Hydrocele with a surprise: Malignant mesothelioma of the tunica vaginalis - Case report and review of literature

Testicular/paratesticular mesothelial tumours: Uncommon histopathologic entities in a very complex anatomical site

Mesothelial tumours of the testicular/paratesticular region are uncommon, poorly characterised and difficult-to-diagnose lesions. They encompass entirely benign proliferations (adenomatoid tumour) and malignant, very aggressive tumours (mesothelioma) whose morphological features can be overlapping, highly variable and confounding. Moreover, testicular/paratesticular mesothelial tumours comprise relatively new entities with indolent behaviour (well-differentiated papillary mesothelial tumour) as well as tumours which cannot be correctly included in any of the aforementioned categories and whose classification is still controversial. The molecular profile of such tumours represents an open issue. In fact, despite the recent discoveries about the genomic landscape of mesothelial proliferations at other sites (pleura, peritoneum), testicular/paratesticular mesothelial tumours, and namely mesotheliomas, are too rare to be extensively studied on large case series and they could arguably hide relevant differences in their molecular background when compared to the more common pleural/peritoneal counterparts.The aim of this review is to provide a guide for the pathological assessment of testicular/paratesticular mesothelial tumours. Herein, we describe the most recent updates on this topic according to the latest (year 2022) World Health Organisation Classification of Urinary and Male Genital Tumours (5th edition) and current literature. The diagnostic criteria, the main differentials and the role of ancillary techniques in the diagnosis of mesothelial testicular/paratesticular tumours are discussed.

Malignant mesothelioma of the tunica vaginalis testis: a rare case and review of literature

Background

Malignant mesothelioma of the tunica vaginalis is a rare tumour which comprises less than 1% of all mesotheliomas.

Case presentation

69-years old patient with painful hard mass and hydrocele in the right scrotum to whom a right hydrocelectomy was performed. Any history of scrotal trauma or exposure to asbestos was not present. Excisional biopsy revealed a multinodular tumour with focal areas of necrosis and infiltrative growth. According to morphological and immunohistochemical findings, diagnosis of malignant biphasic mesothelioma of the tunica vaginalis testis was made. Two months after hydrocelectomy, right inguinal orchidectomy was performed. Post-surgical whole body CT scan revealed paraaortic and pararenal lymphadenopathy, likely to be metastatic. Adjuvant treatment with 6 cycles of cisplatin and pemetrexed was applied. After 3 cycles of chemotherapy, CT scan showed progression and the treatment was changed to gemcitabine 1 month after.

Conclusions

Although malignant mesothelioma of the tunica vaginalis is a rare malignancy, it poses a diagnostic challenge which can mimic common inguinal or scrotal diseases such as hydrocele. Despite aggressive surgical procedures or adjuvant therapies, the prognosis remains poor.

Asbestos exposure and malignant mesothelioma of the tunica vaginalis testis: a systematic review and the experience of the Apulia (southern Italy) mesothelioma register

BACKGROUND

Malignant mesothelioma of the tunica vaginalis testis (MMTVT) is a rare disease with a poor prognosis. The diagnosis and management of these lesions are often difficult for pathologists, surgeons, oncologists and occupational physicians. A preoperative diagnosis of malignancy is rarely made, and there is no established effective therapy except orchidectomy.

METHODS

A systematic literature review was conducted among the articles published in the English literature on primary MMTVT. Moreover four cases from the Apulia mesothelioma register are reported here.

RESULTS

Two hundred eighty-nine cases of MMTVT have been reported from 1943 to 2018. Overall asbestos exposure has been investigated only for 58% of all cases reported in this review, while in 41.8% this data are not available. Noteworthy is the fact that in many reports there is not an anamnestic reconstruction of any asbestos exposure. A history of direct occupational, environmental or familial asbestos exposure is found in 27.6% of the cases. The four cases from the Apulia mesothelioma register are all with ascertained occupational exposure to asbestos.

CONCLUSIONS

The true incidence of asbestos exposure in MMTVT is underestimated because of insufficient information reported in older literature. To establish a broad consensus on the causal relationship between asbestos and MMTVT in the scientific community its necessary to analyze the same variables in the epidemiological studies. In general it should be recommended that a positive history of exposure to asbestos or to asbestos-containing materials are at risk for the development of a MMTVT and should be monitored.

Individualized minimally invasive treatment for adult testicular hydrocele: A pilot study

BACKGROUND

Hydrocelectomy is the gold standard for the treatment of hydrocele, but it often causes complications after surgery, including hematoma, infection, persistent swelling, hydrocele recurrence, and chronic pain. In recent years, several methods for minimally invasive treatment of hydrocele have been introduced, but they all have limitations. Herein, we introduce a new method of individualized minimally invasive treatment for hydrocele.

AIM

To present a new method for the treatment of adult testicular hydrocele.

METHODS

Fifty-two adult patients with idiopathic testicular hydrocele were included. The key point of this procedure was that the scope of the resection of the sheath of the tunica vaginalis was determined according to the maximum diameter (d) of the effusion measured by ultrasound and the maximum diameter of the portion of the sheath pulled out of the scrotum was approximately πd/2. The surgical procedure consisted of a 2-cm incision in the anterior wall of the scrotum, drainage of the effusion, and dissection of part of the sheath of the tunica vaginalis. After the sheath was peeled away to the predetermined target extent, the pulled-out sheath was removed. The intraoperative findings and postoperative complications were analyzed.

RESULTS

All patients were successfully treated with a median operation time of 18 min. The median maximum diameter of the effusion on ultrasound was 3.5 cm, and the median maximum diameter of the resected sheath was 5.5 cm. Complications occurred in four (7.7%) patients: two (3.8%) cases of mild scrotal edema, one (1.9%) case of scrotal hematoma, and one (1.9%) case of wound infection. All of the complications were grade I-II. Recurrent hydrocele, chronic scrotal pain, and testicular atrophy were not observed during a median follow-up of 12 mo.

CONCLUSION

We report a new technique for individualized treatment of testicular hydrocele, which is quantitative and minimally invasive and yields good outcomes. Further study is warranted to verify its potential value in clinical practice.