Scrotal Hydrocele As the First Clinical Manifestation of Occult Gastric Cancer

□ Case Report □

Scrotal Hydrocele as the First Clinical Manifestation of Occult Gastric Cancer

Jeong Kyun Yeo Korean Journal of Urology Vol. 50 No. 11: 1151-1153, From the Department of Urology, College of Medicine, Inje University, Pusan, Korea November 2009 We report a rare case of a metastatic tumor of the tunica vaginalis and DOI: 10.4111/kju.2009.50.11.1151 epididymis with hydrocele from occult gastric cancer. A 72-year-old ： patient showed a painless scrotal swelling. Scrotal ultrasound showed a Received July 21, 2009 Accepted：October 8, 2009 right hydrocele and a follow-up hydrocelectomy showed a mass on the epididymis. The operation was thus converted to radical orchiectomy. The Correspondence to: Jeong Kyun Yeo tumor was revealed as an adenocarcinoma in the tunica vaginalis and Department of Urology, Inje epididymis. Abdominal computed tomography found gastric cancer, University Seoul Paik Hospital, 82, 2-ga, Jeo-dong, Jung-gu, which was confirmed by a gastric fibroscopy biopsy. The patient was Seoul 100-032, Korea referred to the hemato-oncology department for chemotherapy but died TEL: 02-2270-0078 after 3 months. (Korean J Urol 2009;50:1151-1153) FAX: 02-2270-0226 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 E-mail: [email protected]

Key Words: Adenocarcinoma, Stomach, Testicular hydrocele Ⓒ The Korean Urological Association, 2009

Metastatic tumors of the paratesticular tissue are rare. The in the epididymis. Frozen biopsy further revealed an atypical, common primary sites of metastasis of the paratesticular tissue round, clear cell infiltrative lesion into smooth muscle bundles, are the prostate, kidney, gastrointestinal tract, lung, and breast which did not exclude malignancy of the paratesticular tissue. [1,2]. Gastric cancer usually invades the regional lymph nodes, The operation was therefore converted to a radical orchiectomy liver, lung, bone, and brain. The paratesticular tissues are rare with an additional inguinal incision. The pathological diagnosis sites of metastasis from a gastric carcinoma. Here we report was a moderately to poorly differentiated signet ring cell-type the first clinical case of a metastatic tumor of the tunica adenocarcinoma involving the tunica vaginalis, epididymis, and vaginalis and epididymis associated with a hydrocele that surrounding soft tissue (Fig. 2). The results of immunohisto- originated from occult gastric cancer.

CASE REPORT

A 72-year-old patient who had been prescribed medication for benign prostatic hyperplasia showed a painless mass in the right scrotum. The mass was incidentally discovered 2 months previously and had gradually increased in size. In a physical examination, we detected a 7 cm, soft, nontender mass with transillumination in the right scrotum. The patient had neither history nor symptoms of any gastrointestinal abnormality. Scrotal ultrasound showed an anechoic cystic mass on the right testis that was displaced downward. The right testis and epididymis were normal in size without any mass (Fig. 1). Therefore, hydrocele was suspected and a scrotal incision was performed. During the operation, we found an ill-defined, Fig. 1. Scrotal sonogram showing an anechoic cystic lesion on the grayish, localized mass-like lesion measuring about 1.3x0.8 cm right testis. The testis was displaced downward.

1151 1152 Korean Journal of Urology vol. 50, 1151-1153, November 2009

Fig. 2. (A) Gross specimen showing an encapsulated yellow-whitish mass (gray arrow) in the epididymis. (B) Signet ring cells are present in the fibrous tissue of the epididymis (H&E, x400).

basis of these findings, the patient was diagnosed as having a metastatic paratesticular adenocarcinoma originating from a gastric carcinoma with retroperitoneal lymphadenopathy and hepatic metastasis. Accordingly, the patient received cisplatin- based chemotherapy but died with multiple organ failure 3 months after the operation.

DISCUSSION

Less than 50 cases of solid tumor metastasis to the epididymis, with or without spermatic cord involvement, have been reported. Many of these were incidental discoveries at autopsy or examination of orchiectomy specimens removed thera- peutically for prostate cancer [3]. The prostate is the most Fig. 3. Computed tomography showing a heterogeneous tumor (black arrow) with an irregular margin in the antrum and body of common primary site for testis metastasis from epithelial the stomach associated with hepatic metastasis (dotted arrow) and tumors (37%). Other common primary sites are the stomach multiple retroperitoneal lymphadenopathies (gray arrow). (18%), kidney (16%), colon (13%), carcinoid tumor (8%), and pancreas (5%) [4]. In Japan, a paper reported a total of 84 cases chemical stains were positive for cytokeratin, carcinoembryonic of metastatic tumors of the spermatic cord, approximately half antigen, and PAS. Because we suspected metastatic cancer, of which were metastases from gastric cancer [5]. This may be prostate-specific antigen measurement, colon imaging study, the result of the comparatively small number of prostate cancer gastrointestinal fibroscopy, and abdominal computerized tomo- cases in Japan and a therapeutic modality in prostate cancer graphy were performed to detect the primary cancer. The with less invasive treatments like hormonal treatment. gastrointestinal fibroscopy showed a huge mass in the antrum Several routes of metastasis to the tunica vaginalis and and biopsy revealed a signet ring cell-type adenocarcinoma. epididymis have been proposed, such as direct extension from Abdominal computerized tomography uncovered a heteroge- adjacent organs (particularly in a prostatic carcinoma), intra- neous tumor with an irregular margin in the antrum and body ductal spread via the vas deferens, retrograde venous and of the stomach associated with multiple hepatic metastases and lymphatic extension, and arterial embolism. In our case, the multiple retroperitoneal lymphadenopathies (Fig. 3). On the route of lymphatic extension was suspected, particularly in view Jeong Kyun Yeo：The Paratesticular Metastasis of Gastric Cancer 1153 of the multiple retroperitoneal lymphadenopathies. Ultrasonography, the imaging modality of choice, may help REFERENCES in the diagnosis of a secondary tumor, especially in the presence of nodules and a recent diagnosis of another primary 1. Beccia DJ, Krane RJ, Olsson CA. Clinical management of cancer [6]. In the present case, the patient had neither non-testicular intrascrotal tumors. J Urol 1976;116:476-9. 2. Algaba F, Santaularia JM, Villavicencio H. Metastatic tumor of symptoms nor history of gastrointestinal tumors with any the epididymis and spermatic cord. Eur Urol 1983;9:56-9. abnormality except hydrocele in sonography. Hence, it was 3. Dutt N, Bates AW, Baithun SI. Secondary neoplasms of the difficult to find the tumor without operating. male genital tract with different patterns of involvement in The treatment modality for a primary malignant tumor of the adults and children. Histopathology 2000;37:323-31. epididymis and a secondary tumor does not differ because 4. Haupt HM, Mann RB, Trump DL, Abeloff MD. Metastatic chemotherapy is the only possible option at this distant carcinoma involving the testis. Clinical and pathologic distinc- tion from primary testicular neoplasms. Cancer 1984;54:709-14. metastatic stage. The prognosis of this cancer was unfavorable, 5. Kato K, Suzuki K, Sai S, Murase T, Kobayashi Y. A case of because metastatic tumors to the paratesticular tissues are metastatic tumor of spermatic cord with hydrocele from gastric usually identified in the setting of disseminated disease. As cancer. Hinyokika Kiyo 1999;45:859-61. shown in our case, the results were disappointing. 6. Pfister M, Saez D, Celeste F. Sonographic appearance of It is very rare for a paratesticular metastasis to present as malignant mesothelioma of the tunica vaginalis testis in a child. J Clin Ultrasound 1992;20:129-31. the first manifestation of an occult primary neoplasm. We 7. Irisawa C, Yamaguchi O, Shiraiwa Y, Kikuchi Y, Irisawa S, found only one reported case of a metastatic tumor to the Irisawa C. A case of metastatic tumor of the spermatic cord spermatic cord that originated from occult gastric cancer [7]. from gastric carcinoma. Hinyokika Kiyo 1989;35:1807-9. In most cases, the patients had a history of gastric cancer 8. Kageyama Y, Kawakami S, Li G, Kihara K, Oshima H, [5,8,9]. Our report may be the first case of scrotal hydrocele Teramoto K. Metastatic tumor of spermatic cord and tunica vaginalis testis from gastric cancer: a case report. Hinyokika as the first manifestation of occult gastric cancer that Kiyo 1997;43:429-31. metastasized to the tunica vaginalis and epididymis. 9. Lee J, Kang SC, Ban JH, Shin DS, Yeo JK, Yoon DH, et al. Metastatic tumor of tunica vaginalis testis with hydrocele in a patient with gastric cancer. Korean J Urol 2007;48:667-9.