Krukenberg tumor with concomitant ipsilateral hydronephrosis and spermatic cord metastasis in a man: A case report

BACKGROUND: Tumors of the spermatic cord are rare, and approximately 25% are malignant neoplasms. Metastatic spermatic cord tumors are even rarer. Several studies have revealed that the most frequent primary tumors metastasizing to the spermatic cord and peritesticular tissues are neoplasms of the stomach and prostate. Furthermore, metastasis to the spermatic cord or epididymis may occur via retrograde lymphatic and hematic routes. We present the case of a man with gastric cancer that metastasized to the spermatic cord and epididymis, with concomitant ipsilateral hydronephrosis after surgical resection and chemotherapy for his primary tumor. CASE SUMMARY: A 71-year-old man underwent total gastrectomy for pT4aN2 poorly differentiated gastric adenocarcinoma in December 2016. Two months after surgery, he received adjuvant chemotherapy with TS-1 from February 2017 to February 2018. Surveillance computed tomography (CT) was performed in June 2018, which did not reveal any sign of tumor recurrence. In November 2019, he presented with left lower quadrant abdominal pain and a palpable left inguinal-scrotal mass. CT revealed left mild hydronephrosis and a left scrotal mass measuring 4.0 cm × 1.7 cm. Tumor biomarkers, including alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), beta-human chorionic gonadotropin (βHCG), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA19-9) were all normal. Renal and testicular echography showed left hydronephrosis and a left peritesticular soft tissue lesion with blood flow. Diagnostic ureteroscopy showed left lower ureter narrowing without an intraluminal lesion. A biopsy was obtained for the indurated spermatic cord and epididymis, which showed poorly differentiated adenocarcinoma. Immunohistochemical staining demonstrated that the tumor was diffusely and strongly positive for homeobox protein CDX2. The features were consistent with metastatic adenocarcinoma of a primary gastric tumor. CONCLUSION: In patients with a history of primary cancer, an inguinal mass of unknown cause with accompanying ipsilateral hydronephrosis may be a sign of distant metastasis from a primary tumor, especially of gastrointestinal origin.