JCU - January 2022 - 42

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Journal of Clinical Urology 15(1)
Figure 1. Patient A. (a) Ultrasound imaging demonstrating large complex left hydrocele with internal debris and several anechoic
bubble-like areas within. There are several irregular echogenic masses contiguous with and adjacent to the left testis, some with
blood flow that appear to extend through the tunica. (b-d). Magnetic resonance images showing multiple nodular and polypoid
masses with frond-like elements and enhancement within the left hemiscrotum, the largest measuring about 1.8 cm. Several of the
larger lesions abut the periphery of the hydrocele along the inner scrotal wall that do not abut the testicle.
The second patient (patient B) is a 47-year-old man who
presented with painless, gradually enlarging right-sided scrotal
swelling. Clinical examination suggested a right-sided
hydrocele. Scrotal ultrasound confirmed a right hydrocele
without additional suspicious scrotal masses. Intraoperatively,
the patient was found to have a small tunica vaginalis papillary
mass after opening the hydrocele sac. The papillary
mass was completely removed with a grossly clear margin
and the hydrocele sac was excised. Radical orchiectomy was
not performed. Pathology revealed a well-differentiated papillary
tumor with mildly pleomorphic, bland, evenly spaced
mesothelial cells and low mitotic index. There were areas of
fibrotic sarcomatoid stroma with spindling and nuclear pleomorphism.
Immunohistochemical stains were performed
and demonstrated the malignant cells to be positive for calretinin,
cytokeratin 7, AE1/AE3, WT-1, D2-40, and Pax-8,
and negative for CK20 and Ber-EP4. Overall, the histologic
and immunophenotypic findings supported WDPM (Figure
3(a-d)). Multidisciplinary case review recommended surveillance
without adjuvant therapy with history and physical
exam and scrotal ultrasound every 6 months. He has had no
recurrence of disease over 24 months of follow-up.
Discussion
Mesotheliomas arise from malignant transformation of
mesothelial cells that line coelomic cavities. The tunica
vaginalis is a rare site, with fewer than 250 cases reported

JCU - January 2022

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