An 84-year-old gentleman was admitted with complaints of swelling over the right side of scrotum for the past 2 months. The swelling was progressive in nature and was also associated with pain. It was not reducing on lying down. No history of fever or trauma. Patient gave a history of hemorrhoids and angioplasty done 8 years ago. Patient gives no other history of comorbid illness such as tuberculosis, diabetes mellitus, or hypertension.
On examination, performance status according to Eastern Cooperative Oncological Group , Scoring was 2; all the vital parameters were normal. Local examination revealed a 10x15 cm tense, firm, and tender swelling involving the right scrotum. On palpation, the swelling was not reducible. One could get above the swelling. Testicular sensation was lost on the left side. The opposite side testis was normal. A computed tomography scan of the abdomen and pelvis showed heterogeneous soft tissue right testicular mass, which was measuring 10x6x5 cm in size with some evidence of necrosis within the right testicles and there were right inguinal lymph nodes [Figure 1]. At this time, the differential diagnosis was infected hydrocele/pyocele or organized hematoma was entertained. Preoperatively complete blood count, serum biochemistry, and thyroid function tests were normal; viral serology (retroviral and Epstein bar virus) was negative. Beta human chorionic gonadotropin and alpha-fetoprotein values were normal. Hence, he was taken up for surgery. Per-operatively, he seemed to have tumor testes infiltrating the scrotal wall. Therefore, high orchidectomy with excision of hemiscrotum was done. The opinions from four different pathologists were sought. The histopathology gave a differential diagnosis of testicular tumor with scrotal sac wall infiltration/diffuse large cell non-Hodgkins immunoblastic/anaplastic lymphoma; poorly differentiated carcinoma in favor of embryonal carcinoma; poorly differentiated malignant tumor most consistent with plasmacytoma. Immunohistochemistry showed Vimentin, CD30, CD 138 Lambda chains positive, increased Ki 67, EMA, CD79a, S100P positive, in favor of anaplastic plasmacytoma [Figures 2 (a-k) and 3 (a-i)]. EBER, cyclin D1, MiB1, and CD 56 were not done due to logistic reasons. In the meanwhile, workup for MM was done, which showed normal serum electrophoresis and beta2 microglobulin level. Urine was negative for Bence Jones protein. Tc99m Bone scan and bone marrow reports were normal. After a lapse of 2 months due to the diagnostic dilemma, treatment was started for plasmacytoma with daily tab - thalidomide 100 mg weekly tab, dexamethasone 40 mg daily tab, melphalan 5 mg twice daily for 5 days. The patient has completed six cycles of chemotherapy and is in remission.