Dedifferentiated Liposarcoma of the Spermatic Cord: A Series of 42 Cases

Initial local resection versus early referral for spermatic cord sarcoma: Any impact on treatment timelines and oncological outcomes?

OBJECTIVES

Spermatic cord sarcomas are exceedingly rare, often misdiagnosed and subsequently improperly treated at local hospitals. This retrospective study looked at the oncological outcomes of spermatic cord sarcoma cases managed with curative intent resection at a tertiary referral sarcoma centre. We specifically studied how initial inadequate resections impact the oncologic outcomes compared to primary tumour resections at the reference centre.

METHODS

One hundred eighteen consecutive patients affected by primary, localized spermatic cord sarcoma surgically managed at our reference centre from January 2001 through January 2021 were included. Primary endpoints were local relapse free (LRFS), distant metastasis free (DMFS) and overall survival (OS). These outcomes were evaluated with multi-nomial logistic regression and Cox proportional hazards regression models for a co-relation to known patient, tumour and treatment-related prognostic factors, including a prior inadequate resection and time from diagnosis to a complete oncologic resection as independent variables. Secondarily, we compared the above variables and treatment intervals among the subgroups of primary versus re-resection surgery.

RESULTS

Over a median follow-up of 54 months (IQR 25-105), 12 patients (10.2%) developed local recurrence (LR) and 14 (11.6%) had distant metastasis (DM). 5-year local relapse (LRFS) and distant metastasis-free survival (DMFS) were 89.3% and 86.5%, respectively. Higher tumour grade and size were associated with a worse DMFS (p=<0.05). Likewise, marginal (R1) resection correlated with an inferior LRFS (p=< 0.05). Eighty-four patients (71.2%) had their initial diagnosis established on an inadequate surgical excision performed in a local hospital, followed by a re-excision at our centre (Re-resection group). During the same period, 34 (28.8%) were managed primarily with biopsy and treatment at our reference centre (Primary-resection group). The two groups had statistically significant differences in tumour size, histopathology, surgery duration, rate of postoperative complication and R0 resection (p < 0.005). Additionally, the difference in time intervals to achieve the treatment targets was statistically insignificant and did not correlate to the risk of recurrence as an independent variable. Residual disease was present in 51.2 % (n = 43) of the re-excision specimens. However, following a complete R0 resection, this did not correlate with a higher risk of recurrence (p = 0.481).

CONCLUSION

Prompt referral to a tertiary centre, where multidisciplinary evaluation and sound oncologic resections are the standard of treatment, can align the OS and DFS of patients receiving incomplete surgery elsewhere to those treated primarily in referral centres. The primary determinant of prognosis remains surgical margin, tumour size and grade.

Case report: Paratesticular dedifferentiated liposarcoma with poor prognosis

BACKGROUND/AIM

Most paratesticular liposarcomas (PLPSs) are well-differentiated liposarcomas (WDLPSs) with favourable prognoses. As such, the rare occurrence of PLPS often leads to its misdiagnosis as a hernia or hydrocele on physical examination. Curative resection of the tumour may not be possible in cases where PLPSs have transformed into dedifferentiated liposarcomas (DDLPSs) owing to a delay in diagnosis. Herein, we describe a case of unresectable paratesticular dedifferentiated liposarcoma (PDDLPS) with poor prognosis due to delayed diagnosis.

CASE REPORT

A 57-year-old man visited our hospital with a chief complaint of a right scrotal mass, which was diagnosed as scrotal hydrocele but without treatment or follow-up. Eight years later, the patient complained of abdominal distension, and a computed tomography scan revealed the presence of retroperitoneal and right scrotal masses. The right scrotal mass was removed, and histopathology revealed DDLPS. The patient was diagnosed with unresectable PDDLPS metastasising to the retroperitoneum, and the left pleura was treated with doxorubicin. After an initial response, pleural effusion and ascites increased during the sixth cycle of chemotherapy. The patient subsequently received eribulin but died 5 months after the initial DDLPS diagnosis.

CONCLUSION

It is difficult to distinguish PLPS from benign inguinal hernia and hydrocele testis on physical examination. PLPS generally has a considerably good prognosis. However, failure to diagnose WDLPS can be dangerous as it might lead to malignant transformation to DDLPS, which has a poor prognosis. Physicians should consider this malignancy when examining patients with hernias or hydroceles of the inguinal region and should perform ultrasonography or magnetic resonance imaging.

Giant bilateral scrotal lipoma with abnormal somatic fat distribution: A case report

BACKGROUND

Scrotal lipoma is exceedingly rare, so its origin is still unknown. Injury is suggested as a potential factor, but the cause remains unclear. It is difficult to determine the origin of these tumours. Previous studies have suggested that these tumours may be congenital or that they originate from small fatty particles around the cord. Other studies have suggested that these tumours originate from testicles or the tunica.

CASE SUMMARY

A 66-years elderly male with giant scrotal mass. B-ultrasound, computed tomography and magnetic resonance imaging examinations are typical lipoma-like changes, which were confirmed by postoperative pathological analysis. Abnormal somatic fat distribution was confirmed by images. no recurrence after follow-up for 2 years. Previously published English-language literature was reviewed, and a history of inguinal or pelvic surgery was reported in 6 studies (total 21 cases). To our knowledge, this is the heaviest bilateral scrotal lipoma in the English-language literature, and it has the longest postoperative follow-up time. More importantly, the origin of these tumours is reviewed and discussed.

CONCLUSION

Giant bilateral scrotal lipoma in elderly may as part of the symptoms of abnormal somatic fat distribution.

Paratesticular Dedifferentiated Liposarcoma with Epithelioid Features: A Diagnostic Pitfall

Well-differentiated/dedifferentiated liposarcoma (WDLPS/DDLPS) represent a significant number of sarcomas arising within the paratesticular region. DDLPS is notorious for a broad histologic spectrum, but epithelioid morphology is rare. Herein, we describe a unique case of paratesticular DDLPS with prominent epithelioid features and molecular confirmation. The patient is 71-year-old-male who presented with multiple paratesticular masses. Morphologic review of the resection specimen revealed a biphasic adipocytic neoplasm consistent with DDLPS. Additionally, epithelioid foci with acinar and nested architecture and focal keratin expression were noted. These areas raised the possibility of a secondary neoplasm including sex cord stromal tumor, germ cell tumor, and paraganglioma. However, MDM2 immunohistochemistry and FISH showed these areas to express MDM2 and exhibit MDM2 amplification, respectively, confirming that they represented a component of DDLPS. This case further highlights the morphologic diversity of DDLPS as well as the utility of MDM2 studies.

CT imaging of an unusual malignant inguinal mass: metastatic parafunicular dedifferentiated liposarcoma

A man in his 50s was redirected by his general practitioner to our University Hospital for a radiological evaluation after the complaint of a left inguinal swelling. The preliminary ultrasound and CT scan showed a left parafunicolar mass located between the root of the penis and the spermatic cord. The lesion was biopsied shortly after and histologically diagnosed as a dedifferentiated liposarcoma. The patient underwent a cycle of neoadjuvant radiotherapy, which proved to be ineffective. He was then subjected to an organ sparing surgical removal of the mass, followed by a second organ sparing removal of some residual disease. The last CT scan showed absence of the inguinal disease; however, lung and hepatic metastasis were detected, which are scheduled to be treated with a course of chemotherapy and radiofrequency.

Adjuvant radiotherapy in the treatment of dedifferentiated liposarcoma of the spermatic cord: a rare entity

Dedifferentiated liposarcoma (DDL) of the spermatic cord is a very rare entity in which management is remarkably controversial due to scarce literature. Although the actual standard of care is surgery via radical inguinal orchiectomy, adjuvant therapies like radiotherapy have demonstrated improved local control, particularly in cases with higher risk for local recurrence and worse prognosis. The role of adjuvant chemotherapy remains questionable in this subset of patients. On literature review, the most important prognostic factors for survival outcomes were surgical margin status, histological grade and the presence of metastases prior to the initial surgery. In this report, we discuss the case of a 59-year-old man with DDL of the spermatic cord that was treated with surgery followed by adjuvant radiotherapy. We also provide a comprehensive literature review about the management of this entity.

Liposarcoma of the spermatic cord presenting as an inguinal hernia

INTRODUCTION

Dedifferentiated liposarcoma is a rare, highly malignant, rapidly recurring tumor. When found in the spermatic cord, this tumor may deceptively present as an inguinal hernia, and due to its rarity, may not be readily identified.

PRESENTATION OF CASE

We report a case of a 46-year old man with dedifferentiated liposarcoma presenting as a slow-growing right inguinal bulge. His surgical management included ipsilateral orchiectomy and excision with wide margins. He received adjuvant focused radiation therapy.

CONCLUSION

Liposarcoma of the Spermatic Cord is a rare and highly malignant tumor that rapidly recurs. Therefore, a high degree of suspicion, regular surveillance and imaging are justified.

Mesenchymal Neoplasms of the Genitourinary System: A Selected Review with Recent Advances in Clinical, Diagnostic, and Molecular Findings

Mesenchymal neoplasms of the genitourinary (GU) tract often pose considerable diagnostic challenges due to their wide morphologic spectrum, relative rarity, and unexpected incidence at GU sites. Soft tissue tumors arise throughout the GU tract, whether from adventitia surrounding or connective tissues within the kidneys, urinary bladder, and male and female genital organs. This selected article focuses on a subset of these lesions, ranging from benign to malignant and encompassing a range of patterns of mesenchymal differentiation, where recent scholarship has lent greater insight into their clinical, molecular, or diagnostic features.

Dedifferentiated spermatic cord liposarcoma with macroscopic ossification

Introduction

Liposarcoma is a malignant neoplasm of the adipose tissue, and dedifferentiated liposarcoma is a relatively rare subtype. Liposarcomas are typically located in the lower extremities or retroperitoneum, but dedifferentiated liposarcoma of the spermatic cord is rare and no case of it with macroscopic ossification has been reported in the literature.

Case presentation

A male presented to our hospital with a painful, palpable, and hard left suprapubic mass, formed over 3 months. The mass was diagnosed as a spermatic cord tumor and was resected using high orchiectomy. Due to the histological diagnosis of dedifferentiated spermatic cord liposarcoma with ossification and positive margins, a second extended resection and adjuvant radiotherapy were performed.

Conclusion

To differentiate spermatic cord liposarcoma preoperatively is difficult. There is no gold standard treatment for it, although surgical complete resection with clear microscopic margins would be the most effective treatment.

Florid Proliferation of Hyalinized Vessels in a Spermatic Cord STAT6 Positive Solitary Fibrous Tumor and Its Potential Clinical Implications

A solitary fibrous tumor (SFT) arising in the paratesticular region is a rare event. Typically most SFTs present as a lung mass and have a characteristic microscopic appearance. Although uncommon, SFTs may present at just about any anatomical site. Here we present a case of a SFT arising along the right spermatic cord, with histologic features mimicking a cellular angiofibroma. We describe the diagnostic immunohistochemical markers useful for arriving at its diagnosis. We also summarize our current understanding of the structural and molecular features that make up SFTs and discuss how these features may help us better understand the pathophysiology of pluripotent mesenchymal stem cell differentiation.

Diagnosis and management of spermatic cord tumors

PURPOSE OF REVIEW

Spermatic cord tumors (SCT) are very rare. The present review discusses the most recent literature regarding clinical presentation, pathological characteristics, diagnosis, and management of SCT.

RECENT FINDINGS

Although the majority of SCT are benign, when malignant almost all SCT are sarcomas. Liposarcomas are the most common; whereas rhabdomyosarcomas recorded the highest tendency of develop distant metastases. The clinical presentation is usually a unilateral solid slow-growing mass at the level of the inguinal canal and of the scrotum. Surgical excision represents the most common used treatment, and considering the risk in developing local recurrence, radical inguinal orchiectomy and resection of the tumor with negative microscopic surgical margins is mandatory. Adjuvant therapies such as radiotherapy and chemotherapy have been suggested in selected patients, but clear data to demonstrate any improvement in survival are not available.

SUMMARY

SCT are rare tumors with high risk of misdiagnosis or mistreatment. The majority are benign, but when malignant almost all are sarcomas. A surgical excision is the treatment of choice; however, no clear data exists documenting the efficacy of a multimodal treatment in reducing high local recurrence rates after surgery.

Current management of liposarcoma of the spermatic cord: A case report and review of the literature

Liposarcomas of the spermatic cord, a rare cause of an inguinal mass, may closely mimic inguinal hernias on clinical examination. However, these tumors require a different surgical approach and treatment plan; therefore, intraoperative diagnosis might complicate patient management. We report the case of a 63-year-old man who presented with a mobile mass in the inguinal canal consistent with an inguinal hernia. The patient was subsequently diagnosed with a liposarcoma of the spermatic cord and successfully treated with extensive local resection, including radical orchiectomy and en bloc resection of the mass and associated cord structures. No adjuvant therapy was deemed necessary, and the patient remained asymptomatic and disease-free 10 years after surgery. The details of this case are presented, along with a review and discussion of the currently available data regarding the diagnosis and management of this challenging condition.

Neoplastic diseases of the spermatic cord: an overview of pathological features, evaluation, and management

Extracellular tumors found with the spermatic cord, known as neoplasms, are usually identified to be benign. However, the accurate and timely diagnosis of spermatic cord masses is highly crucial, especially when most results are often overlooked or unclear. In this review, we discuss the anatomy and embryology of the spermatic cord. Upon rooting these fundamental concepts, we discuss an array of benign and malignant neoplastic tumors, including their origin, pathological features, clinical evaluation and management, as well as other case-specific characteristics of unique presentation. Many of these neoplasms are based on local neurological, vascular, muscular, bone, soft tissue, or lymphatic origin, while others have metastasized from particular areas of the body.

Giant Scrotal Fibrolipoma

Fibrolipoma, an infrequent histological subtype of lipoma, is considered a benign mesenchymal neoplasm. Fibrolipoma of the scrotum is an even more rare entity. We report a case of a 55-year-old male complaining for a slow-growing, painless mass in his left hemis-crotum. Imaging with ultrasonography and magnetic resonance imaging was inconclusive regarding the nature of the tumor and the tumor was excised, sparing the testis. The surgical specimen was a well-defined, yellowish white, solid, and firm mass, measuring 19.5×7×5 cm. There was no cytological atypia or mitosis and no lipoblasts recognized. On immunohistochemistry, MDM2 and CDK4 were not expressed. The histopathology report was fibrolipoma of the scrotum. To the best of our knowledge, this is only the fourth case of fibrolipoma originating from the scrotal components, spermatic cord or testis that has been reported in the English literature.