Pathology Page

Mesothelioma of the Tunica Vaginalis

ess than 100 cases of malignant mesothelioma of the tunica vaginalis have been reported.13 It occurs in males between 7 and 87 years old, and the majority of patients are between 55 and 75 years old. Approximately a third of patients have a documented history of asbestos exposure. Patients typically present with symptoms and signs that mimic more common inguinoscrotal problems such as simple hydrocele (more than 50%), testicular tumor (32%), epididymitis, scrotal hernia and spermatocele.1 Fine needle aspiration cytology examination of uid from the tunica sac is rarely performed and is only infrequently diagnostic. Ultrasound may demonstrate tumor excrescences or features of complex hydrocele. The majority of cases are diagnosed intraoperatively with the discovery of hemorrhagic hydrocele uid, brotic thickening of the tunica vaginalis, or the presence of white-yellow friable papillary excrescences or small nodules on the tunica vaginalis, which are often multifocal and extensively coat the serosal surface (g. 1).1 Tumors are often partially solid and partially cystic, and may exhibit local extension into the underlying testis, epididymis or adjacent spermatic cord structures.3 The microscopic ndings are similar to those seen in malignant mesothelioma in other sites. Tumors may be epithelial, spindle cell or biphasic.2,3 The epithelial type is the most common (60% to 70%) followed by biphasic or mixed tumors (30% to 40%). Purely sarcomatous cases are rare. Psammoma bodies may be present. Microscopic features of the epithelial type include complex arborizing papillae with brovascular cores, solid nests of cells with eosinophilic cytoplasm, invasive growth patterns and cytological atypia. Nuclei are vesicular and often have prominent nucleoli, and mitotic gures are usually easily identied (g. 2). Spindle cells with atypical nuclei blend with the epithelial nests in the mixed type of malignant mesothelioma, and entirely comprise the neoplasm in the purely sarcomatoid type. The microscopic differential may include other entities such as adenocarcinoma of the epididymis, rete or appendix testis, metastatic adenocarcinoma and various soft tissue sarcomas. Immunohistochemically

FIG. 2. Malignant mesothelioma with mixture of epithelial and spindle cells.

mesothelioma stains positively for keratins, calretinin and thrombomodulin. When malignancy is suspected preoperatively, radical orchiectomy is the standard treatment.1,3 In cases initially treated with transscrotal surgery subsequent hemiscrotectomy or hemiscrotal irradiation is often recommended. Limited retroperitoneal lymph node dissection has been recommended in cases of suspected dissemination.1 Approximately 15% of patients have metastatic cancer at initial diagnosis. Nearly half of the patients are cured by initial therapy but slightly more than half have local or distant recurrence and overall 44% die of cancer.1,3 More than 60% of recurrences are within the rst 2 postoperative years and more than 90% are within 5 years. However, recurrence can be as late as 15 years postoperatively. Recurrences are most often local, followed in frequency by metastases to lymph nodes, lung, liver, pleura, omentum and other sites. Median survival for patients with malignant mesothelioma of the tunica vaginalis is 23 months.1 Prognosis is best for patients younger than 60 years and those with localized disease. M. Carmen Frias-Kletecka and Gregory T. MacLennan Institute of Pathology University Hospitals of Cleveland Case Western Reserve University Cleveland, Ohio REFERENCES
1. Plas E, Riedl CR and Puger H: Malignant mesothelioma of the tunica vaginalis testis: review of the literature and assessment of prognostic parameters. Cancer 1998; 83: 2437. 2. Silverberg, Steven G and DeLellis RA: Silverbergs Principles and Practice of Surgical Pathology and Cytopathology. Edinburgh: Churchill Livingstone/Elsevier 2006; p 1765. 3. Perez-Ordonez P and Srigley JR: Mesothelial lesions of the paratesticular region. Semin Diagn Pathol 2000; 17: 294.

FIG. 1. Exophytic nodular mesothelioma in tunica vaginalis overlying testis.

0022-5347/07/1784-1489/0 THE JOURNAL OF UROLOGY Copyright 2007 by AMERICAN UROLOGICAL ASSOCIATION

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Vol. 178, 1489, October 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.07.067