologically there was no evidence of year history of slowly growing, painless nodules of the residual cyst or epithelial lining around the calcified scrotum. Clinical examination showed a healthy male They strongly argued against any possible rela- with several firm, nontender nodules of various sizes on tionship between epithelial cysts and the calcinosis in the scrotum ( ~ i ~ , 1 ) . A diagnosis of cysts was these cases. Since 1970, at least 11 more cases have been made. After an initial surgical removal of four cysts for reported where the authors did not find any histologic histopathologic diagnosis, the rest were subsequently ex- evidence of epithelial lining in the lesions [2-71. cised. The results of all laboratory tests were within The reported cases Of scrotal calcinosis where epithe- normal limits. lial lining has been noted are about six [8-111, including

Grossly, the dermal nodules ranged from 0.3 to 1.0 cm in diameter. Some contained yellow-white material, 0th- ers were hard and needed before section- ing. Microscopically, epidermis was normal. The dermal

0 1984 Alan R. Liss, Inc.

Accepted for publication December Address reprint requests to D. Sarma, MD, 1601 Perdido Street, New Orleans, LA 70146.

1983,

Scrota1 Calcinosis 77

our present case. Morley and Best (81 had noted stratified squamous epithelium around the calcified masses in an otherwise typical clinical case of scrotal calcinosis. Shap- iro et al [ I ] , in their critical review mention that case [8] but do not accept the description of the epithelial lining. However, Morley and Best’s [S] description of “squa- mous epithelium” appears specific. Swinehart and Golitz 191 describe and nicely illustrate three additional cases of typical clinical scrotal calcinosis, the lesions showing

Fie. I . Clinical amcarancc of the scrotal nodules. Picture was taken

squamous epithelial walls suggestive of epidermal cysts. Bhawan and associates [lo] have noted foreign body granuloma around keratinous material suggesting a rup- tured epidermal cyst in a follow-up biopsy in a patient they originally described as a case of idiopathic scrotal calcinosis [ I 11.

There are no essential clinical differences between the cases described as “idiopathic scrotal calcinosis” and the cases where the calcinosis appears related to epidermal cysts. The reason for not finding an epithelial lining may be (1) destruction and disappearance of the epithelial cells due to chronicity and inflammation, as in ruptured epi- dermal cysts, and (2) inadequate sampling for micro- scopic study. In our case, only one out of nine calcific masses had revealed an epithelial lining. If only a few nodules out of many lesions excised are microscopically studied, evidence of epithelial lining may be easily missed.

In agreement with other authors 18-10], based on the clinico-pathologic observations, we believe the so-called idiopathic scrotal calcinosis is not idiopathic, but rather a process of dystrophic calcification of epidermal cysts.

ACKNOWLEDGMENTS We thank Ms. Roey Holliday for excellent secrctarial

Y .. after cxcisional biopsy of several nodules. assistance.

Fig. 2 . Low-power view showing calcific masses in the dermis. H&E, x4.

78 Sarma and Weilbaecher

Fig. 3. cells, and dense fihrosis H&E, X 100.

Calcific mass surrounded by macrophages, mononuclear

Fig. 4. Calcified mass surrounded by stratified squamous epithe- lium. H&E. X 100.

Scrotal Calcinosis 79

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