Extensive palliative surgery for advanced mesothelioma of the tunica vaginalis

Malignant mesothelioma of the tunica vaginalis is a rare tumor managed principally by radical surgical resection. Chemotherapy and radiotherapy have limited efficacy. We report on a 67-year-old man with severe debilitation from multiple scrotal and inguinal recurrences of a malignant mesothelioma originating in the right tunica vaginalis. Local pain from extensive tumor spread prevented ambulation. Aggressive surgical debridement (total penectomy and scrotectomy) and perineal urethrostomy afforded the patient significant improvement in his quality of life before he finally died of the disease 3 years after diagnosis. UROLOGY 62: 748vii–748ix, 2003. © 2003 Elsevier Inc. A 80 cases of malignant mesothelioma of the tunica vaginalis have been described in published reports.1,2 It can occur in all age groups, including children, but one half are diagnosed in patients between 55 and 75 years of age.1,3 The only known risk factor is asbestos exposure, which can be identified in approximately one third of patients.1,3 A causal association to prior radiotherapy has not been established.4 Malignant mesothelioma of the tunica vaginalis is diagnosed most frequently (56%) at the time of hydrocelectomy for presumed benign hydrocele. Most other cases are diagnosed preoperatively as testicular tumors (33%), and orchiectomy is performed. One third of patients will develop local recurrence after hydrocelectomy, and 11% to 12% will develop recurrence after scrotal or inguinal orchiectomy. One half of all patients will have local (24%) or systemic (36%) recurrence, and two thirds of recurrences occur within the first 2 years after diagnosis. The median survival is less than 2 years and is closer to 1 year in patients who develop local recurrence. Forty percent of patients die of the disease.1 Because radiotherapy and chemotherapy have failed to provide significant remission rates, radical surgical resection is the mainstay of treatment.1,2 This includes radical inguinal orchiectomy in all cases, and hemiscrotectomy in those patients with initial scrotal exploration. Surgical options for recurrent disease are poorly defined. We report a case in which a patient developed multiple local recurrences requiring repeated surgical resection for palliation.