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Primary and Secondary Mesothelioma of the Tunica Vaginalis: a comparative case study

February 23, 2012/by admin Z.9

We report two cases of mesothelioma of the tunica vaginalis, one primary and one secondary, both with a history of possible exposure to asbestos and discuss their pathogenesis, diagnosis and management.

Authors: Swetha Vijayan¹; Richard Carr²; John Strachan

1. Senior House Officer, Department of Urology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom

2. Consultant Histopathologist, Department of Histopathology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom

3. Consultant Urologist, Department of Urology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom

Corresponding Author: Swetha Vijayan, Department of Urology and Department of Histopathology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom. Email: [email protected]

Abstract

The first patient is an 89 year-old man referred with recurrent left scrotal swelling following repeated fluid aspirations. His only exposure to asbestos had been through his son who had died one year previously of asbestosis. At hydrocoelectomy, a thickened tunica vaginalis and heavily blood stained fluid were noted. Histopathology and immuno-staining confirmed malignant mesothelioma and urgent radical orchidectomy was performed. The tumour recurred within a month with spread to mediastinal and para-aortic lymph nodes.

The second patient is a 68 year-old man referred with increasing shortness of breath and pain over the left side of his chest. He was a retired brick layer with possible occupational exposure to asbestos. Investigations and biopsy established a diagnosis of pleural mesothelioma. During evaluation for chemotherapy, he presented with a hard testicular lump and underwent radical orchidectomy. Histology confirmed the presence of mesothelioma involving the tunica vaginalis. Follow-up CT scan showed no abdominal or pelvic disease.

Introduction

Malignant mesothelioma of the tunica vaginalis is an uncommon, locally aggressive tumour, with over 200 cases reported in the literature to date [1]. The disease usually presents in men over 50 years of age, though, there have been cases reported in younger age groups [2] [3]. Exposure to asbestos has been considered as a risk factor. Patients usually present with a hard testicular lump or scrotal swelling. However, the disease lacks characteristic symptoms and signs so that in most cases the diagnosis is made following surgical exploration. Mesothelioma of the tunica vaginalis has a poor prognosis and high rate of recurrence and nodal metastases. Here we present two cases of malignant mesothelioma of the tunica vaginalis, one primary and one secondary, both associated with a history of possible exposure to asbestos.

Case 1

An 89 year old man was referred with a 6-month history of swelling in the left hemi-scrotum. The referring general practitioner, suspecting a hydrocoele, aspirated fluid on two occasions but the swelling soon returned. On examination there was a trans-illuminating large left sided hydrocoele. At elective hydrocoelectomy, we found heavily blood stained fluid and a thickened hydrocoele wall. Microscopic examination of the surgical resection specimen revealed fibrous tissue infiltrated by acinar and papillary structures (Fig. 1).

Figure 1. Microscopic examination of the surgical resection specimen

The differential diagnosis included adenocarcinoma and mesothelioma. Immunohistochemistry supported a final diagnosis of malignant mesothelioma as follows: positivity for calretinin (Fig 1 inset), epithelial membrane antigen (EMA), cytokeratin (CK)20, and negative for CK5, CK6, CEA, BerEP4, thyroid transcription factor 1 (TTF1), oestrogen receptor, thyroglobulin and prostate specific antigen.

The patient underwent radical orchidectomy with wide local excision. Pathological examination confirmed mesothelioma of the tunica vaginalis extensively infiltrating the epididymis (Fig. 1A) and the testicular parenchyma with vascular invasion. Tumor seedlings were also noted in the dermal scar tissue. Following the diagnosis, further questioning revealed no personal history of direct asbestos exposure. However, the patient had been living with his son who had occupational asbestos exposure and had died of asbestosis one year prior to this presentation.

One month later the patient’s wound broke down and on examination nodules were palpable in the wound. A further biopsy confirmed locally recurrent disease. CT scan of the chest and abdomen showed no evidence of pleural or peritoneal tumour, but identified significant mediastinal and left sided para-aortic lymph node disease without any pelvic lymphadenopathy. He declined further active management and died within a few months.

Case 2

A 68 year old retired man was referred by the general practitioner to a respiratory physician, with a history of increasing shortness of breath and fatigue for 2 months. The patient also reported left sided lower chest pain and mild cough. There was no history of haemoptysis, weight loss or night sweats. He was an ex-smoker (for 30 years). There was a possibility of asbestos exposure during his former job as a brick layer. On auscultation, there was decreased air entry on the left side of his chest. Chest X-ray showed a large left sided pleural effusion. An inter-costal tube was placed which drained 6L of thick haemorrhagic fluid over an 11-day period with a good clinical symptomatic response. CT scan of his thorax initially showed no underlying lung or pleural pathology. Pleural fluid cytology was reported as showing individual, dispersed, reactive mesothelial cells, abundant neutrophils and macrophages, but no malignant cells. Subsequent MRI scan also revealed no suggestion of a neoplastic process. Suspecting infection, he was treated with antibiotics and discharged with close follow-up.

Follow-up chest X-ray 6-months later showed some increased markings present locally in the left lower zone possibly indicating focal inflammatory changes. Within the next 3-months, there was a recurrence of his symptoms and the patient was referred to cardiothoracic surgery. A video assisted thoracoscopic examination was suspicious of pleural mesothelioma and a biopsy was taken. Histology confirmed the diagnosis of an epithelioid malignant mesothelioma.

During his preparations for chemotherapy, the patient was referred to urology with the recent onset of a swelling in his right testicle. On examination, the left testis was normal, but the right testis was rock hard. An ultrasound scan showed a solid, low echogenicity, 3.5cm mass within the right inguinal canal that appeared to be arising from the right epididymis. A radical orchidectomy was performed. The histopathology revealed malignant mesothelioma of tunica vaginalis (Fig. 2) enveloping the testis, epididymis and spermatic cord up to and including the proximal resection margin.

Figure 2. Histopathology results

A follow-up CT scan of the thorax, abdomen and pelvis showed significant deterioration in the pleural lesion but no other extra-thoracic abnormality. The patient died of progressive pleural disease 2 years from the first referral (10 months after his radical orchidectomy). There is no information regarding local recurrence of the intra-scrotal disease.

Discussion

Malignant mesothelioma arises from the mesothelial cells lining the pleural, peritoneal, and pericardial cavities and rarely the tunica vaginalis. Pleural mesothelioma is by far the most common form of mesothelioma and has a well-recognised link to asbestos exposure [4]. Mesothelioma of the peritoneum or tunica vaginalis is rare in the absence of pleural disease but peritoneal involvement may present with spread to the tunica vaginalis because the latter develops as a direct extension of the peritoneal mesothelium. During the embryonic period all serous cavities develop from a common coelom and are continuous until partitions separate them. Malignant cells may track down from the pleural cavities via persisting connections between the body cavities or by direct extension of disease through the diaphragm. In our second patient, who developed overt pleural disease and spread to tunica vaginalis without any abdominal lesion, we presume this was the case.

Asbestos exposure, trauma and chronic hydrocoele have all been implicated as risk factors in the development of paratesticular mesothelioma [2] [5]. A few cases have also been reported with no prior associated disease process [6]. Due to the rarity of primary tunica vaginalis mesothelioma, little is known of its pathogenesis. In patients with asbestos exposure, we speculate that the asbestos fibres may collect in the tunica vaginalis via the coelomic connections described earlier. A small number of fibres may also reach the area via the blood stream after being absorbed from the lungs and gastrointestinal tract. Asbestos exposure mainly occurs from breathing in asbestos fibres. When products containing asbestos are disturbed, they release fibres into the air which may be inhaled [7]. Oral and dermal exposures have also been described [8]. Familial occupational exposure may also lead to indirect exposure via contaminants brought home. Plas et al reported in their study that a familial occupational history to asbestos increased the risk of malignant mesothelioma of tunica vaginalis 10-fold [2]. The relationship between asbestos exposure and mesothelioma is well established but the mechanisms underlying tumourogenesis are not fully understood. Chronic irritation leading to a hyperplastic inflammatory response along with oncogenic mutations caused by the asbestos fibres may eventually lead to tumour development [4]. We consider our first case to be a presentation of primary tunica vaginalis mesothelioma without pleural or peritoneal disease. The mediastinal and para-aortic lymph node disease are compatible with metastases from the scrotal disease. The potential source of asbestos exposure was his son who had died one year earlier of asbestosis and who could have brought contaminants home through his work clothes thirty years earlier.

Mesothelioma presenting in the tunica vaginalis usually affects men between 50 to 70 years of age. The disease presents as a scrotal swelling or hard testicular mass but is rarely diagnosed pre-operatively [2]. The histopathological diagnosis of malignant mesothelioma can be challenging and should be supported by immunohistochemical studies. Winstanley et al studied the immunohistochemical profile of 20 testicular malignant mesotheliomas finding the following positivity rates: calretinin and EMA 100%; thrombomodulin 89%; CK7 83%: CK5/6 72% but only 11% were positive for BerEp4. All cases were negative for CK20 & CEA [9]. Calretinin is a vitamin D dependent calcium binding protein, detected in most malignant mesotheliomas, and considered one of the most specific markers for epithelioid mesothelioma [10]. The main differential diagnoses for mesotheliomas are rare primary adenocarcinomas of the rete testis and metastatic adenocarcinomas that are calretinin and CK5/6 negative and usually BerEP4 and CEA positive.

In any case of confirmed mesothelioma of the tunica vaginalis, radical orchidectomy remains the treatment of choice. Adjuvant radio- or chemotherapy is advised during initial management but radiotherapy is considered to be more effective [2]. In 1998, Plas et al reviewed 73 cases of testicular mesothelioma and found 37.5% developed tumour recurrence following local resection of the hydrocoele wall while only 10.5% did so after scrotal orchidectomy and 11.5% after inguinal orchidectomy [2]. The median survival of patients was reported to be 23 months. The risks of recurrence following radical treatment is maximal during the first two years and close monitoring and follow-up is therefore required [2]. Malignant mesothelioma is often extensive at presentation with a high incidence of rapid local progression and metastatic spread as in our two patients.

Conclusion

Primary or secondary mesothelioma of the tunica vaginalis is extremely rare in occurrence. Preoperative diagnosis is difficult due to the rarity of the disease and the non-specific clinical presentations. A high index of suspicion is required in all patients with scrotal swellings and known exposure to asbestos. Increased awareness of the condition might help in improving the pre-operative diagnosis. The tumour has a rapidly progressive course with a high recurrence rate and poor prognosis. Early diagnosis, vigorous management and close follow-up may provide a better outcome and may improve disease free survival.

References

1. Bisceglia M, Dor DB, Carosi I, Vairo M, Pasquinelli G. Paratesticular mesothelioma: Report of a case with comprehensive review of literature. Adv Anat Pathol 2010. 17:53-70.

2. Plas E, Riedl CR, Pflunger H; Malignant mesothelioma of the tunica vaginalis testis: review of the literature and assessment of prognostic parameters. Cancer 1998. 83:2437-2446.

3. De Lima GR, de Oliveira VP, Reis PH, Pinheiro FG, Lima MV, Gonzaga-Silva LF. A rare case of Malignant Hydrocele in a young patient. J Paediatr Urol. 2009 Jun; 5(3):243-5; Epub 2008 Dec 12.

4. Cancer Research UK. Mesothelioma: Risks and Causes. https://cancerhelp.cancerresearchuk.org/type/mesothelioma/about/mesothelioma-risks-and-causes

5. Abe K, Kato N, Miki K, Nimura S, Suzuki M, Kiyota H, Onodera S, Oishi Y. Malignant mesothelioma of testicular tunica vaginalis. International Journal of Urology 2002. 9:602-603.

6. García de Jalón A, Gil P, Azúa-Romeo J, Borque A, Sancho C, Rioja L.A; Malignant mesothelioma of the tunica vaginalis: Report of a case without risk factors and review of the literature. International Urology and Nephrology 2003. 35(1):59-62

7. Agency for Toxic Substances and Disease Registry. What is Asbestos? Retrieved April 10, 2009 from: https://www.atsdr.cdc.gov/asbestos/more_about_asbestos/what_is_asbestos/

8. Agency for Toxic Substances and Disease Registry. Toxicological Profile for Asbestos. September 2001. Retrieved April 10, 2009 from: https://www.atsdr.cdc.gov/toxprofiles/tp61.pdf

9. Winstanley AM, Landon G, Berney D, Minhas S, Fisher C, Parkinson MC. The immunohistochemical profile of malignant mesotheliomas of the tunica vaginalis: a study of 20 cases. Am J Surg Pathol 2006. 30:1-6

10. Candura SM, Canto A, Amatu A, Gerardini M, Stella G, Mensi M, Poggi G. Malignant mesothelioma of the tunica vaginalis testis in a petrochemical worker exposed to asbestos. Anticancer Research 2008 Mar-Apr; 28(2B):1365-68.

Date added to bjui.org: 23/02/2012

DOI: 10.1002/BJUIw-2011-127-web

Metastatic Colon Adenocarcinoma to the Tunica Vaginalis Testis Presenting As Hydrocele

February 19, 2012/by admin Z.9

To the best of our knowledge, ours is the first case of tunica vaginalis metastasis originating from a primary adenocarcinoma of the ascending colon.

Authors: Ji Zheng¹, Gensheng Lu¹, Chengping Xu², Bo Song¹, Zhansong Zhou¹

1. Department of Urology, Southwest hospital, Third Military Medical University, Chongqing, China

2. Department of Pathology, Southwest hospital, Third Military Medical University Chongqing, China

Corresponding Author: Zhansong Zhou, Department of Urology, Southwest hospital, Third Military Medical University, Chongqing, China. E-mail: [email protected]

Case report

A 65-year-old man was referred to our urology clinic complaining of left scrotal enlargement for one month. Seven months before admission, colonoscopy (Figure 1A) and computed tomography (CT) of his abdomen (Figure 1B) showed a mass in his ascending colon and enlarged mesenteric lymph nodes.

Figure 1A and B. CT scan of the abdomen

Fig1colonoscopy-and-computed-tomography-of-abdomen-

Biopsy was consistent with a moderately differentiated adenocarcinoma. He was diagnosed preoperatively with ascending colonic adenocarcinoma, and mesenteric lymph nodes metastases were suspected. Due to his experiencing severe intestinal spasm and bloody stools, the patient requested surgical treatment, though systematic chemotherapy had been advised. He underwent a radical right hemicolectomy, and this pathology revealed moderately differentiated adenocarcinoma with lymph node metastases (Figure 3A).

Figure 3A. Pathology revealed moderately differentiated adenocarcinoma with lymph node metastases

Fig3adenocarcinoma-with-lymph-node-metastases

Two weeks after surgery, in view of his having lymphatic metastases, our patient agreed to and completed the first cycle of a combined chemotherapy regimen with oxaliplatin (150 mg intravenous [IV] day 2), tegafur (600 mg IV days 1 to 3), and calcium folinate (400 mg IV days 1 to 3). Another four cycles of combined chemotherapy were accomplished in the following four months. One month before referral to urology, an ultrasound examination had shown a hydrocele of the left tunica vaginalis testis, thickening of the left perididymis, with a normal appearance of the testis and epididymis (Figure 2A). Ten days previously, a painless intrascrotal nodule had been palpated accidentally and scrotal examination revealed a hard flat mass, 1.5×0.6×0.3 cm in diameter, adhering to the left tunica vaginalis testis. CT scan demonstrated a mass in this area (Figure 2B).

Figure 2A and B. CT scan

Fig2hydrocele-of-the-left-tunica-vaginalis-testis

Serum levels of the tumor-associated proteins CA242 and CA19-9 were significantly elevated to 268 kU/L (normal range 0-20 kU/L) and 372 kU/mL (normal range 0-35 kU/mL), respectively, while those of cancer antigens, carcinoembryonic antigen, neuron-specific enolase, alpha-fetoprotein, prostate specific antigen, CA125, CA15-3 and beta human chorionic gonadotropin were within their normal ranges.

The patient underwent left orchiectomy through an inguinal approach and the mass was found to be densely fixed to the left tunica vaginalis testis but separated from the testis, epididymis and spermatic cord. Frozen sections suggested the mass to be an adenocarcinoma. Interestingly, a left oblique inguinal hernia with greater omentum inside was found and the greater omentum was in direct contact with the lesion of the tunica vaginalis testis. A hernia repair was performed accordingly.

Subsequent biopsy revealed a moderately-differentiated adenocarcinoma infiltrating the tunica vaginalis testis without involvement of the testis or epididymis (Figure 3B). The primary colonic tumor and this tumor shared identical neoplastic glands with intra-cytoplasmic mucin and moderate nuclear pleomorphism (Figure 3A, 3B). Immunohistochemistry was performed using the immunoperoxidase method. The tumor cells showed positivity for Villin (Figure 3C), CK(Figure 3D) and CK20(Figure 3E), but negative for D2-40, TTF1, WT1, Ki67, CK7, SMA, and PSA, which suggested an occult gastrointestinal or colorectal origin of the carcinoma, with a lesser probability of carcinoma of the lung, liver, thyroid, breast, prostate, or hematological system.[1,2]

Discussion

Solid tumor metastasis to the testis and paratesticular region is rare and principally encountered as an incidental autopsy finding.[3] Metastatic carcinoma accounted for respectively five of 112 and nine of 66 paratesticular tumors reviewed.[4,5] The common primary sites of metastasis of the paratesticular tissue are the prostate, kidney, gastrointestinal tract, lung, and breast.[6]

Tumors of the tunica vaginalis testis, both primary and secondary, and whether benign or malignant, are extremely rare.[7,8] Fewer than 10 cases, including our case, have been reported to date in the English and non-English literature,[8–13] and the primary sites for metastatic tumor of tunica vaginalis testis include stomach,[8–10,12] rectum,[11] cecum ,[12] and colon (as in our case). Most cases present with paratesticular mass or hydrocele, and they may or may not be associated with pain.

Metastasis to the paratesticular tissues can be the first sign of tumor recurrence and more rarely present as the first manifestation of an occult primary neoplasm.[14] Our review revealed hydrocele of the tunica vaginalis testis presented as the first clinical manifestation of primary [9] and secondary [8,10–12] and our case tunica vaginalis testis tumors, which suggested that cancerous lesions should be considered in the management of hydrocele, especially in the follow-up of cancer patients. CT or PET-CT is suggested as a rapid and reliable modality for facilitating a preoperative diagnosis.

Clinically, most patients with metastatic paratesticular tumors suffer from a painless intrascrotal mass and the diagnosis is frequently delayed. Hydrocele, inguinal hernia, epididymal cyst, spermatocele and spermatic cord tumors are the most common misdiagnoses of the tumor.[15] The consideration of these diseases in the differential diagnosis of a painless paratesticular mass is critical, as it may allow more precise diagnosis and more targeted treatment, especially in high-risk patients.

Infiltrative lesions of the epididymis [9] and spermatic cord [10,11] can be found in some metastatic tunica vaginalis testis tumor cases, which implies that other primary sites of tunica vaginalis testis metastases may be similiar to primary sites of paratesticular metastatic tumors, and include prostate, gastrointestinal tract, kidney, lung and breast.[15, 16]

Proposed routes of metastasis to the tunica vaginalis testis may include direct extension from adjacent organs, intraductal spread via the vas deferens, retrograde venous and lymphatic extension, arterial embolism [9], and transperitoneal seeding through a patent tunica vaginalis [17] or congenital hydrocele [18]. In our case, the possibility of lymphatic or hematogenous spread was suspected, particularly in view of the primary tumor with lymph node metastasis. However, the presence of a left oblique inguinal hernia in direct contact with the lesion of the tunica vaginalis testis made local tissue invasion another possible mode of spread .[19]

In our review, the median age of patients with metastatic tumor of the tunica vaginalis testis is approximately 62 years, with a reported age range from 50 to 67 years. Tumors metastasising to the paratesticular tissue usually are identified in the setting of disseminated disease and occur only uncommonly as a solitary site of metastasis.[2] The prognosis generally is poor, with the average survival period from the time of diagnosis of the metastasis being 9.1 months.[2] Chemotherapy is the only possible option for the treatment of a secondary tumor at the distant metastatic stage. Our patient completed four cycles of a combined chemotherapy regimen with oxaliplatin (120 mg intravenous [IV] day 1), fluorouracil (500 mg IV days 1 to 2), and calcium folinate (200 mg IV days 1 to 2). He is alive and has been under careful surveillance for about five months up to the time of this report.

In our case and in others reviewed, once paratesticular metastasis had occurred, disease control or cure was negligible.[20] Whether or not a more aggressive approach would lead to a different outcome remains unknown. In some patients, early diagnosis by cytological examination of hydrocele fluid [21] or ultrasound-guided fine-needle aspiration cytology [22] may be helpful for diagnosis and prognosis, as well as treatment of secondary tumors of the tunica vaginalis testis.

To the best of our knowledge, ours is the first case of tunica vaginalis metastasis originating from a primary adenocarcinoma of the ascending colon. Though rare, metastatic lesions of the tunica vaginalis testis should be included in the differential diagnosis of a patient with ambiguous paratesticular masses or in the setting of a hydrocoele. High awareness of this entity may lead to earlier diagnosis and more timely and appropriate treatment, despite the unfavorable prognosis for treatment of secondary tumor of tunica vaginalis testis at present.

References

1.Park SY, Kim HS, Hong EK, et al: Expression of cytokeratins 7 and 20 in primary carcinomas of the stomach and colorectum and their value in the differential diagnosis of metastatic carcinomas to the ovary. Hum Pathol 33:1078-1085, 2002

2.De Lott LB, Morrison C, Suster S, et al:CDX2 is a useful marker of intestinal-type differentiation: a tissue microarray-based study of 629 tumors from various sites. Arch Pathol Lab Med 129:1100-1105, 2005

3.Meacham RB, Mata JA, Espada R,et al:Testicular metastasis as the first manifestation of colon carcinoma. J Urol 116:621-622, 1988

4.Lioe TF, Biggart JD: Tumours of the spermatic cord and paratesticular tissue. A clinicopathological study. Br J Urol 71:600-606, 1993

5.Hartwick RW, Srigley JR, Burns B, et al: A clinicopathologic review of 112 paratesticular tumours[Abstract]. Laboratory Invest 56:83, 1987

6.Algaba F, Santaularia JM, Villavicencio H: Metastatic tumor of the epididymis and spermatic cord. Eur Urol 9:56-59, 1983

7.Plas E, Riedl CR, Pflüger H: Malignant mesothelioma of the tunica vaginalis testis: review of the literature and assessment of prognostic parameters. Cancer 83:2437-2446, 1998

8.Lee J, Kang SC, Ban JH, et al: Metastatic Tumor of Tunica Vaginalis Testis with Hydrocele in a Patient with Gastric Cancer. Korean J Urol 48:667-669, 2007

9.Yeo JK:Scrotal Hydrocele as the First Clinical Manifestation of Occult Gastric Cancer.Korean. J Urol 50:1151-1153, 2009

10.Kageyama Y, Kawakami S, Li G, et al: Metastatic tumor of spermatic cord and tunica vaginalis testis from gastric cancer: a case report . Hinyokika Kiyo 43:429-431, 1997

11.Yasuhide T, Heizo Y, Katsusuke N: Metastatic Tumor of the Tunica Vaginalis Testis Arising from Rectal Cancer:A Case Report. Nishinihon Journal of Urology 61:245-247, 1999

12.Wai HP, Yau TK, Sze WM, et al:Metastatic tumour of the tunica vaginalis testis from carcinoma of the stomach. Int J Clin Pract 54:685-686, 2000

13.Ruiz JM, Sanchis CM, López PC, et al: Metastasis to the tunica vaginalis testis from a primary mucinous tumor of the cecum. Arch Esp Urol 63:235-238, 2010

14.Bennett VS, Bailey DM: Cholangiocarcinoma presenting as a solitary epididymal metastasis: a case report and review of the literature. Diagn Pathol 2:33, 2007

15.Beccia DJ, Krane RJ, Olsson CA. Clinical management of non-testicular intrascrotal tumors. J Urol 116:476-479, 1976

16.Algaba F, Santaularia JM, Villavicencio H: Metastatic tumor of the epididymis and spermatic cord. Eur Urol 9:56-59, 1983

17.Dutt N, Bates AW, Baithun SI: Secondary neoplasms of the male genital tract with different patterns of involvement in adults and children. Histopathology 37:323-331, 2000

18.Hanash KA, Carney JA, and Kelalis PP: Metastatic tumors to the testicles:routes of metastasis. J Urol 102: 465-468, 1969

19.Galanis I, Chatzimavroudis G, Katsougiannopoulos A, et al: Spermatic cord metastasis presenting as strangulated inguinal hernia – first manifestation of a multifocal colon adenocarcinoma: a case report. Cases J 2:61, 2009

20.Charles W, Joseph G, Hunis B, et al: Metastatic colon cancer to the testicle presenting as testicular hydrocele. J Clin Oncol 23:5256-5257, 2005

21.Gupta SC, Gupta AK, Misra V, et al: Pre-operative diagnosis of malignant mesothelioma of tunica vaginalis testis by hydrocele fluid cytology. Eur J Surg Oncol 24:153-154, 1998

22.Bruno C, Minniti S, Procacci C:Diagnosis of malignant mesothelioma of the tunica vaginalis testis by ultrasound-guided fine-needle aspiration. J Clin Ultrasound 30:181-183, 2002

Date added to bjui.org: 19/02/2012

DOI: 10.1002/BJUIw-2011-067-web