Malignant paratesticular mesothelioma

Abstract

Mesothelioma of the tunica vaginalis testis (MTVT) is a rare tumor that usually affects patients after the sixth decade of life. Exposure to asbestos is a known risk factor. Enlargement of the scrotal volume is the most common initial clinical manifestation, and about 15% of cases present metastasis at diagnosis. The treatment relies on surgical resection while the role of adjuvant chemotherapy and radiotherapy remains unclear. The prognosis for patients is generally poor, with a lethal outcome in 30% over a 24-month period. The authors report a case of a 62-year-old patient with the diagnosis of MTVT without a history of asbestos exposure. After surgical treatment, metastatic disease ensued. Chemotherapy was initiated, but could not be continued due to marked and fast clinical deterioration. The authors call attention to the difficulty of early diagnosis of MTVT due to a nonspecific clinical picture, the lack of action by the patient when the scrotal enlargement was first noticed, and the lack of tumor markers. Delayed diagnosis is definitely related to unfavorable prognosis.

Keywords: Chemotherapy, Adjuvant; Mesothelioma; Orchiectomy; Spermatic cord.

Figure 1. – A and B – Ultrasonography of the left scrotal sac showing a heterogeneous mass with some scattered cystic areas (notedly in B).

Figure 2. – Gross view of the surgical specimen showing in: A – longitudinal section of left testicle and scrotal sac showing paratesticular tumor involving the testicle with fascicular areas, and in B – in detail, infiltration of testicular parenchyma in an area of discontinuity of the tunica albuginea.

Figure 3. – Photomicrography of the surgical specimen (paratesticular tumor) showing: in A – stromal infiltration by solid tumor with epithelioid pattern (HE, 200X); B – infiltration by sarcomatoid spindle cells (HE,200X); C – immunohistochemical positive reaction for calretinin (400X); D – immunohistochemical positive reaction for WT-1 (400X).

Figure 4. – Abdominal CT. A – Coronal reformation showing a heterogeneous mass involving the aorta and left iliac artery; B – Axial plane showing periaortic lymph nodes, delayed concentration/excretion of the contrast, and slight hydronephrosis; C – Axial plane showing lymph nodes conglomerate with signs of central necrosis along the left iliac artery; D – axial plane – multiple bilateral enlarged inguinal lymph nodes.