Soft-tissue sarcomas of the genitourinary tract account for only 1–2% of urological malignancies and 2.1% of soft-tissue sarcomas in general. A 69-year-old male complained of a 4 month history of a painless right groin swelling during routine urological review for prostate cancer follow-up. Clinical examination revealed a non-tender, firm right inguinoscrotal mass. There was no discernible cough impulse. Computed tomography of abdomen and pelvis showed a non-obstructed right inguinal hernia. During elective hernia repair a solid mass involving the spermatic cord and extending into the proximal scrotum was seen. The mass was widely resected and a right orchidectomy was performed. Pathology revealed a paratesticular sarcoma. He proceeded to receive adjuvant radiotherapy. Only around 110 cases of leiomyosarcoma of the spermatic cord have been described in the literature. They commonly present as painless swellings in the groin. The majority of diagnoses are made on histology.

BACKGROUNDAdrenal pseudocysts are cystic lesions arising within the adrenal gland surrounded by a fi brous tissue wall devoid of a recognisable lining layer. Adreno-cortical carcinoma is a rare endocrine malignancy causing up to 0.2% of all cancer deaths. Only approximately 7% of pseudocysts are associated with malignancy. CASE PRESENTATIONA 64-year-old woman presented to the emergency department with a 6 week history of progressively worsening severe left abdominal pain, anorexia, anergia and constipation. On examination, she was cachectic with tenderness over the left abdomen and fl ank. One month prior to presentation, she had undergone an oesophogastroduodenoscopy and full colonoscopy, which were unremarkable. Medical history was signifi cant for osteoporosis, gastrooesphageal refl ux disease and chronic anaemia. There was no surgical history. Socially she lived with her husband. She smoked 10-25 cigarettes a day for the preceding 45 years. She did not consume alcohol. Family history was positive for cardiovascular disease, lung and pancreatic cancer. Her father aged 70 years and her brother aged 44 years died from myocardial infarcts. A sister died aged 65 years from lung cancer, and a brother aged 63 years from pancreatic cancer. INVESTIGATIONSDuring her investigation, a well-defi ned para-renal 12×6 centimetre multi-loculated cyst, of uncertain origin was identifi ed on CT ( fi gure 1 ). MRI showed the cyst to be separate from both kidney and pancreas, though very closely adjacent to both ( fi gures 2 and 3 ). The left adrenal gland was not separately identifi ed from the mass, suggesting adrenal origin. The walls of the mass were irregular and thickened, showing uniform enhancement. No lymphadenopathy was seen. The radiological appearance was consistent with an adrenal pseudocyst. Ultrasound-guided biopsy was not diagnostic. Serum and urinary catecholamines and metanephrines were unremarkable. SummaryThe authors report a very rare case of adreno-cortical carcinoma arising in a giant adrenal pseudocyst. A 64-year-old woman presented to the emergency department with a 6 week history of progressively worsening severe left abdominal pain, anorexia, anergia and constipation. On examination, she was cachectic with tenderness over the left abdomen and fl ank. Medical history was signifi cant for gastritis and anaemia. During her investigation, a well-defi ned para-renal 12×6 centimetre multi-loculated cyst, of uncertain origin was identifi ed on CT. Ultrasoundguided biopsy was not diagnostic. MRI showed the cyst to be likely adrenal in origin. Serum and urinary catecholamines were unremarkable. At laparotomy an unresectable large, tense, fi xed, cystic mass was seen to occupy the left side of the abdomen. The cyst was de-roofed. Pathology showed a high-grade poorly differentiated adreno-cortical carcinoma with a pseudo-capsule. She died 2 months postoperatively. TREATMENTDue to the malignant potential of the pseudocyst we proceeded to laparotomy. At laparotomy an unresectable large, tense, fi xed, cystic mass...