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Blackwell Publishing Asian J Androl 2007; 9 (6): 859-860 DOI: 10.1111/j.1745-7262.2007.00266.x AJA www.asiaandro.com Letters to the Editor Inguinal recurrence of malignant mesothelioma of the tunica vaginalis: one case report with delayed recurrence and review of the literature Giovanni Liguori1, Giulio Garaffa1, Carlo Trombetta1, Rossana Bussani2, Stefano Bucci1, Emanuele Belgrano1 Department of Urology, 2Department ofPathology, University of Trieste, Trieste 34149, Italy Correspondence to: Dr Giovanni Liguori, Department of Urology, University of Trieste, Str. di Fiume 447, Trieste 34149, Italy. Tel: +39-040-3994-575 Fax: +39-040-3994-895 E-mail: gioliguori@libero.it Received 2006-03-21 Accepted 2007-01-23 Dear Sir, I am Giovanni Liguori, from Department of Urology, University of Trieste, Italy. We wrtite to you to discuss the malignant mesothelioma of the tunica vaginalis. Ma lignant mesothelioma most often involves the pleural or peritoneal cavity and exposure to asbestos is a wellknown risk factor for its development [1]. Most pa tients seek medical attention after they note a scrotal swelling during the course of several months. On clini cal assessment, these tumours are often believed to rep resent a hydrocele or epididymal cyst. As a result, most patients are initially treated conservatively for a suspected benign entity and the diagnosis of malignancy is often made postoperatively. In October 2005, a 68-year-old male sought our attention after having developed a nontender subcuta neous left inguinal mass. In June 2000, the patient had undergone, in another institution, trans-scrotal surgical excision of a 1.5-cm painless left epididymal mass that, at histopathological evaluation, resulted in the diagnosis of malignant mesothelioma. The patient underwent no further treatment at that stage and in June 2002 pre sented to the same department with a left testicular mass of 5 x 7 cm that was managed by left radical orchiec tomy and excision of the previous scrotal scar. Histopathological evaluation of the mass showed a diffuse in filtration of the tunica vaginalis and scrotal scar by ma lignant mesothelioma. When the patient came to our attention, physical evalu ation revealed an inguinal lesion of 3-cm diameter lo cated underneath the orchiectomy scar that was firmly stuck to the skin. Suspecting the recurrence of mesothe lioma, we performed a radical excision of the lesion and surrounding scar/connective tissue and of an isle of over lying skin. Histopathological examination showed ma lignant mesothelioma. At immunohistochemical study calretinin and cytokeratin 5,6 were positive, while carcinoembryonic antigen was negative. No adjuvant radiation therapy or chemotherapy were administered, and the patient commenced a strict follow-up that con- Figure 1. Tumour infiltration characterized by small round nests of small epithelial neoplastic cells. H & E. 2007, Asian Journal of Andrology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences. All rights reserved. .859. Malignant mesothelioma of the tunica vaginalis sisted of a physical examination every 3 months. An abdominal computerized tomography scan and chest ra diograph were obtained every 6 months. All investiga tions failed to show distant metastases or signs of local recurrence. On clinical assessment these tumours are often ini tially thought to represent a hydrocele or an epididymal cyst and the diagnosis of malignancy is achieved only postoperatively. Approximately one third of patients de velop recurrence after hydrocelectomy and 12% develop recurrence after scrotal or inguinal orchiectomy. Two thirds of recurrences occur within the first 2 years after initial tumor diagnosis. The median survival is less than 2 years and is closer to 1 year in patients who develop local recurrence [2]. Because radiotherapy and chemo therapy have failed to provide significant remission rates, early aggressive surgical excision appears to be the key modality for treatment. These patients are best treated with radical orchiectomy in all cases and hemiscrotectomy in cases of initial violation of the scrotum [1, 3]. The necessity for inguinal or iliac lymph node dissection, if there is no suspicion of metastases, is not supported be cause of the low risk of positive lymph nodes [4]. Our case highlights the importance of a correct pre operative diagnosis of the disease since radical orchiec tomy is the only treatment that prevents tumor seeding, thus dramatically reducing the risk of local recurrence. Unfortunately, one of the major difficulties is to obtain an accurate preoperative diagnosis. The diagnosis should be suspected in all patients exposed to asbestos and pre senting with clinical symptoms of rapidly growing hydrocele. Therefore, in these patients, cytoanalysis of the hydrocele fluid is recommended [3]. Moreover when hemorrhagic hydrocele fluid, white-to-yellowish excres cences or fibrotic thickening of the tunica vaginalis are found intraoperatively, it is very important to take biop sies of the suspected area. Even though the mesothelioma in this patient was managed with radical orchiectomy after the initial histopathological diagnosis, the patient is still alive and has not experienced distant metastases. This case demon strates that late recurrences can occur, thus emphasiz ing the importance of continuing oncological follow-up for more than 5 years. References 1 Spiess PE, Tuziak T, Kassouf W, Grossman HB, Czerniak B. Malignant mesothelioma ofthe tunica vaginalis. Urology 2005; 66: 397-401. 2 Black PC, Lange PH, Takayama T. Extensive palliative sur gery for advanced mesothelioma of the tunica vaginalis. Uro logy 2003; 62: 748. 3 Plas E, Riedl CR, Pfluger H. Malignant mesothelioma of the tunica vaginalis testis: review of the literature and assessment of prognostic parameters. Cancer 1998; 83: 2437-46. 4 Gupta NP, Agrawal AK, Sood S, Hemal AK, Nair M. Malig nant mesothelioma of the tunica vaginalis testis: a report of two cases and review of literature. J Surg Oncol 1999; 70: 251-4. Edited by Dr Guang-Huan Sun .860. http://www.asiaandro.com; aja@sibs.ac.cn