Q1: What is the diagnosis?
Paratesticular liposarcoma with an indirect inguinal hernia. The photomicrograph shows areas of inflammatory and sclerosing types of liposarcoma admixed with a lipoma‐like pattern. Inset (A) shows a tumour giant cell and inset (B) a classic lipoblast.
Q2: What are the differential diagnoses of an incompletely reducible inguinoscrotal lump?
Differential clinical diagnoses in our case would include the following:
Indirect inguinal hernia with an incarcerated omentocele
Indirect inguinal hernia with a vaginal hydrocele
Indirect inguinal hernia with a testicular tumour
Indirect inguinal hernia with a cord lipoma
Indirect inguinal hernia with a paratesticular liposarcoma
Q3: Does the patient require any further treatment postoperatively?
The indications for postoperative radiochemotherapy for paratesticular liposarcoma include: high grade of the tumour, resected margins involved by the tumour, and evidence of lymphovascular invasion.1 This case had none of the above, and hence was not a candidate for adjuvant therapy.
Discussion
Malignant paratesticular tumours are rare. Most paratesticular tumours are benign. Paratesticular neoplasms can arise from the epididymis, spermatic cord, or mesenchymal layers surrounding the testis. Liposarcomas represent about 3% to 7% of all malignant spermatic cord tumours.1 It is not surprising therefore to find only about 200 cases of liposarcoma of the spermatic cord in English language medical literature. It usually presents as a painless, slow growing tumour in the groin or the scrotum. It usually affects patients between 50 to 80 years of age. However, boys and young adults may be affected as well.2
An inguinal hernia may be associated with the tumour and thereby confuse the presenting clinical picture.
It is extremely difficult to diagnose paratesticular liposarcoma preoperatively. If clinically suspected, ultrasound, computed tomography, or magnetic resonance imaging may be helpful in diagnosing a lipoma‐like lesion. No characteristic features have been described for liposarcoma on ultrasound, computed tomography, or magnetic resonance imaging. These findings however, may be consistent with a lipoma or an incarcerated omentocele as well. A metastatic investigation may not be necessary in these patients, as metastasis has never been reported in patients with paratesticular liposarcoma.3
People from filariasis endemic regions may present with inguinoscrotal swellings attributable to inguinal lymphatic dysfunction resulting in lymph varices (lymphangiectasia), large hydroceles, and scrotal elephantiasis. An incidentally associated inguinal hernia can confuse the presentation in these cases. An ultrasound scan (with or without colour Doppler) if performed in these cases may actually detect motile adult Wuchereria bancrofti (filarial dance sign) in dilated intrascrotal lymphatics.4
Treatment of paratesticular liposarcoma includes a wide local excision of the tumour, which includes a high inguinal orchidectomy and may include a hemiscrotectomy if the scrotal skin is infiltrated. Retroperitoneal extension of a spermatic cord liposarcoma through the deep inguinal ring requiring a second surgery for complete excision has also been reported.5,6 Adjuvant radiotherapy is usually used if the resected margins are involved, in case it is a high grade tumour, if there is presence of lymphatic invasion, or if there is a local recurrence.1 Retroperitoneal lymphadenectomy is not indicated as dissemination to these lymph nodes has never been reported.3 Doxorubicin based chemotherapy has however, been used with some success as an adjuvant to local radiotherapy in locally recurrent spermatic cord liposarcomas.1
We present this case to make the medical community aware of a rare entity, which may be associated with an inguinal hernia. If a large incarcerated omentocele is suspected clinically and the testis is not felt separately in the scrotum an informed consent should be taken preoperatively for the possibility of a high inguinal orchidectomy. No imaging modality may be adequate to differentiate a lipoma, liposarcoma, or omentum in the scrotum as all the lesions contain fat. However, if a paratesticular liposarcoma is suspected intraoperatively, every attempt should be made to perform a wide local excision to avoid the morbidity of adjuvant radiotherapy.
Learning points
A high index of suspicion is required to detect a paratesticular liposarcoma preoperatively.
Preoperative metastatic examination is not necessary for a patient with paratesticular liposarcoma.
Wide local excision (including a high inguinal orchidectomy) with sparing of uninvolved skin is the procedure of choice for paratesticular liposarcoma.
Adjuvant therapy is rarely indicated after adequate surgery for paratesticular liposarcoma.
References
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