Int Canc Conf J DOI 10.1007/s13691-014-0190-6
CASE REPORT
Spermatic cord metastasis of gastric cancer diagnosed from right groin pain Ayako Ohtaka • Mayuko Kanayama • Hiroaki Aoki • Kazutaka Terai • Fumitaka Shimizu • Shinichi Hisasue Yoshiaki Wakumoto • Shigeo Horie
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Received: 29 May 2014 / Accepted: 23 August 2014 Ó The Japan Society of Clinical Oncology 2014
Abstract Approximately half of the primary spermatic cord tumors are malignant. Most of them are stromaderived sarcomas. Around 8 % of malignant spermatic cord tumors are reported to be metastatic origin. Here, we report a rare case of gastric adenocarcinoma that metastasized to spermatic cord after 3 years of gastric surgery. Pathological diagnosis of resected spermatic cord was adenocarcinoma of gastric origin whose putative route of metastasis was direct invasion from cancerous ascites. Since this case resulted in a longer survival rate than those reported in the past, this case suggests that surgical intervention in this case might have been beneficial in terms of tumor volume reduction and making accurate diagnosis as well as improving patient’s QOL. Keywords cancer
Spermatic cord tumor Groin pain Gastric
Introduction A spermatic cord cancer is a relatively rare condition, most of which are primary. A metastatic spermatic cord tumor is even rare. The overall prognosis of spermatic cord metastasis from gastric cancer is extremely poor and most patients die within 1 year of diagnosis [7]. It has not been reported so
A. Ohtaka (&) M. Kanayama H. Aoki K. Terai F. Shimizu S. Hisasue Y. Wakumoto S. Horie Department of Urology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan e-mail:
[email protected] S. Horie e-mail:
[email protected]
far that a patient with spermatic cord metastasis from gastric cancer survived long after the diagnosis of recurrence. A patient in this report has survived for as long as 1 year and 6 months after the recurrence. We report a case in which chemotherapy combined with surgery was effective on spermatic cord metastasis.
Case report The patient was a 64-year-old male. Primary complaint was right scrotal swelling and right groin pain. As to his past history, he underwent a radical orchiectomy for left testicular tumor in 1982. The pathological diagnosis was pure seminoma. In December 2010, the patient underwent a distal gastrectomy with D1? lymphadenectomy for gastric cancer. The pathological diagnosis was poorly differentiated adenocarcinoma, non-solid type. Pathological Stage was T4aN3M1, as perioperative cytological diagnosis of ascites was class IV. Adjuvant chemotherapy (TS-1/CDDP: 5 courses, TS-1: 6 courses) was administered postoperatively in accordance with the gastric cancer treatment guidelines, and no recurrence/metastasis was noted. Two years and 4 months after the surgery, he noticed the right scrotal and groin swelling. He was referred to our clinic. Elastic and firm mass of 0.5 cm 9 7 cm was identified along the right spermatic cord to the head of right epididymis by palpitation. The patient complained of pain upon palpation. Consistent with the physiological findings, ultrasound image showed a hypo-echoic mass of 0.5 cm 9 1 cm in diameter in the head of right epididymis (Fig. 1). Pelvic MRI in the coronal plane showed the mass on the epididymis with high signal intensity on T2weighted image and the presence of right hydrocele with typical water intensity (Fig. 2). The tumor demonstrated
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Fig. 1 Ultrasonography showed a hypo-echoic mass 0.5 cm 9 1 cm in diameter in the head of the right epididymis
of
Fig. 3 Coronal Contrast-enhanced T1-weighted MRI demonstrated the tumor with high signal intensity. Section thickness is 6 mm
Fig. 2 Coronal Pelvic MRI showed the mass on the right epididymis with high signal intensity on T2-weighted image with the concomitant right hydrocele. Section thickness is 6 mm
high signal intensity on contrast-enhanced T1-weighted image in the coronal plane (Fig. 3). Thoracic and abdominal CT imaging revealed a swollen lesion of 0.8 cm 9 1.0 cm in diameter in the epididymis, a mass of 2.4 cm 9 3.6 cm in diameter with heterogeneous content in the right testis and no abnormalities in other areas. Urinary sedimentation, urine culture, and urine cytology were normal. Blood count and biochemical results showed no abnormalities. Tumor markers such as HCG, LDH, AFP, IL2, CEA, CA19-9, and PSA were not elevated, either. A right radical orchiectomy was performed. Intraoperative findings revealed the spermatic cord tumor that invaded the ilioinguinal nerve and surrounding tissues. The
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Fig. 4 PET imaging revealed gastric masses around stomach
resected tumor showed homogeneous white-cut surface. A pathological diagnosis was adenocarcinoma, indicating tumor’s continuum from the spermatic cord to the epididymis; the surgical margin was positive.
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Our pathological diagnosis of adenocarcinoma matched that of the pathological specimens taken during the distal gastrectomy. Taken together, our diagnosis was right spermatic cord metastasis from gastric cancer. Postoperative chemotherapy was not administered because the second-line chemotherapy with definite curative effect is yet to be defined, and also, seemingly there was no target lesion on any given imaging tests. After 3 months following our surgery, an induration in the scrotal/penile root area and scrotal pain reappeared. Since this symptom caused dysuria, indwelling urethral catheter was inserted. PET/CT showed sizable gastric masses and peritoneal masses around stomach, despite that endoscopic examination revealed no abnormalities, indicating a submucosal tumor. The image also demonstrated a scrotal mass, indicating a local recurrence (Figs. 4, 5).
We performed a biopsy of this scrotal mass with a subsequent pathological diagnosis of adenocarcinoma. It was diagnosed as a local recurrence of spermatic cord metastasis from gastric cancer. The patient was referred to the gastrointestinal department, where he has been undergoing chemotherapy with the following regimen: docetaxel 60 mg/m2 every 3 weeks combined with administration of 6.6 mg dexamethasone sodium phosphate. The patient has received 18 courses up to this point. Patient got a durable response to the chemotherapy using the docetaxel. The size of tumor decreased by 31.6 % in diameter and an induration in the scrotal/penile root area improved remarkably (Fig. 6). This enabled the removal of indwelling urethral catheter, which improved patient’s QOL. This patient is still alive with relatively good ADL.
Discussion
Fig. 5 PET imaging revealed an abnormal mass in the right scrotum
Approximately half of the primary spermatic cord tumors are benign, most of which are lipomas, and the rest includes angiomas, leiomyomas, fibrous lipomas, lipomatous myxomas, and neurofibromas. By contrast, most malignant spermatic cord tumors are stroma-derived sarcomas, with most being rhabdomyosarcomas, and others including leiomyosarcomas, fibrous sarcomas, and liposarcomas [1]. In addition, 8 % of malignant spermatic cord tumors are reported to be metastatic origin from other organs [2]. To the best of our knowledge, there have been 97 cases of spermatic cord metastasis reported so far, with 43 cases originating from primary gastric cancer, 14 cases from colorectal cancer, and 9 cases from pancreatic cancer [3]. Those originating from the urological field include kidney, prostate, and renal pelvis/ureter cancer in descending order.
Fig. 6 a Axial pelvic MRI showed the mass around the penis with high signal intensity on T2-weighted image before docetaxel administration. Section thickness is 4 mm. b Axial pelvic MRI showed the mass around the penis with high signal intensity on T2-weighted image after 11 courses of chemotherapy with docetaxel. Section thickness is 3 mm. The size of tumor around the penis decreased by 31.6 % in diameter after docetaxel administration
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The common routes of metastasis to the spermatic cord are either hematogenous, retrograde metastasis through lymph vessels due to iatrogenically induced defective valves (e.g. Surgery), retrograde metastasis from prostate/ seminal vesicle via seminal duct, or direct invasion from peritoneal metastasis through the vaginal process of the peritoneum [4, 5]. In addition, as a new aspect of tumor metastasis, it is reported that angiogenesis occurs at the scar of the surgery pathologically, and these immature neovascularization and collaterals contribute to metastasis [6]. In the present case, hematogenous metastasis and retrograde spermatic cord metastasis are unlikely, as there were no abnormalities in the prostate and seminal vesicles. Retrograde metastasis can also be ruled out, as there was no detectable lymphatic metastasis at the time of diagnosis of spermatic cord metastasis. Pathological finding at the time of gastric cancer surgery and perioperative cytological diagnosis of ascites (class IV) supported the diagnosis of direct invasion via peritoneum. Spermatic cord metastasis was found in 0.2 % of 10,946 autopsied cases of gastric cancer [3]. Most cases are reported to occur within 2–3 years after gastrectomy [7]. Gastric cancer treatment guidelines recommend symptomatic treatment including palliative surgery combined with chemotherapy for gastric cancer recurrence after surgery. The guidelines recommend a combination of S-1 and cisplatin as a first-line treatment for metastatic gastric cancer, as this patient had after distal gastrectomy [8]. Although there is no standard second-line chemotherapy regimen so far, some studies maintain that taxane and irinotecan can be eligible candidates. With regard to prognosis, spermatic cord metastasis from gastric cancer often progresses at a remarkable speed, as demonstrated in a report of 28 patients with extremely poor prognosis whose mean survival rate was 6.1 months from the diagnosis of metastasis [9]. The patient in this report has been receiving docetaxel in outpatient clinic for about 1 year and 6 months after the diagnosis of local recurrence of spermatic cord metastasis from gastric
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cancer. Taken together, the surgical intervention in this case might have been beneficial in terms of tumor volume reduction and making accurate diagnosis as well as improving patient’s QOL. Moreover, given the improved overall survival rate of this patient, postoperative chemotherapy might have conferred survival benefits, as well. This case report represents a rare case of spermatic cord metastasis with a relatively good prognosis after the diagnosis of recurrence. In hindsight, right radical orchiectomy we performed, when a patient was first referred to our clinic, turned out to be palliative surgery. The following chemotherapy combined with this palliative surgery might have been conducive to prognosis and patient’s QOL. Conflict of interest of interest.
The authors declare that they have no conflict
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