Case Report

1151

Scrotal Hydrocele as the First Clinical Manifestation of Occult Gastric Cancer

Jeong Kyun YeoFrom the Department of Urology College of Medicine Inje University Pusan Korea

We report a rare case of a metastatic tumor of the tunica vaginalis and epididymis with hydrocele from occult gastric cancer A 72-year-old patient showed a painless scrotal swelling Scrotal ultrasound showed a right hydrocele and a follow-up hydrocelectomy showed a mass on the epididymis The operation was thus converted to radical orchiectomy The tumor was revealed as an adenocarcinoma in the tunica vaginalis and epididymis Abdominal computed tomography found gastric cancer which was confirmed by a gastric fibroscopy biopsy The patient was referred to the hemato-oncology department for chemotherapy but died after 3 months (Korean J Urol 2009501151-1153)985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103Key Words Adenocarcinoma Stomach Testicular hydrocele

Korean Journal of Urology Vol 50 No 11 1151-1153 November 2009

DOI 104111kju200950111151ReceivedJuly 21 2009AcceptedOctober 8 2009

Correspondence to Jeong Kyun YeoDepartment of Urology Inje University Seoul Paik Hospital 82 2-ga Jeo-dong Jung-gu Seoul 100-032 Korea TEL 02-2270-0078FAX 02-2270-0226E-mail yeoluvkdaumnet

The Korean Urological Association 2009

Fig 1 Scrotal sonogram showing an anechoic cystic lesion on the

right testis The testis was displaced downward

　Metastatic tumors of the paratesticular tissue are rare The

common primary sites of metastasis of the paratesticular tissue

are the prostate kidney gastrointestinal tract lung and breast

[12] Gastric cancer usually invades the regional lymph nodes

liver lung bone and brain The paratesticular tissues are rare

sites of metastasis from a gastric carcinoma Here we report

the first clinical case of a metastatic tumor of the tunica

vaginalis and epididymis associated with a hydrocele that

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

grayish localized mass-like lesion measuring about 13x08 cm

in the epididymis Frozen biopsy further revealed an atypical

round clear cell infiltrative lesion into smooth muscle bundles

which did not exclude malignancy of the paratesticular tissue

The operation was therefore converted to a radical orchiectomy

with an additional inguinal incision The pathological diagnosis

was a moderately to poorly differentiated signet ring cell-type

adenocarcinoma involving the tunica vaginalis epididymis and

surrounding soft tissue (Fig 2) The results of immunohisto-

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 (HampE x400)

Fig 3 Computed tomography showing a heterogeneous tumor

(black arrow) with an irregular margin in the antrum and body of

the stomach associated with hepatic metastasis (dotted arrow) and

multiple retroperitoneal lymphadenopathies (gray arrow)

chemical stains were positive for cytokeratin carcinoembryonic

antigen and PAS Because we suspected metastatic cancer

prostate-specific antigen measurement colon imaging study

gastrointestinal fibroscopy and abdominal computerized tomo-

graphy were performed to detect the primary cancer The

gastrointestinal fibroscopy showed a huge mass in the antrum

and biopsy revealed a signet ring cell-type adenocarcinoma

Abdominal computerized tomography uncovered a heteroge-

neous tumor with an irregular margin in the antrum and body

of the stomach associated with multiple hepatic metastases and

multiple retroperitoneal lymphadenopathies (Fig 3) On the

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 epidi-

dymis 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

common primary site for testis metastasis from epithelial

tumors (37) Other common primary sites are the stomach

(18) kidney (16) colon (13) carcinoid tumor (8) and

pancreas (5) [4] In Japan a paper reported a total of 84 cases

of metastatic tumors of the spermatic cord approximately half

of which were metastases from gastric cancer [5] This may be

the result of the comparatively small number of prostate cancer

cases in Japan and a therapeutic modality in prostate cancer

with less invasive treatments like hormonal treatment

　Several routes of metastasis to the tunica vaginalis and

epididymis have been proposed such as direct extension from

adjacent organs (particularly in a prostatic carcinoma) intra-

ductal spread via the vas deferens retrograde venous and

lymphatic extension and arterial embolism In our case the

route of lymphatic extension was suspected particularly in view

Jeong Kyun YeoThe Paratesticular Metastasis of Gastric Cancer 1153

of the multiple retroperitoneal lymphadenopathies

　Ultrasonography the imaging modality of choice may help

in the diagnosis of a secondary tumor especially in the

presence of nodules and a recent diagnosis of another primary

cancer [6] In the present case the patient had neither

symptoms nor history of gastrointestinal tumors with any

abnormality except hydrocele in sonography Hence it was

difficult to find the tumor without operating

　The treatment modality for a primary malignant tumor of the

epididymis and a secondary tumor does not differ because

chemotherapy is the only possible option at this distant

metastatic stage The prognosis of this cancer was unfavorable

because metastatic tumors to the paratesticular tissues are

usually identified in the setting of disseminated disease As

shown in our case the results were disappointing

　It is very rare for a paratesticular metastasis to present as

the first manifestation of an occult primary neoplasm We

found only one reported case of a metastatic tumor to the

spermatic cord that originated from occult gastric cancer [7]

In most cases the patients had a history of gastric cancer

[589] Our report may be the first case of scrotal hydrocele

as the first manifestation of occult gastric cancer that

metastasized to the tunica vaginalis and epididymis

REFERENCES

1 Beccia DJ Krane RJ Olsson CA Clinical management of

non-testicular intrascrotal tumors J Urol 1976116476-9

2 Algaba F Santaularia JM Villavicencio H Metastatic tumor of

the epididymis and spermatic cord Eur Urol 1983956-9

3 Dutt N Bates AW Baithun SI Secondary neoplasms of the

male genital tract with different patterns of involvement in

adults and children Histopathology 200037323-31

4 Haupt HM Mann RB Trump DL Abeloff MD Metastatic

carcinoma involving the testis Clinical and pathologic distinc-

tion from primary testicular neoplasms Cancer 198454709-14

5 Kato K Suzuki K Sai S Murase T Kobayashi Y A case of

metastatic tumor of spermatic cord with hydrocele from gastric

cancer Hinyokika Kiyo 199945859-61

6 Pfister M Saez D Celeste F Sonographic appearance of

malignant mesothelioma of the tunica vaginalis testis in a child

J Clin Ultrasound 199220129-31

7 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 1989351807-9

8 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 199743429-31

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 200748667-9

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 (HampE x400)

Fig 3 Computed tomography showing a heterogeneous tumor

(black arrow) with an irregular margin in the antrum and body of

the stomach associated with hepatic metastasis (dotted arrow) and

multiple retroperitoneal lymphadenopathies (gray arrow)

chemical stains were positive for cytokeratin carcinoembryonic

antigen and PAS Because we suspected metastatic cancer

prostate-specific antigen measurement colon imaging study

gastrointestinal fibroscopy and abdominal computerized tomo-

graphy were performed to detect the primary cancer The

gastrointestinal fibroscopy showed a huge mass in the antrum

and biopsy revealed a signet ring cell-type adenocarcinoma

Abdominal computerized tomography uncovered a heteroge-

neous tumor with an irregular margin in the antrum and body

of the stomach associated with multiple hepatic metastases and

multiple retroperitoneal lymphadenopathies (Fig 3) On the

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 epidi-

dymis 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

common primary site for testis metastasis from epithelial

tumors (37) Other common primary sites are the stomach

(18) kidney (16) colon (13) carcinoid tumor (8) and

pancreas (5) [4] In Japan a paper reported a total of 84 cases

of metastatic tumors of the spermatic cord approximately half

of which were metastases from gastric cancer [5] This may be

the result of the comparatively small number of prostate cancer

cases in Japan and a therapeutic modality in prostate cancer

with less invasive treatments like hormonal treatment

　Several routes of metastasis to the tunica vaginalis and

epididymis have been proposed such as direct extension from

adjacent organs (particularly in a prostatic carcinoma) intra-

ductal spread via the vas deferens retrograde venous and

lymphatic extension and arterial embolism In our case the

route of lymphatic extension was suspected particularly in view

Jeong Kyun YeoThe Paratesticular Metastasis of Gastric Cancer 1153

of the multiple retroperitoneal lymphadenopathies

　Ultrasonography the imaging modality of choice may help

in the diagnosis of a secondary tumor especially in the

presence of nodules and a recent diagnosis of another primary

cancer [6] In the present case the patient had neither

symptoms nor history of gastrointestinal tumors with any

abnormality except hydrocele in sonography Hence it was

difficult to find the tumor without operating

　The treatment modality for a primary malignant tumor of the

epididymis and a secondary tumor does not differ because

chemotherapy is the only possible option at this distant

metastatic stage The prognosis of this cancer was unfavorable

because metastatic tumors to the paratesticular tissues are

usually identified in the setting of disseminated disease As

shown in our case the results were disappointing

　It is very rare for a paratesticular metastasis to present as

the first manifestation of an occult primary neoplasm We

found only one reported case of a metastatic tumor to the

spermatic cord that originated from occult gastric cancer [7]

In most cases the patients had a history of gastric cancer

[589] Our report may be the first case of scrotal hydrocele

as the first manifestation of occult gastric cancer that

metastasized to the tunica vaginalis and epididymis

REFERENCES

1 Beccia DJ Krane RJ Olsson CA Clinical management of

non-testicular intrascrotal tumors J Urol 1976116476-9

2 Algaba F Santaularia JM Villavicencio H Metastatic tumor of

the epididymis and spermatic cord Eur Urol 1983956-9

3 Dutt N Bates AW Baithun SI Secondary neoplasms of the

male genital tract with different patterns of involvement in

adults and children Histopathology 200037323-31

4 Haupt HM Mann RB Trump DL Abeloff MD Metastatic

carcinoma involving the testis Clinical and pathologic distinc-

tion from primary testicular neoplasms Cancer 198454709-14

5 Kato K Suzuki K Sai S Murase T Kobayashi Y A case of

metastatic tumor of spermatic cord with hydrocele from gastric

cancer Hinyokika Kiyo 199945859-61

6 Pfister M Saez D Celeste F Sonographic appearance of

malignant mesothelioma of the tunica vaginalis testis in a child

J Clin Ultrasound 199220129-31

7 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 1989351807-9

8 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 199743429-31

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 200748667-9

Jeong Kyun YeoThe Paratesticular Metastasis of Gastric Cancer 1153

of the multiple retroperitoneal lymphadenopathies

　Ultrasonography the imaging modality of choice may help

in the diagnosis of a secondary tumor especially in the

presence of nodules and a recent diagnosis of another primary

cancer [6] In the present case the patient had neither

symptoms nor history of gastrointestinal tumors with any

abnormality except hydrocele in sonography Hence it was

difficult to find the tumor without operating

　The treatment modality for a primary malignant tumor of the

epididymis and a secondary tumor does not differ because

chemotherapy is the only possible option at this distant

metastatic stage The prognosis of this cancer was unfavorable

because metastatic tumors to the paratesticular tissues are

usually identified in the setting of disseminated disease As

shown in our case the results were disappointing

　It is very rare for a paratesticular metastasis to present as

the first manifestation of an occult primary neoplasm We

found only one reported case of a metastatic tumor to the

spermatic cord that originated from occult gastric cancer [7]

In most cases the patients had a history of gastric cancer

[589] Our report may be the first case of scrotal hydrocele

as the first manifestation of occult gastric cancer that

metastasized to the tunica vaginalis and epididymis

REFERENCES

1 Beccia DJ Krane RJ Olsson CA Clinical management of

non-testicular intrascrotal tumors J Urol 1976116476-9

2 Algaba F Santaularia JM Villavicencio H Metastatic tumor of

the epididymis and spermatic cord Eur Urol 1983956-9

3 Dutt N Bates AW Baithun SI Secondary neoplasms of the

male genital tract with different patterns of involvement in

adults and children Histopathology 200037323-31

4 Haupt HM Mann RB Trump DL Abeloff MD Metastatic

carcinoma involving the testis Clinical and pathologic distinc-

tion from primary testicular neoplasms Cancer 198454709-14

5 Kato K Suzuki K Sai S Murase T Kobayashi Y A case of

metastatic tumor of spermatic cord with hydrocele from gastric

cancer Hinyokika Kiyo 199945859-61

6 Pfister M Saez D Celeste F Sonographic appearance of

malignant mesothelioma of the tunica vaginalis testis in a child

J Clin Ultrasound 199220129-31

7 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 1989351807-9

8 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 199743429-31

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 200748667-9