Carcinosarcoma of the Tunica Vaginalis Following Radiation Therapy for Localized Prostate Cancer

Spermatic cord tumors (SCTs) are rare neoplasms with 80% exhibiting benign pathology. Of the malignant SCTs, 90% are sarcomas. To date there has only been one documented case of primary CS of the spermatic cord which occurred in a 40 year old with no reported medical history. A 76-year-old male with a history of biopsy proven Gleason score 7 (3 + 4) prostatic adenocarcinoma underwent external beam radiation therapy (7920 cGy) in 44 fractions in 2004. He presented with a 3 year history of an asymptomatic right hydrocele. Several scrotal ultrasounds had been performed confirming a hydrocele, with the most recent revealing a hydrocele measuring 10 × 14 cm and several epididymal cysts. During the hydrocelectomy a firm suspicious mass was noted inside the tunica vaginalis and involving the spermatic cord. Given the intraoperative findings, decision was made to proceed with radical orchiectomy. Final pathologic examination revealed the tumor to have a biphasic pattern composed of spindled cells and also cells with an epithelioid morphology. Five months following orchiectomy he patient presented with a painful, enlarging right upper scrotal mass. A CT scan revealed new soft tissue lesions suspicious for necrotic lymph nodes within the right inguinal canal. Additional metastatic evaluation revealed multiple new pleural and parenchymal lung nodules. CT guided needle biopsy of a left lung nodule demonstrated spindle cells with high cellularity and areas of necrosis which were histomorphologically similar to the previous scrotal CS. Gemcitabine therapy was subsequently started. Four months following the diagnosis of metastatic CS, the patient expired. Dedifferentiation of prostatic adenocarcinoma to prostatic CS should be considered as a treatment outcome after localized radiation therapy to the prostate due to the highly aggressive nature of metastatic CS.