It is true that a number of intrascrotal leiomyosarcomas leiomyosarcomas need to to treated aggresively by wide excision; hemiscrotectomy; and sometimes by orchidectomy. However, the approaxh to management of each tumour depends upon the biological behaviour of the tumour and the peculiar characteristics of the tumour. Sometimes over enthusiastic aggressive surgical approach would constitute aggressive overtreatment. This rare peculiar type of pedunculated subcutaneous outpouching intrascrotal leiomyosarcoma has not been described before. It was a subcutanous lump not involving the skin; it was sussounded by normal skin and it had a stalk which was surrounded by normal skin, normal dortos and subcutaneos layer in the stalk. It was protruding like a polyp with normal surrounding skin amenable to complete excision with complete excision of the lump and its surrounding skin as well as the stalk and the base with its subcutaneous tissue. These were all excised in the first instance. The lump did not extend deep into the intrascrotal area and it was far away from the tunica and tests. It was also far away from the cord therefore there was no need for extensive excision to include hemiscrotectomy or orchidectomy.

Decision regarding whether further excision / further extensive surgery should be undertaken depend upon the known peculiar characteristics of the lesion. In this case:

1. The lump (tumour) was truely sucutaneous, mobile and not fixed or tethered to any deep intrascrotal structure and it was clearly defined.

2. The lump was a pedunculated - it was  an outpouched protruding lump with surrounding normal skin and it had a stalk as stated above; this lump could be described as or likened to a polypoidal lesion with surrounding normal skin and normal stalk without any tumour in the stalk - meaning the lesion / tumour was confined to the outpouched / protrusion and not within the main scrotal sac. (This could be comared to a simulate a diverticulum of the urinary bladder with a lesion in it. - this type of leiomyosarcoma inside a scrotal outpouch is rare.)

3. The lump (leiomyosarcoma0 had the historical behavioural characteristics of an innocuous non aggressive tumour in that the lump was noticed by the patient many years years prior to his comming to hospital in that the patient stated the lump had been there for more than 15 years; it had been there for as long as he could remember; there has not been any change in size of the lump and there had not been any change in any characteristics of the lump for as long as he could remember. A long standing lump which had not exhibited any change over numerous years may have the histological characteristics of malignancy but usually such tumours tend to be very slow growing. (The literature would suggest aggressive behaviour of leiomyosarcomas but the preceeding history in this case would be suggestive of a less aggressive or a non aggrssive spectrum of intrascotal leiomyosarcoma).

4. The lump was completely excised with normal surrounding skin and subcutaneous tissue and the tumour and deep to the stalk.

This patient would be followed up for a long time. So far there is no evidence of a local recurrence.

Considering the fact that this lump has been present for numerous years and had not changed in size and it had been completely excised it is unlikely that this lesion would recur. If ater 10 years or more there is no evidence of recurrence then we would be able to confidently add more information to the literature to state that not all intracrotal leiomyosarcomas are aggressive tumours and perhaps intrascrotal leiomyosarcomas that are confined to an oupouched pedunculum should be treated with a wide excision with surrounding normal skin and subcutaneous tissues if there is no tethering to deeper tissues and the histologic characteristics do not revealed large numbers of mitotic figures.

So far after there is no recurrence. The first author is aware of the possibility of late local recurrence that had been reported in some cases previously reported however, our reported case is rare and has its peculiar characteristics which in his opinion would point to a non aggresive tumour.

If there is no recurrence after many years it is only then that recommendations could be made regarding what would constitute the less aggressive spectrum of intrascrotal leiomyosarcomas.