0022-5347 /83/1294-0843$02.00/0 Vol. 129, April
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
EPIDIDYMAL NEOPLASMS: A CASE REPORT AND REVIEW MOHAMMED H. FAYSAL, AARON STREFLING
JON C. KOSEK*
From the Departments of Urology and Pathology, Stanford University School of Medicine, Stanford and Veterans Administration Medical Center, Palo Alto, California
We report a case of a painful epididymal nodule that proved to be metastasis and the first sign of pancreatic carcinoma. Primary neoplasms of the epididymis are rare. According to Mostofi and Price adenomatoid tumors are the most common of the paratesticular tissues, representing 32 per cent of all tumors involving these organs. 1 Metastatic tumors of the epididymis are extremely rare, with only 8 cases reported between 1925 and 1960. z-s Of these 8 cases the primary tumor was in the kidney in 3, stomach in 2, prostate in 2 and ileum in 1. Wachtel and Mehan reported a case of metastatic carcinoma to the epididymis from a primary carcinoma in the sigmoid colon. 9 Herein we report on a patient with adenocarcinoma of the pancreas who presented with a painful epididymal nodule. To our knowledge, this is the first report of adenocarcinoma of the pancreas presenting as an epididymal nodule. CASE REPORT
A 41-year-old black man was hospitalized with painful right scrotal swelling 4 months in duration. He had been treated with tetracycline for 2 weeks for a presumptive diagnosis of acute epididymitis without improvement. Medical history was remarkable only for intermittent vague abdominal pain 1 year in duration, which was relieved by anticholinergic medication, and a 15-pound weight loss during a 3-month period. On physical examination there were no abdominal masses or tenderness but the right epididymis and vas deferens were tender, enlarged and nodular. Laboratory study revealed normal urinalysis and no growth on urine culture. Serum creatinine, electrolyte, amylase and liver function tests, serum acid and alkaline phosphatases, carcinoembryonic antigen and human chorionic gonadotropin were normal. A chest x-ray with apical lordotic views was normal. An excretory urogram showed a deformity in the medial calix of the superior portion of the left upper pole. Purified protein derivative, including double strength, was negative. Positive skin tests were elicited for mumps, coccidioidin and dermatophytid. Right inguinal orchiectomy was performed. The testicle was normal. There were a 1. 7 cm. firm, irregular nodule adjacent to the spermatic cord and 2 firm 0.8 cm. nodules in the epididymis, demonstrating well differentiated adenocarcinoma (probably metastatic) in the epididymis and spermatic cord soft tissues (fig. 1). A barium enema was normal. Abdominal ultrasound showed a mass in the head of the pancreas, which was confirmed by an upper gastrointestinal series that revealed a mass in the body and head of the pancreas, compressing and fixing the gastric antrum with distortion and fixation of the duodenal sweep. A liver spleen scan showed splenomegaly. Endoscopic retrograde cholangiopancreatography revealed a normal stomach, duodenum, biliary tree and gallbladder. Attempts to cannulate the pancreatic duct were unsuccessful. A computerized tomography body scan demonstrated a mass involving the head and body of Accepted for publication April 16, 1982. * Requests for reprints: Department of Pathology, Veterans Administration Medical Center, Palo Alto, Califorina 94304.
FIG. 1. A, testis (below) and spermatic cord tumor nodule (arrow). B, epididymal tubule (above) and smaller glands of metastatic adenocarcinoma (below). H & E, reduced from X200. 843
FAYSAL, STREFLING AND KOSEK
rare. Primary sites reported include the kidney, 2- 4 stomach, 5 • 8 ileum 7 and sigmoid colon. 9 To our knowledge, there is no other case report on pancreatic adenocarcinoma presenting as a metastatic epididymal nodule. All the observations of metastases in the epididymis of carcinoma of the prostate constitute unexpected findings during the course of surgical castration. On the other hand, metastasis in the epididymis of extra urinary adenocarcinomas was not discovered until the increased size and pain in the testicle were noticed, and exploration led to the identification of the tumor in the epididymis. Our case is unique since there were almost no symptoms of the primary tumor. The only reason for the extensive radiologic gastrointestinal study was the unexpected finding of adenocarcinoma in the surgical specimen. Our preoperative diagnosis was epididymal tuberculosis because of the suggestive physical examination and history of weight loss. However, the normal chest x-ray and the negative purified protein derivative, after anergy was ruled out, made the diagnosis unlikely and prompted us to explore the scrotal contents for a rare epididymal tumor. Metastatic carcinoma from the pancreas must be considered in the differential diagnosis of enlargement of the epididymis, in addition to nonspecific and tuberculous epididymal infections, and local extension of testicular neoplasms. REFERENCES 1. Mostofi, F. K. and Price, E. B., Jr.: Tumors of the male genital
FIG. 2. Needle aspiration biopsy of pancreatic defect indicates adenocarcinoma. H & E, reduced from X200. the pancreas. Percutaneous needle aspiration of the pancreas under sonographic control revealed papillary adenocarcinoma consistent with a pancreatic primary and the epididymal neoplasm (fig. 2). The patient was started on chemotherapy, including 5-fluorouracil, doxorubicin and mitomycin C. However, an abdominal mass and progressive inanition developed and the patient died within a year. Necropsy permission was denied.
system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, series 2, fasc. 8, 1973. 2. Henke, F. and Lubarsch, 0.: Handbuch der Speziellen Pathologischen, Anatomie und Histologie. Berlin: Julius Springer, vol. 6, p. 666, 1925. 3. Derman, G.: Ein primiirer gelatini.is-scirrhi.iser Nierenkrebs mit
4. 5. 6. 7.
Although primary neoplasm of the epididymis is an unusual finding metastatic neoplasm to the epididymis is even more
Metastasen in die Epididymis. Virch. Arch. F. Path. Anat. Physiol., 265: 304, 1927. Katzen, P.: Metastatic carcinoma of the epididymis: report of a case. J. Urol., 46: 734, 1941. Lewis, L. G., Goodwin, W. E. and Randall, W. S.: Carcinoma of spermatic cord and epididymis. Extension from primary carcinoma of the stomach. J. Urol., 51: 75, 1944. Humphrey, M.: Metastasis in the epididymis from cancer of the prostate: case report. J. Urol., 51: 641, 1944. O'Brien, J.: Multiple argentiffinomata of ileum revealed by secondary growth in epididymis. Brit. Med. J., 2: 1315, 1951. Brotherus, J. V.: Metastatic tumors of the epididymis and the spermatic cord. J. Urol., 83: 171, 1960. Wachtel, T. L. and Mehan, D. J.: Metastatic tumors of the epididymis. J. Urol., 103: 624, 1970.