Management of spermatic cord tumors: a rare urologic malignancy

Primary adenocarcinoma of the spermatic cord: a case report and review of the literature

BACKGROUND

Primary malignant neoplasms of the spermatic cord are extremely rare, with most reported cases being sarcomas or metastatic carcinomas. However, primary adenocarcinoma of the spermatic cord has not been previously reported.

CASE PRESENTATION

A 34-year-old male with a solid mass in the right spermatic cord, was eventually diagnosed with primary adenocarcinoma. Histological examination revealed a moderately-to-poorly differentiated adenocarcinoma exhibiting glandular, cribriform, or nested growth patterns, characterized by medium to large-sized cells and focal extracellular mucus. Immunohistochemical analysis demonstrated positive staining for CK (AE1/AE3), CK8/18, CK19, MOC31 (EP-CAM), and Ber-EP4, while negative staining was observed for CK7, D2-40, WT-1, MC, PAX-8, NKX3.1, PSA, CEA, TTF-1, and NapsinA. Furthermore, a complete loss of INI-1 expression and consistent BRG1 expression were noted in all tumor cells. Next-generation sequencing revealed SMARCB1 deletion, low tumor mutation burden (TMB-L), and microsatellite stability (MSS).

CONCLUSION

We reported the first case of primary adenocarcinoma of the spermatic cord with SMARCB1 (INI-1) deficiency. This case contributes to the expanding understanding of rare neoplasms and underscores the importance of further research into therapeutic strategies targeting SMARCB1-deficient tumors.

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.

Recurrent paratesticular liposarcoma: a case report

Introduction and importance

Paratesticular liposarcoma (PTL) is a rare condition, with fewer than 200 cases reported worldwide. It is a malignant tumor that originates from fat tissue with high risk of recurrence. Herein, the authors present a contralateral recurrence of a treated PTL. To the best of the authors' knowledge, in the current literature, there are few cases reported with recurrent PTL.

Case presentation

The authors report the case of a 62-year-old man who presented with a rapidly growing painless right hemiscrotal swelling. Clinical and radiographic evidence suggested the presence of two paratesticular tumors. The patient underwent a radical orchidectomy with resection of the two tumors through an inguinal approach. The histologic examination revealed a sclerosing, well-differentiated liposarcoma. The decision of the multidisciplinary consultation meeting was not to do adjuvant treatment. A follow-up of 12 months showed recurrence of the contralateral scrotum revealed by an FDG-PET/scan.

Clinical discussion

PTL, a rare spermatic cord tumor, affects adults aged 50-60, often presenting with scrotal swelling. Diagnosis involves ultrasound, computed tomography, and magnetic resonance imaging. Surgical intervention, including radical orchiectomy and adjuvant radiotherapy, is common for management, while the role of chemotherapy is inconclusive. High-grade subtypes carry a higher recurrence risk.

Conclusion

PTL is often misdiagnosed preoperatively. It is typically managed through radical orchidectomy, which includes wide excision and high ligation to ensure free surgical margins and avoid recurrence. The role of adjuvant therapy remains debatable. Despite a generally favorable prognosis, long-term follow-up is crucial because of the elevated risk of recurrence.

Spermatocytic tumors in 2 patients aged 50 and 77 years: 2 case reports and brief review of the literature

Testicular cancer is predominantly diagnosed in young men aged 15-35 years. However, there are some rare tumors such as spermatocytic tumors that are seen more often in the older male population. Spermatocytic tumors have previously been known as spermatocytic seminomas in the scientific literature. We report the cases of 2 patients aged 50 and 77 years both diagnosed with spermatocytic tumors. In this paper we will discuss the ultrasound and histopathology features of these tumors and review the literature of spermatocytic tumor cases.

Special clinical scenarios in RPS: Involvement of great vessels and pancreas and penetration across natural foramina

The primary treatment for retroperitoneal sarcomas is surgery. This requires a carefully planned, typically multivisceral, resection. A few complex scenarios that may arise include vascular involvement, pancreatic involvement, or herniation of the tumor into another compartment outside of the retroperitoneum. These scenarios must be anticipated before surgery to optimize preoperative preparation, minimize postoperative morbidity and mortality, and improve oncologic outcomes. Our aim is to highlight these clinically challenging anatomic presentations that can be encountered in patients with retroperitoneal sarcomas.

Rare paratesticular localization of dedifferentiated liposarcoma: Case report and review of the literature

RATIONALE

Dedifferentiated liposarcoma is defined as a malignant tumor that changes its shape from a well-differentiated liposarcoma to a non-liposarcomatous form. Most paratesticular liposarcomas manifest as an inguinal, painless, slow-growing mass. The standard treatment is extensive surgical excision, radiotherapy being proposed for cases with positive margins, those with recurrence, or in cases of the existence of unfavorable prognostic factors.

PATIENT CONCERNS

We present the case of a young patient diagnosed initially with left hydrocele, which after 2 years proved to mask a differentiated liposarcoma of the spermatic cord. The initial clinical manifestations were represented by the increase in volume of the left groin-scrotal region and pain at this level.

DIAGNOSIS

Microscopic examination in hematoxylin-eosin staining highlighted the presence of lipoblasts and fibroblasts in association with areas of hemorrhage and tumor necrosis. The performed immunohistochemical tests confirmed the diagnosis of dedifferentiated liposarcoma. To support and confirm the presence of the mouse double minute 2 homolog gene mutation, chromogenic in situ hybridization analysis was performed.

INTERVENTIONS

The initial treatment was the surgical one. After 2 weeks, the patient received zolendronic acid for hypercalcemia which was caused by the osseous metastasis.

OUTCOMES

The patient died secondary to acute renal failure caused by hypercalcemia despite the treatment received.

LESSONS

This case underlines the importance of both the correct management of oncological patients, as well as immunohistochemical and genetic tests in the identification of prognostic factors, with the ultimate goal of administering an appropriate oncological treatment.

Effects of radiotherapy on the survival of patients with malignant spermatic cord tumors: A retrospective cohort study

BACKGROUND

Malignant spermatic cord tumors (SCT) are rare and currently, there is no consensus regarding the role of radiotherapy in their treatment. This study evaluated the effect of radiotherapy on the overall survival (OS) of patients with malignant SCT based on the large-sample advantage of the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patients with malignant SCT recorded in the SEER database from 1975 to 2016 were included. All patients were divided into non-radiation and radiation groups, and propensity score matching (PSM) (1:1) was performed for baseline covariates between the two groups. The overall survival rate between the two groups of patients was analyzed using the Kaplan-Meier curve. The effects of radiotherapy on patient prognosis were analyzed using univariate and multivariate COX regression analyses.

RESULTS

In total, 389 patients with malignant SCT were included. There were 285 (73.26%) and 104 (26.74%) patients who either did or did not receive radiotherapy, respectively. Kaplan-Meier curves before and after PSM showed no significant differences in OS between the two groups. Similarly, multivariate COX regression models before and after PSM showed that radiotherapy was not an independent risk factor for OS in patients with malignant SCT.

CONCLUSIONS

Radiotherapy has no obvious advantage in improving the survival time of patients with malignant SCT.

P2 purinergic receptor dysregulation in urologic disease

P2 purinergic receptors are involved in the normal function of the kidney, bladder, and prostate via signaling that occurs in response to extracellular nucleotides. Dysregulation of these receptors is common in pathological states and often associated with disease initiation, progression, or aggressiveness. Indeed, P2 purinergic receptor expression is altered across multiple urologic disorders including chronic kidney disease, polycystic kidney disease, interstitial cystitis, urinary incontinence, overactive bladder syndrome, prostatitis, and benign prostatic hyperplasia. P2 purinergic receptors are likewise indirectly associated with these disorders via receptor-mediated inflammation and pain, a common characteristic across most urologic disorders. Furthermore, select P2 purinergic receptors are overexpressed in urologic cancer including renal cell carcinoma, urothelial carcinoma, and prostate adenocarcinoma, and pre-clinical studies depict P2 purinergic receptors as potential therapeutic targets. Herein, we highlight the compelling evidence for the exploration of P2 purinergic receptors as biomarkers and therapeutic targets in urologic cancers and other urologic disease. Likewise, there is currently optimism for P2 purinergic receptor-targeted therapeutics for the treatment of inflammation and pain associated with urologic diseases. Further exploration of the common pathways linking P2 purinergic receptor dysregulation to urologic disease might ultimately help in gaining new mechanistic insight into disease processes and therapeutic targeting.

Sarcoidosis of the spermatic cord - case report and literature review

Background

Sarcoidosis is a multi-system disease characterized by the formation of non-caseating granulomas in various organs. The lungs remain the most frequently affected organ, whereas lesions in the genitourinary system affect around 0.2% of patients. The primary site found in the spermatic cord is extremely rare.

Case presentation

We present a patient’s case where the spermatic cord involvement was the first manifestation of sarcoidosis. For several months, a number of tests had been performed, which showed, among others, non-caseating granulomas in pathomorphological material, bilateral hilar lymphadenopathy, and leukopenia with lymphopenia. Tumor markers were normal. Infection with urogenital pathogens (including Chlamydia Trachomatis, Neisseria gonorrhea, Mycoplasma hominis) was excluded. The patient did not report any general symptoms such as fever, excessive fatigue, weight loss. He denied swelling, shortness of breath. At the same time, a complete differential diagnosis was carried out, and the extent of the disease was assessed. Due to interdisciplinary management, the patient’s quality of life and fertility is preserved. In the discussion, we present the diagnosis, treatment, and prognosis of such patients.

Conclusion

Sarcoidosis is a multi-system disease, which should not be omitted in the differential diagnosis. Selective excision of the lesion with intraoperative examination plays a significant role while establishing a diagnosis. However, in the primary site in the genitourinary system, the diagnosis is challenging.

Pathologic Conditions at Imaging of the Spermatic Cord

A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. Online supplemental material is available for this article. ^©RSNA, 2022.

Optimal surgical treatment for paratesticular leiomyosarcoma: retrospective analysis of 217 reported cases

BACKGROUND

Paratesticular leiomyosarcoma (LMS) is a rare tumor. Conventionally, tumor resection by high inguinal orchiectomy is performed as the preferred treatment approach for paratesticular sarcoma. On the other hand, testis-sparing surgery has recently attracted attention as a less-invasive treatment option for paratesticular sarcoma. However, the prognostic predictors and optimal treatment strategy for paratesticular LMS remain unclear because of its rarity. In this study, we systematically reviewed previously reported cases of paratesticular LMS to evaluate the prognostic factors and establish the optimal treatment strategy.

METHODS

A systematic search of Medline, Web of Science, Embase, and Google was performed to find articles describing localized paratesticular LMS published between 1971 and 2020 in English. The final cohort included 217 patients in 167 articles. The starting point of this study was the time of definitive surgical treatment, and the end point was the time of local recurrence (LR), distant metastasis (DM), and disease-specific mortality.

RESULTS

Patients with cutaneous LMS had a slightly better LR-free survival, DM-free survival, and disease-specific survival than those with subcutaneous LMS (p = 0.745, p = 0.033, and p = 0.126, respectively). Patients with higher grade tumors had a significantly higher risk of DM and disease-specific mortality (Grade 3 vs Grade 1 p < 0.001, and Grade 3 vs Grade 1 p < 0.001, respectively). In addition, those with a microscopic positive margin had a significantly higher risk of LR and DM than those with a negative margin (p < 0.001, and p = 0.018, respectively). Patients who underwent simple tumorectomy had a slightly higher risk of LR than those who underwent high inguinal orchiectomy (p = 0.067). Subgroup analysis of cutaneous LMS demonstrated that the difference in LR between simple tumorectomy and high inguinal orchiectomy was limited (p = 0.212). On the other hand, subgroup analysis of subcutaneous LMS revealed a significant difference in LR (p = 0.039).

CONCLUSIONS

Our study demonstrated that subcutaneous LMS and high-grade tumors are prognostic factors for paratesticular LMS. For subcutaneous LMS, tumorectomy with high inguinal orchiectomy should be the optimal treatment strategy to achieve a negative surgical margin.

Spermatic Cord Liposarcoma: A Case Report and Review of the Literature on the Role of Radiotherapy and Chemotherapy in Preventing Locoregional Recurrence

Spermatic cord cancer is a rare entity. Among malignant tumors of the spermatic cord, liposarcomas are the most common type, often presenting as painless slow-growing masses usually in the fifth and sixth decades of life; they can be misdiagnosed as inguinal hernia or hydrocele. Radical orchiectomy with wide local soft tissue resection is an accepted standard of care for spermatic cord liposarcoma and has been curative in some cases. There is no definitive role for other treatment modalities such as chemotherapy, retroperitoneal lymph node dissection (RPLND), and radiotherapy. We present a case of liposarcoma of the spermatic cord managed with radical orchiectomy, wide local excision, and was followed up without disease recurrence. We also engage in a review of the literature on the role of systemic chemotherapy and radiotherapy in preventing locoregional recurrence after primary surgery.

A combination of surgery and postoperative radiotherapy is effective in preventing locoregional spread. Data from case reports support this strategy in certain histologic subtypes or when margins are positive after primary surgery. A follow-up period of up to a decade after surgery is recommended.

Case Report: Paratesticular Rhabdomyosarcoma

Paratesticular rhabdomyosarcoma (RMS) accounts for only 7% of all the RMS cases. Due to the limited available data, there is no consensus on the diagnosis and management of the paratesticular tumors. Here, we interrogated two paratesticular RMS cases in 25 and 27-year-old men presenting with painless and rapidly growing mass in the scrotum. Whereas the data showed no upregulation of tumor markers such as β-human chorionic gonadotropin (β-HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH), scrotal ultrasonography and magnetic resonance imaging indicated the existence of paratesticular and inguinal lesions respectively. There was local recurrence in one patient who underwent radical orchiectomy for the sarcoma one year ago. In addition, the CT scans showed no occurrence of distant metastasis. The two patients underwent radical inguinal orchiectomy or resection of the recurrent tumors with nerve-sparing retroperitoneal lymph node dissection. Histologic examination revealed embryonal RMS (eRMS) without lymph node metastasis. We highlight the importance of multi-disciplinary participation for paratesticular RMS detection and preoperative ultrasound-guided needle biopsy (UNB) for rapid confirmatory diagnosis. Complete surgical resection coupled with chemotherapy and radiotherapy is the main treatment option for the paratesticular RMS. In addition, sperm cryopreservation treatment and endocrine follow-up could increase the overall survival and quality of life of the patients.

LIPOSARCOMA OF THE SPERMATIC CORD - DIAGNOSTIC AND THERAPEUTIC ISSUE

Liposarcoma of the spermatic cord is a malignant tumor so rare that there are less than 200 cases reported in the literature worldwide. Liposarcoma is a malignancy which originates from fat tissue. Although only 3%-7% of all paratesticular sarcomas primarily arise from structures of the spermatic cord, clinical significance of these tumors must not be neglected because they are often preoperatively misdiagnosed. A 66-year-old male presented with a painless swelling on the left side of the scrotum. Local examination revealed a solid, smooth, limited mass of approximately 4x3 cm in the left side of the scrotum. Tumor markers were within the reference range. Ultrasound examination showed a solid, clearly limited non-homogeneous mass of 40x20 mm localized in the left spermatic cord. Magnetic resonance imaging showed an expansive mass measuring 60x85x60 mm in the left inguinoscrotal region without propagation into the abdominal cavity. Both testicles and epididymides appeared normal on magnetic resonance examination and no locoregional enlarged lymph nodes were seen. The patient was treated operatively with radical inguinal orchiectomy. In conclusion, liposarcomas of the spermatic cord are extremely rare neoplasms that clinically present as slow-growing, painless, palpable inguinal or scrotal masses. Radical orchiectomy with high ligation of the spermatic cord and wide excision of the surrounding soft tissues within the inguinal canal remains the gold standard treatment option. Recurrence of the disease is frequent even several years after primary therapy, therefore long-term follow-up is mandatory.

Technical illustration of Volumetric arc conformal radiotherapy planning in a case of paratesticular sarcoma

Introduction:

Paratesticular sarcoma are extremely rare malignant tumours. Unlike other sites, they tend to be lower grade and have higher propensity of lymphatic spread. They tend to fail locally and occasionally in the regional lymph nodes. In the absence of target volume delineation guidelines and technical illustration of conformal planning, we have made an attempt to illustrate conformal planning methodology and define target volume based on current evidence in a case of paratesticular sarcoma.

Methods:

We are presenting a case of 62-year-old male who presented with 15-cm scrotal swelling and underwent high inguinal orchidectomy with ligation of spermatic cord. Histopathology presented a well-differentiated leiomyosarcoma of epididymis. Post-operative radiotherapy target volume included the tumour bed, ipsilateral inguinal nodes and lower pelvic nodes as the clinical target volume.

Conclusion:

Adjuvant radiotherapy using advanced delivery technique such as volumetric arc technique can provide good dose distribution with good sparing of organs at risk. The downside of conformal radiation delivery is that it is a resource-intensive and has no established target volume delineation guidelines.

Krukenberg tumor with concomitant ipsilateral hydronephrosis and spermatic cord metastasis in a man: A case report

BACKGROUND

Tumors of the spermatic cord are rare, and approximately 25% are malignant neoplasms. Metastatic spermatic cord tumors are even rarer. Several studies have revealed that the most frequent primary tumors metastasizing to the spermatic cord and peritesticular tissues are neoplasms of the stomach and prostate. Furthermore, metastasis to the spermatic cord or epididymis may occur via retrograde lymphatic and hematic routes. We present the case of a man with gastric cancer that metastasized to the spermatic cord and epididymis, with concomitant ipsilateral hydronephrosis after surgical resection and chemotherapy for his primary tumor.

CASE SUMMARY

A 71-year-old man underwent total gastrectomy for pT4aN2 poorly differentiated gastric adenocarcinoma in December 2016. Two months after surgery, he received adjuvant chemotherapy with TS-1 from February 2017 to February 2018. Surveillance computed tomography (CT) was performed in June 2018, which did not reveal any sign of tumor recurrence. In November 2019, he presented with left lower quadrant abdominal pain and a palpable left inguinal-scrotal mass. CT revealed left mild hydronephrosis and a left scrotal mass measuring 4.0 cm × 1.7 cm. Tumor biomarkers, including alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), beta-human chorionic gonadotropin (βHCG), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA19-9) were all normal. Renal and testicular echography showed left hydronephrosis and a left peritesticular soft tissue lesion with blood flow. Diagnostic ureteroscopy showed left lower ureter narrowing without an intraluminal lesion. A biopsy was obtained for the indurated spermatic cord and epididymis, which showed poorly differentiated adenocarcinoma. Immunohistochemical staining demonstrated that the tumor was diffusely and strongly positive for homeobox protein CDX2. The features were consistent with metastatic adenocarcinoma of a primary gastric tumor.

CONCLUSION

In patients with a history of primary cancer, an inguinal mass of unknown cause with accompanying ipsilateral hydronephrosis may be a sign of distant metastasis from a primary tumor, especially of gastrointestinal origin.

Paratesticular well-differentiated liposarcoma initially diagnosed as fibrous pseudotumour

Paratesticular tumours are relatively rare and mostly of the mesenchymal origin. Due to its rarity, general surgical pathologists might have limited experience on the diagnostic entities and relevant differential diagnoses related to mesenchymal paratesticular tumours. This may likely cause diagnostic difficulties in a daily pathology practice. Paratesticular liposarcoma is a highly heterogeneous tumour and may be misdiagnosed as a benign fibromatous lesion. Herein we present a case of well-differentiated paratesticular liposarcoma of the sclerosing type initially diagnosed as a fibrous pseudotumour. Main differential diagnostic considerations are highlighted.

Rare benign and malignant testicular lesions: histopathology and management

PURPOSE OF REVIEW

The presence of vascular solid tumors within the testicle is considered to be malignant until proven otherwise. However, it is prudent for clinicians to be aware of rare benign and malignant intratesticular lesions as management can differ from the established treatment algorithms for germ-cell tumors.

RECENT FINDINGS

Utilizing certain histopathologic findings can assist with the diagnosis of rare testis tumors. Often times the tumor subtypes are an important consideration in the grading and classification of the disease, which drives management. The multidisciplinary management of rare malignant testis tumors at an experienced center seems to provide optimal patient outcomes. Regardless of the primary treatment, prolonged follow-up for sex cord stromal tumors and other rare testis malignancies is advocated due to the delayed metastatic potential.

SUMMARY

The clinical presentation of rare benign and malignant testis tumors is often similar to that of germ-cell tumors. Likewise, imaging characteristics are also often indistinguishable. However, the management of these rare tumors is often different from the well established treatment algorithms of germ-cell tumors. To that end, it is important for the practicing urologist to be familiar with the current principles of these tumor characteristics and the management.

Primary Paratesticular Leiomyosarcoma: A Case Report and Literature Review

Paratesticular soft tissue sarcomas are very rare malignant mesenchymal tumors. With only few cases reported in the literature, data regarding diagnostic and management of these tumors are limited. We reported a case of primary paratesticular leiomyosarcoma in a 72-year-old man complaining of a progressively growing painless right scrotal mass. The patient underwent radical inguinal right orchiectomy and adjuvant 3D conformal radiotherapy to the tumor bed including the surgical scar. The prescription dose was 54 Gy, and no pelvic irradiation was performed. He remained free of recurrence for the last 16 months.

Dedifferentiated liposarcoma of the spermatic cord: Case report and review of literature

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Liposarcomas typically presents as bulky heterogeneous solid lesions that are larger/firmer than simple “cord lipoma.” Tumors range from 3 to 30 cm in diameter.

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Current controversy in management of liposarcomas pertains to the use of adjuvant chemotherapy or radiotherapy and whether these treatment options decrease recurrence/survival.

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We recommend an initial complete resection with wide margins without the use of adjuvant therapy with aggressive long-term surveillance.

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Based on extrapolated data from studies pertaining to sarcomas of the extremities, adjuvant radiation or chemotherapy may serve a role but further research is crucial.

Introduction

Malignant spermatic cord tumors have an annual incidence of 0.3 cases/million. The vast majority of tumors in this region are benign. We present a rare case of a dedifferentiated liposarcoma of the spermatic cord successfully treated.

Presentation of case

A 59-year-old gentleman presented complaining of an enlarging painful right groin mass. On exam there was an obvious 10 cm inguinal mass. Imaging illustrated a right inguinal soft tissue mass that was not present on imaging 22 months prior.

The patient underwent a right inguinal exploration, en bloc resection of the mass, and radical orchiectomy to ensure negative margins. Histopathological analysis revealed a grade 2 dedifferentiated liposarcoma that measured 9 × 6 × 5 cm, with 5 cm negative margins. The patient did well and was discharged on postoperative day one. On 6-month follow-up there was no evidence of recurrence.

Discussion

We present a rare dedifferentiated liposarcoma of the spermatic cord that was successfully treated with surgical resection. This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering an enlarging inguinal mass. This rare pathology is lacking level one evidence-based standardized treatment algorithms. The mainstay of treatment is surgical resection.

Conclusion

For spermatic cord liposarcomas, the surgical approach is en bloc resection with radical orchiectomy aiming for R0 margins. Prognosis depends on tumor grade, anatomic site, and the ability to achieve a microscopically tumor negative resection. Despite our patient’s disease free status, prolonged surveillance with physical examination and cross sectional imaging is still warranted.

Paraganglioma of the Spermatic Cord With Spinal Metastasis: A Case Report

A 40-year-old male with presented to the clinic with the chief complaint of right inguinal pain radiating to his right testicle and right thigh with no history of trauma, fever, chills, dysuria, hematuria, or unprotected sexual activity. Physical exam revealed right testicular tenderness with no palpable abnormality of the bilateral testes or spermatic cords. Scrotal ultrasound was performed and was unremarkable for testicular or other intrascrotal pathology. Concurrently, chronic low back pain had prompted a lumbar CT to be performed, which was indeterminate, but subsequent lumbar MRI performed three months later revealed abnormal signals in the vertebral bodies of T12, L3, and L5, concerning for occult metastatic disease or multiple myeloma. PET-CT was performed revealing hypermetabolic lesions throughout the axial skeleton and, most notably, hypermetabolic lesions in the left inguinal and left upper scrotum. At this time, about 4 months after the original visit, physical exam revealed a palpable mobile mass in the left upper scrotum that was distinct from the left testicle, and another mass palpable near the left inguinal ring.

Paratesticular leiomyosarcoma: A clinical case report

We present you a Case of 62 year old man with Paratesticular leiomyosarcoma (LMS) localized to the right sctotal half. Detailed pathological and immunohistochemistry characteristic of the tumor was done. For staging was used the classification of French Federation of Cancer Centres Sarcoma Grading System. The final grading of the tumor is grade 3. Paratesticular LMS is rare identity and serves as a diagnostic and treatment challenge.

Paratesticular liposarcoma: a case report

Paratesticular liposarcomas (PLS) is a very uncommon pathology type of paratesticular sarcomas, with less 200 similar cases reported to date in the English literature. There are a few cases regarding giant paratesticular liposarcoma measuring over 10 cm. We present an unusual case with a giant well differentiated PLS of the left testis extended to the pelvic cavity. We report the case of a 55-year-old man who presented with large left groin mass. The patient underwent left orchiectomy following a cure of a scrotal hernia. Histological and immunohistochemical findings were suggestive of a well-differentiated liposarcoma of spermatic cord. The surgical margins were positive. Metastatic work-up, which included CT of the thorax, abdomen and pelvis, did not reveal any distant metastasis in thorax but there is a left pathological external iliac lymph nodes and a left lateroplevic lipomatous mass extended to the iliac fossa and left parietocolic gutter up to the umbilicus measuring 15x7x17 cm. Our patient refused treatment. A review of the literature revealed that there are fewer cases of giant well differentiated paratesticular liposarcoma extended to the pelvic cavity were reported. This study focuses on the clinical characteristics and treatment of this rare type of tumours.

Paratesticular sarcomas: a case series and literature review

Paratesticular soft tissue tumours are remarkably rare entities, with malignant subtypes accounting for approximately 30%. Due to the paucity of cases, a consensus on the best treatment has not yet been reached, presenting a diagnostic and therapeutic challenge for clinicians. Although rare, three such cases presented to the care of our institution serving a population of approximately 400,000 in the space of 13 months. These were three gentlemen, aged 54, 82 and 86 years old, presenting with left sided testicular swellings. Ultrasound in each case confirmed an extratesticular mass. Only the second gentleman complained of associated pain, however he had experienced scrotal trauma in the preceding weeks. Only one patient had suspicions of metastatic disease, with a 9 mm pulmonary nodule on computed tomography. All patients underwent a radical inguinal orchidectomy with high ligation of the spermatic cord, in keeping with best accepted guidelines. Histology confirmed a well-differentiated liposarcoma, a dedifferentiated liposarcoma and a leiomyosarcoma respectively, all high grade. One gentleman returned to theatre for re-excision of margins. Our case series emphasises the need for full multidisciplinary team specialist sarcoma input, as well as radical resection with judicious margins in order to reduce the risk of local recurrence, in the treatment of these rare tumours.

A rare case of paratesticular leiomyosarcoma

Paratesticular leiomyosarcoma is a rare tumour. It is seldom diagnosed pre-operatively and subsequent secondary resection is often required. Current treatment consensus comprises inguinal radical orchidectomy with high ligation of the spermatic cord. We present a case of a 74-year-old male with a 3-year history of a painless right-sided scrotal mass which following excision was found to be an epididymal leiomyosarcoma. A review of literature and treatment is presented in this article.

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.

Paratesticular myositis ossificans of the spermatic cord

A 56-year-old man presented with a painless scrotal lump, enlarging over the preceding 1 month. The lump was roughly 1 cm in size, and located in his left hemiscrotum and separate from the testis. An ultrasound revealed an echogenic focus with dystrophic tissue calcification. Subsequent surgical excision and histopathological analysis revealed it to be late-stage myositis ossificans, a benign, extraosseous formation of the bone or cartilage. We report of only the second described case of myositis ossificans of the spermatic cord in the literature to date.

Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation

The purpose of this review is to showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. While ultrasound (US) remains the first-line imaging modality for evaluating scrotal pathology, MRI may add valuable information, particularly when US findings are equivocal. The inherent soft tissue resolution characteristics of MRI, as well as the ability to detect subtle enhancement and provide wider field-of-view imaging, can prove useful in evaluating inconclusive US findings. The added value of MR in these instances is critical as it may have a significant impact on patient management.

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.

Liposarcoma of the Spermatic Cord: An Infrequent Pathology

Objective

To describe a rare pathology, the liposarcoma of the spermatic cord (LSC), and discuss its diagnosis and treatment.

Materials and Methods

We report a case of well-differentiated LSC in a 61-year-old man. The main complaint was painless enlargement in the right inguinoscrotal area that appeared 6 months prior to presentation. Ultrasonography showed a heterogeneous and hyperechogenic mass of the right spermatic cord that was highly suspicious of malignancy. Computed tomography confirmed a heterogeneous supratesticular mass. The mass was surgically removed.

Results

Pathological examination showed a well-differentiated LSC. The patient did not receive any additional treatment. The follow-up did not present complications or further symptoms and, at present, the patient is in complete remission.

Conclusion

LCSs are a very rare entity. The diagnosis is difficult and often mistaken with common scrotal swelling associated with a hernia, hydrocele, or other tumour. Treatment should include complete surgical excision, usually by radical inguinal orchiectomy. A long follow-up period is necessary.

Paratesticular Sarcoma: Typical Presentation, Imaging Features, and Clinical Challenges

OBJECTIVE

To describe the major imaging features, together with clinical data, of paratesticular sarcomas.

MATERIALS AND METHODS

A retrospective analysis was performed of available imaging and clinical data of 77 consecutive cases of paratesticular sarcoma referred to the soft tissue sarcoma center at the Royal Marsden hospital between January 2006 and January 2015.

RESULTS

Of the total cases, 87% had been referred postoperatively, 43% of which had been imaged preoperatively and 24% of which required re-resection due to incomplete initial excision. On imaging, abnormal fat was present in 73% of paratesticular liposarcomas, with solid or enhancing components indicating high-grade tumors. Leiomyosarcomas and rhabdomyosarcomas were all purely solid masses.

CONCLUSION

Paratesticular sarcomas are rare, and lack of awareness may compromise treatment and outcome. They may be mistaken for common clinical problems such as inguinal hernias and epididymal cysts. Surgery for these presumed diagnoses may result in inadequate clearance and an increased risk of recurrence. A low threshold for imaging atypical paratesticular masses is needed, as this may better inform management.

Multidisciplinary approach to giant paratesticular liposarcoma

Primary paratesticular tumours are very rare and the spermatic cord (SCT) is the most frequent site of origin, with 20% of malignancy. Although liposarcoma is the most frequent histotype (46.6 %), less than 200 cases have been reported in the literature. We report the case of a 56-year-old man who presented a giant scrotal mass of 25 years of evolution and measuring 40 × 40 cm. It could be considered the greatest paratesticular liposarcoma described to date. Computed tomogaphy (CT) revealed mass features consistent with liposarcoma and the simultaneous presence of bilateral inguinal hernia with bladder involvement. A multidisciplinary approach was taken to remove the mass, solve the hernia, and provide functional results.

Liposarcoma of the cord treated with surgery alone: Our experience of five patients

Background:

Liposarcoma of the spermatic cord is a rare condition presenting as an inguinal or scrotal mass. We describe our experience in the management of five patients diagnosed with this disease.

Methods:

We conducted a retrospective analysis of patients who underwent treatment for the condition between 2011 and 2014. Demographic data collected included the patient’s age, presentation, site of tumour, tumour size and grade and World Health Organisation (WHO) histotypes. Adequacy of tumour resection and the use of adjuvant chemotherapy or radiotherapy were also recorded. The study end points included duration of disease-free survival (DFS) as well as overall survival (OS).

Results:

During the study period we identified five patients with a diagnosis of liposarcoma of the cord with a median age of 67 (range 33–72) years. Three patients presented with primary disease and two were diagnosed post-resection and required re-excision to obtain R0 resection margins. Three patients had well-differentiated and two patients had dedifferentiated liposarcoma. None of the patients required adjuvant chemotherapy or radiotherapy following achievement of R0 resection margins and developed loco-regional recurrence or distant metastases. Median DFS was 30 (range 10–45) months.

Conclusion:

Liposarcomas of the cord are rare soft-tissue sarcomas with a high incidence of recurrence. Treatment of choice is radical orchidectomy, wide excision of the tumour and high ligation of the spermatic cord. Long-term follow-up is necessary.

Organ-sparing Surgery in Treating Patients with Liposarcoma of the Spermatic Cord: Institutional Experience and Pooled Analysis

BACKGROUND

Liposarcoma of the spermatic cord is rare and frequently misdiagnosed. The standard therapeutic approach has been radical inguinal orchiectomy with wide local resection of surrounding soft tissues. The current trend of organ preservation in the treatment of several cancers has started to evolve. Herein we present our testis-sparing surgery experience in the treatment of spermatic cord liposarcoma and a pooled analysis on this topic.

MATERIALS AND METHODS

Clinical information from patient receiving organ-sparing surgery was described. Clinical studies evaluating this issue were identified by using a predefined search strategy, e.g., Pubmed database with no restriction on date of published papers. The literature search used the following terms: epidemiology , surgery , chemotherapy , radiotherapy , testis sparing surgery, spermatic cord sarcomas/ liposarcomas.

RESULTS

Patient received a complete excision of the lesion, preserving the spermatic cord and the testis. The final pathological report showed a well differentiated liposarcoma with negative surgical margins and no signs of local invasion. After 2-year of follow-up, there was no evidence of local recurrence. Since the first case reported in 1952, a total of about 200 well-documented spermatic cord liposarcoma cases have been published in English literature. Among these patients, only three instances were reported to have received an organ-sparing surgery in the treatment of spermatic cord liposarcoma.

CONCLUSIONS

Radical inguinal orchiectomy and resection of the tumor with a negative microscopic margin is the recommended treatment for liposarcoma of the spermatic cord. But for small, especially well-differentiated, lesions, testis-sparing surgery might be a good option if an adequate negative surgical margin is assured.

Histopathological Spectrum of Tumor and Tumor-like Lesions of the Paratestis in a Tertiary Care Hospital

OBJECTIVES

Tumors and tumor-like lesions (TLL) of the paratesticular region are rare. Very few studies depicting the spectrum of lesions of this location are available in the literature. Malignant neoplasms arising in the paratesticular region represent only 7.0% of malignant tumors presenting as a scrotal mass. TLL and benign tumors are of great interest, because of their topography they can simulate a neoplasm in the paratesticular structures. We sought to study the incidence, nature, pattern, clinical, immune, and histopathological characteristics of tumors and TLL of the paratestis.

METHODS

In this six-year study, records of the cases were reviewed and the histopathology slides were reassessed. Blocks were retrieved and stained immunohistochemically for relevant markers.

RESULTS

A total of 47 cases of tumor and TLL of the paratestis were diagnosed over a six-year period. The patients ranged from one to 76 years old and most presented with a scrotal mass. Of these, seven (14.9%) were benign. Lipoma was the most common benign tumor. One case each of adenomatoid tumor, scrotal hemangioma, solitary fibrous tumor, and papillary cyst adenoma were reported. The TLL (70.2%) comprised of 17 cases of epididymal cyst, seven cases of tuberculous epididymitis, four cases of filarial epididymitis, two cases each of non-specific granulomatous epididymitis and fibromatous periorchitis, and one case of mesothelial cyst. Seven malignant tumors (14.9%) were diagnosed all of which were sarcomas. All seven were primary to the paratesticular region. The most common malignant tumor was embryonal rhabdomyosarcoma. One case each of malignant mesothelioma, malignant fibrous histiocytoma, atypical lipomatous tumor/well-differentiated liposarcoma, and myxoid liposarcoma were identified.

CONCLUSION

Neoplasms of the paratesticular region affect patients of all ages, with potentially life-threatening sequelae. Awareness of the entire spectrum and meticulous histopathological examination and immunohistochemical studies are of prime importance in the diagnosis of the various lesions as these influence the mode of therapy and subsequent prognosis of the patient.

Metastatic Tumor of the Spermatic Cord in Adults: A Case Report and Review

Metastatic spermatic cord (SC) tumor is extremely rare. Recently, we experienced a case of late-onset metastatic SC tumor from cecal cancer. This case is a 68-year-old man presenting with a painless right SC mass. He had undergone a right hemicolectomy for cecal cancer 6 years ago. Radical orchiectomy and adjuvant chemotherapy with S-1 were performed. No recurrence was found after one year of follow-up. We identified a total of 25 cases, including our case, on a literature search via PubMed from January 2000 to April 2015. The most frequent primary sites of the tumors metastasizing to the SC were the stomach (8 cases, 32%) and the colon (8 cases, 32%), next the liver (2 cases, 8%), and kidney (2 cases, 8%). The majority of the cases underwent radical orchiectomy for the metastatic tumors of the SC. Over half of the cases received adjuvant interventions based on the regimens for the primary tumors. Prognosis in the patients with metastatic tumor of the SC was unfavorable except for late-onset metastasis. In patients with a mass in the SC and a history of neoplasm, especially in gastrointestinal tract, the possibility of metastasis from the primary cancer should be considered.

Spermatic Cord and Peritoneal Metastases from Unruptured Hepatocellular Carcinoma

Extrahepatic metastases are not uncommon in patients with late-stage hepatocellular carcinoma (HCC). These extrahepatic lesions are most commonly found in the lungs, lymph nodes and bones. The authors report the case of a patient with chronic liver disease who presented with left inguinal swelling which was thought to be incarcerated hernia on clinical examination. Further evaluation revealed that the patient had HCC with spermatic cord metastasis which was masquerading as inguinal hernia. He also had extensive peritoneal dissemination. Awareness and accurate detection of these unusual sites of extrahepatic dissemination of HCC is of paramount importance for radiologists to avoid unnecessary surgery as well as after loco regional therapy to assess for recurrence. Details of the case are discussed with a review of the relevant literature.

[Liposarcoma of the spermatic cord]

The paper reviews the literature on primary paratesticular tumors. It describes the classification, brief characteristics of liposarcomas and the morphological pattern of the tumor with an immunohistochemical profile. A clinical case of differentiated liposarcoma of the spermatic cord with myxoid and rhabdomyoblastic differentiation is depicted in a 61-year-old man.

Dedifferentiated paratesticular liposarcoma with osseous metaplasia

Paratesticular liposarcoma is a rare tumour of the genitourinary track but the most common of all sarcomas in adults. The dedifferentiated variation occurs only in 10% of liposarcoma cases. The typical clinical presentation is similar to an inguinal hernia or a benign lipoma. We present the case of a dedifferentiated paratesticular liposarcoma with osseous metaplasia of the spermatic cord, in a male presented with acute scrotum.

Leiomyosarcoma of the inguinal canal

We describe a rare case of a leiomyosarcoma in the inguinal canal in a patient presenting clinically with an inguinal hernia. The clinical details, histological findings and surgical management are reviewed.

Paratesticular sarcomas: two cases with different evolutions

Paratesticular sarcomas are rare and account for less than 1% of all adult sarcomas. Intrascrotal tumours can be testicular or paratesticular, paratesticular tumours being rarer (7-10%). Only 30% of paratesticular tumours are malignant and 90% of these are sarcomas. Histological subtypes include leiomyosarcoma, rhabdomyosarcoma, liposarcoma and undifferentiated high-grade pleomorphic sarcoma. Recurrence is frequent in this type of tumour and can occur years from initial diagnosis. These reports show two cases of paratesticular sarcoma with very distinct evolutions. The first case concerns a patient who presented with low-grade leiomyosarcoma with two local recurrences treated with surgery, and distance recurrence with cutaneous, subcutaneous, pulmonary and hepatic metastasis 30 years after surgery of the primary tumour. The second case reports of a patient who presented with high-grade myxoid liposarcoma with local and distance recurrence 3 years after surgery of the primary tumour, which progressed after chemotherapy; the patient died 7 months after diagnosis of recurrence.