Malignant fibrous histiocytoma of the spermatic cord: report of two cases and review of the literature

Diagnosis and management of spermatic cord tumors

PURPOSE OF REVIEW

Spermatic cord tumors (SCT) are very rare. The present review discusses the most recent literature regarding clinical presentation, pathological characteristics, diagnosis, and management of SCT.

RECENT FINDINGS

Although the majority of SCT are benign, when malignant almost all SCT are sarcomas. Liposarcomas are the most common; whereas rhabdomyosarcomas recorded the highest tendency of develop distant metastases. The clinical presentation is usually a unilateral solid slow-growing mass at the level of the inguinal canal and of the scrotum. Surgical excision represents the most common used treatment, and considering the risk in developing local recurrence, radical inguinal orchiectomy and resection of the tumor with negative microscopic surgical margins is mandatory. Adjuvant therapies such as radiotherapy and chemotherapy have been suggested in selected patients, but clear data to demonstrate any improvement in survival are not available.

SUMMARY

SCT are rare tumors with high risk of misdiagnosis or mistreatment. The majority are benign, but when malignant almost all are sarcomas. A surgical excision is the treatment of choice; however, no clear data exists documenting the efficacy of a multimodal treatment in reducing high local recurrence rates after surgery.

Neoplastic diseases of the spermatic cord: an overview of pathological features, evaluation, and management

Extracellular tumors found with the spermatic cord, known as neoplasms, are usually identified to be benign. However, the accurate and timely diagnosis of spermatic cord masses is highly crucial, especially when most results are often overlooked or unclear. In this review, we discuss the anatomy and embryology of the spermatic cord. Upon rooting these fundamental concepts, we discuss an array of benign and malignant neoplastic tumors, including their origin, pathological features, clinical evaluation and management, as well as other case-specific characteristics of unique presentation. Many of these neoplasms are based on local neurological, vascular, muscular, bone, soft tissue, or lymphatic origin, while others have metastasized from particular areas of the body.

Management of spermatic cord tumors: a rare urologic malignancy

Primary spermatic cord tumors are rare yet clinically significant urologic lesions that affect patients of all ages. They are the most common tumors of the paratesticular region and generally present as asymptomatic, slow growing, firm, palpable paratesticular masses. Although most of them are benign comprised primarily of lipomas, approximately 25% are potentially life-threatening malignant tumors. The most common reported malignant histological types include liposarcomas, leiomyosarcomas, rhabdomyosarcomas, malignant fibrous histiocytoma, and fibrosarcomas. Management of these malignant tumors has been difficult because of their rarity, therefore there is little consensus regarding optimal surgical and adjunctive treatment strategies. It is recommended that radiological techniques such as scrotal ultrasound (US), computed tomography, and magnetic resonance be used to evaluate these masses before surgery. The curative treatment of choice is radical orchiectomy with high cord ligation and wide excision of surrounding soft tissue structures within the inguinal canal. Patients with inadequately resected disease should undergo a reoperative procedure for wide inguinal re-resection. Retroperitoneal lymphadenectomy is recommended when there is preoperative evidence of retroperitoneal lymph node metastasis and as an adjuvant treatment for rhabdomyosarcomas since they have a higher propensity for lymphatic spread. Adjuvant treatments, such as radiotherapy and chemotherapy, have shown little efficacy, except in the management of patients with local recurrence or high-grade rhabdomyosarcomas. Long-term follow up is recommended given their high recurrence rates.

Malignant fibrous histiocytoma of the spermatic cord: case report and literature review

This case study reports on a rare case of malignant fibrous histiocytoma arising in the right spermatic cord. An 80-year old male presented with a 2-week history of a right inguinal mass, with mild pain in the same region. Ultrasonography and computed tomography showed a mass arising from the right spermatic cord. A right radical orchiectomy was performed with wide dissection of the mass; the right testicle and epididymis were found not to be grossly involved. The patient had an uneventful postoperative course and recovered well. The patient and his family refused further adjuvant radiotherapy. There was no evidence of recurrence or metastasis during 20 months of regular follow-up. The diagnosis, histological classification, treatment and prognosis of this case are presented, together with a review of the literature.

Pleomorphic malignant fibrous histiocytoma/undifferentiated high-grade pleomorphic sarcoma of the scrotum in a patient presenting as fournier gangrene: a case report

Pleomorphic malignant fibrous histiocytoma (MFH), also known as undifferentiated high-grade pleomorphic sarcoma according to the latest World Health Organization classification, is a diagnosis of exclusion and extremely rare in adult scrotal/paratesticular region. Clinical presentation of scrotal/paratesticular pleomorphic MFH is usually a painless and gradual scrotal swelling. We report a case of scrotal MFH in a 63-year-old man who presented as Fournier gangrene after 10-month painful scrotal swelling and multiple procedures. The specimen of emergent debridement was submitted for pathologic and bacteriologic examination. Microscopically, the lesion had marked architectural and cytologic pleomorphism. The neoplastic cells were positive for vimentin, but negative for all lineage-specific markers. Fluorescence in-situ hybridization showed an aneuploid karyotype and negative results for lipomatous tumor abnormalities. Bacterial cultures of the specimen showed extensive growth of virulent polymicrobes. The diagnosis of scrotal/paratesticular pleomorphic MFH with concurrent Fournier gangrene was made. Thoracic computed tomography scan showed bilateral multiple pulmonary nodules. The patient died 1 month later.

[Locally recurrent malignant fibrous histiocytoma of the kidney and spermatic cord]

OBJECTIVE

In this study, 26 patients with locally recurrent malignant fibrous histiocytoma of the kidney and spermatic cord after initial R0 resection were reviewed with regard to therapeutic options and prognosis.

PATIENTS AND METHODS

Based on a literature query in the PubMed database, we identified 24 cases with locally recurrent malignant fibrous histiocytoma of the kidney and spermatic cord after initial R0 resection. Two of our own patients were included and afterwards the entire patient group was analyzed with regard to the time period of the first local recurrence and the overall survival rate.

RESULTS

The average patient age was 58 years; in 17 cases (65%) the left side was affected. After primary therapy the 5-year survival rate was 25%; adjuvant therapy did not achieve any significant improvement in survival time ( p=0.259). The local recurrence was on average diagnosed after 13 months (with a median of 12 months). The prognosis of malignant fibrous histiocytoma after detection of the local recurrence was extraordinary poor, only 4 of 26 patients survived for longer than 3 years. The 1-, 2- and 5-year survival rates then were 34%, 28%, and 14%, respectively. The mean survival time was 31 months with a median survival of 9 months. Patients with a locally recurrent malignant fibrous histiocytoma of the spermatic cord showed a significant better survival prognosis than patients with a local recurrence of a renal malignant fibrous histiocytoma ( p=0.04).

CONCLUSION

Malignant fibrous histiocytoma of the genitourinary tract are rare tumors with a high rate of local recurrence. If there are no distant metastases a R0 resection can result in a curative objective. Nevertheless, the prognosis of this disease is poor. Even early detection of local therapy failure and promptly initiated aggressive salvage therapy may offer the chance of long-term survival only in selected cases. Lifelong follow-up is necessary for patients with a malignant fibrous histiocytoma of the kidney or spermatic cord.

Hypoxia-mediated down-regulation of Bid and Bax in tumors occurs via hypoxia-inducible factor 1-dependent and -independent mechanisms and contributes to drug resistance

Solid tumors with disorganized, insufficient blood supply contain hypoxic cells that are resistant to radiotherapy and chemotherapy. Drug resistance, an obstacle to curative treatment of solid tumors, can occur via suppression of apoptosis, a process controlled by pro- and antiapoptotic members of the Bcl-2 protein family. Oxygen deprivation of human colon cancer cells in vitro provoked decreased mRNA and protein levels of proapoptotic Bid and Bad. Hypoxia-inducible factor 1 (HIF-1) was dispensable for the down-regulation of Bad but required for that of Bid, consistent with the binding of HIF-1alpha to a hypoxia-responsive element (positions -8484 to -8475) in the bid promoter. Oxygen deprivation resulted in proteosome-independent decreased expression of Bax in vitro, consistent with a reduction in global translation efficiency. The physiological relevance of Bid and Bax down-regulation was confirmed in tumors in vivo. Oxygen deprivation resulted in decreased drug-induced apoptosis and clonogenic resistance to agents with different mechanisms of action. The contribution of Bid and/or Bax down-regulation to drug responsiveness was demonstrated by the relative resistance of normoxic cells that had no or reduced expression of Bid and/or Bax and by the finding that forced expression of Bid in hypoxic cells resulted in increased sensitivity to the topoisomerase II inhibitor etoposide.

Florid von Brunn nests mimicking urothelial carcinoma: a morphologic and immunohistochemical comparison to the nested variant of urothelial carcinoma

Florid von Brunn nests may mimic the nested variant of urothelial carcinoma. We examined formalin-fixed, paraffin-embedded tissue from 21 cases of florid von Brunn nests and 11 cases of nested variant of urothelial carcinoma. Morphologic features were recorded in detail. Also, cases were stained with monoclonal antibodies against MIB-1, p53, p27, and cytokeratin 20. Percentage positivity was calculated by counting 300 to 500 cells from each case. Clinical follow-up information was also obtained. Florid von Brunn nests from the bladder were comprised of large nests with regular spacing, and all the nests extended to the same horizontal level at the base of the proliferation. Central lumen formation was often seen within florid von Brunn nests, at times with cystic dilatation, such that there was a spectrum from proliferating von Brunn nests to cystitis glandularis to cystitis cystica. Small, crowded nests with variable spacing and an infiltrative base characterized nested variant of urothelial carcinoma. Four cases showed detrusor muscle invasion on biopsy with an additional case showing detrusor muscle invasion at cystectomy. One additional patient with nested variant of urothelial carcinoma had distant metastases and another had prostatic invasion. Nine of 21 florid von Brunn nests cases were from either the ureter or renal pelvis, whereas all cases of nested variant of urothelial carcinoma arose in the bladder. The ureteral and pelvic florid von Brunn nest cases showed smaller, more variable nests with irregular spacing closely mimicking nested variant of urothelial carcinoma but had a noninfiltrative base and often areas with either a lobular or linear array. Immunohistochemical studies showed nested variant of urothelial carcinoma to have higher MIB-1 expression (8.8% vs. 2.8%, P = 0.01). Nested variant of urothelial carcinoma had nonsignificantly higher p53 positivity (4.2% vs. 1.5%, P = 0.06) and lower p27 positivity (4.7% vs. 7.8%, P = 0.22). Cytokeratin 20 staining was not discriminatory. However, staining with each antibody was widely variable. Wide variation in staining for MIB-1, p53, p27, and cytokeratin 20 was seen in both florid von Brunn nests and nested variant of urothelial carcinoma, such that except for a few cases, a specific cutoff value could not be determined for diagnostic purposes. The findings underscore the importance of morphologic assessment in the distinction of florid von Brunn nests and nested variant of urothelial carcinoma.

Paratesticular liposarcoma: a clinicopathologic study

Paratesticular liposarcomas are rare and typically reported as isolated cases or as components of larger studies of liposarcomas. We studied a series of these tumors. All cases of paratesticular liposarcomas were retrieved from the archives of the Royal Marsden Hospital and the Johns Hopkins Hospital. Slides were reviewed and clinical information obtained. There were 30 paratesticular liposarcomas from men aged 41-87 years (mean 63 years; median 65 years) that involved the spermatic cord (23, 76%), testicular tunics (6, 20%), and epididymis (1, 4%). Tumors ranged from 3 to 30 cm (mean 11.7 cm; median 10 cm). Nineteen were well-differentiated liposarcomas (WDLs) and 10 were dedifferentiated liposarcomas (DDLs, five with high-grade and five with low-grade dedifferentiation). One was a myxoid/round cell liposarcoma with 70% round cell areas. All patients were treated by radical orchiectomy. One patient with WDL received radiation after his second recurrence and the myxoid/round cell liposarcoma received radiation and chemotherapy. Follow-up information was available for 16 of the patients, including 10 WDLs (range 24-216 months, mean 106 months), 5 DDLs (14-30 months, median 24 months), and for the myxoid/round cell liposarcoma (14 months) (range for all cases 14 months to 22 years; mean 87 months, median 36 months). Six of the WDLs (60%) recurred at 2, 4, 6, 10, 18, and 21 years (median 8 years). The lesion that recurred at 18 years (case no. 6) displayed foci of high-grade dedifferentiation in the recurrence, although the patient was disease free at 19 years. One patient with WDL had two recurrences at 4 and 7 years, and another had six recurrences over a 17-year period. Only one example of DDL recurred, at 30 months; another patient, who refused therapy for 15 years, had a primary tumor 30 cm in diameter, displayed pulmonary metastases 1 month after excision, and died after 14 months. The patient with MRCL had abdominal metastases after 1 year and was alive at 14 months. In summary, paratesticular WDL had a prolonged course with recurrences in more than half the cases, sometimes late. There were no metastases and the overall prognosis was good. One DDL recurred and only one of five (20%) developed metastases, but the mean follow-up for DDL was only 24 months.

Pleomorphic Malignant Fibrous Histiocytoma of the Spermatic Cord: An Unusual Site for Such a Tumor

The authors report the clinico-pathological features of a rare case of pleomorphic malignant fibrous histiocytoma of the spermatic cord. A review on the topic is provided.