Hydroceles: Disturbing Discoveries During Routine Repair

B Ganai1, M Seywright2, D Hendry1

Department of Urology1 and Pathology2, Gartnavel General Hospital, Glasgow, Scotland.

Corresponding Author:

Mr. Bhaskar Ganai, SHO in Urology, Urology secretaries, Level 6A, Department of Urology, Gartnavel General Hospital, Glasgow, G12 0YN

  E-mail: bganai@doctors.org.uk

SMJ 2008 53(1): 60

 

Abstract

Hydroceles are a common presenting complaint to the urological surgeon. They are known to harbour malignancy in a small percentage of cases. We report a case of malignant mesothelioma of the tunica vaginalis and a case of isolated lymphoma of the spermatic cord, both presenting during routine hydrocele repair. These are both rare diagnoses with a handful of reported cases worldwide. The literature of both these pathological entities is reviewed.

Key words: hydrocele, lymphoma, mesothelioma, spermatic cord, tunica vaginalis

 

Introduction

Hydroceles are known to harbour sinister pathology in a small proportion of cases. We report two cases of unexpected ominous findings at the time of routine hydrocele repairs. In both cases, pre-operative ultrasonography reported no abnormalities. Biopsies taken during surgery confirmed the diagnosis of malignant mesothelioma in one patient, and lymphoma in the other. We present both cases, and review the literature of malignant mesothelioma of the tunica vaginalis, and lymphoma of the epididymis.

 

Case Report 1

A 55 year old Caucasian man presented to the clinic with a lump on his enlarged left testicle. This was pain free, with no preceding orchitis. He had a vasectomy 11 years previously. Clinical examination revealed a left-sided hydrocele. Ultrasonography confirmed a moderate sized hydrocele, and reported the testicle to be normal, with no space occupying lesion. There was possible occupational asbestos exposure.

 

At surgery, papillomatous lesions were seen within the tunica vaginalis, and a firm white nodule within the spermatic cord of the left testicle near the epididymis. Clinically, this was consistent with a sperm granuloma and was biopsied. Immunoperoxidase staining, light and electron microscopy revealed sheets and glandular formations of epithelioid cells, with the features being consistent with epithelioid papillary mesothelioma. Positive staining was found for CAM5.2, calretinin, ERA, CK7, HMBE1, BerEP4, CK5 and CA125. The electron microscopy findings helped secure the diagnosis.

 

The patient underwent a staging chest, abdomen and pelvis CT scan, showing no evidence of pleural or peritoneal mesothelioma. No calcified pleural plaques were seen to suggest previous asbestos exposure.

 

A left radical hemiscrotectomy and orchidectomy was subsequently performed. Light microscopy showed no lymphatic or vascular spread, and surgical resection margins were clear of disease. There was a 15mm left para-aortic node seen.

 

Follow-up CT scanning revealed the left para-aortic node that resolved at his 3 month follow up scan. At one year, there is no evidence of recurrent or distant disease, both clinically and radiographically.

 

 

Fig 1a, 1b: Histological features of malignant mesothelioma of the tunica vaginalis.

 

Case Report 2

A previously healthy 25 year old Caucasian man presented to the outpatient clinic with a 1 year history of a large right-sided hydrocele. There was no associated pain, and the hydrocele had been gradually enlarging in size. There was no testicular mass felt, and this was confirmed with ultrasonography. A right-sided hydrocele was confirmed.

 

During surgery, a hard nodule was noted on the spermatic cord separate from both the vas deferens and the epididymis. The epididymis was noted to be thickened and largely separate from the testicle. An excision biopsy of the nodule was undertaken, and the remainder of the procedure was completed without incident.

 

The histology confirmed this lesion to be a grade 3b follicular lymphoma of the spermatic cord, with a diffuse large B-cell lymphoma component. Staging abdomen and pelvis CT scan, showing no evidence of any other disease.

 

Treatment was with 6 cycles of R-CHOP (rituximab, cyclophasphamide, adriamycin, vincristine, prednisolone) chemotherapy. Two high doses of intravenous methotrexate was added in an effort to prevent central nervous system involvement.

 

An inguinal orchidectomy was performed 4 months after the initial Jaboulay repair. There was no evidence on lymphoma in the resected testicle. At the initial operation, the entire nodule could not be removed without compromising the testicular blood supply. As there was no worrying diagnosis at the time of the hydrocele repair, it was not felt appropriate to sacrifice the testicle in this young man without definite pathology.

 

At 15 months follow-up after his initial surgery, he was still in remission.

 

 

Fig 2a: Neoplastic lymphoma follicle of pale blast cells

Fig 2b: Diffuse luymphoma with large cells infiltrating collagen bundles.

 

 

Discussion

Malignant mesothelioma of the tunica vaginalis is a rare entity with less than 80 cases reported in the literature.1 It is a tumour of mesodermal origin, and can affect any serosal membrane including pleura and peritoneum. Disease of the tunica vaginalis represents less than 5% of all malignant mesotheliomas in humans.2

 

The most common presenting feature is a hydrocele, with or without a mass.3 Due to there being little in the way of characteristic symptoms, less than 3% of cases are diagnosed pre-operatively.1 One report of preoperative diagnosis was by cytological analysis of aspirated hydrocele fluid.4 The most consistent risk factor is asbestos exposure, with a third of patients having contact.1 The latency of asbestos exposure to development of malignant mesothelioma is thought to be the reason why it is commonest in the 55-75 year old age group.1

 

At surgery, multiple nodules studding the hydrocele sac are usually seen.3 Radical surgery initially is important as it has been shown that there is a three fold increase in recurrence following simple excision of the hydrocele sac compared with inguinal orchidectomy (35.7% vs 11.5%).1 Retroperitoneal lymph node dissection has been performed in one case at the time of radical surgery, where 4 in 20 resected nodes had tumour present, in the absence of CT changes.5 However, routine dissection of the retroperitoneal lymph nodes is still debated, as the overall risk of positive lymph nodes is low.1 Adjuvant chemotherapy has been tried, but response to cisplatin and doxorubicin is poor.6

 

Prompt staging with CT scans, and aggressive surgical resection are the mainstay of management.

 

Isolated lymphoma of the spermatic cord is a rare entity with 14 cases reported in the literature.7 Certainly, lymphoma of the testes is the commonest secondary tumour of this organ, and in a patient over the age of 50 with an enlarged testicle, it is high on the list of differential diagnoses.8 The majority of testicular lymphomas are non-Hodgkin of a B-cell lineage, and this seems to be true in epididymal lymphoma.7,9 In 39% of cases of testicular lymphoma there is spermatic cord involvement.10 Other authors have given scrotal irradiation in addition to chemotherapy to patients with isolated epididymal lymphoma, with promising results at 6 months follow-up.9

 

These cases highlight the importance of biopsies when unusual features are found at time of surgery, despite normal ultrasonography. A retrospective audit in a busy city urology unit highlighted the above 2 cases in 86 hydrocele repairs in a 2 year period. Despite the frequency with which hydroceles present to the urologist, there is no clear data as to the proportion of hydroceles harbouring a malignant process. A low threshold for biopsies at hydrocele surgery is suggested, as 10% of testicular tumours present with an associated reactive hydrocele.8

 

 

References

 

  1. Plas E, Riedl CR, Pflunger H. Malignant mesothelioma of the tunica vaginalis testis: review of the literature and assessment of prognostic parameters. Cancer 1998; 83: 2437-46.

  2. Shimanda S, Ono K, Suzuki Y, Mori N. Malignant mesothelioma of the tunica vaginalis testis: a case with a predominant sarcomatous component. Path Int 2004; 54: 930-4.

  3. Jones MA, Young RH, Schully RE. Malignant mesothelioma of the tunica vaginalis: a clinicopathologic analysis of 11 cases with review of the literature. Am J Surg Pathol 1995; 19: 815-25.

  4. Japko L, Horta AA, Schreiber K, Mitsudo S, Karwa GL, Singh G, Koss LG. Malignant mesothelioma of the tunica vaginalis testis: report of first case with preoperative diagnosis. Cancer 1982; 49: 119.

  5. Smith JJ, Malone MJ, Geffin J, Silverman ML, Libertino JA. Retroperitoneal lymph node dissection in malignant mesothelioma of tunica vaginalis testis. J Urol 1990; 144: 1242-3.

  6. Umekawa T, Kurita T. Treatment of mesothelioma of the tunica vaginalis testis. Urologia Internationalis 1995; 55: 215-7.

  7. Okabea M, Kurosawa M, Suzuki S et al. Primary lymphoma of spermatic cord. Leukemia & Lymphoma. 2001; 40: 663-6.

  8. Walsh PC, Retik AB, Vaughan ED, Wein AJ. Cambell’s Urology, 7th Edition, WB Saunders, 2002.

  9. Vega F, Medeiros LJ, Abruzzo LV. Primary paratesticular lymphoma. A report of 2 cases and review of the literature. Arch Pathol Lab Med 2001; 125: 428-32.

  10. Ferry JA, Harris NL, Young RH et al. Malignant lymphoma of the testis, epididymis, and spermatic cord. A clinicopathologic study of 69 cases with immunophenotypic analysis. Am J Surg Pathol 1994; 18: 376-90.

 

Back to February Contents