Results
The men in this case series had a variety of exposures to asbestos. Many were exposed as children during home renovation work or to dust brought by relatives to their homes. Adult exposures included those from home renovation and construction work, vehicle maintenance, shipyard work and exposures at railroads. The pattern of exposures is similar to that described by Welch and colleagues in a case series of men with peritoneal mesothelioma and by Boffetta in a review of peritoneal mesothelioma in cohort studies.
Conclusion
Malignant mesothelioma of the tunica vaginalis testis is a variant of peritoneal mesothelioma and shares similar asbestos causation.
During normal human embryonic development, the testes descend from the abdominal cavity to the scrotal sac. Passage occurs through the processus vaginalis, which arises as an outpouching of the parietal peritoneum at the beginning of the third month of gestation. After the testis descends into the scrotum (between 7 and 9 months of gestation), the processus vaginalis is normally obliterated. However, the processus vaginalis remains patent at birth in 20% of the population. Most boys born with a patent processus vaginalis remain asymptomatic throughout life, but incomplete closure of the processus vaginalis may lead to a variety of abnormalities. Complete patency may result in a communicating hydrocele or a congenital inguinoscrotal hernia.
Nine men diagnosed with malignant mesothelioma of the tunica vaginalis testis sought legal representation with law firms in the United States. Their personal, medical and work histories, and information about their asbestos exposures, were developed in the usual course of litigation through investigation, record collection, deposition testimony, written discovery and consultation with expert witnesses. This information was collected by the subjects’ various lawyers during their legal cases and was provided, with express written permission, to the principal author who sought it out and collected it for purposes of this report.
Results
Case 1:
Case 1 is a Caucasian male aged 60 years at the time of diagnosis. Malignant mesothelioma was diagnosed on the right side of the scrotum after surgical biopsy and immunohistochemical staining. Surgical resection of the tumour, testicle, spermatic cord, tunica vaginalis, tunica albuginea and epididymis was performed. The subject died 15 months after diagnosis following tumour recurrence.
The subject was first exposed to asbestos around the age of 8 or 9 (53 years prior to diagnosis) years when his father removed asbestos insulation from the heating pipes in the basement of the family home. The asbestos fibre type in that insulation is unknown. In the mid- to late-1970s, he had exposure to chrysotile-containing products such as joint compound, furnace cement, flooring and roofing materials while doing renovation and repair work on his homes. While working as a civil engineer for a road contractor, in the 1970s, he had frequent exposure to dusts from crocidolite- and chrysotile-containing asbestos-cement pipe used for sewers and water lines. Some of this exposure was as a supervisor/bystander and some was hands-on cutting and grinding the pipe with power tools. He also had occasional bystander exposure at his employer’s garage to friction products and gaskets (likely chrysotile-containing) used with the construction equipment during routine maintenance and repair work.
Case 2:
Case 2 is a Caucasian male aged 70 years at the time of diagnosis. Malignant mesothelioma (epithelioid type) was diagnosed on the right side of the scrotum after surgical biopsy and immunohistochemical staining. The tumour involved the tunica vaginalis and tunica albuginea and invaded into the testis and lymphatics. Surgery was performed 5 weeks after diagnosis, including resection of the right scrotal sac, testis, epididymis and vas deferens. He was still alive 46 months after diagnosis with no known recurrence.
He was first exposed to asbestos as a young child (64 years prior to diagnosis) through household contact with his father and intermittent contact with an uncle, both of whom worked at a local shipyard during World War II. The asbestos fibre type from any potential exposure through the shipyard is unknown but is likely to have been mixed. He had sporadic paraoccupational exposure to asbestos through work on home renovation projects in the late 1950s and 1970s that included the use of chrysotile-containing joint compound, flooring material and home siding. Occupationally, he worked as a professional vehicle and equipment mechanic for 30 years from the 1950s to the 1980s including some time as a professional truck driver. He also performed maintenance work on family automobiles and farm equipment. These automotive and equipment exposures included chrysotile-containing friction materials, chrysotile-containing gaskets, chrysotile-containing automotive undercoatings and amphibole-containing (crocidolite and anthophyllite) automatic transmission parts. Many vintage samples of these products were recovered from the workshop at his home. Every chrysotile product that was tested revealed some level (all <1%) of amphibole contamination (mostly tremolite/actinolite with occasional amosite or ‘other amphibole’). Crocidolite and anthophyllite in the automatic transmission parts was confirmed by light microscopy and transmission electron microscopy. In the case of the crocidolite parts, crocidolite was also confirmed by the product manufacturer’s material safety data sheets.
Case 3:
Case 3 is a Caucasian male aged 59 years at the time of diagnosis. He sought treatment for a right-sided testicular mass (present for approximately 5 years prior), and a diagnosis of malignant mesothelioma of the tunica vaginalis testis (epithelioid type) was made by surgical biopsy. Computed tomography scans of his chest revealed bilateral pleural plaques and possible evidence of fibrosis. He was still alive 71 months after diagnosis.
He was first exposed to asbestos 48 years prior to his diagnosis when he began to help his father with building renovation work involving the use of chrysotile-containing drywall taping compounds and floor tiles, and potentially other products of mixed fibre types used in the renovation work. He was later exposed to asbestos from chrysotile-containing drywall taping compounds and floor tiles while helping a family member on residential electrical jobs. He served in the United States Navy for 4 years and repaired aircraft turbines during two of those years while stationed aboard an aircraft carrier (mixed fibre types). He also worked many years for the railroad where he had additional exposures to insulation and other materials (mixed fibre types).
Case 4:
Case 4 is a Caucasian male aged 44 years at the time of diagnosis. Malignant mesothelioma (epithelioid type) of the spermatic cord was diagnosed on the right side of the scrotum by surgical biopsy and immunohistochemical staining. Surgical resection of the tumour, right testicle and spermatic cord was performed less than 1 month after diagnosis. The tumour recurred repeatedly over the course of the next year, including on the left side, and required additional surgeries and biopsies. Each subsequent biopsy confirmed the original diagnosis of malignant mesothelioma. Disease progression continued, and he died later that year at the age of 45 (14 months after diagnosis) years.
He was first exposed to asbestos 26 years prior to his diagnosis when he began work as a ‘scrapper’ and equipment operator for a mining company (fibre type unknown). He worked for 24 years in the service department at an auto-dealership as a mechanic and later as a service consultant. He was exposed to asbestos from his own work on brakes and from the work of others working with brakes (most likely chrysotile with probable trace levels of tremolite/actinolite).
Case 5:
Case 5 is a Hispanic male aged 74 years at the time of diagnosis. Malignant mesothelioma was diagnosed on the right side after an ‘inguinal canal mass’ was discovered during surgery for an elective hernia repair. Pathological examination and additional immunohistochemical staining confirmed the diagnosis of mesothelioma originating in the tunica vaginalis testis. A right orchiectomy was performed a few months after diagnosis. Chest radiographs were suggestive of bilateral pleural thickening and pleural asbestosis. Over the next 2 years, the tumour recurred, and abdominal scans and subsequent biopsies confirmed the diagnosis of mesothelioma and showed metastatic disease around the liver, in the lymph nodes and in the peritoneum. He died at the age of 79 (54 months after diagnosis) years.
He was first exposed to asbestos 58 years prior to his diagnosis when he began a lengthy career as a Longshoreman in the shipping industry (likely mixed fibre types).
Case 6:
Case 6 is an African-American male aged 63 years at the time of diagnosis. Malignant mesothelioma (epithelioid type) was diagnosed on the right side of the scrotum after surgical biopsy and immunohistochemical staining. The tumour quickly metastasized to the kidney and lungs, and he died only 1 month after diagnosis.
He was first exposed to asbestos (fibre types unknown) 48 years prior to his diagnosis when he began work as a maintenance mechanic at an automobile manufacturing plant, which included exposure to asbestos products used in the physical plant of that facility. He held that job for approximately 8 years. Further investigation into his work history is still ongoing.
Case 7:
Case 7 is a Caucasian male aged 51 years at the time of diagnosis. Malignant mesothelioma (epithelioid type) of the tunica vaginalis was discovered during a left-sided hydrocelectomy. The tunica vaginalis, tunica albuginea, spermatic cord, vas deferens, testicle and a section of scrotal skin were removed during surgery. The diagnosis was confirmed by a combination of cytology, surgical pathology and immunohistochemical staining. There has been no known recurrence to date (54 months from diagnosis).
He was first exposed to asbestos during his childhood, approximately 41 years prior to his diagnosis, when he began to assist his father on weekends with automotive brake and clutch work at his father’s place of employment (most likely chrysotile-containing friction products with trace tremolite/actinolite). His own subsequent employment included 2 years working at a major military installation in a job that involved sweeping up the motor pool repair shop. He also worked for approximately 18–24 months as a truck driver, which sometimes included picking up, hauling and delivering asbestos-cement pipe (crocidolite- and chrysotile-containing). These runs would variously include picking up the pipe at the manufacturing plant or at a local supply house, unloading the pipe at his employer’s warehouse, sweeping the truck after deliveries and delivering pipe to construction sites. He was also responsible for sweeping his employer’s warehouse, including areas where the pipe was stored and where the pipe was cut by other workers using a power saw. He later worked for another trucking company for approximately 3 years and occasionally picked up, loaded and delivered asbestos-cement pipe (crocidolite- and chrysotile-containing) and swept the truck.
Case 8:
Case 8 is a Caucasian male aged 51 years at the time of diagnosis. Malignant mesothelioma of the tunica vaginalis was diagnosed on the right side by surgical pathology and immunohistochemical staining. Two surgeries were performed that included the removal of the right testicle and spermatic cord, along with an epididymal mass, a scrotal scar and a right hydrocele sac. There has been no known recurrence to date (43 months from diagnosis).
He was first exposed to asbestos 31 years prior to diagnosis when he worked as a commercial and residential painter and was exposed to dust from a variety of construction activities, including the sanding of sheetrock (fibre types unknown but likely included chrysotile-containing taping compounds). He later worked a very short period of time as a contractor doing painting, sandblasting and cleaning work at petrochemical plants (fibre types unknown). He also had paraoccupational exposure to asbestos over many years doing automotive repair work to various vehicles owned by himself and by friends, including gaskets, brakes and clutches for motorcycles, cars and light trucks (likely chrysotile-containing with trace tremolite/actinolite).
Case 9:
Case 9 is a Caucasian male aged 65 years at the time of diagnosis. Malignant mesothelioma (epithelioid type) was diagnosed by surgical pathology and immunohistochemical staining. The tumour involved the right testicle, spermatic cord and ‘peritesticular soft tissue’. Two years after the initial diagnosis and treatment, the tumour recurred on the left side and within 6 months had spread to the shaft of the penis, resulting in additional surgery and requiring the removal of the left testicle and the penis itself. There has been no known recurrence since that time. He is now 39 months from his initial diagnosis.
He was first exposed to asbestos 49 years prior to his diagnosis when he first started working on his own automobiles, changing brakes, clutches and gaskets (likely chrysotile), which he continued to do for approximately 20 years. He also worked as a professional auto mechanic for 3 years where he had exposure to brakes, clutches and gaskets (likely chrysotile).
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