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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 135-137

A rare case of scrotal neoplasm-paratesticular liposarcoma


1 Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Pathology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission25-Jun-2021
Date of Decision12-Sep-2021
Date of Acceptance05-Nov-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
D V Sneha
Department of General Surgery, Pondicherry Institute of Medical Sciences, Kalathumettupathai, Ganapathichettikulam Village No. 20, Kalapet, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_53_21

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  Abstract 


Paratesticular tumors are rare and account for 7% of intrascrotal neoplasms which generally present as painless inguinal or scrotal swelling. Around 200 cases of paratesticular liposarcoma cases have been reported worldwide. They are usually misdiagnosed before surgery. Incomplete treatment may lead to local recurrence. We report a rare case of paratesticular liposarcoma. A 65-year-old man presented with right scrotal painless swelling for 2 years and gradually increasing in size. On examination, swelling in the right inguinal scrotal region was cystic in consistency. Testicular tumor markers were normal. The patient underwent right high orchidectomy with tumor excision. Sample sent for biopsy. Histopathological study reveals paratesticular liposarcoma. The long-term survival is approximately 50% with a favorable prognosis.

Keywords: Orchidectomy, paratesticular liposarcoma, scrotal swelling


How to cite this article:
Sneha D V, Poral SK, Kiran C M, Marenika M, Maunika MR, Phinehas E. A rare case of scrotal neoplasm-paratesticular liposarcoma. J Curr Res Sci Med 2021;7:135-7

How to cite this URL:
Sneha D V, Poral SK, Kiran C M, Marenika M, Maunika MR, Phinehas E. A rare case of scrotal neoplasm-paratesticular liposarcoma. J Curr Res Sci Med [serial online] 2021 [cited 2022 Jun 28];7:135-7. Available from: https://www.jcrsmed.org/text.asp?2021/7/2/135/334460




  Introduction Top


Liposarcoma, a malignant tumor, derives from mesodermal tissues. Paratesticular tumors are rare and account for 7%–10% of intrascrotal neoplasms which generally present as painless scrotal swelling that gradually increases in size. Around 200 cases of paratesticular liposarcoma cases were reported worldwide. Sarcomas arise from the spermatic cord in the intrascrotal region and are generally misdiagnosed before surgery. The most common reason for local recurrence is incomplete local resection. In this study, we present a case of paratesticular liposarcoma in a 65-year-old man.


  Case Report Top


A 65-year-old man came to our outpatient department with complaints of right scrotal swelling for 2 years which was painless and gradually increasing in size. On physical examination, there was a swelling in the right scrotum of size 15 cm × 10 cm which was cystic in consistency. The swelling was neither reducible nor transilluminating and there was a loss of rugosity over the scrotum. Both the testes felt separately and were normal in texture.

Laboratory investigations such as tumor markers were normal.

  • β-Human chorionic gonadotropin (β-HCG): <0.100 m IU/ml
  • Alpha-fetoprotein (AFP): 7.7 ng/ml
  • Lactate dehydrogenase (LDH): 170 IU/L.


Ultrasound scrotum was suggestive of right-sided complex hydrocele [Figure 1].
Figure 1: Ultrasound scrotum suggestive of right-sided complex hydrocele

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The preoperative diagnosis based on ultrasound scrotum finding was complex hydrocele which correlated with clinical findings, and the patient had the report of tumor markers done outside found to be normal. The patient cannot afford further investigations, so we proceeded for the management of complex hydrocele and hence scrotal incision was made. It was a surprise intraoperative finding and high orchidectomy was not decided before surgery.

Scrotal exploration showed two well-demarcated swellings of size approximately 12 cm × 10 cm and 8 cm × 10 cm with well-defined capsules on the right side. The right testis was attached anteriorly inseparable with one of the swellings. The other swelling was close but not attached to the spermatic cord [Figure 2].
Figure 2: Showing spermatic cord (arrowhead), testis (hash), and paratesticular swelling (asterisk). Right testis was attached anteriorly inseparable with one of the swellings. The other swelling was in close proximity but not attached to the spermatic cord

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Hence, high orchidectomy was done and the paratesticular swellings were excised.

The postoperative period was uneventful [Figure 3].
Figure 3: Showing two well-demarcated paratesticular swelling (asterisk) of size approximately 12 cm × 10 cm and 8 cm × 10 cm with well-defined capsules on right side. “Hash” – Spematic cord

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On the gross section, the tumors were creamy yellow, lobulated with the admixture of grayish-white and yellow areas that are neither necrotic nor hemorrhagic.

Microscopically, the excised swellings revealed similar morphologies featuring encapsulated lipogenic tumors composed of spindle cells with bipolar cytoplasm and nuclear atypia. Few classical lipoblasts were seen with no evidence of tumor infiltration [Figure 4].
Figure 4: Atypical spinal cells with bipolar cytoplasm and lipoblast (A) Suggestive of well-differentiated liposarcomas

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Hence, the final histopathological diagnosis of well-differentiated liposarcomas with a negative margin was made.


  Discussion Top


Paratesticular liposarcoma is a rare case scenario difficult to diagnose. Less than 200 cases were reported up to date.[1] Spermatic cord is the most common site followed by testicular tunica and epididymis (76%, 20%, and 4%, respectively). The average age at presentation is 55 years (range: 16.5–85). Occasionally, paratesticular liposarcoma presents as a swelling rapidly increasing in size. In <6% of cases, there is a history of scrotal surgery or trauma. The presentation can be mistaken for inguinal hernia or hydrocele which often leads to misdiagnosis before surgery. Computed tomography and magnetic resonance imaging can be done while suspecting paratesticular liposarcoma.[2] It is used preoperatively and postoperatively for staging and follow-up, respectively. In the above-discussed case scenario, we had no preoperative diagnosis of testicular or paratesticular malignancy and the patient cannot afford further management; hence, FNAC and further investigations were not done. Based on histological appearances, liposarcomas are generally classified into myxoid (most common 40%), dedifferentiated, well-differentiated, and pleomorphic.[3],[4] Liposarcomas tend to spread by local extension. Hematogenous and lymphatic spread is usually present in high-grade tumors. When paratesticular liposarcoma is diagnosed, radical orchidectomy is done with wide local excision of the tumor. Studies suggest that there is no therapeutic advantage in performing superficial inguinal or radical lymphadenectomy. Liposarcomas generally respond to radiation therapy but the role of radiation in paratesticular liposarcoma is less clear.[5] Recurrence after radiotherapy is highly noted in high-grade and more aggressive neoplasm with dedifferentiation. Radiation therapy is recommended along with surgery with the evidence of more aggressive behavior of the tumor. Paratesticular liposarcoma has a high tendency for local recurrence. The most common reason for local recurrence is incomplete local resection. Khandekar et al. stated that the 3-year local recurrence-free survival was 100% for negative margins compared with 29% for positive margins.[6] Prognosis and survival vary with histopathological classification. Myxoid and well differentiated have a better prognosis than pleomorphic liposarcoma with a 5-year survival rate of 80% and 20%, respectively.


  Conclusion Top


Paratesticular tumors were often misdiagnosed clinically and radiologically. When diagnosed or suspected preoperatively, radical orchidectomy with wide local excision is the recommended treatment. Adequate local resection is important to avoid local recurrence. Adjuvant radiation should be done if tumor of intermediate or high grade. Regardless of initial therapy, the risk of local recurrence and subsequent increase in grade needs long-term follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li Z, Zhou L, Zhao L, Chen P, Liu Y, Ding Y, et al. Giant paratesticular liposarcoma: A case report and review of the literature. Mol Clin Oncol 2018;8:613-6.  Back to cited text no. 1
    
2.
Alyousef H, Osman EM, Gomha MA. Paratesticular liposarcoma: A case report and review of the literature. Case Rep Urol 2013;2013:806289.  Back to cited text no. 2
    
3.
Mouden K, Wakrim S, Semmar A. Paratesticular liposarcoma: A case report. Pan Afr Med J 2019;33:282.  Back to cited text no. 3
    
4.
Doyle LA. Sarcoma classification: An update based on the 2013 World Health Organization classification of tumors of soft tissue and bone. Cancer 2014;120:1763-74.  Back to cited text no. 4
    
5.
Unlü Y, Huq GE, Ozyalvaçli G, Zengin M, Koca SB, Yücetas U, et al. Paratesticular sarcomas: A report of seven cases. Oncol Lett 2015;9:308-12.  Back to cited text no. 5
    
6.
Khandekar MJ, Raut CP, Hornick JL, Wang Q, Alexander BM, Baldini EH. Paratesticular liposarcoma: Unusual patterns of recurrence and importance of margins. Ann Surg Oncol 2013;20:2148-55.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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