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Images in Clinical Urology Preoperative Diagnosis of Malignant Mesothelioma of the Tunica Vaginalis Using Doppler Ultrasound Piyush Aggarwal, Abhinav Sidana, Sadaf Mustafa, and Ronald Rodriguez Malignant mesothelioma (MM) of the tunica vaginalis is a rare aggressive tumor with a high predilection for metastatic spread. Because there is no preoperative diagnostic modality available, it has high recurrence and mortality rates, which emphasizes the importance of early preoperative diagnosis for proper and adequate treatment. We describe a case of MM of the tunica vaginalis in a 73-year-old man who presented with hydrocele and was preoperatively diagnosed with MM using Doppler in addition to scrotal ultrasound. He underwent early radical orchiectomy through an inguinal approach, resulting in improved survival. UROLOGY 75: 251–252, 2010. © 2010 Elsevier Inc. A 75-year-old man presented with a painless left scrotal enlargement for a year. Examination re- vealed a tense transilluminating hydrocele with nonpalpable testis. Ultrasound revealed small masses aris- ing from tunica vaginalis with a central vascular stalk. Doppler ultrasound demonstrated increased signal in the stalk. On the basis of examination, sonogram, and Doppler ultrasound, malignant mesothelioma (MM) was suspected and the patient underwent radical orchiectomy. Patho- logic findings were consistent with MM. The patient remained recurrence-free until 30 months when com- puted tomography scan demonstrated enlarged para-aor- tic nodes. Retroperitoneal lymph node dissection re- vealed metastatic disease. He presented 2 years later with tumor deposits in skin and enlarged abdominal nodes on computed tomography. Palliative radiotherapy was insti- tuted. Subsequent scans demonstrated metastatic disease in the lungs and liver. He later succumbed to his illness in hospice, 76 months after surgery. Radical orchiectomy through an inguinal approach is the recommended surgical treatment of MM, recurrence From the James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland Reprint requests: Piyush Aggarwal, M.B.B.S., Department of Urology, Johns Hopkins Hospital, Marburg 205B, 600 N Wolfe Street, Baltimore, MD 21287. E-mail: [email protected] Submitted: January 19, 2009, accepted (with revisions): July 31, 2009 Figure 1. Scrotal ultrasound showing polypoid masses (solid arrows) arising from tunica vaginalis (arrow) into hy- drocele fluid. Figure 2. Doppler showing increased signal (solid arrow) in the fibrovascular stalk of a tumor nodule. © 2010 Elsevier Inc. 0090-4295/10/$34.00 251 All Rights Reserved doi:10.1016/j.urology.2009.07.1275
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