Spermatic cord liposarcoma

A 60-year-old male patient presents with a slow-growing mass in the left inguinoscrotal region, painless, without inflammatory signs.

CT was the first imaging modality performed for better characterisation. At axial (Fig. 1) contrast-enhanced CT, we can appreciate a large soft-tissue fat-containing mass on the left inguinal region, extending into the scrotum.
T1-weighted (Fig. 2) MR image of the scrotum demonstrates a large mass with high-signal intensity on T1-and on T2-weighted images, and low-signal intensity on T2-fat-saturated T2FS-images (Fig. 3), a finding that is consistent with fat. There are soft-tissue septa with intermediate-signal intensity on the T1-weighted image and increased-signal intensity on the T2FS-images. The scrotal wall and testicle were unremarkable.

Spermatic cord liposarcoma is a quite rare entity, nevertheless being the most common type of soft-tissue sarcoma of this region. The majority of spermatic cord tumours are benign, being lipoma mostly.  Most patients with liposarcomas of the spermatic cord present in the fifth or sixth decades (mean age of 63 years). Clinically, liposarcoma presents as a firm, painless, slow-growing and palpable paratesticular mass. [1]
It can be divided into five histological subtypes that include well-differentiated, dedifferentiated, myxoid, round cell, and pleomorphic (less common). The most common of these are the well-differentiated tumours, which are low-grade tumors and frequently spread by local extension, followed by the dedifferentiated tumours, which are higher grade tumours that spread by haematogenous and lymphatic routes. The subtype of liposarcoma will determine the relative percentages of soft-tissue and macroscopic fat seen at CT and MR. A well-differentiated liposarcoma has large amounts of macroscopic fat and relative enhancing soft-tissue, while dedifferentiated liposarcomas have small amounts of macroscopic fat within a predominantly soft-tissue mass. [1,2]
Liposarcomas of the spermatic cord are challenging to diagnose clinically. This diagnosis should be taken into account when evaluating a possible inguinal hernia and should prompt further imaging studies. [2,3]
Ultrasonography (US) is most of the time the first imaging modality chosen to evaluate paratesticular masses and it demonstrates a predominantly hyperechoic and heterogeneous mass. However, US findings are nonspecific and do not usually allow definitive characterisation. Computed tomographic (CT) and magnetic resonance (MR) imaging provide a greater characterisation and staging information because these modalities have the ability to evaluate morphologic features and solid-tissue characteristics and confidently demonstrate the fat component of these paratesticular tumours. [3,4,5]
At CT, the fat-containing component is detected as regions with negative Hounsfield unit measurements. At MR imaging, macroscopic fat is identified as high-signal intensity regions at T1-and T2-weighted images that demonstrate signal loss on fat-suppression images. [4,5]
The preferred first line treatment is surgical resection and radical orchidectomy. 25% of patients develop local recurrence and 10% develop distant metastases [1]. In case of recurrence or metastatic disease, treatment can include radiation therapy or chemotherapy. [6]
In our clinical case, ultrasound-guided biopsy was performed and pathology confirmed the diagnosis of a low-grade, well-differentiated liposarcoma of the spermatic cord and the patient underwent surgical resection with radical orchidectomy.
Written informed patient consent for publication has been obtained.