Spermatic Cord Sarcomas: Sonographic and CT Features Gilda Cardenosa, t Nicholas P a p a n i c o l a o u ] Claire Y. Fung, 2 Glenn A. Tung, ~ Isabel C. Yoder, ~ Alex F. Althausen, 3 and William U. Shipley, 2 Departments of IRadiology,2Radiation Medicine, and the 3UrologyService, Massachusetts General Hospital, and the Departments of tRadiology, 2Radiation Medicine, and 3Surgery, Harvard Medical School, Boston, Massachusetts, USA
Five patients with sarcomas o f the spermatic cord were imaged with sonography a n d / o r c o m p u t e d t o m o g r a p h y (CT). The former modality is m o s t helpful in demonstrating the extratesticular origin o f the mass and evaluating its scrotal extension for local staging. C T is necessary for pelvic staging and searching for distant metastasis. The fat in liposarcomas was easily identified by CT, alt h o u g h it was not echogenic o n sonography. Sonography should be the p r i m a r y imaging modality for scrotal or inguinal masses. I f a neoplasm is found, C T should be used for staging, prior to definitive surgical treatment. Key words: spermatic cord, imaging -- Sarcoma -- L i p o s a r c o m a -- Malignant fibrous h i s t i o c y t o m a -- L e i o m y o s a r c o m a .
spermatic cord masses [5-10]. We present the c o m puted t o m o g r a p h i c (CT) a n d / o r sonographic features o f a series o f five spermatic cord sarcomas. The role o f the radiologic studies in the m a n a g e m e n t o f these patients is discussed.
Materials and Methods Five patients with histologicallyproven sarcoma of the spermatic cord were treated at our hospital between January 1985 and June of 1990. Sonographywas performed using a 10-MHzsector transducer (Diasonics, Miltipas, CA, USA). CT imaging was performed with a 1440 Technicare or GE 9800 scanner (GE Medical Systems, Milwaukee, WI, USA). Table 1 summarizes the imaging features and pathologic diagnosis of the five patients.
Case Reports Case I
Sarcomas o f the spermatic cord are rare neoplasms, which m a y cause significant m o r b i d i t y and mortality if inadequately treated [1-4]. Since the clinical presentation and findings at physical examination often are consistent with a nonspecific inguinal or scrotal mass, cross-sectional imaging can be indispensible, by determining the origin and extent o f these neoplasms. Several case reports in a radiologic literature describe the imaging features o f certain
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A 47-year-old white man presented with a hard left scrotal mass. A sonogram showeda hypocchoicsolid spermatic cord mass (Fig. 1). The left epididymis and testis were normal. A radical left orchiectomywas performed with no additional treatment. Pathologically,a grade I/III, sclerosingliposarcoma was diagnosed. The patient was free of disease by follow-up CT and physical examination 2 years followinghis surgery, but has since been lost to follow-up.
Case 2 A 72-year-old white man presented 4 years ago at another institution with what was presumed to be an incarcerated fight inguinal hernia. At the time of surgerya mass involving the right scrotum was removed and diagnosed as selerosing liposarcoma. He received no further treatment at that time. The patient was admitted to our hospital 18 months ago with gradual development and enlargement of a distinct mass associated with his right
G. Cardenosa et al.: Spermatic Cord Sarcomas
Table 1. Imaging features and pathologic diagnosis of five patients with histologically proven sarcoma of the spermatic cord Age Sonography
Solid hypoechoic left scrotal mass ~-
Sclerosing liposarcoma Sclerosing liposarcoma
-Homogeneous solid hypoechoic right scrotal mass Mixed echogenicity right scrotal mass
Postoperative study, no lymphadenopathy Mostly fat density right scrotal and anterior abdominal wall mass (recurrence) Soft tissue density right scrotal mass Fat and soft tissue density right scrotal mass Postoperative study, pelvic lymphadenopathy
testis and right anterolateral abdominal wall. Abdominal CT scan confirmed a right scrotal mass with extension into the inguinal canal and right abdominal wall 3 cm above the pubic symphysis (Fig. 2). He received 3000 rads preoperatively. At surgery, a mass involving the right anterolateral abdominal wall with extension into the right scrotum intimately associated with the spermatic cord was found. A mixed iipoma-like and sclerosing-type liposarcoma grade II/III with positive surgical resection margins was found pathologically. An additional 3000 rads was administered postoperatively. The patient is free of disease 1 year later.
Case 3 A 79-year-old white man presented with a 3-month history of a painless right scrotal mass. An abdominal CT revealed a soft tissue density mass in the right spermatic cord below the inguinal canal (Fig. 3). The pelvic lymph nodes were of normal size. The patient underwent surgical removal of the right spermatic cord and testis. A spindle cell sarcoma consistent with malignant fibrous histiocytoma grade II/III of the spermatic cord was found pathologically. The patient has just completed radiation therapy to the pelvic nodes, the scrotum, and lower right inguinal region.
Case 4 A 65-year-old white man with a long history of Crohn's disease requiring small bowel resections, developed over a period of several months a palpable mass in his right scrotum. The mass was biopsied and a well-differentiated liposarcoma grade I/III, lipoma-like, and sclerosing-type was diagnosed pathologically. An abdominal CT showed a right inguinal-scrotal mass consisting of soft tissue and fat densities (Fig. 4). No pelvic adenopathy was seen. Scrotal sonography disclosed normal testes and a homogeneous, hypoechoic right inguinal-scrotal mass. The patient underwent a radical orchiectomy and has recently completed radiation therapy.
Case 5 A 61 -year-old white man presented with a 4-month history of a nontender enlargement of the right side of the scrotum. A sonogram showed a mixed echogenicity extratestieular scrotal mass, extending cephalad into the right inguinal canal and displacing the right testis inferiorly (Fig. 5). The mass and ipsilateral testis were removed. The pathologic examination disclosed a leiomyosarcoma of the spermatic cord and a normal fight testis. Sub-
sequent CT study of the abdomen revealed pelvic adenopathy, for which the patient underwent lymph node dissection. He is currently being treated with radiation therapy to the right inguinal area and the pelvis. Discussion T h e s p e r m a t i c c o r d originates at the internal inguinal ring a n d d e s c e n d s via the inguinal canal i n t o the s c r o t u m to the testis. It c o n t a i n s the testicular arteries, veins a n d l y m p h a t i c s , the vas deferens a n d its artery as well as the n e r v e a n d artery to the c r e m asteric muscle. T h r e e layers f o r m the wall o f the cord: (1) the internal s p e r m a t i c fascia w h i c h is an e x t e n s i o n o f the transversalis fascia, (2) the c r e m a s teric layer w h i c h is striated m u s c l e c o n t i g u o u s with the internal oblique, a n d (3) the external fascia w h i c h is an extension o f the external o b l i q u e a p o n e u r o s i s . E m b r y o l o g i c a l l y , the c o n t e n t s o f the s p e r m a t i c c o r d originate f r o m m e s o d e r m a l tissues; therefore, the o v e r w h e l m i n g m a j o r i t y o f m a l i g n a n t t u m o r s o f the c o r d are s a r c o m a s . R h a b d o m y o s a r c o m a s are the m o s t c o m m o n lesions in infants, children, a n d y o u n g adults [3, 11 ]. I n the a d u l t p o p u l a t i o n , leiom y o s a r c o m a s , l i p o s a r c o m a s , a n d m a l i g n a n t fibrous h i s t i o c y t o m a s are the p r e d o m i n a n t histologic types . T h e r h a b d o m y o s a r c o m a s c o m m o n l y h a v e a propensity toward lymphatic dissemination, whereas direct e x t e n s i o n a n d h e m a t o g e n o u s spread characterizes the o t h e r s a r c o m a s [3, 11]. S p e r m a t i c c o r d s a r c o m a s , h o w e v e r , h a v e b e e n r e p o r t e d to s p r e a d v i a the l y m p h a t i c s in as m a n y as o n e t h i r d o f all patients [1-4]. Local r e c u r r e n c e a n d spread can be e x p e c t e d to follow the structures o f the cord; therefore, the pelvis m u s t be e v a l u a t e d carefully, since the vas deferens l y m p h a t i c s feed into the external iliac system. F u r t h e r m o r e , spread along the testicular artery a n d / o r l y m p h a t i c s results in p a r a - a o r t i c l y m p h a d e n o p a t h y . I n v o l v e m e n t o f the a n t e r i o r abd o m i n a l wall, as seen in case 2, is also possible. M e t a s t a t i c disease to the c o r d c o n t e n t s does o c c u r a n d is usually associated with n e o p l a s m s o f gastrointestinal o r prostatic origin o r l y m p h o m a s .
G. Cardenosa et al.: Spermatic Cord Sarcomas
Fig. 1. Sonography ofa liposarcoma of the left spermatic cord. Transverse sonogram above the testis shows a large, hypoechoic mass replacing the normal structures of the spermatic cord (ar-
165 Clinical presentation a n d physical e x a m i n a t i o n alone s o m e t i m e s c a n n o t d e t e r m i n e the origin a n d nature o f a scrotal or inguinal mass. T h e differential diagnosis o f the rare s a r c o m a s o f the spermatic cord includes m o r e c o m m o n entities, such as fluid collections, hernia, scrotal h e m a t o m a or abscess, testicular n e o p l a s m , benign conditions o f the spermatic cord, a n d varicocele. Cross-sectional imaging can be very helpful in this regard. T h e sonographic a n d C T features o f 20 spermatic cord t u m o r s h a v e been previously described [5-8, 10]. S o n o g r a p h y is m o s t helpful in d e m o n s t r a t i n g the extratesticular origin o f the n e o p l a s m , especially since s a r c o m a s m a y often arise f r o m the intrascrotal p o r t i o n o f the cord. S o n o g r a p h y also is useful in ruling out other diagnostic possibilities. T h e sonographic pattern, however, does n o t allow for definite tissue characteriza-
Fig. 2. CT imaging of a liposarcoma of the right spermatic cord. A A large, fat-containing mass causes asymmetric enlargement of the right spermatic cord and displaces the vessels and the vas anteriorly (arrow). B In the scrotum, the tumor displaces the ipsilateral testis medially (arrows). Fig. 3. CT imaging of a malignant fibrous histiocytoma of the right spermatic cord. A focal mass enlarges the right spermatic cord
(arrow). Fig. 4. CT imaging of the right spermatic cord. A mixed fat and soft tissue attenuation mass is seen causing enlargement of the right spermatic cord (arrow).
Fig. 5. Sonography ofa leiomyosarcoma of the right spermatic cord. Sagittal sonogram above the testis shows a large, mixed echogenicity mass.
tion of the tumor or differentiation between a benign or malignant entity. Two of the three liposarcomas we studied with sonography were hypoechoic. The CT study in one of them showed abundant fat within the mass. Gooding reported two lipomas that were of medium to low echo intensity . Hailer et al., in contrast, described an echogenic liposarcoma and a hypoechoic polymorphic sarcoma . Fat and fat-containing tissues or masses appear quite echogenic on sonography. The issue of the anechoic renal sinus lipomatosis has been clarified as caused by peripelvic cysts rather than fat [ 12]. The recent sonographic literature contains no examples of sonolucent fat, with the exception of the two lipomas reported by Gooding and, now, our two liposarcomas . The potential hypoechoic appearance of fat has been attributed to the variable relationship of the fat cells to the interstices of the adipose tissue or mass [8, 13]. Our experience, as well as that of others, indicates that malignant neoplasms of the cord appear on CT as focal masses [6, 9]. In addition, the low attenuation of the mass in two of our cases suggested a fat-containing neoplasm. CT is indicated in the evaluation of a spermatic cord sarcoma primarily for staging prior to surgery, as well as for follow-up treatment. CT also may be helpful in distinguishing a primary spermatic cord tumor from a rare extension of a retroperitoneal sarcoma into the scrotum .
G. Cardenosa et al.: Spermatic Cord Sarcomas
Magnetic resonance (MR) imaging of the scrotum is in the early phase of clinical applications. The appearance of the normal testis and spermatic cord, as well as a variety of testicular and extratesticular pathologic processes have been described [l 517]. MR imaging is able to distinguish testicular from extratesticular lesions and cystic from solid scrotal lesions. To date, no MR imaging of a spermatic cord sarcoma has been reported in the literature. In the case of a scrotal or inguinal mass, sonography should be the initial imaging modality, since it can often determine the origin of the process. If a spermatic tumor is suspected, a biopsy is performed. Once the diagnosis of a sarcoma is confirmed by biopsy, CT is then necessary for staging of the pelvis and abdomen, especially when the tumor is not well-differentiated. In this latter case, lymph node involvement can occur in as many as one third of the patients and has led many investigators to advocate pelvic lymph node dissection and/or radiation to the pelvis, in addition to the radical orchiectomy [1-4].
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