Excluding lipomas, 56% of the spermatic cord masses are malignant [1]. Among spermatic cord sarcomas, Rhabdomyosarcoma and Liposarcoma are the most prevalent, with rhabdomyosarcoma having a higher incidence [3]. Conversely, leiomyosarcoma is infrequent in the context of spermatic cord sarcomas. Rhabdomyosarcomas are more commonly observed in children, whereas other sarcomas occur in older individuals [3]. A consensus regarding the type of surgery and adjuvant treatment is yet to be determined. The rate of local recurrence in the scrotum and groin after orchidectomy ranges from 25 to 37%, indicating the need for aggressive surgery or adjuvant treatment [21]. Wide radical resection remains the first and perhaps the most important step [22]. Negative surgical margins are important to reduce the recurrence rate, and MRI is a useful examination to assess the extent of sarcoma extension.

Spermatic cord rhabdomyosarcomas are the most frequently encountered malignant paratesticular tumors, accounting for approximately 40% of all cases. It commonly occurs in infants and children, with peak incidence during the first decade of life. Spermatic cord rhabdomyosarcomas are characterized by their aggressive nature, with approximately 40% of patients presenting with metastasis at diagnosis [2]. Some cases are painful and can be mistaken clinically for epididymitis [23].

On MRI, spermatic cord rhabdomyosarcomas may present as heterogeneous masses with variable-signal intensity often with irregular margins and areas of necrosis or hemorrhage (Fig. 11) [24, 25]. However, these imaging features lack specificity and may overlap with those of other extratesticular tumors.

Rhabdomyosarcoma in a 21-year-old male with a left scrotal mass enlargement. a, b Coronal fat-suppressed T2-weighted MR images shows a heterogeneous hyperintense mass (white arrow) located in the spermatic cord. The mass invades the epididymis (white arrowhead), but the testis is preserved

The cornerstone of treatment for paratesticular rhabdomyosarcomas is radical orchiectomy, which involves complete surgical removal of the affected testis and surrounding structures [26]. Cases in which metastases are present or suspected, retroperitoneal lymph node dissection may be indicated to assess and manage regional lymph node involvement. Given the aggressive nature of paratesticular rhabdomyosarcomas, aggressive adjuvant chemotherapy regimens are often employed as part of multimodal therapy to improve outcomes and reduce the risk of recurrence [2, 26].

Liposarcoma of the spermatic cord is a rare malignancy that accounts for approximately 5–7% of spermatic cord sarcomas [27]. Most cases occur in the spermatic cord; however, some arise in the retroperitoneum, extend into the inguinal region, and involve the spermatic cord [28]. Low-grade liposarcomas, including atypical lipomatous tumor (ALT) /well-differentiated liposarcoma, typically spread by local extension and involve adjacent structures within the testis and epididymis. Clinically, low-grade spermatic cord liposarcomas may be mistaken for an inguinal hernia [28]. In contrast, high-grade liposarcomas may exhibit more aggressive behavior and potentially spread via the hematogenous and lymphatic routes to distant sites.

MRI findings of spermatic cord liposarcoma vary based on the degree of differentiation. Low-grade liposarcoma has mostly fatty component with focal enhancing components that are suspicious for malignancy. In contrast, a high-grade liposarcoma may be a heterogeneous solid mass with only a small fatty component. In both low- and high-grade liposarcomas, the presence of a fat component on computed tomography (CT) or MRI is the basis for diagnosis. The presence of a fat component within the lesion, as detected by imaging modalities, such as MRI, can aid in distinguishing these tumors from other extratesticular masses (Fig. 12).

Liposarcoma in an 83-year-old male with the left scrotum swollen. a–c Axial T2-weighted MR images demonstrate hyperintense mass (white arrow) in the left scrotum. The mass is located in the left inguinal canal, and the mass compresses the spermatic cord (white arrowhead) anteriorly. d Axial T1-weighted MR image shows a small hyperintense area (yellow arrow) in the mass. e Axial fat-suppressed T1-weighted MR image shows hypointense area (yellow arrow) that is hyperintense on T1-weighted MR image (d, yellow arrow), suggesting that the tumor contains fat component. f Axial contrast-enhanced fat-suppressed T1-weighted MR image shows heterogeneous enhancement of the mass (white arrow)

The primary treatment for spermatic cord liposarcomas is radical orchiectomy, which involves the complete surgical removal of the affected testis and surrounding structures, to achieve local control. Adjuvant radiation therapy is typically recommended for intermediate- or high-grade lesions to target the residual disease and reduce the risk of local recurrence. In addition to radiation therapy, postoperative adjuvant chemotherapy may be considered, particularly in cases with high-risk features or evidence of systemic spread [2].

Spermatic cord leiomyosarcoma is a rare malignancy that accounts for approximately 10% of all spermatic cord sarcomas. These tumors typically originate in the scrotal part of the spermatic cord. This is in contrast with leiomyomas, which are more commonly located in the inguinal region of the spermatic cord [3].

MRI is valuable for evaluating spermatic cord leiomyosarcomas and providing insights into the extent of tumor spread. However, the imaging features of these tumors are often nonspecific, making qualitative diagnosis challenging [3, 29]. Spermatic cord leiomyosarcomas typically manifest as solid masses on MRI and exhibit heterogeneous enhancement within the scrotal region of the spermatic cord (Fig. 13).

Leiomyosarcoma in a 60-year-old male with a left scrotal mass enlargement 3 months ago. a Coronal fat-suppressed T2-weighted MR image shows mild hypointense mass (white arrow) superior to the left testis (white arrowhead). There is no invasion of the testis. b Axial T2-weighted MR image shows mild hypointense mass with lobulated shape (white arrow). The yellow arrowhead indicates the normal right testis. c Axial diffusion weighted MR image shows a hyperintense mass (white arrow) comparable to that of the normal right testis (yellow arrowhead). d Apparent diffusion coefficient (ADC) images show that the mass (white arrow) has a low ADC value (0.874 × 10−3mm2/sec) compared to the normal right testis (yellow arrowhead)

The primary treatment for spermatic cord leiomyosarcoma is transinguinal radical orchiectomy, which involves complete surgical removal of the affected testis and surrounding structures, to achieve local control. Adjuvant radiation therapy may be recommended to reduce the risk of local recurrence, particularly in cases of high-grade lesions or tumors with aggressive features [29, 30]. Chemotherapy may also be considered in cases of high-grade lesions or in those with evidence of distal metastases with the aim of targeting systemic diseases and improving overall outcomes.

Metastasis to the spermatic cord is rare, with an incidence ranging from 0.02 to 2.5% [31]. Metastasis to the spermatic cord most commonly originates from primary tumors in the stomach (60%), followed by the rectum, pancreas, and kidneys [32]. Interestingly, in some cases, metastases to the spermatic cord may be identified before detection of the primary tumor. Spermatic cord metastases may be associated with pain; however, they may also be asymptomatic.

Metastasis to the spermatic cord can occur through various pathways. The most common route is the retrograde lymphatic spread, followed by dissemination through adjacent structures [33]. Hematogenous metastasis, in which cancer cells travel through the bloodstream, has also been observed. Metastases may also occur via retrograde venous or vascular spread, although these routes are infrequent [33]. Among these five metastatic pathways, dissemination occurs more commonly in cases where the peritoneal sac is patent and is often accompanied by an inguinal hernia [33].

Spermatic cord metastases are typically diagnosed using CT or MRI. Diagnosis is relatively easy when there is a nodule or tumor in the inguinal canal accompanied by other metastases, such as in the lungs. However, in some cases, they may present as infiltrative lesions with indistinct borders, making them recognizable only as thickening fasciae without forming distinct masses (Fig. 14). In such cases, diagnosis can be challenging.

Metastasis to the spermatic cord in a 69-year-old male with right scrotal pain. Post rectal cancer surgery was performed 1 year ago. The histology of the primary tumor was signet-ring cell carcinoma. a–c Axial contrast-enhanced fat-suppressed T1-weighted MR image shows heterogeneously enhanced-thickening of the layer comprising the cremasteric muscle sandwiched between the internal and external spermatic fasciae (yellow arrows). Owing to the lack of a radical cure and severe pain, radical high-inguinal orchiectomy was performed, and the pathology showed solitary infiltrating tumor cells in the fatty and connective tissues of the spermatic cord

The treatment for metastases to the spermatic cord usually involves a multidisciplinary approach that includes surgical resection, chemotherapy, and/or radiation therapy [32]. The choice of treatment depends on factors such as the primary tumor site, extent of metastases, and overall health of the patient.