Case Reports in Medicine clinical ﬁndings usually could not point out the diagnosis of malignant mesothelioma. Firm, painless scrotal mass accom- panied by a reactive hydrocele is the usual presentation. The hydrocele or the mass itself may gradually increase in size [3]. The diagnosis can sometimes be made only after presentation with a recurrent hydrocele or invasion of the scrotum [15]. Similarly, our case had a history of longstanding scrotal pain and swelling suggestive of epididymitis. Suspected diagnosis should be conﬁrmed with imag- ing modalities such as ultrasonography and computerized tomography. On ultrasonography, malignant mesothelioma is usually characterized by a hypoechoic hydrocele with het- erogeneous masses of increased echogenicity at the periphery [16]. However, ultrasonographic appearance may not be conclusive about the nature of the disease process. This was the fact in our patient whose ultrasonographic ﬁndings were limited to moderately enlarged hydrocele and epididymal engorgement. Radical inguinal orchiectomy is accepted as the optimal treatment for paratesticular malignant mesothelioma [12]. However, given the inconclusive ultrasonographic appear- ance and chronic hemiscrotal symptomatology, we decided to proceed with surgical exploration. Epididymal inﬂamma- tory changes, which were most prominent in the caput region, were noted, and caput epididymis was excised in order to document the underlying pathology. Histopatholog- ical ﬁndings were consistent with malignant mesothelioma originating from the tunica vaginalis. Although, tumor seemed to be localized to paratesticular tissues both clinically and radiographically, radical excision (orchiectomy and hemiscrotectomy) was performed as an additional procedure due to the possible aggressive clinical behaviour. Although the followup in published series is often short and variable, almost half of the patients have been reported to develop recurrence or metastasis after radical orchiectomy for paratesticular malignant mesothelioma. Local recurrence after orchiectomy is reported in approximately 10% of the patients [12]. Moreover approximately 40% of the patients die from their disease, with a median survival of 24 months [12, 17]. Given these relatively poor outcomes, some authors proposed adjuvant radiotherapy or retroperitoneal lymph node dissection [18]. Similarly, diagnostic laparoscopy, which was performed for staging purposes in another center after conﬁrming the diagnosis, should have been oﬀered with these facts in mind. However, strict recommendations about the role of adjuvant therapy or staging laparoscopy in the management of paratesticular malignant mesothelioma cannot be made based upon these limited data. We opted for active surveillance for this particular patient who accepted to comply with the follow-up protocol. He is disease-free and alive at 26 months of followup without any adjuvant treatment, which is above the median survival duration reported in the literature. In conclusion, paratesticular neoplasms should always be kept in mind while evaluating chronic, recurrent hemis- crotal symptoms. These tumors may not be distinguishable from testicular counterparts based on preoperative ﬁndings. However once suspected, interventional measures should be 3 prompted since delays in diagnosing paratesticular tumors may have prognostic implications. References [1] M. Yamamoto, K. Miyake, and H. Mitsuya, “Intrascrotal extra- testicular neuroﬁbroma,” Urology, vol. 20, no. 2, pp. 200–201, 1982. [2] F. K. Mostoﬁ and E. B. Price, “Tumors and tumor like con- ditions of testicular adnexal structures,” in Atlas of Tumour Pathology, Second Series, W. H. Hartmann and L. H. Sobin, Eds., pp. 143–176, Washington, DC, USA, 1973. [3] J. P. Richie, “Neoplasm of testis,” in Campbell’s Urology, P. C. Walsh, A. B. Retik, E. D. Vaughan, and A. J. Wein, Eds., pp. 2411–2452, Philadelphia, Pa, USA, 7th edition, 1998. [4] F. Brimo, P. B. Illei, and J. I. Epstein, “Mesothelioma of the tunica vaginalis: a series of eight cases with uncertain malig- nant potential,” Modern Pathology, vol. 23, no. 8, pp. 1165– 1172, 2010. [5] V. Barbera and M. Rubino, “Papillary mesothelioma of the tunica vaginalis,” Cancer, vol. 10, no. 1, pp. 183–189, 1957. [6] M. Bisceglia, D. B. Dor, I. Carosi, M. Vairo, and G. Pasquinelli, “Paratesticular mesothelioma. Report of a case with compre- hensive review of literature,” Advances in Anatomic Pathology, vol. 17, no. 1, pp. 53–70, 2010. [7] R. Hassan and R. Alexander, “Nonpleural mesotheliomas: mesothelioma of the peritoneum, tunica vaginalis, and peri- cardium,” Hematology/Oncology Clinics of North America, vol. 19, no. 6, pp. 1067–1087, 2005. [8] M. L. Janssen-Heijnen, R. A. Damhuis, P. J. Klinkhamer, R. M. Schipper, and J. W. Coebergh, “Increased but low incidence and poor survival of malignant mesothelioma in the south- eastern part of The Netherlands since 1970: a population- based study,” European Journal of Cancer Prevention, vol. 8, no. 4, pp. 311–314, 1999. [9] Y. Murai, “Malignant mesothelioma in Japan: analysis of reg- istered autopsy cases,” Archives of Environmental Health, vol. 56, no. 1, pp. 84–88, 2001. [10] L. Mangone, A. Romanelli, C. Campari, and S. Candela, “Malignant mesothelioma in Emilia-Romagna: incidence and asbestos exposure,” Epidemiologia e Prevenzione, vol. 26, no. 3, pp. 124–129, 2002. [11] M. Menegozzo, F. Izzo, M. L. Canfora, M. F. Petronzio, and S. Menegozzo, “Activity of the campania register of mesothe- lioma from July 2003 to October 2007,” Giornale Italiano di Medicina del Lavoro ed Ergonomia, vol. 29, supplement 3, pp. 642–644, 2007. [12] E. Plas, C. R. Riedl, and H. Pﬂuger, “Malignant mesothelioma of the tunica vaginalis testis. Review of literature and assess- ment of prognostic parameters,” Cancer, vol. 83, no. 12, pp. 2437–2446, 1998. [13] B. Jasani and A. Gibbs, “Mesothelioma not associated with asbestos exposure,” Archives of Pathology and Laboratory Medi- cine, vol. 136, no. 3, pp. 262–267, 2012. [14] I. Roushdy-Hammady, J. Siegel, S. Emri, J. R. Testa, and M. Carbone, “Genetic-susceptibility factor and malignant meso- thelioma in the Cappadocian region of Turkey,” The Lancet, vol. 357, no. 9254, pp. 444–445, 2001. [15] J. M. Reynard, N. Hasan, S. I. Baithun, L. Newman, and M. G. Lord, “Malignant mesothelioma of the tunica vaginalis testis,” British Journal of Cancer, vol. 74, no. 3, pp. 389–390, 1994. [16] J. M. Fields, S. A. Russel, and S. M. Andrew, “Case report: ultrasound appearances of a malignant mesothelioma of the