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Presented by Dr. Jonathan Epstein and prepared by Dr. Robby Jones.
History: A 54 year old man was found to have a paratesticular mass at the time of a hydrocele repair.
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1. Question
Choose the correct diagnosis:
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Answer: C. Well-differentiated papillary mesothelioma of uncertain malignant potential
Histology: Multiple nodules were present on the tunica vaginalis. In areas the tumor was composed of simple papillary structures lined by single layer of cuboidal cells. Other areas had more complex papillary architecture with tubular component, focal fusion of papillae with stratification of lining cells and focal cribriform formation. Invasion into the underlying connective tissue was not present. Cytologically, the cells were bland and relatively uniform with only modest amount of eosinophilic cytoplasm. Mitotic figures were not present.
Discussion: All of the choices in this case are mesotheliomas. We don’t use the term “mesothelioma” for an adenomatoid tumor, despite it having all the immunohistochemical features of a mesothelioma, since it is a well-characterized benign entity that has been known as “adenomatoid tumor”. Adenomatoid tumors typically involve the epididymis and not the tunica vaginalis. They are composed of tubules, lined by flattened often vacuolated cells, that are embedded within either a fibrous or smooth muscle stroma, not resembling the papillary morphology seen in the current case. Malignant mesotheliomas typically have greater cytological atypia, increased mitotic activity, and infiltrate beneath the surface mesothelium lining the tunica. Well-differentiated papillary mesothelioma is composed entirely of simple papillary structures lined by single layer of cuboidal cells, and behaves in a benign fashion but can be multifocal. The term of well-differentiated papillary mesothelioma of uncertain malignant potential is used for well-differentiated papillary mesothelioma with areas having more complex architecture, yet without cytological atypia and invasion. Although to date these borderline lesions have also behaved in a benign fashion, because experience with them is limited their benign diagnosis is qualified with “uncertain malignant potential”.Mesothelioma of the tunica vaginalis: a series of eight cases with uncertain malignant potential.
Brimo F, Illei PB, Epstein JI.
Mod Pathol. 2010 Aug;23(8):1165-72.Incorrect
Answer: C. Well-differentiated papillary mesothelioma of uncertain malignant potential
Histology: Multiple nodules were present on the tunica vaginalis. In areas the tumor was composed of simple papillary structures lined by single layer of cuboidal cells. Other areas had more complex papillary architecture with tubular component, focal fusion of papillae with stratification of lining cells and focal cribriform formation. Invasion into the underlying connective tissue was not present. Cytologically, the cells were bland and relatively uniform with only modest amount of eosinophilic cytoplasm. Mitotic figures were not present.
Discussion: All of the choices in this case are mesotheliomas. We don’t use the term “mesothelioma” for an adenomatoid tumor, despite it having all the immunohistochemical features of a mesothelioma, since it is a well-characterized benign entity that has been known as “adenomatoid tumor”. Adenomatoid tumors typically involve the epididymis and not the tunica vaginalis. They are composed of tubules, lined by flattened often vacuolated cells, that are embedded within either a fibrous or smooth muscle stroma, not resembling the papillary morphology seen in the current case. Malignant mesotheliomas typically have greater cytological atypia, increased mitotic activity, and infiltrate beneath the surface mesothelium lining the tunica. Well-differentiated papillary mesothelioma is composed entirely of simple papillary structures lined by single layer of cuboidal cells, and behaves in a benign fashion but can be multifocal. The term of well-differentiated papillary mesothelioma of uncertain malignant potential is used for well-differentiated papillary mesothelioma with areas having more complex architecture, yet without cytological atypia and invasion. Although to date these borderline lesions have also behaved in a benign fashion, because experience with them is limited their benign diagnosis is qualified with “uncertain malignant potential”.Mesothelioma of the tunica vaginalis: a series of eight cases with uncertain malignant potential.
Brimo F, Illei PB, Epstein JI.
Mod Pathol. 2010 Aug;23(8):1165-72.
