High grade dedifferentiated liposarcoma of the spermatic cord: an uncommon inguinoscrotal malignancy in an elderly male

High grade dedifferentiated liposarcoma of the spermatic cord: an uncommon inguinoscrotal malignancy in an elderly male | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report High grade dedifferentiated liposarcoma of the spermatic cord: an uncommon inguinoscrotal malignancy in an elderly male Rajshekhar C Jaka, Aishwarya Madasamy Swaminathan, Sunil Kumar Shetty This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7562583/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Paratesticular sarcomas are rare, with liposarcoma the commonest histology; dedifferentiated variants are exceptionally uncommon and aggressive. Case presentation: A 75 year old man presented with fever and lower urinary tract symptoms. During evaluation, an incidental large right inguinoscrotal mass was identified. Imaging (ultrasonography, contrast enhanced CT, and FDG PET CT) revealed a heterogeneous, necrotic mass arising from the right spermatic cord without nodal or distant metastasis. He underwent composite wide local excision of the spermatic cord tumour with radical orchidectomy. Histopathology showed a high grade spindle cell neoplasm with pleomorphism and tumour giant cells, admixed with adipocytes; immunohistochemistry demonstrated diffuse p16 and strong MDM2 positivity with patchy SMA and scattered SOX10, while AE1/AE3, desmin, caldesmon, S100, ALK1, CD117, calretinin, myogenin and MyoD1 were negative, consistent with dedifferentiated liposarcoma (FNCLCC grade 3). All margins were negative. Postoperative recovery was uneventful, and the patient remains under surveillance. Conclusions: Dedifferentiated liposarcoma of the spermatic cord should be considered in elderly men presenting with heterogeneous inguinoscrotal masses. Complete surgical excision with negative margins and long term follow up are essential due to a high risk of local recurrence. spermatic cord paratesticular tumour dedifferentiated liposarcoma inguinoscrotal mass sarcoma orchidectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Primary tumours of the spermatic cord are rare, and sarcomas constitute a small fraction of intrascrotal neoplasms. Liposarcoma is the most frequent histological subtype of paratesticular sarcoma; however, dedifferentiated liposarcoma (DDLPS), defined by the coexistence of well differentiated liposarcoma with abrupt transition to a non lipogenic high grade sarcoma, is distinctly uncommon in this location and associated with increased risk of local recurrence [1–3]. Diagnosis is often postoperative because clinical features are nonspecific and imaging cannot reliably distinguish histological subtypes [ 4 , 5 ]. Management hinges on complete surgical excision with wide margins, while the roles of radiotherapy and chemotherapy are individualised due to limited evidence [ 1 , 2 , 6 , 7 ]. Case Presentation A 75 year old man with a history of coronary artery bypass grafting and permanent pacemaker presented with fever, burning micturition and urinary frequency. Laboratory evaluation showed leukocytosis (11,900/µL), elevated C reactive protein (163 mg/L), poor glycaemic control (HbA1c 11.5%), and glucosuria without pyuria. He was treated with intravenous antibiotics and basal bolus insulin. Incidentally, a large, firm right inguinoscrotal swelling was detected, extending into the inguinal region (Figure 1). Investigations- Ultrasonography/Doppler: Solid cystic, vascular lesion in the right inguinal region; grade IV varicocele; bilateral hydroceles. CT abdomen/pelvis: Large lobulated heterogeneous right inguinoscrotal mass (13 × 9 × 8 cm) with central necrosis, displacing urethra; associated hydrocele and varicocele. FDG PET CT: Necrotic FDG avid inguinoscrotal mass (SUVmax 15.5), no nodal/distant metastasis (Figure 2 and 3). Treatment and histopathology- The patient underwent composite excision of the tumour with radical orchidectomy (Figure 4, 5 and 6). Proximal spermatic cord margin was confirmed negative by frozen section. Discussion Paratesticular sarcomas are rare, accounting for <7% of intrascrotal malignancies [1]. Among these, liposarcoma is the most common histology in adults, but DDLPS of the spermatic cord is exceptional [2,3]. Surgical approach and margins: Radical orchidectomy with wide local excision of the spermatic cord up to the deep inguinal ring is the standard of care [1,4,6]. Adequate margins are critical, as positive margins strongly predict local recurrence [4]. En bloc removal of the cord with surrounding soft tissue is recommended; some authors advocate pre-peritoneal dissection at the internal inguinal ring to ensure negative margins [1,4,6]. Coleman et al. reported that local recurrence occurred in up to 30% of cases with close/positive margins [1]. Ballo et al. similarly highlighted that inadequate excision was the main predictor of failure [4]. Thus, wide margins (≥1 cm or anatomic fascial planes) are necessary wherever feasible. Adjuvant radiotherapy: While not routinely indicated, radiotherapy may reduce local recurrence in high grade tumours, close/positive margins, or recurrent disease [4,6,7]. Blitzer et al. demonstrated improved local control with adjuvant radiotherapy in spermatic cord sarcomas, especially when margins were compromised [7]. Contemporary sarcoma guidelines (extrapolated from extremity/retroperitoneal sites) support its selective use in high risk scenarios. Chemotherapy: Systemic therapy has limited benefit in localised disease. Anthracycline based regimens (doxorubicin ± ifosfamide) are standard in advanced or metastatic soft tissue sarcomas [5]. Response rates in DDLPS are modest, as liposarcoma is generally chemotherapy resistant [5]. Newer approaches include MDM2 antagonists and CDK4 inhibitors, currently under trial, but not standard practice. Surveillance: Given the high local recurrence risk and late metastatic potential, long term surveillance with clinical examination and periodic imaging is essential. Most recurrences occur within 2-5 years, but late relapses have been documented [2,5]. Conclusions Dedifferentiated liposarcoma of the spermatic cord is a rare but aggressive paratesticular tumour. Diagnosis depends on histopathology and confirmatory immunohistochemistry (MDM2/CDK4). The cornerstone of management is radical orchidectomy with en bloc spermatic cord excision and negative margins up to the deep inguinal ring. Adjuvant radiotherapy is considered in high risk cases, while chemotherapy is reserved for advanced disease. Long term follow up is mandatory due to the significant recurrence risk. Patient’s perspective: “I was admitted with fever and urinary problems, and only then did I learn about the mass. After surgery I recovered well. I have regular follow ups now and feel reassured that the tumour was removed with clear margins.” Learning Points: Dedifferentiated liposarcoma of the spermatic cord is rare but aggressive. Wide surgical excision with tumour free margins up to the internal ring is essential. Radiotherapy may be considered in high risk cases; chemotherapy is reserved for advanced disease. Long term surveillance is crucial due to high recurrence risk. Abbreviations DDLPS: Dedifferentiated liposarcoma PET CT: Positron emission tomography computed tomography IHC: Immunohistochemistry FNCLCC: Fédération Nationale des Centres de Lutte Contre le Cancer Declarations Ethics approval and consent to participate- Not applicable (single case report; institutional policy does not require ethics approval). Clinical trial number - Not applicable. Consent for publication- Written informed consent for publication of case details and images was obtained from the patient. Availability of data and materials- All data generated or analysed during this study are included in this published article. Competing interests- The authors declare that they have no competing interests. Funding- None. Authors’ contributions- Rajshekhar C Jaka: Performed the surgery and provided senior clinical oversight. Aishwarya Madasamy Swaminathan: Involved in patient care, data collection, and initial drafting of the manuscript. Sunil Kumar Shetty: Assisted in literature review, critical revision, and drafting of the manuscript. All authors read and approved the final manuscript. Acknowledgements- We thank the pathology team for rapid intraoperative frozen section reporting and comprehensive immunohistochemistry workup. References Coleman J, Brennan MF, Alektiar K, Russo P. Adult spermatic cord sarcomas: management and results. Ann Surg Oncol . 2003 Jul;10(6):669-75. doi: 10.1245/aso.2003.11.014. PMID: 12839852. Rodríguez D, Olumi AF. Management of spermatic cord tumors: a rare urologic malignancy. Ther Adv Urol . 2012 Dec;4(6):325-34. doi: 10.1177/1756287212447839. PMID: 23205059; PMCID: PMC3491755. Evans, H.L. (1979) Liposarcoma: A Study of 55 Cases with a Reassessment of Its Classification. American Journal of Surgical Pathology, 3, 507-523. http://dx.doi.org/10.1097/00000478-197912000-00004 Ballo MT, Zagars GK, Pisters PW, Feig BW, Patel SR, von Eschenbach AC. Spermatic cord sarcoma: outcome, patterns of failure and management. J Urol. 2001 Oct;166(4):1306-10. doi: 10.1016/s0022-5347(05)65758-8. PMID: 11547063. Thway K, Flora R, Shah C, Olmos D, Fisher C. Diagnostic utility of p16, CDK4, and MDM2 as an immunohistochemical panel in distinguishing well-differentiated and dedifferentiated liposarcomas from other adipocytic tumors. Am J Surg Pathol. 2012 Mar;36(3):462-9. doi: 10.1097/PAS.0b013e3182417330. PMID: 22301498. Khoubehi B, Mishra V, Ali M, Motiwala H, Karim O. Adult paratesticular tumours. BJU Int. 2002 Nov;90(7):707-15. doi: 10.1046/j.1464-410x.2002.02992.x. PMID: 12410753. Blitzer PH, Dosoretz DE, Proppe KH, Shipley WU. Treatment of malignant tumors of the spermatic cord: a study of 10 cases and a review of the literature. J Urol. 1981 Nov;126(5):611-4. doi: 10.1016/s0022-5347(17)54650-9. PMID: 7299919. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7562583","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":514911712,"identity":"dae74e1b-338f-44af-ac07-78705fa91cd8","order_by":0,"name":"Rajshekhar C Jaka","email":"","orcid":"","institution":"FRCS Senior Surgical Oncologist Manipal Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Rajshekhar","middleName":"C","lastName":"Jaka","suffix":""},{"id":514911713,"identity":"85951b0b-ae59-4622-a09f-cc16e6366a3a","order_by":1,"name":"Aishwarya Madasamy Swaminathan","email":"","orcid":"","institution":"MS General Surgery 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1","display":"","copyAsset":false,"role":"figure","size":460046,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photograph showing a right inguinoscrotal swelling with a visible inguinal mass arising from the spermatic cord region.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/2197ae20f37ef6dcdfdc053a.png"},{"id":91959388,"identity":"10592d33-8aa5-426d-9cfa-f0306a5f57af","added_by":"auto","created_at":"2025-09-23 07:39:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":709906,"visible":true,"origin":"","legend":"\u003cp\u003eA) Contrast enhanced CT scan of the abdomen and pelvis (sagittal view) demonstrating a large lobulated heterogeneous mass in the right inguinoscrotal region (13×9×8 cm) with areas of central necrosis (B) Corresponding sagittal PET CT image demonstrating intense FDG uptake within the mass, consistent with high metabolic activity.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/50406be4457b14201ea90353.png"},{"id":91959379,"identity":"dd0007f1-e65b-4d94-ad9d-ceb7aa6f6a0d","added_by":"auto","created_at":"2025-09-23 07:39:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":538818,"visible":true,"origin":"","legend":"\u003cp\u003eA) Contrast enhanced CT scan (axial view) showing a well circumscribed, heterogeneously enhancing soft tissue mass arising from the right spermatic cord region, displacing the urethra. Adjacent small inguinal lymph nodes are noted. (B) Corresponding axial PET CT scan demonstrating intense FDG uptake within the mass, confirming its metabolically active nature.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/65184e975b0aa8ed4af22641.png"},{"id":91959393,"identity":"d49a76a3-1f6e-457d-a113-8d1ccf1c3cdc","added_by":"auto","created_at":"2025-09-23 07:39:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":366118,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative photograph showing a right inguinoscrotal swelling with surgical site prepared and incision marking outlined along the inguinal region.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/cf41e3e6b126c779a001d0cf.png"},{"id":91960446,"identity":"ff01a82b-ad4e-4c27-a548-8d93c468ee48","added_by":"auto","created_at":"2025-09-23 07:47:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":366162,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative photograph showing a well encapsulated vascular soft tissue mass arising from the right spermatic cord, exposed through an inguinoscrotal approach.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/7ab607f6607bec201b70cd88.png"},{"id":91959383,"identity":"81ed9d6d-3a02-42d5-8b28-fb248e4cd6aa","added_by":"auto","created_at":"2025-09-23 07:39:04","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":712765,"visible":true,"origin":"","legend":"\u003cp\u003eExcised specimen showing a well encapsulated, lobulated soft tissue mass arising from the right spermatic cord, with attached cord structures. A measuring scale is placed alongside for size reference.\u003c/p\u003e\n\u003cp\u003e◆ \u003cstrong\u003eGross:\u003c/strong\u003e Tumour 130 × 100 × 90 mm, pale friable with 60% necrosis, compressing but not infiltrating testis.\u003c/p\u003e\n\u003cp\u003e◆ \u003cstrong\u003eMicroscopy:\u003c/strong\u003e Fascicles of spindle cells with marked pleomorphism, tumour giant cells, abrupt transition to adipocytes, dense neutrophilic infiltrate, mitotic count 5/mm² (Figure 7).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/9cc946198d267eb4c3ad37a3.png"},{"id":91959387,"identity":"cf546efc-dedf-4749-8c34-8411afa902b1","added_by":"auto","created_at":"2025-09-23 07:39:04","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":357429,"visible":true,"origin":"","legend":"\u003cp\u003ePhotomicrograph showing a well differentiated liposarcoma with variation in adipocyte size and atypical hyperchromatic stromal nuclei, blending with dedifferentiated tumour areas (H\u0026amp;E, ×400).\u003c/p\u003e\n\u003cp\u003e◆ \u003cstrong\u003eIHC:\u003c/strong\u003e Diffuse p16, strong MDM2 positivity (Figure 8); patchy SMA, scattered SOX10; negative AE1/AE3, desmin, caldesmon, S100, ALK1, CD117, calretinin, myogenin, MyoD1. Features confirmed DDLPS (FNCLCC grade 3, AJCC pT3 \u0026gt;10 cm). Margins negative.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/28144b57b8edbfa24d9ac4d0.png"},{"id":91959394,"identity":"cb58c108-301f-4972-b153-b1f69eda85d1","added_by":"auto","created_at":"2025-09-23 07:39:05","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":333096,"visible":true,"origin":"","legend":"\u003cp\u003ePhotomicrograph showing strong nuclear expression of MDM2 in tumour cells, supporting the diagnosis of dedifferentiated liposarcoma (MDM2 immunohistochemistry, ×400).\u003c/p\u003e\n\u003cp\u003e◆ \u003cstrong\u003eOutcome:\u003c/strong\u003e Uneventful recovery; on surveillance.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/ab65c5887b49f9d820f7d137.png"},{"id":92249200,"identity":"bf94971e-04ae-4bce-bfdc-f4372d5f2ca5","added_by":"auto","created_at":"2025-09-26 10:17:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5222985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7562583/v1/b525b1fb-82f8-4017-b3ab-7d35f3f96b52.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High grade dedifferentiated liposarcoma of the spermatic cord: an uncommon inguinoscrotal malignancy in an elderly male","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary tumours of the spermatic cord are rare, and sarcomas constitute a small fraction of intrascrotal neoplasms. Liposarcoma is the most frequent histological subtype of paratesticular sarcoma; however, dedifferentiated liposarcoma (DDLPS), defined by the coexistence of well differentiated liposarcoma with abrupt transition to a non lipogenic high grade sarcoma, is distinctly uncommon in this location and associated with increased risk of local recurrence [1\u0026ndash;3].\u003c/p\u003e\u003cp\u003eDiagnosis is often postoperative because clinical features are nonspecific and imaging cannot reliably distinguish histological subtypes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Management hinges on complete surgical excision with wide margins, while the roles of radiotherapy and chemotherapy are individualised due to limited evidence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 75 year old man with a history of coronary artery bypass grafting and permanent pacemaker presented with fever, burning micturition and urinary frequency. Laboratory evaluation showed leukocytosis (11,900/\u0026micro;L), elevated C reactive protein (163 mg/L), poor glycaemic control (HbA1c 11.5%), and glucosuria without pyuria. He was treated with intravenous antibiotics and basal bolus insulin. Incidentally, a large, firm right inguinoscrotal swelling was detected, extending into the inguinal region (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigations-\u003c/strong\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e\u003cstrong\u003eUltrasonography/Doppler:\u003c/strong\u003e Solid cystic, vascular lesion in the right inguinal region; grade IV varicocele; bilateral hydroceles.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCT abdomen/pelvis:\u003c/strong\u003e Large lobulated heterogeneous right inguinoscrotal mass (13 \u0026times; 9 \u0026times; 8 cm) with central necrosis, displacing urethra; associated hydrocele and varicocele.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFDG PET CT:\u003c/strong\u003e Necrotic FDG avid inguinoscrotal mass (SUVmax 15.5), no nodal/distant metastasis (Figure 2 and 3).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment and histopathology-\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient underwent composite excision of the tumour with radical orchidectomy (Figure 4, 5 and 6). Proximal spermatic cord margin was confirmed negative by frozen section.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eParatesticular sarcomas are rare, accounting for \u0026lt;7% of intrascrotal malignancies [1]. Among these, liposarcoma is the most common histology in adults, but DDLPS of the spermatic cord is exceptional [2,3].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical approach and margins:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadical orchidectomy with wide local excision of the spermatic cord up to the deep inguinal ring is the standard of care [1,4,6]. Adequate margins are critical, as positive margins strongly predict local recurrence [4]. En bloc removal of the cord with surrounding soft tissue is recommended; some authors advocate pre-peritoneal dissection at the internal inguinal ring to ensure negative margins [1,4,6]. Coleman et al. reported that local recurrence occurred in up to 30% of cases with close/positive margins [1]. Ballo et al. similarly highlighted that inadequate excision was the main predictor of failure [4]. Thus, wide margins (\u0026ge;1 cm or anatomic fascial planes) are necessary wherever feasible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdjuvant radiotherapy:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile not routinely indicated, radiotherapy may reduce local recurrence in high grade tumours, close/positive margins, or recurrent disease [4,6,7]. Blitzer et al. demonstrated improved local control with adjuvant radiotherapy in spermatic cord sarcomas, especially when margins were compromised [7]. Contemporary sarcoma guidelines (extrapolated from extremity/retroperitoneal sites) support its selective use in high risk scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChemotherapy:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSystemic therapy has limited benefit in localised disease. Anthracycline based regimens (doxorubicin \u0026plusmn; ifosfamide) are standard in advanced or metastatic soft tissue sarcomas [5]. Response rates in DDLPS are modest, as liposarcoma is generally chemotherapy resistant [5]. Newer approaches include MDM2 antagonists and CDK4 inhibitors, currently under trial, but not standard practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurveillance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the high local recurrence risk and late metastatic potential, long term surveillance with clinical examination and periodic imaging is essential. Most recurrences occur within 2-5 years, but late relapses have been documented [2,5].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDedifferentiated liposarcoma of the spermatic cord is a rare but aggressive paratesticular tumour. Diagnosis depends on histopathology and confirmatory immunohistochemistry (MDM2/CDK4). The cornerstone of management is radical orchidectomy with en bloc spermatic cord excision and negative margins up to the deep inguinal ring. Adjuvant radiotherapy is considered in high risk cases, while chemotherapy is reserved for advanced disease. Long term follow up is mandatory due to the significant recurrence risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s perspective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I was admitted with fever and urinary problems, and only then did I learn about the mass. After surgery I recovered well. I have regular follow ups now and feel reassured that the tumour was removed with clear margins.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning Points:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDedifferentiated liposarcoma of the spermatic cord is rare but aggressive.\u003c/li\u003e\n \u003cli\u003eWide surgical excision with tumour free margins up to the internal ring is essential.\u003c/li\u003e\n \u003cli\u003eRadiotherapy may be considered in high risk cases; chemotherapy is reserved for advanced disease.\u003c/li\u003e\n \u003cli\u003eLong term surveillance is crucial due to high recurrence risk.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDDLPS: Dedifferentiated liposarcoma\u003c/p\u003e\n\u003cp\u003ePET CT: Positron emission tomography computed tomography\u003c/p\u003e\n\u003cp\u003eIHC: Immunohistochemistry\u003c/p\u003e\n\u003cp\u003eFNCLCC: F\u0026eacute;d\u0026eacute;ration Nationale des Centres de Lutte Contre le Cancer\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate-\u003c/strong\u003e Not applicable (single case report; institutional policy does not require ethics approval).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e- Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication-\u003c/strong\u003e Written informed consent for publication of case details and images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials-\u003c/strong\u003e All data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests-\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding-\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions-\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eRajshekhar C Jaka:\u0026nbsp;\u003c/strong\u003ePerformed the surgery and provided senior clinical oversight.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAishwarya Madasamy Swaminathan:\u0026nbsp;\u003c/strong\u003eInvolved in patient care, data collection, and initial drafting of the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSunil Kumar Shetty:\u0026nbsp;\u003c/strong\u003eAssisted in literature review, critical revision, and drafting of the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements-\u003c/strong\u003e We thank the pathology team for rapid intraoperative frozen section reporting and comprehensive immunohistochemistry workup.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eColeman J, Brennan MF, Alektiar K, Russo P. Adult spermatic cord sarcomas: management and results. \u003cem\u003eAnn Surg Oncol\u003c/em\u003e. 2003 Jul;10(6):669-75. doi: 10.1245/aso.2003.11.014. PMID: 12839852.\u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez D, Olumi AF. Management of spermatic cord tumors: a rare urologic malignancy. \u003cem\u003eTher Adv Urol\u003c/em\u003e. 2012 Dec;4(6):325-34. doi: 10.1177/1756287212447839. PMID: 23205059; PMCID: PMC3491755.\u003c/li\u003e\n\u003cli\u003eEvans, H.L. (1979) Liposarcoma: A Study of 55 Cases with a Reassessment of Its Classification. American Journal of Surgical Pathology, 3, 507-523. http://dx.doi.org/10.1097/00000478-197912000-00004\u003c/li\u003e\n\u003cli\u003eBallo MT, Zagars GK, Pisters PW, Feig BW, Patel SR, von Eschenbach AC. Spermatic cord sarcoma: outcome, patterns of failure and management. J Urol. 2001 Oct;166(4):1306-10. doi: 10.1016/s0022-5347(05)65758-8. PMID: 11547063.\u003c/li\u003e\n\u003cli\u003eThway K, Flora R, Shah C, Olmos D, Fisher C. Diagnostic utility of p16, CDK4, and MDM2 as an immunohistochemical panel in distinguishing well-differentiated and dedifferentiated liposarcomas from other adipocytic tumors. Am J Surg Pathol. 2012 Mar;36(3):462-9. doi: 10.1097/PAS.0b013e3182417330. PMID: 22301498.\u003c/li\u003e\n\u003cli\u003eKhoubehi B, Mishra V, Ali M, Motiwala H, Karim O. Adult paratesticular tumours. BJU Int. 2002 Nov;90(7):707-15. doi: 10.1046/j.1464-410x.2002.02992.x. PMID: 12410753.\u003c/li\u003e\n\u003cli\u003eBlitzer PH, Dosoretz DE, Proppe KH, Shipley WU. Treatment of malignant tumors of the spermatic cord: a study of 10 cases and a review of the literature. J Urol. 1981 Nov;126(5):611-4. doi: 10.1016/s0022-5347(17)54650-9. PMID: 7299919.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"spermatic cord, paratesticular tumour, dedifferentiated liposarcoma, inguinoscrotal mass, sarcoma, orchidectomy","lastPublishedDoi":"10.21203/rs.3.rs-7562583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7562583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Paratesticular sarcomas are rare, with liposarcoma the commonest histology; dedifferentiated variants are exceptionally uncommon and aggressive.\u003cbr\u003e\n\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 75 year old man presented with fever and lower urinary tract symptoms. During evaluation, an incidental large right inguinoscrotal mass was identified. Imaging (ultrasonography, contrast enhanced CT, and FDG PET CT) revealed a heterogeneous, necrotic mass arising from the right spermatic cord without nodal or distant metastasis. He underwent composite wide local excision of the spermatic cord tumour with radical orchidectomy. Histopathology showed a high grade spindle cell neoplasm with pleomorphism and tumour giant cells, admixed with adipocytes; immunohistochemistry demonstrated diffuse p16 and strong MDM2 positivity with patchy SMA and scattered SOX10, while AE1/AE3, desmin, caldesmon, S100, ALK1, CD117, calretinin, myogenin and MyoD1 were negative, consistent with dedifferentiated liposarcoma (FNCLCC grade 3). All margins were negative. Postoperative recovery was uneventful, and the patient remains under surveillance.\u003cbr\u003e\n\u003cstrong\u003eConclusions:\u003c/strong\u003e Dedifferentiated liposarcoma of the spermatic cord should be considered in elderly men presenting with heterogeneous inguinoscrotal masses. Complete surgical excision with negative margins and long term follow up are essential due to a high risk of local recurrence.\u003c/p\u003e","manuscriptTitle":"High grade dedifferentiated liposarcoma of the spermatic cord: an uncommon inguinoscrotal malignancy in an elderly male","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:38:48","doi":"10.21203/rs.3.rs-7562583/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09d84f62-ab74-4872-b3ed-1c82aa10e56b","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T10:09:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:38:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7562583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7562583","identity":"rs-7562583","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}