Posted on July 6, 2018
By Francisco Báez Baquet
Dedication: To all the victims of asbestos … who never knew they had been.
Faced with a supposed relative deficit, of connection
The relationship between exposure to asbestos and paratesticular mesothelioma is already deduced from the same statement of the titles of several articles in the medical literature: Attanoos & Gibbs (2000), Candura et al. (2008), Chollet (1999), Fligiel & Kaneko (1976), Gisser et al. (1977), Gorini et al. (2005), Hsu et al. (2014), Huncharek et al. (1995), Ikegami et al. (2008), Karunaharan (1986), Meisenkothen & Finkelstein (2013), Mensi et al. (2012), Mirabella (1991), Schneider & Woitowitz (2001), Skammeritz et al. (2011). Exceptionally, that mention of asbestos in the title of the work, will be to deny the relationship, in the case of the specific patient addressed in it: Goel et al. (2008).
In some cases, this relationship is supported by a poly-morbid condition, in which the same patient is simultaneously subjected to malignant mesothelioma settled in gonads, and to other asbestos-related pathologies: Watanabe et al. (1994). However, and unlike what happens with other settlements of malignant mesothelioma, only in a minority of cases is it possible to demonstrate this relationship.
Thus, for example, in Plas et al. (2000), we will be told that: “Reviewing the literature on asbestos exposure and mesothelioma of the tunica vaginalis, a positive history was confirmed for 34.2% of patients.”
Similarly, in Mirabella (1991), the figure is of the 31.5%. In his own cohort, in Butnor et al. (2001), that proportion will be of the 42.86% (6/14).
The essential issue that we wish to highlight, is defined when, in the work of Amin (2005), the author states that: “Exposure to asbestos remains the only known risk factor and is documented in more than a third of the cases. However, the information about the exhibition may not have always been adequate.”
A case of pleuro-pulmonary metastasis of primary malignant mesothelioma settled in the tunica vaginalis is described in Pannier et al. (2011). This demonstrates, in our opinion, the convenience or necessity of a clinical examination -analytical, radiological- that allows discarding, or if necessary confirming, the possible coexistence of such co-morbidities. See also: Ehya (1984), Dietemann-Molard et al. (1987).
A case of simultaneous mesothelioma involvement of the tunica vaginalis and the pleura is also described in Müller et al. (2008), while in Ascoli et al. (1996) we have described another, in which the concomitant involvement in the same patient was due to pleural mesothelioma, peritoneal mesothelioma, and also primary mesothelioma, settled in tunica vaginalis testis.
Coincident involvement, due to malignant peritoneal mesothelioma and benign and localized testicular mesothelioma, is described in Acuña Torres (1959).
The recognition of a situation of previous exposure to asbestos, favors the comprehension, in general, of the etiological panoply of the disease, but, at the same time, it also favors the specific therapeutic strategy against the specific case of each patient to be treated, and so we will have, for example, that in Liguori et al. (2007), the authors indicate that “The diagnosis should be suspected in all patients exposed to asbestos and who present clinical symptoms of fast-growing hydrocele”.
Therefore, no deontological scruple can be formulated, in general terms, with respect to any diagnostic maneuver that aims to clear up any question regarding a possible previous exposure to asbestos.
If we raise the question about whether in the list of works with which we headed this article, whose list includes those articles in which asbestos is already cited in the title, asking us if they correspond in most or all to authors who have other works related to asbestos, other than those mentioned here, the answer must be affirmative.
At the same time, if we ask a similar question, but contrary, for the rest of the works included in the bibliography related to malignant mesothelioma based on the attributes of masculinity, but this time without mention of asbestos, questioning whether the authors what is the difference between asbestos, the answer must also be affirmed: indeed, this absence is observed.
This context leads us to doubt about the question whether the comparatively meager proportion of mesotheliomas of the aforementioned settlement, with a recognized connection with the condition of the previous exposure to asbestos, can not be determined, at least in part, by the distance that of its habitual professional familiarity, it can suppose, for urologists, nephrologists, or surgeons of the urogenital system, etc., the strategies of investigation or diagnostic techniques required to be able to make present that hypothetical previous exposure, that would need to clarify.
Indeed, and in our view, that presumed prior exposure, would have come clarified, relying on the tripod that provide three types of evidence: anamnesis, verification of other asbestos-related pathologies, eventually concomitant, and possible presence of asbestos fibers and / or “asbestos bodies”, in the tissues or exudates of the patient.
This set of inquiries, are specified, always according to our personal criteria, in a decalogue of precise inquiries to clarify that possible prior exposure, according to the enumeration that we will address next.
It should not be limited to what is merely remembered by the patient and / or his relatives, but should include all kinds of documentary evidence that is accessible.
In the case of Spain, we will have the official document known as “working life”, issued by the National Institute of Social Security (INSS), which includes (exhaustively, provided that no illegal situations of ” submerged economy” have occurred), all the companies in which the patient has worked throughout his work activity.
Obviously, this document is only the first step of verification, since afterwards it has to subtract all a “detective” work of inquiry of the respective industrial sectors corresponding to those companies, etc., etc.
More problematic is the identification of situations of environmental exposure, by neighborhood with respect to the industrial focus of pollution by asbestos, either in respect of the home, or by proximity to the workplace.
Regarding the latter, special attention should be given to competition in the industrial polygons, with industries clearly linked to the industrial use of asbestos, as has been the case, for example, large motor vehicle repair shops (including replacement brake shoes of motor vehicles) or the manufacture of home appliances that incorporated among their raw materials the aforementioned mineral, of deadly effects.
Here the relevance, almost the necessity, of a brief reflection on what the remedy supposes, often a mere palliative, consisting of the recourse to radical orchiectomy or emasculation -surgical castration-, is required to face the outcrop of a paratesticular mesothelioma , that if badly it does not come it could have been originated, merely by the chance that our domicile was located in proximity to where a company took the decision to install a factory in which the asbestos was going to be one of the raw materials managed in the manufacture of your product, to be able to sell it, and thus be able to obtain the corresponding private economic benefits.
The quantification of the previously identified exposure is a punctilious aspiration, difficult to comply with, and that can even induce errors of appreciation, by attributing hypothetical values, by extrapolation or by interpolation, which in fact may not correspond to those actually occurred.
The possible observation in the patient of this type of deformation in the hands, will be indicating the possible concurrence with other asbestos-related ailments.
The finding of the presence of inspiratory basal crepitations, we would be pointing out the possible involvement of the bronchial tree and / or the parenchyma surrounding it, probably because of a previous exposure to asbestos.
Exploration of lung function
The eventual presentation of a restrictive or mixed pattern will also be pointing out the contingency of a possible asbestosis.
Gas exchange evaluation
In accordance with the general condition of the patient, the opportunity to carry out tests that, as is the case of evaluation of gas exchange, could allow the eventual early detection of an asbestosis, before what would have made it manifest the radiological exploration.
It will detect the possible presence of pleural plaques, pleural thickening, incipient asbestosis, etc., pathognomonic signs that share the condition of being asymptomatic or paucisymptomatic, especially in their respective initial phases.
The possible presence of the so-called “asbestos bodies”, and their quantification, in the sputum, can allow to verify the previous exposure to the asbestos. It is a non-invasive technique that is easy and economical to perform (optical microscopy).
Histological examination of resected tissues
La extirpación quirúrgica de los tejidos constitutivos del órgano afectado por el mesotelioma, permite intentar constatar, mediante microscopía electrónica, la eventual presencia de fibras de amianto, y su cuantificación, como medio de poder confirmar, en su caso, la exposición previa al contaminante.
The surgical extirpation of the constitutive tissues of the organ affected by mesothelioma, allows us to try to verify, by means of electronic microscopy, the possible presence of asbestos fibers, and their quantification, as a means of being able to confirm, if necessary, the previous exposure to the contaminant.
We believe that only the exhaustive exhaustion of a whole protocol of action such as the one described here, can justify, in your case, that it can be asserted that no evidence of previous exposure to asbestos has been found.
As we have had occasion to appreciate, this is a set of checks, which exceed, in general, the usual professional skills and competencies that are usually attributed to practitioners of medical specialties that usually deal with cases of mesothelioma settled in the male reproductive organ.
As a consequence, the different – less – proportion in which mesotheliomas with such a concrete settlement are usually linked to previous exposure to asbestos, could merely obey, with a high probability of actually being so, the mere fact that they may not be have exhausted all reasonably imaginable forecasts, to have been able to achieve it.
The access link to the “Dropbox” file that contains it is then provided: https://www.dropbox.com/s/qjk5rlus3wq3lgm/Bibliograf%C3%ADa%20sobre%20mesotelioma%20paratesticular.doc?dl=0