According to the SEER database, liposarcoma is the most common histological entity amongst the different histological types of paratesticular tumours, accounting for up to 46% of cases, followed by leiomyosarcoma (29%) and histiocytoma (13%) [2]. Clinical presentation of liposarcoma is typically a painless, firm, slow-growing, intra-scrotal mass. STM should be routinely performed along with other inflammatory markers (CRP), especially when associated with infections like epididymitis or orchitis. Ultrasound generally shows a heterogenous hypervascular soft tissue mass in the hemiscrotum. Even though paratesticular sarcomas have a propensity to invade the testis locally, sometimes the ipsilateral testis can be identified. But in the index case the ipsilateral testis was completely involved with the malignant process, while the contralateral testis was pushed and compressed at the periphery by the huge mass, making it difficult to identify. In some cases the mass can also involve the scrotal skin, which later demands hemiscrotectomy [3]. In the index case we had to excise almost 90% of the scrotal skin because of oncologic and cosmetic reasons. The fixity of the skin to the tumour could not be properly assessed and because of the size of the tumour, there would have been excess useless skin left. Moreover, the large ulcer at the bottom of the scrotum was removed at the same time.

Surgical removal of the tumour is the unanimously accepted first tier of the treatment. Currently, there are no widely accepted adjuvant treatment protocols for paratesticular liposarcomas. The role of prophylactic lymph node dissection remains unclear. Proponents of lymphadenectomy enunciate the need of the same in almost 29% of cases where metastases could be found in the regional lymphatics [4]. Although argued by some authors, the true incidence of nodal metastases has never actually been documented [5]. The general consensus has been that the most common soft tissue sarcomas, namely, liposarcoma and leiomyosarcoma, rarely involve locoregional lymph nodes, as they frequently recur and spread by direct extension [6, 7]. This might explain why to date no benefit has been demonstrated for patients who have undergone regional lymphadenectomy. The SEER data set does not report on the details of lymphadenectomy. In the index patient, even with the huge tumour, only a few inguinal and iliac lymph nodes were enlarged, to which both the tumour and inflammatory processes could contribute. The role of adjuvant radiation and chemotherapy in the management of SCTs remains controversial [7, 8]. Re-staging showed regredient lymph nodes in our case and we initiated further follow-up. After discussion in the interdisciplinary tumour conference, we initiated follow-ups every three months by a CT-scan of the chest and the abdomen including physical and sonographic controls according to national guidelines [9]. The impact of recurrence by removing skin is unclear. A study that examined the recurrence rates of skin tumours after resection showed that liposarcomas are correlated with a higher local recurrence rate [10]. For this reason, considering the trophic ulcer, we performed radical surgery for oncologic safety. The reason for the delayed presentation in our outpatient clinic with a locally advanced finding was due to psychosocial aspects. In our social anamnesis, the reasons for neglecting such a condition were on the one hand personal stress nursing a family member in need of care and on the other hand matters of shame. This case demonstrates the feasibility of radical surgery even in locally advanced stages of paratesticular liposarcoma with good aesthetic and oncologic outcome.