Radical and Partial Orchiectomy for Testicular Mesothelioma

 

Testicular mesothelioma is a rare cancer that develops in the thin layer of tissue surrounding the testicles, known as the tunica vaginalis. It accounts for less than 1% of all mesothelioma cases and is caused by exposure to asbestos. With fewer than 300 cases reported worldwide, this condition presents unique challenges for diagnosis and treatment.

An Overview of Testicular Mesothelioma: Causes, Symptoms, and Diagnosis

The tunica vaginalis is a protective membrane around the testicles, and testicular mesothelioma begins in the cells that form this lining. Exposure to asbestos is the cause, typically from occupational settings where the material was handled. The condition most commonly affects men aged 55 to 75, with risks increasing over time.

 

Symptoms are often subtle and can resemble non-cancerous issues. Approximately 65% of patients experience swelling or a noticeable mass in the scrotum, while about 55% have hydrocele, which causes a sense of heaviness due to fluid accumulation. Pain is less frequent early on, affecting around 11% of cases, but may develop as the disease progresses. In some instances, it is discovered incidentally during evaluations for other concerns, such as symptoms similar to an inguinal hernia.

 

Diagnosis usually involves a series of tests. Scrotal ultrasound is common, used in about 48% of cases, to identify masses, irregular thickening, or fluid collections. CT scans, performed in 40% of diagnoses, help determine if the cancer has spread. MRI or PET scans may provide further clarity when needed. Blood tests check for tumor markers like alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH) to distinguish it from other testicular cancers. Final confirmation comes from examining tissue samples under a microscope, often obtained through biopsy or during surgery. The cancer is classified into types: epithelioid (about 60%), biphasic (around 22.5%), or sarcomatoid.

 

Given its rarity, treatment approaches draw from experiences with similar cancers. Early detection offers the best chance for effective management.

The Importance of Surgery in Managing Testicular Mesothelioma

Surgery is the foundation of treatment for testicular mesothelioma, carried out in nearly 98% of cases. The primary aim is to remove the cancer entirely and reduce the risk of it returning. The two main procedures are radical orchiectomy, which is the most frequently used, and partial orchiectomy, applied in specific situations. Decisions depend on factors such as the tumor’s size and location, the patient’s age, and considerations like preserving fertility. These methods are adapted from protocols for other testicular cancers, accounting for the aggressive behavior of mesothelioma.

Radical Orchiectomy: The Primary Surgical Approach

Radical orchiectomy is the standard procedure, performed in about 75% of cases. It involves removing the entire affected testicle and the spermatic cord—the structure containing blood vessels, nerves, and tubes connecting the testicle to the body. The surgery is done through an incision in the groin to minimize the chance of cancer cells spreading, avoiding direct access through the scrotum.

 

The process typically proceeds as follows: Under general or regional anesthesia, the surgeon makes an incision above the pubic bone. The spermatic cord is clamped early to prevent cell dissemination, and the testicle is removed as a single unit. If lymph node involvement is suspected, these may be sampled or removed during the same operation. The procedure lasts about 45 to 60 minutes, with most patients discharged the same day or after a short hospital stay.

 

This approach is preferred because it provides the highest likelihood of complete removal, particularly for cancers that tend to invade nearby tissues. In early-stage cases, it can achieve disease-free survival in up to 80% of patients. However, residual cancer at the edges occurs in 5-43% of surgeries, which can increase recurrence risks.

 

Complications are uncommon, including infection or hematoma in 1-2% of cases, or temporary numbness in the thigh from nerve irritation. Removal of one testicle generally does not impact hormone levels or sexual function, as the remaining testicle compensates. In rare bilateral cases, hormone replacement therapy may be needed to address symptoms like fatigue or mood changes. For those concerned about fertility, sperm banking is recommended before surgery. Prosthetic implants are an option to restore appearance and can be placed during or after the procedure.

Partial Orchiectomy: A More Conservative Option

Partial orchiectomy involves removing only the tumor and a surrounding margin of healthy tissue, preserving the rest of the testicle. This method is less common for testicular mesothelioma due to the cancer’s potential to be multifocal or infiltrative, which raises the risk of incomplete removal and recurrence. It is considered for small, localized tumors, especially in younger patients who wish to maintain fertility or hormonal balance, or when only one testicle is present.

 

During the operation, ultrasound guides the surgeon to the tumor, and immediate tissue analysis ensures clear margins. The incision may be in the scrotum or groin. Insights from related cancers indicate that this preserves normal function in over 90% of early cases without affecting survival rates.

 

Advantages include retaining natural hormone production and fertility potential. Risks involve possible bleeding, infection, or the need for follow-up surgery if cancer remains (5-10%). While not routine for this condition, it offers a balanced choice in appropriate scenarios.

Complementary Treatments Used with Surgery

For localized disease, surgery alone may suffice, but additional therapies are often incorporated to target any remaining microscopic cells, especially in higher-risk situations. These adjuvant options are informed by treatments for other mesotheliomas, adapted due to the limited data on testicular cases.

 

Chemotherapy is utilized in approximately 10% of patients, usually after surgery. Common regimens include platinum-based drugs like cisplatin or carboplatin combined with pemetrexed, administered intravenously over 4-6 cycles. Alternatives such as doxorubicin or gemcitabine may be used if needed. This helps control residual disease, particularly with lymph node involvement. Side effects can include nausea, fatigue, kidney effects, or nerve sensitivity, but supportive medications manage these effectively.

 

Radiation therapy is applied in about 9% of cases to focus on remaining cancer or affected areas, using doses of 25-60 Gy. It can reduce recurrence by 30-50% in incomplete resections. Care is taken to protect sensitive tissues, though potential issues like skin changes or fertility impacts are monitored.

 

Innovative treatments are emerging, such as immunotherapy with agents like nivolumab, which activates the immune system against cancer cells showing specific markers. It is used off-label based on success in other mesotheliomas. Targeted therapies for genetic changes, such as BAP1 mutations, are in development through clinical trials. Multimodal combinations—surgery with chemotherapy and radiation—appear to offer the strongest outcomes, though overall survival benefits are still under study (median around 24 months).

 

In cases with abdominal spread, techniques like hyperthermic intraperitoneal chemotherapy (HIPEC) may be explored, involving heated drugs applied during surgery. Participation in clinical trials can provide access to advanced approaches; consulting your healthcare team is advised.

Recovery Process, Potential Outcomes, and Ongoing Care

Recovery from orchiectomy is generally straightforward. Discomfort lasts about a week, managed with pain relief and rest. Avoid strenuous activities for 4-6 weeks. Regular follow-up scans, starting every 3-6 months, monitor for changes. Hormone monitoring and replacement, if necessary, address any deficiencies. Emotional and psychological support is important, as body image concerns may arise.

 

Prognosis is more favorable than for other mesotheliomas, with 5-year survival at 49% and 10-year at 33%. Positive indicators include smaller tumors (under 4 cm), no spread, and epithelioid type. Recurrence occurs in 42% of cases, often locally or in distant sites like lymph nodes or lungs, typically within two years, emphasizing the need for consistent surveillance.

Final Thoughts: Support for Your Journey

Testicular mesothelioma requires a thoughtful treatment plan, with radical orchiectomy as the core method and partial orchiectomy for select cases. Integrating chemotherapy, radiation, or emerging therapies enhances control. At Unbreakable Journeys we offer mesothelioma resources, community connections, and encouragement to help you navigate this path. Contact us today to connect with others from the mesothelioma community. Always discuss options with your medical team for personalized guidance.