Introduction

The patient centered interviewing and physical examination, with appropriate laboratory exams, and radiologic testing, represent the cornerstone of medical diagnosis. However, we should be aware that any method has its own constraints. In the usual medical practice, the causes of inguinal lymphadenopathy are infectious, autoimmune, or neoplastic disorders¹. In the latest, it is extremely unusual to cope with the primary malignant spermatic cord neoplasms, even for urologists². However, in these uncommon tumors, there are exceptional ways of presentation seldom seen³,⁴.

Case presentation

A 66-years-old male patient presented with his family physician with a 3-year history of a left groin slow-growing lump; just recently, the swelling generated pain. The general practitioner established the clinical diagnosis of lymphadenopathy, and the patient was sent to our service. On the physical examination, a hard, irregular, and immovable 19-cm groin swelling, extending to the upper pole of the homolateral testis, was found (Fig. 1A); excluding local discomfort, the patient denied any other symptom. A computed tomography revealed a solid tumor affecting the spermatic cord, groin lymph nodes, abdominal wall, and epididymis (Fig. 1B). With this evidence, a wide groin tumor excision including an inguinal radical orchiectomy was scheduled. During surgery, the left testis with its spermatic cord was extirpated, with an abdominal wall segment, in block with the superficial groin lymph nodes to obtain macroscopic free margins (Fig. 2A); post-operative evolution was uneventful. The surgical specimen revealed a spermatic cord tumor spreading to abdominal muscle wall, lymph nodes, and epididymis (Fig. 2B); using immunohistochemical studies, a malignant fibrous histiocytoma of the spermatic cord was diagnosed (Fig. 2C). Considering the tumor size, and invasion to surrounding structures, the patient received adjuvant radiotherapy. For 14 months, the patient was tumor-free. Later, a right groin 2-cm lymphadenopathy appeared and was extirpated; a metastasis of the malignant fibrous histiocytoma was diagnosed. A radical inguinal lymph node dissection was suggested, but the patient declined the surgery. Radiotherapy was applied on the right groin; unfortunately, even though all treatments, the patient progressed and died.

Figure 1 A: Clinical aspect of the left inguinal tumor. B: Coronal image of computed tomography showing tumor activity in the left side of the scrotum and groin. 

Figure 2 A: Macroscopic aspect of the fresh surgical specimen. B: Macroscopic aspect of the formalin fixed surgical specimen opened along its axis, shows fleshy-looking nodules, arising from the spermatic cord, which infiltrates the epididymis. C: Microphotography, phosphotungstic acid H-E staining, 100×. Storiform pattern, multiple spindle cells. 

Discussion

The spermatic cord malignant tumors are rare¹. In general, these tumors are of considerable size, and they originate below the external inguinal ring growing into the scrotum, and rarely prevailing as a groin mass as in our case.

Like in this case, clinical impression is not enough to identify spermatic cord malignant tumors¹,³. Therefore, imaging studies as ultrasound, computed tomography, and magnetic resonance are valuable tools to attempt their diagnosis¹,³. Nonetheless, these lesions have not pathognomonic imaging findings and is difficult to obtain a pre-operative diagnosis. Therefore, surgical excision is essential for a precise histological diagnosis¹,³.

The indicated surgical management for spermatic cord sarcomas is radical inguinal orchiectomy with high ligation of the spermatic cord, including a wide excision of surrounding soft tissue to reach negative microscopic surgical margins¹,³,⁵. Long-term follow-up is advocated given their excessive recurrence rates³. Disappointingly, adjuvant treatments like radiotherapy and chemotherapy have little value¹.

The malignant fibrous histiocytoma of spermatic cord is exceptional¹,³. There have been reported few cases and most occurred in the elderly⁴. This neoplasm tends to cause lymph node metastases⁶; therefore, regional lymph node dissection may improve local control of this disease according to some surgeons⁶. Due to spermatic cord malignant fibrous histiocytoma rarity, there are no agreed treatment principles, and their generally prognosis is poor⁷,⁸.

Conclusion

The spermatic cord malignant tumors are rare. They originate below the external inguinal ring growing into the scrotum, and rarely prevailing as a groin mass as in our case.