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  Table of Contents    
CASE REPORT  
Year : 2020  |  Volume : 63  |  Issue : 3  |  Page : 475-477
Mesothelioma of the tunica vaginalis testis: A case report


1 Department of Urology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey
2 Trabzon Fatih State Hospital, Urology Clinic, Trabzon, Turkey
3 Department of Pathology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey

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Date of Submission02-Dec-2018
Date of Decision09-Mar-2019
Date of Acceptance17-Mar-2019
Date of Web Publication7-Aug-2020
 

   Abstract 


Primary mesotheliomas of the tunica vaginalis testis are very rare malignant tumors. They are generally associated with exposure to asbestos. They may manifest as hydrocele, testis tumor, inguinal hernia, or epididymitis. After differential diagnosis, treatment is primarily surgical. Adjuvant therapeutic methods for mesotheliomas of the tunica vaginalis testis, with their high mortality, are controversial. Here, we present a mesothelioma case derived from tunica vaginalis testis acting as long-term pyocele with no known asbestos exposure.

Keywords: Mesothelioma, testis, tunica vaginalis

How to cite this article:
Kazaz IO, Teoman AS, Mungan S. Mesothelioma of the tunica vaginalis testis: A case report. Indian J Pathol Microbiol 2020;63:475-7

How to cite this URL:
Kazaz IO, Teoman AS, Mungan S. Mesothelioma of the tunica vaginalis testis: A case report. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Oct 31];63:475-7. Available from: https://www.ijpmonline.org/text.asp?2020/63/3/475/291690





   Introductıon Top


Mesotheliomas of the tunica vaginalis testis are rare malignant tumors usually associated with exposure to asbestos. Diagnosis is generally based on histopathology following hydrocele surgery. We report a case of mesothelioma of the tunica vaginalis testis in a patient with long-term pyocele with no known exposure to asbestos.


   Case Hıstory Top


A 75-year-old male patient was admitted to our clinic due to left testicular swelling. His history revealed that this painless swelling had persisted for several years, and exhibited continuous growth. The patient had no history of trauma or infection. A physical examination revealed a fluid-filled palpable mass approximately 10 cm in size filling the left hemiscrotum and extending to the inguinal canal. Other external genital organs were normal. No abnormal finding was determined at biochemical tests. Urine culture was negative, while fluid collection compatible with pyocele was reported in the left hemiscrotum at scrotal ultrasonography (USG). A consent form had been taken and surgical exploration was performed. A malignant-appearing mass deriving from the paratesticular region and involving the entire cord was detected, and orchiectomy was performed [Figure 1]. Histopathological examination of the excised material reported mesothelioma invasion or metastasis, and metastatic paratesticular lymphadenopathy. Thoracoabdominal computerized tomography (CT) was performed to investigate primary mesothelioma, but no primary or metastatic focus was identified. The case was therefore regarded as primary mesothelioma of the tunica vaginalis testis. The patient died two months after diagnosis due to impairment of his general condition, and no adjuvant therapy could be administered.
Figure 1: Tunica vaginalis and testis in left orchiectomy specimen

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   Dıscussıon Top


Mesotheliomas are rare, malignant tumors developing from the mesothelium. They generally derive from the pleura and peritoneum, and less frequently from the pericardium. Mesotheliomas of the tunica vaginalis testis are a rare subgroup first described 60 years ago. More than 300 cases have been reported to date in the literature.[1] The prevalence of mesotheliomas is 2.1 per million, and that of paratesticular or tunica vaginalis testis mesotheliomas is 0.2 per million.[2] More than 50% of cases in the literature are associated with exposure to asbestos. However, less than half of mesotheliomas of the tunica vaginalis testis have been found to be associated with known asbestos exposure.[3] Other clinical manifestations implicated in the etiology are scrotal trauma, long-term presence of hydrocele, and epididymitis. There were about 50% of patients present to clinics with presence of hydrocele, 36% with testicular tumor, 10% with inguinal hernia, and 3% with epididymitis.[4]

There are three types of mesothelioma of the tunica vaginalis testis; epithelial, biphasic, and sarcomatoid. Their findings similar to primary pleural mesotheliomas are determined in mesotheliomas of the tunica vaginalis testis at histopathological examination. Papillary and tubulopapillary formations are the most common pattern in microscopic architecture. These are generally well differentiated, and have better prognosis.[5] Invasion of subtunical connective tissue, the testis, epididymis or scrotum has been documented in one third of cases of tumors of the tunica vaginalis testis. These tumors may exhibit local invasion, and have also been reported to be capable of causing metastasis via the lymphatic or hematogenous pathways.[6]

In the immunohistochemical profile of these tumors, cytokeratin-7 and 5/6, calretinin, EMA, D2-40 and thrombomodulin stain positive, while cytokeratin-20 (CK-20), BerEP4, B72.3, Moc-31 and Leu-21 exhibit negative staining.[7] Calretinin staining positive and BerEP4 staining negative are the most important molecular markers in differentiating mesothelioma from adenocarcinoma. In our case, and correlated with the literature; cytokeratin-7 [Figure 2]a, D2-40 [Figure 2]b, and calretinin [Figure 2]c stained positive.
Figure 2: Immunohistochemical study with neoplastic cells (a) expressed Cytokeratin-7 (CK-7) diffusely (b) expressed D2-40 diffusely (c) expressed calretinin diffusely as expected in mesothelioma

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Mesotheliomas of the tunica vaginalis testis follow an aggressive clinical course. Local invasion and metastasis are described in approximately one patient in three from time of diagnosis, and 14% appear in the form of lymph node metastasis. Recurrence is seen in 60% of patients, and mortality in the first two years in 30%. Lymph node metastasis and older age are poor prognostic factors, and a median survival rate of 24 months has been reported.[8]

These is no definitive method of treatment or guideline information for mesotheliomas of the tunica vaginalis testis. The radical inguinal orchiectomy is the primary surgical treatment.[9] Chemotherapy can be administered after surgery, as with pleural mesotheliomas, but its contribution to survival is controversial. Studies have reported that chemotherapy can prolong median survival by up to 10 months. Radiotherapy has been shown to be potentially more beneficial than chemotherapy and to be more successful in young patients.[10] Adjuvant therapy was planned in our case, but could not be given due to impairment of general condition. The patient died two months after diagnosis due to rapid and aggressive disease course.


   Conclusion Top


Primary mesotheliomas of the tunica vaginalis testis are very rare malignant tumors associated with exposure to asbestos. They may manifest as hydrocele, testis tumor, inguinal hernia, or epididymitis, and treatment after differential diagnosis is primarily surgical. Adjuvant therapeutic methods for mesotheliomas of the tunica vaginalis testis, with their high mortality, are controversial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Trenti E, Palermo SM, D'Elia C, Comploj E, Pycha A, Carella R, et al. Malignant mesothelioma of tunica vaginalis testis: Report of a very rare case with review of the literature. Arch Ital Urol Androl 2018;90:212-4.  Back to cited text no. 1
    
2.
Marinaccio A, Binazzi A, Di Marzio D, Scarselli A, Verardo M, Mirabelli D, et al. Incidence of extrapleural malignant mesothelioma and asbestos exposure, from the Italian national register. Occup Environ Med 2010;67:760-5.  Back to cited text no. 2
    
3.
Recabal P, Rosenzweig B, Bazzi WM, Carver BS, Sheinfeld J. Malignant mesothelioma of the tunica vaginalis testis: Outcomes following surgical management beyond radical orchiectomy. Urology 2017;107:166-70.  Back to cited text no. 3
    
4.
Alesawi AM, Levesque J, Fradet V. Malignant mesothelioma of the tunica vaginalis testis: Comprehensive review of literature and case report. J Clin Urol 2015;8:147-52.  Back to cited text no. 4
    
5.
Zazzara M, Nazaraj A, Mastromauro M, Cardo G, Scarcia M, Rizzo P, et al. Well-differentiated papillary mesothelioma of the tunica vaginalis: Case report and literature review. Urol Case Rep 2019;22:13-4.  Back to cited text no. 5
    
6.
Hispán P, Pascual JC, González I, Bravo D, Peiró G. Cutaneous metastases from malignant mesothelioma of the tunica vaginalis testis. Am J Dermatopathol 2016;38:222-5.  Back to cited text no. 6
    
7.
Winstanley AM, Landon G, Berney D, Minhas S, Fisher C, Parkinson MC. The immunohistochemical profile of malignant mesotheliomas of the tunica vaginalis: A study of 20 cases. Am J Surg Pathol 2006;30:1-6.  Back to cited text no. 7
    
8.
Jankovichova T, Jankovich M, Ondrus D, Kajo K, Dubravicky J, Breza J. Extremely rare tumour--malignant mesothelioma of tunica vaginalis testis. Bratisl Lek Listy 2015;116:574-6.  Back to cited text no. 8
    
9.
Park YJ, Kong HJ, Jang HC, Shin HS, Oh HK, Park JS. Malignant mesothelioma of the spermatic cord. Korean J Urol 2011;52:225-9.  Back to cited text no. 9
    
10.
Plas E, Riedl CR, Pflüger H. Malignant mesothelioma of the tunica vaginalis testis. Cancer 1998;83:2437-46.  Back to cited text no. 10
    

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Correspondence Address:
Ahmet S Teoman
Trabzon Fatih State Hospital, Urology Clinic, Trabzon - 61040
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_780_18

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   Case Hıstory
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