Management of leiomyosarcomas of the spermatic cord: the role of reconstructive surgery

Soft Tissue Coverage for Foot and Ankle Trauma

Lower extremity trauma can result in extensive soft tissue loss, which can require a staged multispecialty approach. Flaps can be an excellent choice for significant soft tissue loss. A variety of variables goes into the selection of a flap including understanding what the recipient site needs, available donor sites, nature of trauma, and utilization of indices to predict limb salvageability in order to strategically select the correct flap option.

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.

Epididymal leiomyosarcoma: Report of a rare case

Epididymal leiomyosarcoma (LMS) is a rare malignancy. Because the risk of recurrence is high, proper approach is important. Here, we present a patient with scrotal swelling who underwent surgical excision via scrotal incision, and the histopathological diagnosis was epididymal LMS. The decision was then made to perform inguinal radical orchiectomy.

Leiomyosarcoma of the spermatic cord presenting as an incarcerated inguinal hernia: a rare presentation of a rare condition

Leiomyosarcomas of the spermatic cord are rare malignancies with only sporadic cases (less than 150) reported in the literature. Preoperative diagnosis of a paratestical leiomyosarcoma is challenging. Clinicians do not typically consider inguinoscrotal lumps as underlying sarcomas due to their relatively low prevalence compared with hernias. As a result the diagnosis of a sarcoma of the paratesticular area is often hard to reach. Herein, we report a rare case of a leiomyosarcoma originating from the spermatic cord, masquerading as a strangulated inguinal hernia. Intraoperatively, a mass arising from the spermatic cord was found and excised. A supplementary orchiectomy with high ligation of the spermatic cord was also performed.

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.

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.

Role of Radiotherapy in the Treatment of Fibrosarcoma of the Spermatic Cord: A Case Report and Review of the Literature

Background

Spermatic cord sarcomas are rare. The therapeutic approach is based only on case reports and small series. The standard treatment is radical orchiectomy with wide local resection, while the role of adjuvant therapies is not clear. We present a case of fibrosarcoma of the spermatic cord treated with surgery and adjuvant radiotherapy. A review of the literature about the role of adjuvant treatments is also discussed.

Case Report

A 59-year-old man presented a right testicular mass of about 4 × 3 cm in size. Biopsy showed a high-grade polymorphous sarcoma, consistent with a diagnosis of poorly differentiated fibromyosarcoma. He underwent a right radical inguinal orchiectomy and adjuvant radiotherapy (total dose: 5940 cGy). During treatment the patient developed a G3 skin toxicity (RTOG score) in the inguinal fold. After a follow-up of 57 months, he is alive and without evidence of local or distant recurrence. No late toxicity was noted.

Conclusion

The optimal adjuvant management of spermatic cord sarcoma is still uncertain. Looking at the literature, it seems that adjuvant radiotherapy can improve locoregional control and disease-free survival without additional late toxicity.

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.

Leiomyosarcoma of the Spermatic Cord in a Seventy-Five-Year-Old man

Introduction:

Leiomyosarcoma is a malignant soft tissue tumor that can arise from any tissue containing smooth muscle. Leiomyosarcomas of the spermatic cord are rare tumors of non-testicular origin, which drain into the retroperitoneal lymph nodes and have been reported in less than 150 cases in the literature until now. Radical inguinal orchiectomy and high ligation of the cord is the standard primary surgical procedure in spermatic cord leiomyosarcoma.

Case Presentation:

Here we reported a 75-year-old man who presented with a painless lump in the right hemiscrotum. A right radical orchiectomy was performed. Histopathology confirmed a neoplastic tissue with mesenchymal origin in spermatic cord; further evaluation revealed a leiomyosarcoma of the spermatic cord. The patient was followed up for 1-year and shows no signs of recurrence

Conclusions:

Preoperative diagnosis of spermatic cord leiomyosarcma is difficult and commonly made by histological examination and immunochemical staining.

Prognostic factors and outcome of spermatic cord sarcoma

PURPOSE

To evaluate management and outcome in a large series of patients with spermatic cord sarcomas (SCS), a rare malignancy.

METHODS

Eighty-two patients with localized SCS treated at two dedicated sarcoma units between 1992 and 2013 were included. Disease-specific survival (DSS) and crude cumulative incidence of local recurrence and distant metastases (DM) were estimated by Kaplan-Meier plots and log rank tests.

RESULTS

Median follow-up was 33 months (interquartile range 13-72 months). Sixty-one patients presented with primary disease. Liposarcoma was the most common histotype, but surprisingly, 37 % of tumors were of high grade. Seventeen patients (21 %) received radiotherapy and 12 patients (15 %) chemotherapy. Five-year DSS for the whole series was 92 % [95 % confidence interval (CI) 83-97]. Five-year rates of local recurrence and DM were 26 % (95 % CI 15-42) and 24 % (95 % CI 15-38), respectively. Tumor grade was found to be a significant predictor of both DSS and DM (both p < 0.001). Quality of surgical margins was proved to affect the local outcome (p = 0.025), while the rates of distant metastases were found to differ significantly by histology (p = 0.010). Exclusively in the liposarcoma subgroup, quality of surgical margins was also directly associated with DSS (p = 0.043).

CONCLUSIONS

Wide excision of the tumor is critical for cure, especially in the liposarcoma subgroup. The role of radiotherapy and chemotherapy is not established.

Primary spermatic cord tumors: disease characteristics, prognostic factors, and treatment outcomes

INTRODUCTION

Experience with management of spermatic cord tumors (SCTs) is uncommon. We utilized a large population-based cancer registry to characterize the demographic, pathological, treatment characteristics, and outcomes of SCTs.

MATERIAL AND METHODS

The Surveillance, Epidemiology, and End Results database (1973-2007) was queried.

RESULTS

From the database, 362 patients were identified with SCT. The annual incidence of SCT was 0.3 cases per million and did not change over time. The most common histologic types were liposarcoma (46%), leiomyosarcoma (20%), histiocytoma (13%), and rhabdomyosarcoma (9%). The median age of diagnosis for rhabdomyosarcomas was (26.3 y), whereas for other SCTs, it was (64.7 y) (P<0.001). On multivariate analysis, a worse outcome was observed with undifferentiated tumor grade, distant disease, positive lymph nodes, and leiomyosarcoma or histiocytoma cell histology.

CONCLUSION

We describe the largest cohort of SCT studied to date. Liposarcoma was most common, while leiomyosarcoma and histiocytoma histologic subtypes were observed to be the most aggressive. Multivariate analysis revealed that tumor grade, stage, histologic type, and lymph node involvement were independently predictive of prognosis.

Management of spermatic cord tumors: a rare urologic malignancy

Primary spermatic cord tumors are rare yet clinically significant urologic lesions that affect patients of all ages. They are the most common tumors of the paratesticular region and generally present as asymptomatic, slow growing, firm, palpable paratesticular masses. Although most of them are benign comprised primarily of lipomas, approximately 25% are potentially life-threatening malignant tumors. The most common reported malignant histological types include liposarcomas, leiomyosarcomas, rhabdomyosarcomas, malignant fibrous histiocytoma, and fibrosarcomas. Management of these malignant tumors has been difficult because of their rarity, therefore there is little consensus regarding optimal surgical and adjunctive treatment strategies. It is recommended that radiological techniques such as scrotal ultrasound (US), computed tomography, and magnetic resonance be used to evaluate these masses before surgery. The curative treatment of choice is radical orchiectomy with high cord ligation and wide excision of surrounding soft tissue structures within the inguinal canal. Patients with inadequately resected disease should undergo a reoperative procedure for wide inguinal re-resection. Retroperitoneal lymphadenectomy is recommended when there is preoperative evidence of retroperitoneal lymph node metastasis and as an adjuvant treatment for rhabdomyosarcomas since they have a higher propensity for lymphatic spread. Adjuvant treatments, such as radiotherapy and chemotherapy, have shown little efficacy, except in the management of patients with local recurrence or high-grade rhabdomyosarcomas. Long-term follow up is recommended given their high recurrence rates.

[Long-term paratesticular leiomyosarcoma. Conceptual and literature review]

INTRODUCTION

To know the incidence and clinical and pathologic characteristics of the paratesticular leiomyosarcoma (LMS) with the contribution of a case of long evolution, studying the histopathologic criteria that must be valued for this type of tumours.

MATERIAL AND METHODS

A 73-year-old patient includes for study with scrotal tumour present left side for 30 months. Histopathologic and imunohistochemical study is realized. Of equal form there is realized a bibliographical search of this type of tumours and their different subtypes across Medline and of not index-linked search.

RESULTS

Our case is the second of greater evolution of international literature, first in greater of 60 years and one of those of smaller mitotic index (1 x 50 cga). Nevertheless, his atipia, tumorlike necrosis next to 50% of the injury and its pleomorphic properties, as well as his inmunophenotypic characterization corresponds with a well differentiated LMS, degree 1 (French Federation Cancer). We have found only 107 published cases of this type of sarcomas, of them 5 in our country, which gives to a profile of the low incidence of these tumours, that within sarcomas 1% do not reach. We included the clinical and pathologic profile of such.

CONCLUSIONS

The long evolution of a paratesticular tumour and the absence of metastasis does not exclude its malignancy. The low incident of the LMSs in this location, implies that a protocol of actuation validate for such does not exist. We considered of great importance, its creation on the part of urologist, oncologists, radiologists and pathologists like he took control of located in retroperitoneal cavity and deep soft tissues.

Leiomyosarcoma of the spermatic cord: case report and literature review

A 51-year-old man presented with a 2-year history of painless lump in the left hemiscrotum. Scrotal examination demonstrated a 3-cm, firm-to-hard mass attached to the left spermatic cord. Scrotal ultrasound scan revealed a heterogeneous mass separate from the left testis and epididymis. An orchidectomy was recommended to the patient; however, he declined surgery and underwent excision biopsy of the lesion with preservation of the left testis. Histology suggested a leiomyosarcoma of the spermatic cord and positive margins. Following a normal staging CT scan, the patient was referred to the regional sarcoma clinic. He was treated with an orchidectomy. Microscopic examinations showed fibrosis in the spermatic cord and negative margins. The patient has been followed up for 12 months with CT scans and shows no signs of recurrence.