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Multiple Mesotheliomas of the Hydrocele Sac: A Case Report
THE JOURNAL OF UROLOGY
Vol. 79, No. 1, January 1958 Printed in U.S.A.
MULTIPLE MESOTHELIOMAS OF THE HYDROCELE SAC: A CASE REPORT CHARLES L. REYNOLDS, JR. From the Urology Service, Veterans Administration Hospital, Dallas, Texas and the University of Texas, Southwestern Medical School, Dallas, Texas
This paper concerns the so-called mesotheliomas, or adenomatoid tumors, of the genitourinary system with a discussion of their clinical manifestations and pathogenesis. A case which appears to be the only multiple mesothelioma of the tunica vaginalis on record is presented. This rare tumor occurs in the epididymis, spermatic cord, and testicular tunics of the male, and on the uterus, fallopian tubes, and ovaries of the female. In an excellent review of 106 cases collected from the literature in 1956, Rankin concluded that in the male these tumors were unilateral, slightly more common on the left, and associated with hydrocele in 15 per cent. Among the cases collected by Rankin, all with two exceptions were detected after the third decade of life, the average age of occurrence being 40. He found no reports of multiple tumors or any cases in which there were secondary implants, metastases, or recurrences after removal. Therefore, simple excision appears to be adequate for cure. The rarity of mesotheliomas of the tunica vaginalis is shown by the record of the Mayo Clinic: Out of 800,000 new admissions by 1950, only one such tumor was found. Mylius, in his review of world literature, reports 64 cases occurring in males; less than 20 per cent were on the tunica vaginalis. Rankin did not quote a percentage, but stated that out of his 106 cases only a few were of the tunica vaginalis. Grossly these tumors vary in size from a few millimeters to 4 cm. in diameter. They are firm, solid, and circumscribed. The cut surfaces are smooth or finely trabeculated, and the color may vary from greyish-white to tan. There are three microscopic patterns: 1) canalicular, with large vascular-like spaces lined by flattened cells; 2) tubular, having gland-like spaces lined with cuboidal or low columnar cells; and 3) plexiform, with solid strands of cuboidal epithelioid cells. The characteristic cells are mesothelial lining cells which lack a true basement membrane, cilia, or mitotic figures. Large foamy histocytes and lymphocytes may be found within the stroma. An outstanding feature of the tumor is the wide variation between the so-called characteristic lining cells in a single tumor and in different tumors. The origin of these tumors is not clear cut and several hypotheses have been advanced. Teilum believes the tumors have a common origin from mesonephric mesodermal primordium. Evans, Masson and associates, and Ambrose regard them as of mesothelial origin, while Mylius traces them to the miillerian duct. Sakaguchi thinks the tumors originate from the wolffian duct. Golden and Ash suggested calling all of them "adenomatoid tumors," a term which has the advantage of being "morphologically correct and genetically neutral." Accepted for publication April 30, 1957. 134
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CASE REPORT
R. L. W., register number 59 804, Veterans Administration Hospital, Dallas, Texas, was a 45-year-old colored man. He was admitted to the hospital on September 17, 1956, complaining of a large mass in the right scrotum which was beginning to cause pain from pulling or weight, but was not tender. When first noted, about 15 years prior to admission, the mass was only the size of a marble and remained so until one year prior to admission, since which time it had grown progressively larger. He had no history of injury or anything else of significance. The physical examination was normal except for a mass measuring about 10 cm. in diameter in the right scrotum which had the consistency of a hydrocele. The mass transilluminated light and one could see darkened areas on transillumination. Hard nodules measuring about 0.5 to 1 cm. in diameter could be palpated in what was felt to be a hydrocele sac wall. Laboratory work including blood chemistries, complete blood count and urinalysis were normal. The Wassermann test was positive. At operation about 400 cc fluid containing what appeared to be cholesterin was removed from a hydrocele sac. Numerous hard, nodular growths appeared on the sac wall. Two of these small growths could be seen on the surface of the testicle. The testicular capsule, as well as the hydrocele sac wall, was thickened. The hydrocele extended to the external inguinal ring, but no further. A hydrocelectomy was performed along with a testicular biopsy. Gross examination of the specimen showed a number of polypoid lesions projecting from one surface of the sac (fig. 1). These were paler in color than the surrounding surface and varied in size from a few millimeters to 1.5 cm. The cut section showed a mottled yellow-to-tan appearance. Microscopically, the papillary projections were covered by a fairly uniform single layer of mesothelial cells (fig. 2). The stalks were composed of loose, fibrous tissue and some dense hyalinized collagen with scattered lymphocytes and occasional poly-
Frn. I. Gross specimen. Note numerous polypoid projections from its surface
136
CHARLES L. REYNOLDS, JR.
FIG. 2. A, polypoid lesion attached to tunica vaginalis by narrow fibrous stalk. B, single layer of mesothelial cells line papillary formations of polypoid lesion.
morphonuclear cells present within the stroma. Occasional foci of large foamy histocytes were present within the papillary projections. The diagnosis was multiple mesotheliomas of hydrocele sac. The pathological report of the testicular biopsy was normal. The patient was examined six months postoperatively and no evidence of recurrence was seen. SUMMARY
The author reports a case of multiple mesotheliomas of tunica vaginalis of the spermatic cord believing that it may be unique. Special thanks are extended to Dr. Martha Meredith of the Department of Pathology for her help in preparing the pathological data. REFERENCES AMBROSE, S.S., JR.: Adenomatoid tumor of the tunica vaginalis. J. Urol., 70: 110-112, 1953. EVANS, NEWTON: Mesotheliomas of uterine and tubal serosa and tunica vaginalis testis: Report of 4 cases. Am. J. Path., 19: 461-471, 1943.
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137
EVANS, NEWTON: Mesothelioma of epididymis and tunica vaginalis. J. Urol., 50: 249-254, 1943. GOLDEN, ALFRED AND AsH, J.E.: Adenomatoid tumors of genital tract. Am. J. Path., 21: 63-79, 1945. LEE, M. J., JR., DOCKERTY, M. D., THOMPSON, G. J. AND WAUGH, J.M.: Benign mesotheliomas (adenomatoid tumors) of genital tract. Proc. Staff Meet., Mayo Clin., 25: 665672, 1950. MASSON' p.' RIOPELLE' J. L. AND SIMARD' L. C.: Le mesotheliome benin de la sphere genitale. Rev. canad. de biol., 1: 720-751, 1942. MYLrns, E. A.: Mesotheliome benin de la sphere genitale. Acta. chir. scandinav., 104: 201-205, 1952 E. RANKIN, N. E.: Adenomatoid tumors of epididymis and tunica albuginea: Two cases. Brit. J. Urol., 28: 1~7-193, 1956. SAKAGUCHI, Y.: Uber das Adenomyom des Nebenhodens. Frankf. Ztschr. f. Path., 18: 379-387, 1915-16. TEI LUM, G.: Histogenesis and classification of mesonephric tumors of female and male genital system and relationship to benign so-called adenomatoid tumors (esotheliomas): comparative histological study. Acta. Path. et Microbiol. Scandinav., 34: 431-481, 1954.
Vol. 79, No. 1, January 1958 Printed in U.S.A.
MULTIPLE MESOTHELIOMAS OF THE HYDROCELE SAC: A CASE REPORT CHARLES L. REYNOLDS, JR. From the Urology Service, Veterans Administration Hospital, Dallas, Texas and the University of Texas, Southwestern Medical School, Dallas, Texas
This paper concerns the so-called mesotheliomas, or adenomatoid tumors, of the genitourinary system with a discussion of their clinical manifestations and pathogenesis. A case which appears to be the only multiple mesothelioma of the tunica vaginalis on record is presented. This rare tumor occurs in the epididymis, spermatic cord, and testicular tunics of the male, and on the uterus, fallopian tubes, and ovaries of the female. In an excellent review of 106 cases collected from the literature in 1956, Rankin concluded that in the male these tumors were unilateral, slightly more common on the left, and associated with hydrocele in 15 per cent. Among the cases collected by Rankin, all with two exceptions were detected after the third decade of life, the average age of occurrence being 40. He found no reports of multiple tumors or any cases in which there were secondary implants, metastases, or recurrences after removal. Therefore, simple excision appears to be adequate for cure. The rarity of mesotheliomas of the tunica vaginalis is shown by the record of the Mayo Clinic: Out of 800,000 new admissions by 1950, only one such tumor was found. Mylius, in his review of world literature, reports 64 cases occurring in males; less than 20 per cent were on the tunica vaginalis. Rankin did not quote a percentage, but stated that out of his 106 cases only a few were of the tunica vaginalis. Grossly these tumors vary in size from a few millimeters to 4 cm. in diameter. They are firm, solid, and circumscribed. The cut surfaces are smooth or finely trabeculated, and the color may vary from greyish-white to tan. There are three microscopic patterns: 1) canalicular, with large vascular-like spaces lined by flattened cells; 2) tubular, having gland-like spaces lined with cuboidal or low columnar cells; and 3) plexiform, with solid strands of cuboidal epithelioid cells. The characteristic cells are mesothelial lining cells which lack a true basement membrane, cilia, or mitotic figures. Large foamy histocytes and lymphocytes may be found within the stroma. An outstanding feature of the tumor is the wide variation between the so-called characteristic lining cells in a single tumor and in different tumors. The origin of these tumors is not clear cut and several hypotheses have been advanced. Teilum believes the tumors have a common origin from mesonephric mesodermal primordium. Evans, Masson and associates, and Ambrose regard them as of mesothelial origin, while Mylius traces them to the miillerian duct. Sakaguchi thinks the tumors originate from the wolffian duct. Golden and Ash suggested calling all of them "adenomatoid tumors," a term which has the advantage of being "morphologically correct and genetically neutral." Accepted for publication April 30, 1957. 134
MULTIPLE MESOTHELIOMAS OF HYDROCELE SAC
135
CASE REPORT
R. L. W., register number 59 804, Veterans Administration Hospital, Dallas, Texas, was a 45-year-old colored man. He was admitted to the hospital on September 17, 1956, complaining of a large mass in the right scrotum which was beginning to cause pain from pulling or weight, but was not tender. When first noted, about 15 years prior to admission, the mass was only the size of a marble and remained so until one year prior to admission, since which time it had grown progressively larger. He had no history of injury or anything else of significance. The physical examination was normal except for a mass measuring about 10 cm. in diameter in the right scrotum which had the consistency of a hydrocele. The mass transilluminated light and one could see darkened areas on transillumination. Hard nodules measuring about 0.5 to 1 cm. in diameter could be palpated in what was felt to be a hydrocele sac wall. Laboratory work including blood chemistries, complete blood count and urinalysis were normal. The Wassermann test was positive. At operation about 400 cc fluid containing what appeared to be cholesterin was removed from a hydrocele sac. Numerous hard, nodular growths appeared on the sac wall. Two of these small growths could be seen on the surface of the testicle. The testicular capsule, as well as the hydrocele sac wall, was thickened. The hydrocele extended to the external inguinal ring, but no further. A hydrocelectomy was performed along with a testicular biopsy. Gross examination of the specimen showed a number of polypoid lesions projecting from one surface of the sac (fig. 1). These were paler in color than the surrounding surface and varied in size from a few millimeters to 1.5 cm. The cut section showed a mottled yellow-to-tan appearance. Microscopically, the papillary projections were covered by a fairly uniform single layer of mesothelial cells (fig. 2). The stalks were composed of loose, fibrous tissue and some dense hyalinized collagen with scattered lymphocytes and occasional poly-
Frn. I. Gross specimen. Note numerous polypoid projections from its surface
136
CHARLES L. REYNOLDS, JR.
FIG. 2. A, polypoid lesion attached to tunica vaginalis by narrow fibrous stalk. B, single layer of mesothelial cells line papillary formations of polypoid lesion.
morphonuclear cells present within the stroma. Occasional foci of large foamy histocytes were present within the papillary projections. The diagnosis was multiple mesotheliomas of hydrocele sac. The pathological report of the testicular biopsy was normal. The patient was examined six months postoperatively and no evidence of recurrence was seen. SUMMARY
The author reports a case of multiple mesotheliomas of tunica vaginalis of the spermatic cord believing that it may be unique. Special thanks are extended to Dr. Martha Meredith of the Department of Pathology for her help in preparing the pathological data. REFERENCES AMBROSE, S.S., JR.: Adenomatoid tumor of the tunica vaginalis. J. Urol., 70: 110-112, 1953. EVANS, NEWTON: Mesotheliomas of uterine and tubal serosa and tunica vaginalis testis: Report of 4 cases. Am. J. Path., 19: 461-471, 1943.
MULTIPLE MESOTHELIOMAS OF HYDROCELE SAC
137
EVANS, NEWTON: Mesothelioma of epididymis and tunica vaginalis. J. Urol., 50: 249-254, 1943. GOLDEN, ALFRED AND AsH, J.E.: Adenomatoid tumors of genital tract. Am. J. Path., 21: 63-79, 1945. LEE, M. J., JR., DOCKERTY, M. D., THOMPSON, G. J. AND WAUGH, J.M.: Benign mesotheliomas (adenomatoid tumors) of genital tract. Proc. Staff Meet., Mayo Clin., 25: 665672, 1950. MASSON' p.' RIOPELLE' J. L. AND SIMARD' L. C.: Le mesotheliome benin de la sphere genitale. Rev. canad. de biol., 1: 720-751, 1942. MYLrns, E. A.: Mesotheliome benin de la sphere genitale. Acta. chir. scandinav., 104: 201-205, 1952 E. RANKIN, N. E.: Adenomatoid tumors of epididymis and tunica albuginea: Two cases. Brit. J. Urol., 28: 1~7-193, 1956. SAKAGUCHI, Y.: Uber das Adenomyom des Nebenhodens. Frankf. Ztschr. f. Path., 18: 379-387, 1915-16. TEI LUM, G.: Histogenesis and classification of mesonephric tumors of female and male genital system and relationship to benign so-called adenomatoid tumors (esotheliomas): comparative histological study. Acta. Path. et Microbiol. Scandinav., 34: 431-481, 1954.