Spermatic Cord Mass in an Older Male

Specimen Type:

Spermatic Cord

History:

A 47-year-old man presented with a scrotal mass attached to the spermatic cord. The mass is 1.5 cm in diameter, pale tan with a solid cut surface. No hemorrhage and necrosis are seen.

Pathologic Features:

The sections reveal a round non-encapsulated tumor with smooth margin (Figure1). The entire tumor consists of smooth muscle bundles (Figure2). Most of the tumor resembles normal smooth muscle cells with normal cellularity and bland cytologic features (Figure3). Some areas have increased cellulariy (Figure4), brisk mitotic activity (17 per 10 HPF) (Figure5), and marked nuclear pleomorphism (Figure6).

Differential Diagnosis:

  • Leiomyoma
  • Leiomyosarcoma

Leiomyoma: Although leiomyoma and lipomas are the most common benign soft tissue tumors in the paratesticular region, leiomyoma of this region still is a very rare neoplasm, and only few cases were reported (references 1, 2). The diagnosis is made using the same criteria as in the ovary and soft tissue.

Leiomyosarcoma: Leiomyosarcoma in the paratesticular region arises most often from the soft tissues of the spermatic cord, but may also arise from the epididymis. Grossly, the tumors are solid, grayish white and may be whorled but high grade may show hemorrhage and necrosis. Microscopically, the diagnosis is usually straightforward, with fascicles of spindled-shaped cells possessing cigar-shaped nuclei. Nuclear pleomorphism and anaplasia vary in individual cases, and tumors covering the entire spectrum of differentiation from low to high grade may be seen. Immunohistochemically, the tumor shows evidence of smooth muscle differentiation.

Diagnosis:

Leiomyosarcoma of the spermatic cord

Key Features:

  • Grossly: solid, grayish white, whorled; hemorrhage and necrosis may be present
  • Microscopically: smooth muscle bundles, with malignant features including increased cellularity, nuclear pleomorphism, mitotic figures, necrosis, hemorrhage
  • Immunohistochemically: smooth muscle actin positive

Comment: The chief differential diagnostic consideration is separation of low-grade leiomyosarcoma from leiomyoma. The criteria for malignancy have not been standardized because of the relatively few cases reported, mostly as single case reports (references 3, 4). It is recommended that cellularity, pleomorphysm, and necrosis should be taken into account, in addition to mitotic figures, in rendering the diagnosis. Of note, the threshold for “leimyosarcoma” diagnosis is relatively low since among the reported cases in the literature, approximately one third of the patients died of metastasis.

References:

  1. Elmer EB, Levine R, Nolan J. Leiomyoma of spermatic cord with unusual features. Urology. 1989 Mar;33(3):236-7.
  2. Sarma DP, Weilbaecher TG. Leiomyoma of the spermatic cord. J Surg Oncol. 1985 Apr;28(4):318-20.
  3. Grey LF, Sorial RF, Shaw WH. Spermatic cord sarcoma. Leiomyosarcoma and retroperitoneal lymph node dissection. Urology. 1986 Jan;27(1):28-31.
  4. Alberghini M, Zanella L, Bacchini P, et al. Leiomyosarcoma of the spermatic cord: a light and ultrastructural description of one case. Pathol Res Pract. 2004;200(6):487-91.