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Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 53-55  

Spermatic cord metastasis as early manifestation of small bowel adenocarcinoma

1 Assistant Professor of Hematology/Medical Oncology, Urmia University of Medical Sciences, Urmia, Iran
2 Assistant Professor of Urology, Urmia University of Medical Sciences, Urmia, Iran

Date of Submission11-Apr-2011
Date of Acceptance18-Jun-2011
Date of Web Publication5-Feb-2013

Correspondence Address:
Ali Tehranchi
Department of Urology, Imam Khomeini Hospital, Urmia University of Medical Science
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DOI: 10.4103/0974-7796.106971

PMID: 23662014

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Malignant tumors of the spermatic cord are rare. There are a few case reports on spermatic cord metastasis from colonic, gastric, pancreas, and prostatic cancer. Here, we report a 36-year-old man with brucellosis presenting with spermatic cord metastasis as early manifestation of small bowel adenocarcinoma.

Keywords: Adenocarcinoma, metastasis, small intestine, spermatic cord

How to cite this article:
Valizadeh N, Oskuie AE, Tehranchi A. Spermatic cord metastasis as early manifestation of small bowel adenocarcinoma. Urol Ann 2013;5:53-5

How to cite this URL:
Valizadeh N, Oskuie AE, Tehranchi A. Spermatic cord metastasis as early manifestation of small bowel adenocarcinoma. Urol Ann [serial online] 2013 [cited 2020 Oct 27];5:53-5. Available from: https://www.urologyannals.com/text.asp?2013/5/1/53/106971

   Introduction Top

Malignant tumors of the spermatic cord are extremely uncommon. Prevalence of metastatic tumors of the spermatic cord account for less than 10% of malignant tumors of this site. [1],[2] The most common primary site for spermatic cord metastasis is the gastrointestinal tract, pancreas, prostate, and kidneys. [2],[3] There are few reports regarding spermatic cord metastasis in gastric, [4],[5],[6],[7] colorectal cancer, [8],[9],[10],[11],[12] prostatic cancer, [13] and pancreatic adenocarcinoma. [2]

We present a 35-year-old man with  Brucellosis More Details who had unilateral hydrocele, spermatic cord metastasis, and in whom we found small intestinal adenocarcinoma as the primary site.

   Case Report Top

A 35-year-old man presented with weight loss, anorexia, and painful right inguinal mass with referral pain to the testis. Physical examination revealed right inguinal firm and painful mass adhesive to the spermatic cord and new onset hydrocele. In medical history, he had brucellosis two years ago and had been treated with anti-brucellosis drugs. Sonography showed a solid hypoechoic mass measuring 16 × 11 mm in the right inguinal canal and normal sized, normal echoic right testis with localised fluid collection in the superio-lateral part of the right testis (epididymal cyst or hydrocele). In sonography, the left testis had normal size and echogenicity. He underwent biopsy of the right inguinal mass. During operation, we encountered a firm mass adhesive to spermatic cord vessels and vas deferens, so it was impossible to resect the mass completely; we then decided to do a biopsy from the mass.

The pathologist reported primary or metastatic adenocarcinoma, and then the patient underwent trans-inguinal radical orchiectomy with complete mass resection, according to the pathologist's report of metastatic adenocarcinoma of the spermatic cord; after the resection, the margin was free of tumor. Immunohistochemistry was positive for cytokeratin and Epithelial Membrane Antigen (EMA) and negative for Leukocyte Common Antigen (LCA), S100, desmin, vimentin, Neuron-Specific Enolase (NSE), thyroglobulin, Alpha-Fetoprotein (AFP), and Prostate-Specific Antigen (PSA). He was admitted with nausea, vomiting, and abdominal pain. Gastroenterologist consultation was done, after which upper gastrointestinal endoscopy and colonoscopy were recommended, both of which had normal result. PSA (free and total) was in normal range. Transrectal sonography revealed an area (13 × 17 mm) with non-homogeneous echogenicity in the peripheral side of the left prostate lobe and biopsy was done, which reported as normal prostatic tissue and one core was granulation tissue. Laboratory findings include: White Blood Cells (WBC) = 6700/μl [Polymorphonuclear Leukocytes (PMN) = 63%, Lymph = 27%), Hemoglobin (Hb) = 17.2 gr/dl, Platelet Count Test (PLT) = 217,000/μl, Fetal Bovine Serum (FBS) = 105 mg/dl, albumin = 4.9 g/dl, protein = 8.1 g/dl, Aspartate Aminotransferase (AST) = 25 U/L, Alanine Aminotransferase (ALT) = 58 U/L, calcium = 13 mg/dl, Na = 126 meq/L, K = 4.6 meq/L, Cr = 0.84 mg/dl, Urea = 24 mg/dl, Parathyroid Hormone (PTH) = 18 (NL:8-69) pg/ml, 2ME = 1/160, total bilirubin = 0.9 mg/dl, direct bilirubin = 0.28 mg/dl, Magnesium = 2.42 mg/dl (NL:1.8-2.6), Lactate Dehydrogenase (LDH) = 428 U/L, Alkaline phosphatase = 256 U/L. Wright = 1/160, Coombs Wright = 1/320. Hepatitis B Surface. Antigen (HbsAg), anti-Hepatitis C Virus Antibody (HCV Ab), and HIV Antibody (HIV Ab) all showed negative results. Thyroid function tests yielded normal results. Tumor markers including CA15-3, CA19-9, ß-Human Chorionic Gonadotropin (ß-hCG), and AFP were in normal ranges. Abdominopelvic computed tomographic (CT) scan showed severe distention in the stomach and jejunum. Serum 8 am basal fasting cortisol level was 29.01 ug/dl (Nl:6.2-19.4). Abdominopelvic sonography showed distention only in the gastrointestinal loops. Chest X-ray and brain CT scan were reported to be normal. Whole body bone scan was unremarkable. We consulted with infectious disease specialist who recommended starting anti-brucellosis therapy for the patient due to elevation of Wright's and Coombs Wright's tests. Therefore, we administered ofloxacin and rifampin for the patient.

In the hospital, his nausea and vomiting did not resolve and he developed a state of delirium and abdominal distention. In repeated physical examination, we found sinus tachycardia, tenderness, and guarding in abdominal examination. We sent for a surgical consultation, but before consultation his family got the patient released from the hospital. They took him to another centre and at that center with diagnosis of acute abdomen he had been underwent laparotomy. During operation, the surgeon noticed a small bowel loop with a stricture in the middle portion and a tumoral lesion in that area with serosal involvement. Small bowel tumor resection revealed small bowel adenocarcinoma with full thickness and vascular involvement and three nodes out of six lymph nodes were involved. Chemotherapy with Capecitabine-plus-Oxaliplatin (XELOX) regimen was started and continued at three-week intervals. At present, six months after the operation, he has a good general condition, without any metastatic symptoms and signs.

   Results Top

In this 35-year-old patient, inguinal pain and new onset hydrocele due to spermatic cord metastasis was the first manifestation of small intestine adenocarcinoma.

   Discussion Top

The most frequent primary tumors metastatic to the spermatic cord and epididymis are carcinomas of the stomach (42.8%) and the prostate (28.5%). [2] Of these metastases, 23.8% are subclinical and when discovered the diagnosis concerning the origin of the primary tumor is always wrong. [2] The average survival, subsequent to the diagnosis of the metastasis, is 9.1 months. [2] Fifty-four Japanese patients with metastasis from the digestive organs to the spermatic cord and/or the intrascrotal contents were analyzed. The most frequent primary site was the stomach and the most frequent metastatic site was the spermatic cord. [3]

We recommend radical orchiectomy and immunohistochemistry in any patient with firm, adhesive, tender, and hypoechoic spermatic cord mass. Although chronic epididymo-orchitis is reported in patients with brucellosis but, in this case of brucellosis, we found metastatic adenocarcinoma of the right spermatic cord. We should consider small intestine adenocarcinoma in any patient with spermatic cord metastatic adenocarcinoma. Abdominal pain, nausea, vomiting, abdominal distention, weight loss are important clues that guide physicians to perform further assessment for a possible gastrointestinal primary site. Normal upper gastrointestinal endoscopy and colonoscopy are not adequate to rolling out small intestinal malignancies, and then an upper gastrointestinal series or enteroscopy would be necessary in this setting.

   References Top

1.Dutt N, Bates AW, Baithun SI. Secondary neoplasms of the male genital tract with different patterns of involvement in adults and children. Histopathology 2000;37:323-31.  Back to cited text no. 1
2.Algad F, Santaularia JM, Villavicencio H. Metastatic tumour of the epididymis and spermatic cord. Eur Urol 1983;9:56-9.  Back to cited text no. 2
3.Kanno K, Ohwada S, Nakamura S, Ohya T, Iino Y, Morishita Y, et al. Epididymis metastasis from colon carcinoma: A case report and a review of the Japanese literature.Jpn J Clin Oncol 1994;24:340-4.  Back to cited text no. 3
4.Irisawa C, Yamaguchi O, Shiraiwa Y, Kikuchi Y, Irisawa S, Irisawa C. A case of metastatic tumor of the spermatic cord from gastric carcinoma. Hinyokika Kiyo 1989;35:1807-9.  Back to cited text no. 4
5.Pozzobon D, Caldato C, Pavanello M, Di Falco G. Metastatic gastric neoplasm in the spermatic cord: report of a case. ChirItal 2001;53:729-32.  Back to cited text no. 5
6.Kageyama Y, Kawakami S, Li G, Kihara K, Oshima H, Teramoto K. Metastatic tumor of spermatic cord and tunica vaginalis testis from gastric cancer: A case report. Hinyokika Kiyo 1997;43:429-31.  Back to cited text no. 6
7.Schaefer I. M, Sauer U, Liwocha M, Schorn H, Loertzer H, FüzesiL.Occult gastric signet ring cell carcinoma presenting as spermatic cord and testicular metastases: "Krukenberg tumor" in a male patient. Pathol Res Pract 2010;206:519-21.  Back to cited text no. 7
8.Shida Y, Miyata Y, Igawa T, Sakai H, Koga S, Kanetake H. A case of metastatic tumor of spermatic cord from ascending colon carcinoma.Hinyokika Kiyo 2006;52:733-5.  Back to cited text no. 8
9.Janeiro Pais JM, Busto Castañón L, BarbagelataLópez A, Diaz-Reixa JP, Romero Selás E, Casas Agudo VP, et al. Metastasis of colon adenocarcinoma to the epididymis and spermatic cord. Arch Esp Urol 2006;59:746-8.  Back to cited text no. 9
10.Melone F, Olmastroni M, Petacchi D, Bianchi S, Messerini L, Farina U. Metastatic tumor of the spermatic cord from a primary silent colorectal adenocarcinoma. Minerva Urol Nefrol 1997;49:57-61.  Back to cited text no. 10
11.Polychronidis A, Tsolos C, Sivridis E, Botaitis S, Simopoulos C.Spermatic cord metastasis as an initial manifestation of sigmoid colon carcinoma: Report of a case. Surg Today 2002;32:376-7.  Back to cited text no. 11
12.Galanis I, Chatzimavroudis G, Katsougiannopoulos A, Galanis N, Makris J, Atmatzidis K. Spermatic cord metastasis presenting as strangulated inguinal hernia-first manifestation of a multifocal colon adenocarcinoma: A case report. Cases J 2009;2:61.  Back to cited text no. 12
13.Bawa AS, Singh R, Bansal VK, Punia RS.Spermatic cord metastasis from prostatic cancer. J Postgrad Med 2003;49:97-8.  Back to cited text no. 13
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