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| Year : 2010 | Volume
: 21
| Issue : 5 | Page : 927-930 |
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| Liposarcoma scroti: A rare tumor |
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Rajul Rastogi1, PK Karan2, Anubhav Sarikwal1, Vaibhav Rastogi1
1 Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Moradabad (UP), India
2 Vivekanand Hospital and Research Center, Kanth Road, Moradabad (UP), India
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| Date of Web Publication | 31-Aug-2010 |
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 Abstract | | |
Malignant extratesticular tumors (EXTT) are rare. Majority of EXTT are benign; lipoma being the commonest. Most of the malignant tumors are solid and have nonspecific features on ultrasonography (US). Computed tomography (CT) and magnetic resonance imaging (MRI) are more helpful. The authors report a rare case of liposarcoma of scrotum that was suspected on ultrasonography and computed tomography and confirmed on histopathology.
How to cite this article:
Rastogi R, Karan P K, Sarikwal A, Rastogi V. Liposarcoma scroti: A rare tumor. Saudi J Kidney Dis Transpl 2010;21:927-30 |
| Introduction | |  |
Majority of the malignant extratesticular tumors (EXTT) arise from spermatic cord. Sarcomas are the commonest malignant tumors with rhabdomyosarcoma being commonest in children and liposarcoma in adults. [1] But leiomyosarcoma, malignant fibrous histiocytoma, mesothelioma and lymphoma also occur in scrotum. Liposarcoma is a rarely reported tumor of scrotum. [2]
| Case Report | | |
A 48 year old male presenting with a painless scrotal enlargement since 4-6 months came for scrotal US. Clinical examination revealed enlargement of the left scrotal sac with soft to firm palpable nontender mass separable from testis. History of removal of fatty scrotal tumor 7-8 years ago was given, but no medical records were available to support the same. Rest of the clinical examination and laboratory tests were unremarkable.
US scrotum revealed a large, solid extratesticular mass in the left scrotal sac with preserved left testis and left epididymis [Figure 1]. The mass had two components-one was homogeneously echogenic while the other part consisted of hypoechoic nodules interspersed in an echogenic background [Figure 2]. Evidence of high vascularity with moderate PSV and low RI and PI was noted especially in between the nodules suggesting malignant pattern of blood flow [Figure 3]. Based on the US findings and previous history of removal of fatty tumor, diagnosis of liposarcoma was suggested. Right scrotal sac, bilateral inguinal region and abdomen US were unremarkable. Noncontrast CT of the abdomen and scrotum revealed a large, lipomatous tumor in the left scrotal sac, extratesticular in location with irregular sheet like and nodular areas of soft tissue attenuation [Figure 4],[Figure 5]. No evidence of omental herniation or calcification was noted. Hence, a diagnosis of liposarcoma scroti possibly secondary to malignant degeneration of lipoma was suggested. | Figure 2 :US scan shows a mass with homogeneous echogenic component and with hypoechoic nodules in echogenic background.
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 | Figure 3 :Color doppler US scan shows vascularity in the mass with low RI and PI values.
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 | Figure 4 :Noncontrast axial CT image shows lipomatous mass (thin arrow) pushing the normal appearing testis (thick arrow) to one side of left scrotal sac.
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 | Figure 5 :Noncontrast axial CT image shows a lipomatous mass with regions and nodules of soft tissue attenuation s/o liposarcoma.
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The patient underwent hemiscrotectomy along with radical excision of the soft tissues of the inguinal region and inguinal nodes on left side. Surgery revealed a bulky tumor with yellowish color arising from the spermatic cord with no involvement of testis and epididymis. Histopathology revealed a well differentiated liposarcoma of the spermatic cord with no evidence of tumoral involvement of inguinal soft tissues and lymph nodes. As a tumor free margin of more than 2 cm was achieved, adjuvant radio-therapy was not advised. Six month follow up of the patient was unremarkable.
| Discussion | | |
Besides the testis, the scrotum contains epididymis, spermatic cord and fascia that accompany the testis during the embryologic journey from pelvis in to the scrotum. Majority of the tumor arising from these extratesticular structures are benign and arise from spermatic cord; lipoma being the commonest. [1] More than 80% of the spermatic cord tumors are also benign. [2] More than 50% of the spermatic cord tumors are malignant, if lipoma is excluded. [3] Most common malignant tumors are sarcomas; rhabdomyosarcoma in children and liposarcoma in adults. [4] Majority of these sarcoma arise just inferior to superficial inguinal ring, hence they present mainly as scrotal rather than as abdominal masses. [1]
Liposarcoma is a solid, bulky lipomatous tumor with heterogeneous architecture, often containing areas of calcification and appear yellowish on gross appearance. [5] They often occur in the middle aged and elderly. [2],[5] It represents 10-20% of all malignant EXTT. [2],[6]
US appearance though variable and nonspecific but gives a clue about the presence of lipomatous matrix. [4],[7] It shows echogenic areas corresponding to fat often with poor sound transmission with areas of heterogeneous echogenicity corresponding to nonlipomatous component. CT and MR imaging are more specific, as they can easily recognize fatty component along with other soft tissue component. [4],[8]
An association of the scrotal liposarcoma has been reported with multiple liposarcoma of the retroperitoneum in a case of multicentric liposarcoma. [9] This association makes scrutiny of entire abdomen mandatory in such cases.
Other non-lipomatous malignant tumors that are included in the differential diagnosis include lymphoma, malignant fibrous histiocytoma, mesothelioma, etc. [1] Mesothelioma is often associated with hydrocele and lymphoma may show tell tale signs elsewhere in the body.
Majority of liposarcoma arising from cord are well differentiated and the treatment of choice is hemiscrotectomy with wide excision of the inguinal soft tissues and nodes especially if the tumor margins are ill-defined to prevent tumor recurrences. Round cell type is poorly differentiated and is highly metastatic. Recurrences are seen in a quarter of patients and metastases are seen in one tenth patients with spermatic cord liposarcoma through lymphatic or hematogenous route. [5],[6] If the sufficient tumor free margin could not be achieved, adjuvant radiotherapy covering the inguinal region and scrotum should be considered. [2]
To summarize, though most of the extratesticular tumors are benign, yet any painless echogenic mass with heterogeneous architecture on US and relative high vascularity should arouse the suspicion of liposarcoma. CT and MR imaging can be used as a problem solving tool in difficult cases by adding more confidence in recognizing fat and other soft tissue component separately, simultaneously ruling out true lipoma and omental hernia.
| Acknowledgement | | |
We are highly thankful to Mr. Shivam and Ms. Anju for their kind help in acquisition of images.
| References | | |
| 1. | Woodward PJ, Schwab CM, Sesterhenn IA. Extratesticular scrotal masses: Radiologic-pathologic correlation. Radiographics 2003;23: 215-40.  [PUBMED] [FULLTEXT] |
| 2. | Maximilian B, Joachim T, Sebastian M. Liposarcoma of the spermatic cord: Report of two cases and review of the literature. Int J Urol 2005;3. |
| 3. | Beccia DJ, Krane RJ, Olsson CA. Clinical management of non-testicular intrascrotal tumors. J Urol 1976;116:476-9. [PUBMED] |
| 4. | Cardenosa G, Papanicolaou N, Fung CY, et al. Spermatic cord sarcomas: sonographic and CT features. Urol Radiol 1990;12:163-7. [PUBMED] |
| 5. | Bostwick DG. Spermatic cord and testicular adnexa. In: Bostwick DG, Eble JN, eds. Urologic surgical pathology. St Louis, Mo: Mosby, 1997;647-74. |
| 6. | Thanakit V, Nelson SD, Udomsawaengsup S. Round cell liposarcoma of scrotum with indolent course in young adult J Med Assoc Thai 2005;88:1302-7. |
| 7. | Frates MC, Benson CB, DiSalvo DN, Brown DL, Laing FC, Doubilet PM. Solid extratesticular masses evaluated with sonography: pathologic correlation. Radiology 1997;204:43-6. [PUBMED] [FULLTEXT] |
| 8. | Cramer BM, Schlegel EA, Thueroff JW. MR imaging in the differential diagnosis of scrotal and testicular disease. RadioGraphics 1991;11: 9-21. [PUBMED] [FULLTEXT] |
| 9. | Michihiko H, Nobutaka K, Toshiyuk N, Naohiko K, Wataru A, Jun A. Liposarcoma Situated in the Scrotum to Retro-peritoneum: A Case Report. J Jpn Surg Assoc 2002;63:1279-82. |
Correspondence Address:
Rajul Rastogi
Yash Hospital & Research Center, Civil Lines, Kanth Road, Moradabad (UP)
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 20814134 
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] |
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