Malignant Mesothelioma of the Tunica Vaginalis Testis: Outcomes Following Surgical Management Beyond Radical Orchiectomy

Our plain-English summary of Malignant Mesothelioma of the Tunica Vaginalis Testis: Outcomes Following Surgical Management Beyond Radical Orchiectomy, by P. Recabal, B. Rosenzweig, W.M. Bazzi, et al (Urology, 2017).

The study

• Authors: P. Recabal, B. Rosenzweig, W.M. Bazzi, B.S. Carver, J. Sheinfeld
• Journal: Urology
• Published: 2017;107:166-170
• Cited by: 24 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objective: To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy.

Methods: Patients with confirmed MMTVT at a single tertiary care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves.

Results: Overall, 15 patients were included. Initial presentation was a scrotal mass in 7 of 15 (47%) and hydrocele in 5 of 15 (33%) patients. Clinical staging revealed enlarged nodes in 5 of 15 (33%) patients. Radical orchiectomy was the initial treatment in 5 of 15 (33%) patients. Positive surgical margins were found in 6 of 14 (43%) radical orchiectomies and were associated with worse survival (P = .007). The most frequent histologic subtype was epithelioid, associated with better survival (P = .048). Additional surgeries were performed on 12 of 15 (80%) patients. Pathologic examination revealed MMTVT in 6 of 12 (50%) hemiscrotectomies, 7 of 8 (88%) retroperitoneal lymph node dissections, 1 of 7 (14%) pelvic lymph node dissections, and 10 of 10 (100%) groin dissections. Five patients received adjuvant chemotherapy. Two also received adjuvant radiation therapy. Three patients with lymph node involvement remain no evidence of disease over 6 years after diagnosis. After a median follow-up of 3.5 years (interquartile range: 1.2-7.2), 5 patients have died, all of MMTVT; the median overall survival has not been reached. Common sites of relapse were lungs (5 of 7) and groin (3 of 7).

Conclusion: The pattern of metastatic spread of MMTVT is predominantly lymphatic. Nodes in the retroperitoneum and the groin are commonly involved. Prognosis is poor, but there may be a role for aggressive surgical resection including hemiscrotectomy, and inguinal and retroperitoneal lymph nodes.

Copyright © 2017 Elsevier Inc. All rights reserved.

In plain English

This study reviewed the records of 15 patients with malignant mesothelioma of the tunica vaginalis testis, a rare cancer of the lining around the testis. They were treated at Memorial Sloan Kettering Cancer Center between 1997 and 2014. Asbestos exposure was recorded for 2 of the 15 patients. The authors noted that exposure was not recorded in a standard way and may be under-reported. Twelve patients had surgery beyond removal of the testis. Cancer was found in 7 of 8 retroperitoneal lymph node dissections, 1 of 7 pelvic lymph node dissections, all 10 groin dissections, and 6 of 12 hemiscrotectomy specimens. Positive surgical margins and older age were associated with worse survival. The epithelioid subtype was associated with better survival. After a median follow-up of 3.5 years, 7 patients had disease progression and 5 had died, all from this cancer. Two patients with retroperitoneal lymph node spread remained disease-free 6 and 8 years after surgery alone. The authors concluded that spread is mainly lymphatic and that aggressive surgery may have a role. They noted the study was small and retrospective.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of a prospectively collected database at a single institution (case series of patients with malignant mesothelioma of the tunica vaginalis testis)
• Who was studied: 15 patients with pathologically confirmed malignant mesothelioma of the tunica vaginalis testis at Memorial Sloan Kettering Cancer Center, New York, over a 17-year period (1997 to 2014); median age at diagnosis 62 years
• Exposure: The study examined treatment rather than asbestos exposure. Asbestos exposure was recorded in 2 of 15 patients (13%); no fiber types, jobs or doses were reported. Treatments studied were surgeries beyond radical orchiectomy and adjuvant chemotherapy (pemetrexed plus cisplatin).
• Main results:
  • Positive surgical margins were found in 6 of 14 radical orchiectomy specimens (43%) and were associated with worse survival (p=0.007)
  • The epithelioid subtype was the most frequent (8 of 15) and was associated with better survival (p=0.048)
  • Age as a continuous variable was inversely associated with cancer-specific survival in the Cox model (p less than 0.001)
  • Residual tumor was found in 6 of 12 hemiscrotectomy specimens (50%)
  • Positive nodes were found in 7 of 8 patients undergoing retroperitoneal lymph node dissection (88%)
  • Positive nodes were found in 1 of 7 patients undergoing pelvic lymph node dissection (14%)
  • Malignancy was found in 10 of 10 groin dissection specimens (100%); all these patients had a suspicious groin mass
  • Retroperitoneal lymph node dissection in 5 clinical stage I patients found metastatic mesothelioma in all of them
  • After a median follow-up of 3.5 years, 7 patients had disease progression; relapse sites were lungs (5 of 7), groin (3 of 7) and peritoneal carcinomatosis (2 of 7)
  • Five patients died, all from metastatic disease; median overall survival was not reached
  • Two patients with retroperitoneal lymph node involvement remained free of disease 8 and 6 years after surgery, without adjuvant treatment
  • Suboptimal initial surgical technique (scrotal violation or opening the tunica vaginalis) was identified in 11 of 15 patients (73%)
• The authors' conclusion: The authors concluded that the cancer spreads mainly through the lymphatic system, most often to retroperitoneal and groin nodes. They concluded that prognosis is poor but that aggressive surgery, including hemiscrotectomy and groin and retroperitoneal lymph node dissections, and adjuvant combination chemotherapy may have a role.
• Limitations the authors state:
  • Retrospective design and small sample size
  • Wide confidence intervals reflect low statistical power
  • Asbestos exposure was not documented in a standardized way and may be under-reported
  • Limited generalizability because patients were treated at a tertiary center by highly experienced surgeons
  • Selection bias prevented analysis of whether surgery or chemotherapy gave a clinical benefit
  • No data on groin dissection in patients without a clinically suspicious groin

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Tunica Vaginalis, Orchiectomy, Kaplan-Meier Curve, Hydrocele, Staging, Histological Subtype, Epithelioid.

Related studies

• Retroperitoneal lymph node dissection in malignant mesothelioma of tunica vaginalis testis — J.J. Smith, M.J. Malone, et al. (1990)
• Malignant mesothelioma of the tunica vaginalis: a case with an unusually indolent course following radical orchidectomy and radiotherapy — J.L. Harmse, A.T. Evans, et al. (1999)
• Clinicopathological characteristics and outcomes in men with mesothelioma of the tunica vaginalis testis: analysis of published case-series data — J.B. Grogg, J.N. Fronzaroli, et al. (2021)
• Malignant mesothelioma of tunica vaginalis testis: Report of a very rare case with review of the literature — E. Trenti, S.M. Palermo, et al. (2018)
• Mesothelioma of the tunica vaginalis testis — K.J. Butnor, E.N. Pavlisko, et al. (2019)
• Mesothelioma of the tunica vaginalis testis: report of 2 cases with asbestos occupational exposure — G. Gorini, M. Pinelli, et al. (2005)

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