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Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : PD04 - PD06 Full Version

Liposarcoma of Spermatic CordEncountered While Operating the Inguinoscrotal Hernia

Published: November 1, 2022 | DOI:
Tharun Ganapathy Chitrambalam, Ramyasree Paladugu, Nidhi Mariam George, Koshy Mathew Panicker, Sundeep Selvamuthukumaran

1. Associate Professor, Department of General Surgery, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India. 2. Senior Resident, Department of General Surgery, Srm Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India. 3. Postgraduate Student, Department of General Surgery, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India. 4. Senior Resident, Department of General Surgery, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India. 5. Senior Resident, Department of General Surgery, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India.

Correspondence Address :
Dr. Nidhi Mariam George,
Postgraduate Student, Department of General Surgery, SRM Medical College Hospital and Research Center, Chengalpattu, Tamil Nadu, India.


Liposarcomas in the spermatic cord are rare and difficult to diagnose preoperatively, since they present as inguinal or scrotal masses which are frequently evaluated only by ultrasonogram, and other imaging modalities. This case report is about a 48-year-old male, who presented with a painless swelling in the right inguinal region extending to the scrotum, since two years. Upon inguinal exploration, a single irregular fatty mass, arising from the cord, which was found in addition to a small inguinal hernia. En-bloc resection of the mass with inguinal orchidectomy was done and histopathology proved it to be a well-differentiated liposarcoma. A rare malignancy with a deceptive presentation must be taken into account while evaluating scrotal masses, particularly in patients with suspected recurrent hernias of the inguinal region.


En-bloc resection, Hamilton bailey’s operation, Orchidectomy, Testicular neoplasms

Case Report

A 48-year-old male patient presented with a painless swelling in the right inguinal region extending to the scrotum, which slowly progressed to attain the present size over two years. He was married for 20 years with two healthy children. He was a non smoker with no co-morbid conditions.

On clinical examination, a 12×10×8 cm inguinoscrotal swelling was seen on the right-side with expansile cough impulse. No skin involvement was observed. The swelling was granular in consistency, non tender with negative transillumination and non reducible. The right testis was separately palpable from the swelling. The left inguinal region and the left hemi-scrotum was normal. The leftsided testis with cord structure appeared to be normal. Penis was normal in position. General and systemic examination of the patient was unremarkable. A routine preoperative ultrasonogram of the abdomen and scrotum was done, which revealed a defect of 3 cm in the right inguinal region with herniating omentum suggestive of an irreducible right inguinal hernia. Bilateral testis and cord structures were normal. The left inguinal region appeared to be normal.

On a routine elective operating list, with a diagnosis of right inguinoscrotal hernia, the patient was posted for right open hernioplasty and right inguinal exploration was done. Surprisingly, upon opening the inguinal canal, a single large irregular fatty yellow coloured hard mass of size 12×10×8 cm was found engulfing the spermatic cord, extending to the scrotal sac (Table/Fig 1). A small direct inguinal hernia of 2 cm was noted in the posterior wall with the normal intact internal ring. The incision was extended and the fatty mass was dissected off the adjacent tissues and found to be arising from the spermatic cord in the low inguinal canal (Table/Fig 2). The fatty mass was extending into the scrotum upto 2 cm above the right testis without the involvement of testis or epididymis sparing a few centimetres of the distal spermatic cord. With an intraoperative diagnosis of lipoma/liposarcoma of the cord, en-bloc resection of the mass along with cord structures from the internal ring to a few centimetres above the testicular sac (Hamilton Bailey’s operation) was done [Table/Fig-(3),(4). In view of suspected malignancy, the mesh was not placed and modified Bassini’s herniorrhaphy was done to strengthen the posterior wall.

Histopathological slides of the tumour, predominantly showed lobules of mature fatty tissue with areas of fat necrosis, haemorrhage, aggregates of lymphoplasmacytic infiltrate and hemosiderin-laden macrophages. Occasional cells showed intranuclear inclusion, pleomorphism, vacuolated cytoplasm and lipoblasts with no evidence of mitosis suggestive of Well Differentiated Liposarcoma without infiltrating the testicular tissue and the margins were free of the tumour (Table/Fig 5). Subsequent work-up (whole-body positron emission tomography scan) showed no evidence of intra-abdominal or lung metastasis. As the tumour was well-differentiated with R0 resection, no radiotherapy was given and the patient was on close follow-up as recommended by the medical oncologist. The patient improved well postoperatively with no complaints. A recent followup Computed Tomography (CT) scan at two years showed no local recurrence of the tumour. The patient is on close surveillance with a six monthly follow-up over the past three years.


In 1845, Lesauvage reported the first case of sarcoma of the cord (1). Liposarcomas, as small as 3 cm have been reported. All scrotal masses are initially imaged with ultrasound, on which avid vascular flow, favours the diagnosis of liposarcoma over paratesticular lipoma (2). Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) is highly useful in diagnosing suspected spermatic cord malignancies and retroperitoneal liposarcomas. Contrast-Enhanced Ultrasound (CEUS) can provide complementary information by identifying distinct enhancement patterns (2). Identification of well-differentiated liposarcomas can be a challenge because they are usually poorly demarcated from surrounding normal fat, homogenous, and low density. In contrast, high grade liposarcomas present as solid, heterogeneous, high density masses (2),(3). However, the definitive diagnosis of liposarcoma requires pathological inspection of inguinal masses, to rule out other paratesticular and testicular neoplasms.

As there is no gold standard treatment, an en-bloc resection with R0 margins is the key to the management of spermatic cord liposarcomas. If the margins are positive, re-resection should be performed after the index surgery (4). Peralta JP et al., reported a similar case of liposarcoma of the spermatic cord where organ sparing surgery was performed with no documented recurrence after a year’s follow-up. However, this approach is not routinely advocated and may be undertaken in cases where the risk factors for recurrence are negligible (5). The abdominal wall defect can be closed by herniorrhaphy and reinforcement with a mesh if necessary. The choice of mesh, biological or synthetic is a point of debate, considering the high incidence of loco-regional recurrence and the possibility of adhesions to the vital structures postradiotherapy (5). Wetzel E et al., reported a similar case of liposarcoma of the spermatic cord, which presented as an inguinal hernia. The patient underwent ipsilateral orchidectomy and excision with wide margins following which he received adjuvant focussed radiation therapy (6). However, in this case, a polypropylene mesh was used to strengthen the defect. Regional lymph node dissection is not of value, because the dissemination of LSC is essentially haematogenous whereas the lymphatic pattern of metastasis seems to be infrequent and has no survival benefit (4).

Radiation therapy is recommended, in addition to surgery for high grade tumours, the presence of lymphatic invasion, inadequate margins, associated poor prognostic factors, and relapses (7). Pikramenos K et al., reported a case of well-differentiated sclerosing liposarcoma with myxoid liposarcoma of the spermatic cord where the patient underwent surgery with negative margins. However, the patient did not undergo any further adjuvant treatment and there was no local or metastatic diseases after one year follow-up (8). There is no definite role of chemotherapy and most of the recommendations are based on cases with recurrences (9). The role of neoadjuvant chemotherapy and radiotherapy has not been fully investigated. Chowdhry VK et al., emphasised the negative effects of preoperative radiotherapy in regard to wound healing (10). Local recurrence is a major issue with an incidence of 30-50%. Delayed local recurrences have been reported even after two years of treatment (4). Morozumi K et al., reported a case of a 54-year-old male who underwent 7 resections following local recurrence over a period of 8 years (11). A long follow-up of 10-20 years is therefore required in all cases (12),(13). As distant metastasis is rare in LSC, the prognosis is good with a high five-year survival rate (14).


This rare case report aimed to emphasise the differential diagnosis of liposarcoma of the cord among irreducible inguinoscrotal hernias and complex inguinal/scrotal masses. Treatment of liposarcoma of the spermatic cord involves en-bloc resection with negative margins. Distant metastasis is rare, but local recurrences are common even after several years, hence, close surveillance and long follow-up is required in these cases.


Schwartz SL, Swierzewski SJ, Sondak VK, Grossmann HB. Liposarcoma of the spermatic cord: Report of 6 cases and review of the literature. J Urol. 1995;153:154-57.[crossref] [PubMed]
Naser-Tavakolian A, Gulati M, Duddalwar V, Chopra S, Aron M, Djaladat H. Contrast-enhanced ultrasound of spermatic cord and retroperitoneal liposarcoma. Ultrasound Q. 2018;34:292-96. [crossref] [PubMed]
Shintaku M, Yoshida T, Hirose T. Dedifferentiated liposarcoma of the spermatic cord with features of epithelioid rhabdomyosarcoma and a rapidly fatal outcome. Pathol Int. 2018;68(10):579-81. [crossref] [PubMed]
Chalouhy C, Ruck JM, Moukarzel M, Jourdi R, Dagher N, Philosophe B. Current management of liposarcoma of the spermatic cord: A case report and review of the literature. Mol Clin Oncol. 2017;60:438-40. [crossref] [PubMed]
Peralta JP, Godinho R, Rabac¸ a C, Reis M. Spermatic cord liposarcoma: Organsparing surgery. BMJ Case Rep. 2013;2013:bcr2013009926. [crossref] [PubMed]
Wetzel E, Adjamian N, Diaz G, Steen S, Hobbs J. Liposarcoma of the spermatic cord presenting as an inguinal hernia. Int J Surg Case Rep. 2020;76:274-77. [crossref] [PubMed]
Cerda T, Martin É, Truc G, Créhange G, Maingon P. Safety and efficacy of intensity modulated radiotherapy in the management of spermatic cord sarcoma. Cancer/ Radiothérapie. 2017;21(1):16-20. [crossref] [PubMed]
Pikramenos K, Katsimperis S, Zachou M, Giannakakou M, Mitsogianni M. Liposarcoma of the spermatic cord mimicking an inguinal hernia. Cereus. 2022;14(8):e28269. [crossref]
Mokrani A, Guermazi F, Meddeb K, Kacem LBH, Chakroun M, Yahyaoui Y, et al. Liposarcoma of the spermatic cord: A case report and review of literature. Urol Case Rep. 2018;21:19-20. [crossref] [PubMed]
Chowdhry VK, Kane J, Wang K, Joyce D, Grand’Maison A, Mann G. Testicular, spermatic cord and scrotal soft tissue sarcomas: Treatment outcomes and patterns of failure. Sarcoma. 2021:8824301. [crossref] [PubMed]
Morozumi K, Kawasaki Y, Kaiho Y, Kawamorita N, Fujishima F, Watanabe M, et al. Dedifferentiated liposarcoma in the spermatic cord finally diagnosed at 7th resection of recurrence: A case report and bibliographic consideration. Case Rep Oncol. 2017;10:713-19. [crossref] [PubMed]
Coleman J, Brennan MF, Alektiar K, Russo P. Adult spermatic cord sarcomas: Management and results. Ann Surg Oncol. 2003;10:669-75. [crossref] [PubMed]
Fagundes MA, Zietman AL, Althausen AF, Coen J, Shipley WU. The management of spermatic cord sarcoma. Cancer. 1996;77:1873-76. [crossref]
Gregorio MD, D’Hondt L, Lorge F, Nollevaux MC. Liposarcoma of the spermatic cord: An infrequent pathology. Case Rep Oncol. 2017;10(1):136-42. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/58850.17171

Date of Submission: Jul 05, 2022
Date of Peer Review: Aug 10, 2022
Date of Acceptance: Oct 01, 2022
Date of Publishing: Nov 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Jul 07, 2022
• Manual Googling: Sep 24, 2022
• iThenticate Software: Sep 27, 2022 (19%)

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