|Year : 2018 | Volume
| Issue : 1 | Page : 60-62
Malignant Mesothelioma of Testis: A Report of Three Cases and Review of Literature
Nirav Priyadarshi, Suresh Bhat, Fredrick Paul, Suyog Shetty
Department of Urology, Government Medical College, Kottayam, Kerala, India
|Date of Web Publication||8-May-2018|
141, Tejas, Near Arpookara Temple, Near Medical College, Kottayam - 686 008, Kerala
Source of Support: None, Conflict of Interest: None
Malignant mesothelioma of the testis is a rare condition. It usually affects the elderly. The common clinical manifestations include painless testicular mass. The tumor markers are normal. Ultrasonography helps in differentiating it from testicular tumors as these are situated at the periphery of the testis. Inguinal orchidectomy is diagnostic. Staging is usually done with abdominal computed tomography scan and chest X-ray. Role of adjuvant chemotherapy, radiotherapy, and lymph node dissection is controversial.
Keywords: Mesothelioma, testicular tumor, tunica vaginalis
|How to cite this article:|
Priyadarshi N, Bhat S, Paul F, Shetty S. Malignant Mesothelioma of Testis: A Report of Three Cases and Review of Literature. Med J DY Patil Vidyapeeth 2018;11:60-2
|How to cite this URL:|
Priyadarshi N, Bhat S, Paul F, Shetty S. Malignant Mesothelioma of Testis: A Report of Three Cases and Review of Literature. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Jan 25];11:60-2. Available from: http://www.mjdrdypv.org/text.asp?2018/11/1/60/232066
| Introduction|| |
Mesotheliomas are uncommon tumors arising from the serosal membranes of the coelomic cavities. They commonly involve pleura and peritoneum but also rarely involve tunica vaginalis. The usual presentation of malignant mesothelioma of the tunica vaginalis is painless intrascrotal mass with hydrocele. Preoperative diagnosis is difficult due to nonspecific clinical and imaging features. Despite radical inguinal orchidectomy, tumor progression with the development of lymphatic or distant tumor metastases is common.,,,,, Most of the patients with disseminated mesothelioma usually receive chemotherapy, radiotherapy, or a combination of both. However, treatment of disseminated mesothelioma is still considered investigational. Here, we are reporting three cases of malignant mesothelioma of tunica vaginalis.
| Case Reports|| |
Case report 1
A 24-year-old male presented with a 5-month history of intrascrotal swelling. Physical examination revealed two irregular firm masses in the upper part of the left testis with no evidence of adenopathy or distant metastases. Serum tumor markers were normal. Ultrasonography of the scrotum revealed two nodular lesions in the upper part of the testis [Figure 1]a. At inguinal exploration, two masses arising from the tunica vaginalis were found. Histological examination showed malignant mesothelioma of the tunica vaginalis [Figure 1]b and [Figure 1]c. At 1-year follow-up, the patient was symptom free and subsequently lost to follow-up.
|Figure 1: (a) Two separate nodular lesions in the left testis marked by box. (b) Microscopic examination showing epithelial cells lined by papillary cells. (c) Multiple papillary architecture on H and E stain|
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Case report 2
An 8-year-old boy presented with a gradually increasing left hydrocele [Figure 2]a. On physical examination, a firm mass adjacent to the hydrocele sac was palpable. The patient underwent a left high inguinal orchidectomy. Histological examination showed malignant mesothelioma of the tunica vaginalis [Figure 2]b. The patient was referred to oncology department from where he was lost to follow-up.
|Figure 2: (a) Ultrasound showing small nodule arising from tunica vaginalis. (b) Cuboidal epithelial cell with bland cytoplasm shown by arrowhead|
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Case report 3
An 18-year-old medical student presented with right testicular swelling of 2 months' duration. Examination revealed a hard nodule on the lateral aspect of the testis. Ultrasonography revealed a mixed echogenic mass. Computed tomography (CT) scan of the abdomen and pelvis, chest X-ray, and serum tumor markers were normal. Inguinal orchiectomy revealed malignant mesothelioma [Figure 3]. On follow-up at 3 years, CT scan revealed multiple retroperitoneal lymph nodes. Retroperitoneal lymph node dissection was performed. The patient received 6 cycles of cyclophosphamide-based chemotherapy. At 7 years' follow-up, the patient is married and asymptomatic.
| Discussion|| |
Mesothelioma is an uncommon disease usually arising from the pleura, pericardium, peritoneum, and very rarely from tunica vaginalis. Both benign and malignant forms of mesothelioma of tunica vaginalis have been reported in literature. Malignant mesothelioma of tunica vaginalis forms 1%–5% of cases of all malignant mesotheliomas. Exposure to asbestos is a strong risk factor for the development of mesothelioma. Jones et al. reported a positive occupational asbestos exposure history in 41% of 27 reviewed cases. A number of other agents such as erionite and fluoro-edenite or ionizing radiation with the use of thorotrast have also been implicated in the development of malignant mesothelioma.
The most common mode of presentation of malignant mesothelioma of tunica vaginalis is intrascrotal mass with hydrocele. This tumor commonly affects patients aged between 55 and 75 years, however it may rarely occur in young patients also, as seen in our case reports. Majority are unilateral on presentation, and till now, only four cases of bilateral mesothelioma of the tunica vaginalis have been reported. Other less common presentations are inguinal hernia, long-standing epididymitis, spermatocele, and testicular torsion. One of the major difficulties in managing malignant mesothelioma of tunica vaginalis is making an accurate preoperative diagnosis. Ultrasonography is the most commonly used diagnostic modality for testicular mesothelioma. Findings on ultrasonography include extratesticular mass with atypical features such as heterogeneous mass with increased echogenicity in peripheral area. Microscopically, most of the tumors are epithelial with papillary, tubulopapillary, or solid patterns. The neoplastic cells are classically cuboidal with scant-to-moderate amounts of eosinophilic cytoplasm and bland cytologic features in the well-differentiated tumors; however, they may appear highly malignant in poorly differentiated tumors.
Radical inguinal orchidectomy with hemiscrotectomy is the optimal treatment for malignant mesothelioma. As the diagnosis is rarely made preoperatively, scrotal surgery is usually done initially, mandating radical inguinal orchidectomy later. Tumor progression and development of lymphatic and distant tumor metastases have been reported in many cases. The presence of positive lymph nodes at diagnosis is associated with significant shorter survival. Retroperitoneal lymph nodes are the primary lymphatic drainage in testicular diseases, but in metastatic disease, inguinal and/or iliac lymph nodes can be involved. The necessity for inguinal or iliac lymph node dissection as primary therapy remains controversial. Role of adjuvant therapy with systemic chemotherapy, radiotherapy, or combination therapy has been described in earlier reports. Doxorubicin and cyclophosphamide are given most frequently, but till now, there is no supportive data available for the recommendation of these agents due to limited experience. Similarly, data supporting the efficacy of radiotherapy are also not available. In some cases, radiotherapy is considered to have better results than chemotherapy.
Younger age and organ-confined disease at diagnosis are significant factors correlated with survival. Both early and late recurrences are seen in malignant mesothelioma,, with many of them presenting within 2 years of diagnosis. Lifelong follow-up by clinical examinations and computerized tomographic scan or retroperitoneal ultrasound should be performed.
In conclusion, malignant mesothelioma of tunica vaginalis is a rare but highly malignant tumor. Preoperative diagnosis is usually not possible due to lack of specific clinical features, tumor markers, and diagnostic criteria on imaging. Radical inguinal orchidectomy followed by lifelong follow-up is usually the recommended treatment.
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[Figure 1], [Figure 2], [Figure 3]