Current management of paratesticular rhabdomyosarcoma

Challenges, Treatment Strategies, and Surgical Techniques in the Management of Spermatic Cord Sarcomas

Spermatic cord sarcomas (SCS) are a group of mesenchymal tumors whose rarity and anatomical location often lead to clinical misdiagnosis such as inguinal hernia, testicular tumor, or other conditions. Any inguinoscrotal mass with suspicious characteristics should prompt clinicians to perform imaging assessments (such as ultrasound or, in uncertain cases, magnetic resonance imaging (MRI)) and refer the patient promptly to a specialized center. Histological characterization of all suspicious masses via percutaneous biopsy is recommended, with staging completed through computed tomography (CT) scan for confirmed cases. Optimal management is multidisciplinary and should consider both the tumor's histological subtype and specific characteristics of the tumor and patient. Radiotherapy and chemotherapy, while awaiting more robust data in the literature, are valuable adjuncts to surgery, which remains the cornerstone of treatment. Surgery should also be proposed for patients who initially underwent nonspecialist procedures, as a completion approach. The surgical strategy involves en bloc resection through radical orchifunicolectomy, ipsilateral hemiscrotectomy, ligation of the spermatic cord at the internal inguinal ring, and, where necessary, resection of the inguinal canal. Reconstruction may employ mesh or pedicled flaps. The prognosis of SCS, when treated at referral centers, is superior to that of mesenchymal tumors at other sites, underscoring the need for early recognition and prompt multidisciplinary care.

Pediatric Genitourinary Tumors: The Developmental Angle

Pediatric cancer is relatively rare compared to cancer in adults. Most pediatric neoplasms affect the hemopoietic and central nervous systems. Of the solid extracranial tumors, renal and genitourinary lesions are among the most frequent pediatric neoplasms. Wilms tumors (nephroblastomas) and their variants predominate. Others are less frequent, and their rarity leads to significant diagnostic challenges. This review presents the most important points for diagnosis using histopathological, immunophenotypical, and molecular novel information on the most important renal and genitourinary pediatric neoplasms.

A Rare Case of Paratesticular Sarcoma: A Case Report

Paratesticular rhabdomyosarcoma (PRMS) is a rare and aggressive soft tissue tumour that can mimic testicular sarcoma on initial imaging studies, leading to diagnostic ambiguity and treatment delays. In this case report, we present the case of a 45-year-old male who came to our department and was evaluated under ultrasound imaging along with colour Doppler. The patient underwent further examination under a multi-slice CT machine, which provided additional information, and finally underwent a 1.5T MRI scan. After a provisional diagnosis was made, the patient underwent surgery, and the specimen was sent for histopathology and relevant immunohistopathological markers. This case underscores the diagnostic challenges posed by PRMS and emphasizes the need for a multidisciplinary approach involving radiologists, oncologists, and surgeons for timely diagnosis and optimal management. We discuss the clinical implications, imaging characteristics, differential diagnosis, and therapeutic considerations for PRMS to guide clinicians in similar diagnostic dilemmas.

18F-FDG PET/CT findings of paratesticular alveolar rhabdomyosarcoma

Rhabdomyosarcoma (RMS) originates from primitive mesenchymal cells and is the most common soft tissue tumor in childhood. 18F-fluoro-deoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) has been reported to be valuable in RMS staging and risk stratification. Paratesticular RMS is a relatively uncommon form of RMS, most of which are of the embryonal histologic type. Paratesticular alveolar RMS is associated with aggressive behavior, high metastatic potential, and poor outcomes. To the best of our knowledge, 18F-FDG PET/CT imaging findings of paratesticular alveolar RMS have never been described. Here, we report on a 16-year-old boy's rare paratesticular alveolar RMS with multiple metastases and its findings on 18F-FDG PET/CT. This case also demonstrates the potential value of 18F-FDG PET/CT in RMS staging and treatment decisions, and may aid in the differential diagnosis.

Primary paratesticular embryonal rhabdomyosarcoma - An unusual presentation

Paratesticular embryonal rhabdomyosarcoma (RMS) is a very rare and aggressive mesenchymal tumor. It is usually seen in children and adolescents presenting as a painless intrascrotal mass, localized in the paratesticular region. Hereby, we report two cases of paratesticular embryonal RMS in adults. One case was clinically suspected to be a testicular abscess, whereas the other presented with testicular swelling and lung metastasis. Localized forms have a good prognosis, whereas tumors presenting with metastases show a poor outcome. A treatment based on surgery and chemotherapy yields good results. Sperm cryopreservation and endocrine follow-up improve the overall survival and quality of life of these patients.

Surgical resection of a massive residual retroperitoneal mass after chemotherapy for a paratesticular rhabdomyosarcoma: a case report

INTRODUCTION

Paratesticular rhabdomyosarcoma is a rare and aggressive mesenchymal tumor, accounting for only 7% of all rhabdomyosarcomas. It is mainly encountered in children and adolescents. The standard treatment consists of radical orchidectomy with negative surgical margins. However, chemotherapy is recommended to control retroperitoneal micrometastasis. The place of surgery for progressive retroperitoneal lymph node metastases remains controversial. We present a case of paratesticular rhabdomyosarcoma with progressive retroperitoneal lymph node metastases treated with surgery.

CASE REPORT

We report a case of a 17-year-old North African male with no particular medical history who presented with a left scrotal mass that had been evolving for several months. Beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase were normal. Scrotal ultrasonography revealed the presence of a 6 cm heterogeneous hypoechogenic tissular mass with cystic areas adherent to the left scrotal wall, which was thickened in some places and vascularized by color Doppler. It exerted a mass effect on the homolateral testicle, which was of average volume. The thoracic-abdominal-pelvic computed tomography scan showed the presence of suspicious paraaortic lymph nodes. The most voluminous one measured 16 × 23 mm². A left orchidectomy was performed. The final pathology report revealed an 8 cm paratesticular rhabdomyosarcoma of the embryonic type that displaced the testicle without invading it. Without going beyond it, it infiltrated the epididymis, the rete testis, and the albuginea. The surgical margin at the level of the spermatic cord was free. The patient had adjuvant chemotherapy (ifosfamide, vincristine, and dactinomycin). The patient had a challenging paraaortic lymph node dissection since the mass enlaced the left ureter and renal vessels. On histological examination, the paraaortic lymph nodes were metastatic.

CONCLUSION

Rhabdomyosarcoma is an aggressive malignancy with high metastatic potential. Therefore, only an accurate diagnosis and early treatment can ensure better survival. Surgery in expert hands seems to be a good option for progressive retroperitoneal nodes. However, further studies are needed to determine the place of surgery in this setting.

Pediatric genitourinary tumors: Distribution, demographics, and outcomes

Importance

The diversity of pediatric genitourinary malignancies requires a timely resource detailing tumor characteristics and survival.

Objective

To determine the incidence, demographics, and outcomes of all pediatric genitourinary tumors within the United States.

Methods

A population-based search for patients diagnosed with genitourinary cancers under age 15 was performed using the National Cancer Institute's Surveillance, Epidemiology, and End Results 18 registry. Information on primary tumor location, histologic type, patient age, sex, year of diagnosis, race, treatment, cause of death, and survival months was extracted. Descriptive epidemiological and survival statistics were calculated for all variables.

Results

A total of 4576 cases from 1973 through 2015 were identified. The most common primary tumor sites were the kidney (80.3%), testis (12.3%), bladder (2.8%), and vagina (1.5%). Nephroblastoma (87.9%) and sarcoma (3.4%) were the most common renal malignancies. Rhabdomyosarcoma was common in the vagina, bladder, and testis at rates of 66.2%, 61.2%, and 24.6%, respectively. Germ cell tumors (71.0%) were the most common primary tumor of the testis. Ten-year overall survival (OS) for renal nephroblastoma and sarcoma was 88% and 82%, respectively. Ten-year OS for RMS of the testis was 91%, the bladder was 79%, the vagina was 79%, and the prostate was 56%. Germ cell tumor 10-year OS were 96% in the testis and 100% in the vagina.

Interpretation

A better understanding of the overall distribution and outcomes associated with pediatric genitourinary cancers allows physicians to best understand the patient's disease in the context of current frequency in a genitourinary setting and reported outcomes.

Alveolar Paratesticular Rhabdomyosarcoma in an Adult Patient Mimicking Epididymo-Orchitis: A Case Report and a Literature Review

The majority of patients with paratesticular rhabdomyosarcoma (RMS) present in the pediatric age group with a unilateral, painless, palpable scrotum mass. By contrast, cases of RMS presenting as painful edema are rare. We present a case of alveolar paratesticular RMS in a 30-year-old man who had been suffering from a painful swelling of the scrotum on the left side for two years and a preceding mass four months before visiting the clinic. Complete resection of the left epididymal mass was performed through a left inguinal incision. The histopathological and immunohistochemical examination of the mass revealed alveolar RMS of the paratesticular region. Urologists should be aware that paratesticular RMS may present in adults with atypical symptoms such as scrotal pain and edema, especially in those who do not respond to antibiotics. Hence, such patients should have an additional evaluation.

Spontaneous Rupture of Rhabdomyosarcoma of the Testis With Unilateral Ptosis: A Case Report and Literature Review

Spontaneous rupture of testicular rhabdomyosarcoma is very rare. We report a case of spontaneous testicular rupture that was pathologically confirmed as rhabdomyosarcoma with unilateral blepharoptosis. The patient, a 19-year-old male, and his father had weakness of the left eyelid muscle. The patient was suspected to have a right inguinal hernia by a family doctor but was not treated further. 2 days later, there was skin itching in the right inguinal area, accompanied by redness, swelling and discomfort of the right scrotum, and the patient went to the local hospital again. Ultrasound examination showed that a contusion of the right testis may have been complicated with orchitis. Oral levofloxacin was ineffective. In addition, the swelling of scrotal increased significantly. He came to the emergency room of our hospital and also was treated with levofloxacin, but the pain was still not relieved. CT and ultrasound examination could not identify the cause of the disease. Exploration of the right scrotum was performed under general anesthesia and confirmed that the right testis had spontaneously ruptured. The pathological diagnosis was rhabdomyosarcoma of the right testis. Testicular rhabdomyosarcoma is clinically rare, and spontaneous rupture is even rarer. The pathogenesis of the disease needs to be further studied, and the diagnosis should be made on a case-by-case basis. Overall, the prognosis of testicular rhabdomyosarcoma is poor. As seen in this case, further study is required to determine whether there is some association between testicular rhabdomyosarcoma and ptosis. Unfortunately, the patient's family rejected a genetic examination because of financial difficulty. We only report a single case of this rare phenomenon here.

Case Report: Paratesticular Rhabdomyosarcoma

Paratesticular rhabdomyosarcoma (RMS) accounts for only 7% of all the RMS cases. Due to the limited available data, there is no consensus on the diagnosis and management of the paratesticular tumors. Here, we interrogated two paratesticular RMS cases in 25 and 27-year-old men presenting with painless and rapidly growing mass in the scrotum. Whereas the data showed no upregulation of tumor markers such as β-human chorionic gonadotropin (β-HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH), scrotal ultrasonography and magnetic resonance imaging indicated the existence of paratesticular and inguinal lesions respectively. There was local recurrence in one patient who underwent radical orchiectomy for the sarcoma one year ago. In addition, the CT scans showed no occurrence of distant metastasis. The two patients underwent radical inguinal orchiectomy or resection of the recurrent tumors with nerve-sparing retroperitoneal lymph node dissection. Histologic examination revealed embryonal RMS (eRMS) without lymph node metastasis. We highlight the importance of multi-disciplinary participation for paratesticular RMS detection and preoperative ultrasound-guided needle biopsy (UNB) for rapid confirmatory diagnosis. Complete surgical resection coupled with chemotherapy and radiotherapy is the main treatment option for the paratesticular RMS. In addition, sperm cryopreservation treatment and endocrine follow-up could increase the overall survival and quality of life of the patients.

Rare Tumours of the Testis: Twelve Years of Experience

Rare tumours of the testis includes a wide variety of tumours. We aim to present clinical and histological characteristics of our patients with rare tumours of the testis. The medical records of 33 patients who were treated and followed-up for testicular rare tumours in our center between 2007 and 2020 were retrospectively reviewed. Of all the 243 testicular tumours, 222 cases (91.4%) were germ cell tumours and 21 cases (8.6%) were non-germ cell tumours. Thirty-three rare tumours of the testis including rare germ cell tumours and non-germ cell tumours were detected. The mean age of the patients at diagnosis was 34 years (range 18-68 years). The histological types of rare testicular tumours were as follows: teratoma 4.5% (n=11), sex-cord stromal tumours 4.5% (n=11), paratesticular tumours 3.2% (n=8), and the others [lymphoma 0.4% (n=1), mesothelioma 0.4% (n=1) and choriocarcinoma 0.4% (n=1)]. The median duration of follow-up was 32 months (range 1 to 256 months). None of the patients with non-metastatic disease stage developed recurrence after having received appropriate therapy. Metastatic disease was documented in 9 cases at the time of diagnosis (five patients with teratomas, two patients with Leydig cell tumour, one patient with choriocarcinoma and rhabdomyosarcoma). The most common subtypes of testicular rare tumours in our center was teratoma and sex-cord stromal tumours. Because of testicular rare tumours have different biological features and different clinical outcomes, the management of each tumour requires a different approach.

Rhabdomyosarcoma and Extraosseous Ewing Sarcoma

Rhabdomyosarcoma (RMS) is a malignant tumor that represents the most common form of pediatric soft tissue sarcoma. It arises from mesenchymal origin and forms part of the group of small round blue cell tumors of childhood. It has a constant annual incidence of 4.5 cases per 1,000,000 children. The known histological diagnosis of the two major subtypes (embryonal and alveolar) has been recently enhanced by tumor biological markers and molecular differentiation diagnostic tools that have improved not only the updated classification based on risk stratification, but also the treatment approach based on the clinical group. Ewing sarcoma (ES) is a round cell tumor, highly malignant and poorly differentiated that is currently the second most common malignant bone tumor in children. In rare instances, it develops from an extraskeletal origin, classified as extraosseous Ewing sarcoma (EES). We provide an updated, evidence-based and comprehensive review of the molecular diagnosis, clinical and diagnostic approach and a multidisciplinary medical and surgical management according to the latest standard of care for the treatment of pediatric RMS and EES.

Alveolar paratesticular rhabdomyosarcoma mimicing epididymitis: Case report and literature review

RATIONALE

Most patients with paratesticular rhabdomyosarcoma may typically present as a unilateral, painless palpable scrotum mass. However, only a few cases of RMS presenting as painful edema of the scrotum mimicing epididymitis. We herein report an unusual case of alveolar paratesticular rhabdomyosarcoma misdiagnosed as epididymitis.

PATIENT CONCERNS

A 19-year-old adolescent, presented to urologist with painful swelling of the scrotum on the left side over the preceding several days. Antibiotics were administered by physician for two months and the pain improved, but the swelling did not fade.

DIAGNOSES

Alveolar praratesticular rhabdomyosarcoma.

INTERVENTIONS

A left, soft tissue mass in the scrotum without definite metastasis or lymphadenopathy was confirmed by computed tomography (CT) and magnetic resonance imaging. A radical left orchiectomy via the inguinal approach was performed successfully.

OUTCOME

The patient received 8 cycles of adjuvant chemotherapy, the patient remains recurrence- and metastasis-free at 13 months after surgery.

LESSONS

When paratesticular RMS is presenting with symptoms of epididymitis, this malignant tumor is usually overlooked. When patients complain of painful scrotal swelling, RMS arise from paratesticular tissue should be considered.

Epidemiologic study of 230 cases of testicular/paratesticular tumors or masses: 15-year experience of a single center

PURPOSE

This study retrospectively investigated the cases of testicular tumors/masses treated in our center from 2002 to 2017 and analyzed their epidemiologic features.

METHODS

Data were collected by searching our center's database using "testicular tumor" or "testicular mass" as keywords. Patients not operated in our hospital were excluded. Preoperative serum alpha-fetoprotein (AFP) levels were reviewed in germ cell tumor (GCT) cases and analyzed to predict malignancy in various age groups.

RESULTS

In total, 230 cases were identified: 151 were benign (78 in the left, 72 in the right, and 1 bilateral) with 3.63years mean age during the operation, and 79 were malignant (42 in the left, 36 in the right, and 1 bilateral) with 2.21years mean age during the operation. Main pathological diagnoses were mature teratoma (92, 40.00%), yolk sac tumor (53, 23.04%), dermoid cyst (23, 10.00%), embryonic carcinoma (15, 6.53%), immature teratoma (14, 6.09%), benign cyst (8, 3.48%), Leydig cell tumor (6, 2.61%), and paratesticular rhabdomyosarcoma (5, 2.17%). All GCT cases with AFP >1000ng/ml, >100ng/ml, >20ng/ml were malignant in <7-, 7-9-, and ≥10-month-old groups, respectively.

CONCLUSIONS

Radical inguinal orchiectomy without biopsy is suggested in 7-9- and ≥10-month-old cases with AFP >100ng/ml and >20ng/ml, respectively.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

Level III-IV.

Perspectives in Pediatric Pathology, Chapter 25. Testicular and Paratesticular Tumors in the Pediatric Age Group

Testicular tumors in the prepubertal age are relatively rare, representing only 9.4% of the total testicular and paratesticular specimens from a 20-year review performed at a large pediatric hospital [ 1 ]. They account for 1% to 2% of all solid tumors in the pediatric age group, with an annual incidence between 0.5/100 000 and 2/100 000 boys according to Coppes et al [ 2 ] and data from the Prepubertal Testicular Tumor Registry [ 3 ]. Similar to other neoplasms afflicting children, a bimodal age distribution is observed. The first peak is between birth and 3 years of age, and a second one occurs at the onset of puberty, extending to the fourth decade. Reports on their frequency vary because some investigators include the adolescent period, while others do not [ 4 ]. The vast majority of testicular tumors are germ cell neoplasms, accounting for 95% across all ages [ 5 ]. In children, germ cell tumors also predominate, representing 71% of all testicular neoplasms. These include yolk sac tumors (49%), teratomas (13%), seminomas and mixed germ cell tumors (9%), and sex-cord stromal tumors (29%). Malignant potential is significantly lower (less than 70%) in the pediatric age group compared to adults (90%) [ 6 ]. According to Pohl et al, 74% of prepubertal testicular tumors are benign [ 7 ].

Paratesticular rhabdomyosarcoma: Importance of initial therapy

PURPOSE

To evaluate factors associated with progression-free and disease-specific survival in patients with paratesticular rhabdomyosarcoma, we performed a cohort study. Also, since many patients present to our institution after initial therapy, we analyzed the effects of salvage therapy for scrotal violation.

PATIENTS AND METHODS

We retrospectively reviewed the records of all consecutive patients with histologically confirmed paratesticular rhabdomyosarcoma treated at our institution between 1978 and 2015. Fifty-one patients were initially identified, but two with incomplete data were excluded from analysis. Variables evaluated for correlation with survival were TNM staging, Children's Oncology Group Soft Tissue Sarcoma pretreatment staging, margins at initial resection, presence of scrotal violation, hemiscrotectomy and/or scrotal radiation. The log-rank test was used to compare survival distributions.

RESULTS

For the analytic cohort of 49 patients, the median age and follow-up were 15.7years (95% CI: 14.2-17.5, range: 0.8-25.1years) and 6.9years (95% CI: 4.4-9.0, range 0.2-37.5years), respectively. The 5-year overall disease-specific survival was 78.7% (95% CI: 67.7%-91.4%) and the progression-free survival was 66.9% (95% CI: 54.8%-81.6%). Median time to recurrence was 0.9years (95% CI: 0.7-0.9, range 0.1-6.2years). Scrotal violation occurred in 41% (n=20) and tripled the risk of recurrence for patients not appropriately treated with either hemiscrotectomy or scrotal radiation therapy (RR=3.0, 95% CI: 1.16-7.73).

CONCLUSIONS

The strongest predictors of disease-specific survival were nodal status and distant metastasis at diagnosis. Scrotal violation remains a problem in paratesticular rhabdomyosarcoma and is a predictor of disease progression unless adequately treated. The risk of progression could be reduced with appropriate initial resection.

LEVEL OF EVIDENCE

Level IV; retrospective study with no comparison group.