Leiomyosarcoma of scrotum mimicking an epidermal cyst
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The following case has been reported in the journal Urology Case Reports.

A 36-year-old male presented with a small scrotal mass, which had slowly enlarged over the last 8 months. It was a non-tender, firm, irregular, and mobile mass. It measured 2 cm in diameter and had an irregular elliptical shape. It did not exhibit continuity with the testis. The irregular form of the mass was confirmed by ultrasonography, and the interior of the mass was heterogeneous.

Laboratory tests did not reveal any significantly abnormal values, including in the levels of tumor markers, such as cancer antigen 19–9, squamous cell carcinoma antigen, interleukin-2 receptor, human chorionic gonadotropin, and alpha-fetoprotein. The patient was initially diagnosed with an epidermal cyst, however, there was still a possibility that it has a malignant potential because of the increase in size. Therefore, the mass was surgically removed.

No adhesion between the tumor and the neighboring structures was observed during the excision, and we did not see any continuity between the mass and the testis either. Biopsy revealed hematoxylin and eosin staining revealed that the mass consisted of spindle-shaped cells, multiform cells, and mitotic cells. There were 15–17 mitoses per 10 high power fields.

An immunohistochemical examination demonstrated that the tumor cells were strongly positive for smooth muscle actin and 30% positive for Ki-67. Staining for S-100 was negative. Chest and CT examinations did not show any abnormal findings. The patient was pathologically diagnosed with a primary subcutaneous leiomyosarcoma. Based on a discussion with the dermatologists and pathologists a secondary surgical procedure was performed, with the intention of widely removing the surrounding structures, including the right testis.

Japanese guidelines for the treatment of soft tissue tumor, recommend that soft tissue tumors should be resected together with a 20-mm safety margin. The authors followed this approach so that scrotal skin around the prior operative scar with testis was excised. No leiomyosarcoma cells were found in the excised tissue. Follow-up CT was performed every 6 months, and no signs of local recurrence or distant metastasis have been seen for 28 months.

Key takeaway:-
After a histological diagnosis has been obtained, appropriate medical management of scrotal tumors is essential, even for small scrotal masses.

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