Retroperitoneal sarcoma presenting as a right-sided varicocele

Case contributed by David Pryde
Diagnosis certain


Patient presented with 'lumpy' right testis for investigation.

Patient Data

Age: 70 years
Gender: Male

Scrotal ultrasound demonstrates a large right-sided varicocele. Both testes were normal (not shown).

On scanning of the kidneys, a large mass with internal vascularity was found, in close contact with the right kidney. 

There is a large vascular mass related to the right kidney with a large tortuous draining vein, thought to be the renal capsular vein, passing inferomedial to the kidney and communicating with the gonadal vein, thus causing reflux of the vein down to the scrotum as well as draining, as expected, into the IVC.

Case Discussion

In this case, an ultrasound finding of a prominent right-sided varicocele prompted further scanning of the abdomen, and this, in turn, demonstrated a large retroperitoneal vascular tumor, later proven to be a sarcoma.

Right radical nephrectomy was performed.

Pathology: Attached to mid-portion of kidney there was a mass which did not infiltrate the renal parenchyma. Histology showed a pleomorphic spindle cell sarcoma with smooth muscle differentiation.

Related to this was a large varicose draining vein passing to gonadal vein and rendering it incompetent - hence the varicocele. Most right varicoceles are caused by a left-sided varicocele with a cross flow to the right side. 
Left-sided varicoceles are mostly caused by an incompetent gonadal vein; however, when seen for the first time on ultrasound the left kidney and left renal vein (into which the gonadal vein drains) are normally examined. Pathologies include renal masses, renal vein thrombosis, and nutcracker syndrome.

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