Liposarcoma

Anu Bansal, MD - Case Coordinator
Mitali Bapna, MD - Radiology Discussion
Ron Firestein, MD, PhD - Pathology Discussion
Pablo R Ros, MD, MPH - Attending Radiologist

June 23, 2003

Presentation

Imaging Findings

Transverse and sagittal ultrasound images show a homogeneous, fairly normal left testicle. Just inferior to the testis there is an abnormal area of mixed echogenicity. This apparent soft tissue mass appears to be separate from the testicle.

Differential Diagnosis

Diagnosis

Discussion

The orchiectomy specimen includes a 5-cm, glistening, smooth mass involving the spermatic cord. The mass has a thick, fibrous capsule and has a further fibrous element to its composition (septae running throughout). The mass is comprised of plump, atypical cells with hyperchromatic nuclei. Cytogenetic evaluation shows a supernumerary ring and giant marker chromosomes, consistent with atypical lymphomatous tumor (also known as a well-differentiated liposarcoma).

Radiology Discussion:

There are two basic principles associated with scrotal imaging. First, an intratesticular lesion is considered to be malignant until proven otherwise. Second, an extratesticular lesion is more likely the result of inflammation, trauma, or benign neoplasm.

Epididymal masses include spermatoceles, adenomatoid tumors, sperm cell granulomas, cystadenomas, metastases, and sarcoidosis. Spermatoceles contain spermatozoa. If spermatozoa are not present, the same mass is called an epididymal cyst. These lesions are well circumscribed, anechoic, and can be multiple. They are typically caused by prior inflammation or trauma and are benign. They may cause mass effect. Adenomatoid tumors affect men aged 20-50 years. These small, benign, slow-growing nodules may be palpable, but are often just a few mm in size. They are typically echogenic. Adenomatoid tumors are generally not removed unless the patient is bothered by symptoms. Sperm cell granulomas are formed by the leakage of sperm after vasectomy. Cystadenoma is often associated with von Hippel Lindau disease.

The majority of extratesticular scrotal masses, however, arise from the spermatic cord. Lipomas are the most common of all extra-testicular tumors. The next most common category is sarcoma. In adults, these are primarily undifferentiated sarcoma (30%), followed by leiomyo-, lipo-, fibro-, and myxochondro-sarcoma. In children, rhabdomyosarcoma is the most common type (20%). In fact, this is the most common solid adnexal tumor in boys and young men. Rhabdomyosarcoma can also involve testis or epididymis. The masses are often large and ill defined. They are associated with poor prognosis; the disease may include lymphatic and hematogenous metastases. Other tumors of the spermatic cord include cord leiomyoma and cord fibroma, which is a reactive nodular proliferation of paratesticular tissues.

The third category of extra-testicular scrotal mass arises from the tunica. Mesothelioma typically occurs in older men and is usually benign. It is occasionally malignant, however, in a patient with a history of asbestos exposure. The appearance is echogenic on ultrasound. The mass is often associated with a hydrocele. Fibrous pseudotumor is a rare benign fibromatous condition. These typically arise as painless scrotal masses that may be associated with a hydrocele or a history of trauma or infection. Occasionally, they include focal calcification. These lesions are thought to be reactive in nature.

References

Kirks DR. Practical Pediatric Imaging. Boston, Mass: Little Brown & Co., 1991:1032.

Feld R, Middleton WD. Recent advances in sonography of the testis and scrotum. Rad Clin North Am. 1992;30:1033-1051.

Rowland RG, Foster RS, Donohue JP. Scrotum and testis. In: Gillenwater JY, Grayhak JT, Howards SS, Ducket JW, eds. Adult and Pediatric Urology. St. Louis, MO: Mosby, 1996:1917-1918, 1943-1946.

Frates MC, Benson CB, Di Salvo DN, Brown DL, Laing FC, Doubilet PM. Solid extratesticular masses evaluated with sonography: pathologic correlation. Radiology. 1997 Jul; 204(1):43-46.

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