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Year : 2018  |  Volume : 11  |  Issue : 1  |  Page : 60-62  

Malignant Mesothelioma of Testis: A Report of Three Cases and Review of Literature

Department of Urology, Government Medical College, Kottayam, Kerala, India

Date of Web Publication8-May-2018

Correspondence Address:
Nirav Priyadarshi
141, Tejas, Near Arpookara Temple, Near Medical College, Kottayam - 686 008, Kerala
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Source of Support: None, Conflict of Interest: None


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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 2021 May 12];11:60-2. Available from: https://www.mjdrdypv.org/text.asp?2018/11/1/60/232066

  Introduction Top

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.[1],[2],[3],[4],[5],[6] 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 Top

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.
Figure 3: Epithelial mesothelioma showing sheet of cells

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  Discussion Top

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.[7] 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.[8] 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,[9] 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.[10] 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.[11] 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.[9] 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.[9] 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.[12] 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.[9] Similarly, data supporting the efficacy of radiotherapy are also not available. In some cases, radiotherapy is considered to have better results than chemotherapy.[9]

Younger age and organ-confined disease at diagnosis are significant factors correlated with survival. Both early and late recurrences are seen in malignant mesothelioma,[9],[13] 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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There are no conflicts of interest.

  References Top

Chen KT, Arhelger RB, Flam MS, Hanson JH. Malignant mesothelioma of tunica vaginalis testis. Urology 1982;20:316-9.  Back to cited text no. 1
Dressler W, Permanetter W, Peters HP, Wieland WF. Malignant mesothelioma of the tunica vaginalis testis. Pathologe 1988;9:318-21.  Back to cited text no. 2
Eden CG, Bettochi C, Coker CB, Yates-Bell AJ, Pryor JP. Malignant mesothelioma of the tunica vaginalis. J Urol 1995;153 (3 Pt 2):1053-4.  Back to cited text no. 3
Ehya H. Cytology of mesothelioma of the tunica vaginalis metastatic to the lung. Acta Cytol 1985;29:79-84.  Back to cited text no. 4
Eimoto T, Inoue I. Malignant fibrous mesothelioma of the tunica vaginalis: A histologic and ultrastructural study. Cancer 1977;39:2059-66.  Back to cited text no. 5
Grove A, Jensen ML, Donna A. Mesotheliomas of the tunica vaginalis testis and hernial sacs. Virchows Arch A Pathol Anat Histopathol 1989;415:283-92.  Back to cited text no. 6
Shimada S, Ono K, Suzuki Y, Mori N. Malignant mesothelioma of the tunica vaginalis testis: A case with a predominant sarcomatous component. Pathol Int 2004;54:930-4.  Back to cited text no. 7
Jones MA, Young RH, Scully RE. Malignant mesothelioma of the tunica vaginalis. A clinicopathologic analysis of 11 cases with review of the literature. Am J Surg Pathol 1995;19:815-25.  Back to cited text no. 8
Plas E, Riedl CR, Pflüger H. Malignant mesothelioma of the tunica vaginalis testis: Review of the literature and assessment of prognostic parameters. Cancer 1998;83:2437-46.  Back to cited text no. 9
Chen JL, Hsu YH. Malignant mesothelioma of the tunica vaginalis testis: A case report and literature review. Kaohsiung J Med Sci 2009;25:77-81.  Back to cited text no. 10
Chekol SS, Sun CC. Malignant mesothelioma of the tunica vaginalis testis: Diagnostic studies and differential diagnosis. Arch Pathol Lab Med 2012;136:113-7.  Back to cited text no. 11
Smith JJ 3rd, Malone MJ, Geffin J, Silverman ML, Libertino JA. Retroperitoneal lymph node dissection in malignant mesothelioma of tunica vaginalis testis. J Urol 1990;144:1242-3.  Back to cited text no. 12
Antman K, Cohen S, Dimitrov NV, Green M, Muggia F. Malignant mesothelioma of the tunica vaginalis testis. J Clin Oncol1984; 2: 447-51.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]


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