Ultrasound Presentation of Epithelioid Malignant Mesothelioma of the Tunica Vaginalis

Ultrasound Presentation of Epithelioid Malignant Mesothelioma of the Tunica Vaginalis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Ultrasound Presentation of Epithelioid Malignant Mesothelioma of the Tunica Vaginalis Chidi Ollawa, Eyo Akpan, Yannick Yangue, Ruchi Nasa, Emmanuel Abiola Babington, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6346910/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Malignant mesothelioma of the tunica vaginalis (MMTV) is rare and accounts for less than 3% of all mesothelioma cases. Diagnosing MMTV is challenging because of its nonspecific clinical and radiological presentation. A 69-year-old male with no history of asbestos exposure, scrotal surgeries, or infections was initially suspected to have a large hydrocele on clinical examination. The ultrasound scan revealed turbid fluid with internal echoes and multiple hypoechoic, nodular adherent lesions in the tunica vaginalis. A subsequent MRI scan revealed a large complex encysted hydrocele with peripheral nodular opacities attached to the wall. Histopathology and immunohistochemistry confirmed a malignant epithelioid neoplasm that was positive for Pan-CK (AE1/3, calretinin, WT1, vimentin. CK5/6, CK7 and BerEP4), confirming the diagnosis of epithelioid MMTV. Consequently, MMTV should be suspected during scrotal ultrasound when multiple hypoechoic nodules accompanied by a chronic complex hydrocele are observed along the tunica vaginalis. Preventive Medicine Urology & Nephrology Oncology Nuclear Medicine & Medical Imaging Epithelioid malignant mesothelioma scrotal ultrasound chronic hydrocele. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Malignant mesothelioma is a rare, aggressive cancer that affects the mesothelial cells lining the pleural, peritoneal, and pericardial cavities and the tunica vaginalis [ 1 ]. Mesotheliomas of the tunica vaginalis (MMTVs) account for 1–3% of all mesotheliomas and originate from mesothelial cells in this area [ 2 ]. Within the scrotum, the visceral layer of the tunica vaginalis serves as the outer covering of the tunica albuginea, which encases the testes. The parietal layer of the tunica vaginalis is proximal to the scrotal wall muscles, fascia, and skin [ 3 ]. This leaves potential space between the tunica layers to accommodate fluid build-up. Hydrocele is characterised by fluid accumulation between the visceral and parietal layers of the tunica vaginalis, leading to scrotal swelling [ 4 ]. This condition can arise from various aetiologies, including trauma, infection, or idiopathic causes. Ultrasound is the primary imaging modality used to assess scrotal swelling or potential tumours. This is due to its easy availability, use of non-ionising radiation, cost-effectiveness, and real-time features. However, ultrasound is highly operator-dependent and, therefore, requires adequate training. Other modalities, such as MRI or CT, can be considered when ultrasound findings are equivocal. Histology analysis of surgically removed (or biopsied) scrotal tumours is the gold standard for diagnosis [ 5 ]. Although rare, tumours of the tunica vaginalis include fibrous pseudotumors and malignant mesotheliomas [ 4 ]. They both primarily affect middle-aged men and are characterised by painless nodules and scrotal enlargement [ 4 ]. The common sonographic appearance suggestive of malignant mesothelioma of the tunica vaginalis MMTV includes the presence of singular painless nodules in the tunica vaginalis with hydrocele [ 6 ]. This case report aims to present a multinodular variant of MMTV associated with a complex hydrocele. CASE PRESENTATION A 69-year-old Caucasian male consulted the hospital for gradually enlarging, painless scrotal swelling that appeared suddenly and persisted for 12 months. The patient's medical history revealed no exposure to asbestos, no previous scrotal surgeries, and no infections. Routine blood tests yielded normal results. On physical examination, a nontender hydrocele was identified, with no palpable masses, leading to an initial clinical diagnosis of a benign hydrocele. A scrotal ultrasound was subsequently requested to determine the aetiology. A scrotal ultrasound was performed per the departmental protocol via a high-frequency linear transducer. Ultrasound imaging revealed a complex left hydrocele with internal echoes producing a ‘snowstorm’ appearance. Four hypoechoic, irregular, nodular lesions adhered to the tunica vaginalis (Fig. 1 a-d), with the largest nodule measuring 21 mm × 19 mm (Fig. 1 a). This largest nodule showed internal vascularity on power Doppler interrogation (see Fig. 1 d). The testes and epididymis appeared sonographically normal in size, shape, and echotexture, with normal arterial and venous vascularity on power Doppler imaging (see Fig. 1 d). The presence of multiple nodules in the tunica vaginalis raised suspicion of malignancy, and the sonographer issued a cancer alert per departmental policy. The urologist arranged an urgent scrotal MRI scan, which (see Figs. 2 a & 2 b) revealed a large complex left encysted hydrocele with peripheral nodular opacities attached to the wall. The MRI was not specific regarding the nature of the hydrocele or the characterisation of the nodules. MR imaging was extended to include the thorax, abdomen, and pelvis as per the protocol, and no extra-testicular distant spread in the abdomen or locoregional lymphadenopathy was observed. This case was discussed in subsequent urology multidisciplinary team (MDT) meetings, where it was decided to proceed with radical treatment. Thus, a radical left orchiectomy was performed. Histopathological analysis of the radical orchiectomy sample revealed large islands of epithelioid cells separated by fine fibrovascular septa, indicating a tightly packed papillary architecture consistent with epithelioid malignant mesothelioma. The tumour cells presented indistinct cell borders, moderately pale eosinophilic cytoplasm, and oval, enlarged nuclei with prominent nucleoli. There was abundant mitotic activity, and areas of necrosis were observed (see Figs. 3 a-d). Notably, the tumour did not invade adjacent structures, suggesting an early stage of the disease, and the specimen margins were clear. The largest tumour nodule was polypoid, exhibiting surface fibrous degeneration. Immunohistochemistry (IHC) findings revealed that the cells were diffusely positive for CK AE1/3, calretinin, WT1, and vimentin, as well as patchy positivity for CK5/6 and CK7. Focal patchy positivity was also noted for BerEP4. The histological and IHC findings confirmed the diagnosis of malignant mesothelioma (MMTV). The negative markers included mCEA and D2-40. DISCUSSION Globally, fewer than 100 reported cases of MMTV have been reported in the available literature, emphasising its rarity [ 7 ]. In the UK, according to Cancer Research, mesothelioma incidence rates in females have increased by nearly 90% since the early 1990s, whereas rates in males rose by more than 40% from 2017–2019. Most mesothelioma cases are linked to asbestos exposure [ 2 ], although some patients have no known history of exposure [ 8 ]. The connection between asbestos and tunica vaginalis mesothelioma is particularly unclear, indicating that other factors may contribute to its development in this location. Diagnoses of tunica vaginalis mesothelioma often occur incidentally during surgeries for other scrotal conditions. The uncommon nature of the condition further complicates the collection of comprehensive epidemiological data and contributes to the lack of standardised diagnostic and treatment protocols [ 7 ]. The diagnosis of MMTV presents challenges due to nonspecific clinical manifestations, such as hydrocele or a painless scrotal mass [ 9 ]. These symptoms are also common in several benign conditions, which may lead to delays in diagnosis and further investigation [ 9 ]. Despite its rarity, MMTV shares similar clinical, histological, and molecular characteristics with mesotheliomas found at other sites, including epithelioid and biphasic morphologies, as well as gene mutations, such as NF2 and TP53 [ 2 ]. Unfortunately, despite aggressive treatment approaches, the prognosis of the biphasic variant remains poor [ 8 ]. Therefore, increasing the degree of clinical suspicion in high-risk patients and achieving the right-rightest result during a scrotal ultrasound examination may improve the MMTV prognosis, similar to that of most cancers. A vague clinical picture often necessitates a thorough diagnostic approach. Ultrasound is the first-line imaging modality for evaluating scrotal pathology. The rarity of MMTV means that sonographers might lack experience in interpreting its specific ultrasound characteristics [ 4 ]. In addition, the authors believe that the rarity of MMTV may also be attributed to the underreporting of the condition, which can stem from the sonographer's lack of confidence in raising a radiological concern about a potential malignancy when ultrasound-specific features are present. This issue is also compounded by clinicians' low index of suspicion regarding the condition from the outset. Typically, an inconclusive ultrasound finding would warrant a multimodality imaging approach, including computed tomography (CT) scans and magnetic resonance imaging (MRI) scans, to aid in comprehensive evaluation and staging [ 10 ]. Ultimately, histopathological examination through surgical excision or biopsy is essential for confirming the diagnosis of MMTV [ 2 , 8 ]. Our case highlights the diagnostic importance of detailed ultrasound assessment in the early detection and intervention of MMTV, which can significantly impact patient prognosis. A systematic and thorough evaluation of the tunica vaginalis during the initial ultrasound is crucial for identifying nodules and papillary excrescences, which are key features of MMTV. These excrescences provoke local inflammatory responses that can lead to hydroceles and thickening of the tunica [ 11 ]. The extent of cellular desquamation and debridement varies depending on the degree of inflammation and the aggressiveness of the MMTV subtype, resulting in differing complexities of the ensuing hydrocele [ 11 ]. This emphasises the critical role of the ultrasound operator in early diagnosis and appropriate referral, aligning with the Getting It Right the First Time (GIRFT) initiative of the National Health Service (NHS) in England. Despite the potential of ultrasound for diagnosis, the subtlety of MMTV findings and the absence of specific serum biomarkers require a high suspicion index in any atypical chronic hydrocele case. Imaging modalities such as ultrasound, CT, and MRI are essential for diagnosing MMTV. They are critical for identifying the tumour morphology, assessing local invasion, guiding tissue sampling, and staging the disease [ 12 ]. However, the sensitivity and specificity of these modalities in diagnosing MMTV are not well established due to the rarity of the disease. While ultrasound is highly sensitive for detecting structural abnormalities, its specificity for diagnosing MMTV is limited because it may not differentiate MMTV from other benign or malignant conditions such as testicular germ cell tumours [ 12 ]. In cases of pleural mesothelioma, ultrasound-guided percutaneous needle biopsy has shown high sensitivity (83.39%) and specificity (100%) for diagnosing malignant mesothelioma [ 13 ]. Based on the findings from pleural mesothelioma and general imaging principles, ultrasound is highly sensitive and has limited specificity. Therefore, the authors recommend that sonographers receive training to enhance or advance their practice in fine needle aspiration cytology and ultrasound-guided biopsy of nodules of the tunica vaginalis within a one-stop rapid-access clinic to expedite the diagnosis of MMTV. This will ensure the collection of comprehensive epidemiological data and contribute to the standardisation of diagnostic and treatment protocols for MMTV. Conversely, the sensitivity and specificity of CT and MRI in diagnosing malignant mesothelioma of the tunica vaginalis have not been well established. However, CT and MRI offer complementary advantages in staging and assessing local invasion. Further research is needed to determine the diagnostic accuracy of these modalities, specifically for MMTV. The primary treatment for MMTV is radical orchiectomy, which is often supplemented by adjuvant therapy in aggressive or metastatic cases. This underscores the challenging nature of managing MMTV [ 11 ]. The prognosis varies significantly, with five-year survival rates ranging between 30% and 50% [ 2 ], further emphasising the need for ongoing research into more effective treatment options. CONCLUSION Scrotal ultrasound is the main imaging technique used to diagnose mesothelial tumours of the tunica vaginalis (MMTV). In our case, the sonographic features indicative of MMTV included multiple nodules along the tunica vaginalis accompanied by a complex hydrocele. Ultrasound practitioners must be aware of these distinct features, thoroughly assess the scrotum, and raise a cancer alert upon their initial observation of these malignant features. In addition, while most cases report a single nodule or papillary excrescence in the tunica vaginalis, our case illustrates a multinodular variant with a chronic complex hydrocele. These findings suggest that MMTV can also present as multiple nodules without prior asbestos exposure. Declarations ACKNOWLEDGEMENTS The authors thank Nina Fielding for providing valuable guidance that aided the publication of this case report. CONFLICT OF INTEREST STATEMENT The authors declare that they have no conflicts of interest. STATEMENT OF DECLARATIONS The authors have no funding or competing financial interests to disclose, and appropriate informed consent has been obtained for the study. Consent: The patient consented to the publication of this case report for academic purposes. References Brevet, M. (2016). Comparative Genetics of Diffuse Malignant Mesothelioma Tumors of the Peritoneumand Pleura, With Focus on BAP1 Expression . 1 (2), 91–97. https://doi.org/10.1515/PP-2016-0007 Drevinskaite, M., Smailyte, G., Kevlicius, L., Patasius, A., & Mickys, U. (2020). Malignant mesothelioma of the tunica vaginalis testis: a rare case and review of literature. BMC Cancer, 20(1). https://doi.org/10.1186/s12885-020-6648-3 Tiwana, M. S., & Leslie, S. W. (2020). Anatomy, Abdomen and Pelvis, Testicle . https://www.ncbi.nlm.nih.gov/books/NBK470201/ Yang, J., Chen, H., Yan, H., Zhang, Y., & Liu, J. (2024). Clinical and ultrasound features of fibrous pseudotumor of tunica vaginalis of the testis: eight cases and literature review. Frontiers in Oncology , 14 . https://doi.org/10.3389/fonc.2024.1485723. Bri, L. & Kern, I. (2020). Clinical significance of histologic subtyping of malignant pleural mesothelioma. AME Publishing Company. https://doi.org/10.21037/tlcr.2020.03.38 Liu, H., Dong, L., Xiang, L.-H., Xu, G., Wan, J., Fang, Y., Ding, S.-S., Jin, Y.-Q., Sun, L.-P., & Xu, H. (2022). Multiparametric ultrasound for the assessment of testicular lesions with negative tumoral markers. Asian Journal of Andrology , 25 (1), 50–57. https://doi.org/10.4103/aja202235 Emile, S. H., Balata, M., Elfallal, A. H., & Abdelnaby, M. (2019). Malignant Mesothelioma of the Tunica Vaginalis: Incidental Diagnosis of a Rare Condition. Indian Journal of Surgery , 81 (1), 80–82. https://doi.org/10.1007/S12262-018-1778-4 Mishra, K., Siddiquee, S., & Mislang, A. R. (2023). A rare presentation of malignant mesothelioma of the tunica vaginalis managed with immunotherapy and review of the literature. Clinical Case Reports, 11(6). https://doi.org/10.1002/ccr3.7610 Zhang, N., Fu, N., Peng, S., & Luo, X. (2017). Malignant mesothelioma of the tunica vaginalis testis: a case report and literature review.. Molecular and clinical oncology. https://doi.org/10.3892/mco.2017.1450 Sahu, R. K., Ruhi, S., Al-Goshae, H. A., Bhattacharjee, B., Bhattacharya, S., Khan, J., Goyal, M., Syed, A., Jangde, R. K., Ekasari, W., Nagdev, S., Widyowati, R., & Jeppu, A. K. (2023). Malignant mesothelioma tumours: molecular pathogenesis, diagnosis, and therapies accompanying clinical studies. Frontiers in Oncology, 13. https://doi.org/10.3389/fonc.2023.1204722 Nazar, T., Gopalakrishnabhaktan, A., et al. (2024). Testicular mesothelioma disguised as hydrocele: A case report. Journal of Medical Case Reports. Chekol, S. S., & Sun, C.-C. (2012). Malignant mesothelioma of the tunica vaginalis testis: diagnostic studies and differential diagnosis. Archives of Pathology & Laboratory Medicine , 136 (1), 113–117. https://doi.org/10.5858/ARPA.2010-0550-RS Ladevaia, C., D’Agnano, V., Pagliaro, R., Nappi, F., Lucci, R., Massa, S., Bianco, A., & Perrotta, F. (2024). Diagnostic accuracy of ultrasound-guided percutaneous pleural needle biopsy for malignant pleural mesothelioma. Journal of Clinical Medicine , 13 . https://doi.org/10.3390/jcm13092600 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6346910","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":436480484,"identity":"4fde95f8-3a4c-4b36-aeb6-70f7eff41961","order_by":0,"name":"Chidi Ollawa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACCcYGiQQGBhk+ECehgiGBaC08bCDOgzNQLQfwagEjiBbGh21EaOGf3dx44wGDDQ8b+xnDD4nz7uTJN/AefPwBnyV3DjZbJDCk8bDx5BhLJG57VmxwgC/ZAJ8tBhKJbUC/HAY6LHcDUMvhxA0MPGYSxGnhf7v5R+Kcw4nzG3jMfxCnRSJ3m0Riw+HEhgM8Zni9L3EjEegXA6BfJN5/s0g4BnTYYR5jiTN4tPDPSH9480eFjRw/f1ryzR81QIe19xh+qMCjBeo8ZA4zQeWjYBSMglEwCggBAHBSTeUf4aQwAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2705-5576","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Chidi","middleName":"","lastName":"Ollawa","suffix":""},{"id":436480485,"identity":"316feb68-2efb-470a-993a-08138aeba784","order_by":1,"name":"Eyo Akpan","email":"","orcid":"https://orcid.org/0000-0002-2284-0970","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Eyo","middleName":"","lastName":"Akpan","suffix":""},{"id":436480486,"identity":"da967f0b-20ef-4382-98b6-88911e01cbb5","order_by":2,"name":"Yannick Yangue","email":"","orcid":"","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Yannick","middleName":"","lastName":"Yangue","suffix":""},{"id":436480487,"identity":"59edac45-b92b-442a-9427-6ee5f8800146","order_by":3,"name":"Ruchi Nasa","email":"","orcid":"https://orcid.org/0000-0002-4817-6983","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Ruchi","middleName":"","lastName":"Nasa","suffix":""},{"id":436480488,"identity":"6e5d61dd-f9ab-4fbe-9290-e69461194e70","order_by":4,"name":"Emmanuel Abiola Babington","email":"","orcid":"https://orcid.org/0000-0002-0889-8383","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"Abiola","lastName":"Babington","suffix":""},{"id":436480489,"identity":"e367750b-e96a-499b-b0ea-af1abbc0519e","order_by":5,"name":"Ernest Upeh","email":"","orcid":"https://orcid.org/0000-0002-3032-8002","institution":"North Cumbria Integrated Care NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Ernest","middleName":"","lastName":"Upeh","suffix":""}],"badges":[],"createdAt":"2025-03-31 17:14:30","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6346910/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6346910/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80286868,"identity":"a305c0f1-5314-43c3-a4ae-ce0ac6c999f6","added_by":"auto","created_at":"2025-04-10 06:58:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":983985,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea - d\u003c/strong\u003e Longitudinal section through a turbid hydrocele showing multifocal nodules with the largest nodule (Figure 1a: golden-coloured star) measuring 21mm × 19 mm.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6346910/v1/90ed77980617c9e3de42cb98.png"},{"id":80286867,"identity":"ed886286-604f-48af-9c04-8f83dd6bceaa","added_by":"auto","created_at":"2025-04-10 06:58:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":543867,"visible":true,"origin":"","legend":"\u003cp\u003eMR images of an encysted hydrocele (star) with peripheral nodular opacities attached to the wall.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6346910/v1/b3fdfc5d8f9207e89b97f378.png"},{"id":80286870,"identity":"e2ca6560-0d48-40be-875a-7f39e7508fcd","added_by":"auto","created_at":"2025-04-10 06:58:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1154075,"visible":true,"origin":"","legend":"\u003cp\u003eMicroscopic sections of the testicular neoplasm.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6346910/v1/fa983b842b1ef55ded4e9685.png"},{"id":80287221,"identity":"294f9e3c-24dd-4450-af7b-341833d10ec2","added_by":"auto","created_at":"2025-04-10 07:06:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3662232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6346910/v1/47356ab7-48b7-4a7b-9ba6-4dc986b8a825.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eUltrasound Presentation of Epithelioid Malignant Mesothelioma of the Tunica Vaginalis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMalignant mesothelioma is a rare, aggressive cancer that affects the mesothelial cells lining the pleural, peritoneal, and pericardial cavities and the tunica vaginalis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Mesotheliomas of the tunica vaginalis (MMTVs) account for 1\u0026ndash;3% of all mesotheliomas and originate from mesothelial cells in this area [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin the scrotum, the visceral layer of the tunica vaginalis serves as the outer covering of the tunica albuginea, which encases the testes. The parietal layer of the tunica vaginalis is proximal to the scrotal wall muscles, fascia, and skin [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This leaves potential space between the tunica layers to accommodate fluid build-up. Hydrocele is characterised by fluid accumulation between the visceral and parietal layers of the tunica vaginalis, leading to scrotal swelling [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This condition can arise from various aetiologies, including trauma, infection, or idiopathic causes.\u003c/p\u003e \u003cp\u003eUltrasound is the primary imaging modality used to assess scrotal swelling or potential tumours. This is due to its easy availability, use of non-ionising radiation, cost-effectiveness, and real-time features. However, ultrasound is highly operator-dependent and, therefore, requires adequate training. Other modalities, such as MRI or CT, can be considered when ultrasound findings are equivocal. Histology analysis of surgically removed (or biopsied) scrotal tumours is the gold standard for diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough rare, tumours of the tunica vaginalis include fibrous pseudotumors and malignant mesotheliomas [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. They both primarily affect middle-aged men and are characterised by painless nodules and scrotal enlargement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The common sonographic appearance suggestive of malignant mesothelioma of the tunica vaginalis MMTV includes the presence of singular painless nodules in the tunica vaginalis with hydrocele [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This case report aims to present a multinodular variant of MMTV associated with a complex hydrocele.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 69-year-old Caucasian male consulted the hospital for gradually enlarging, painless scrotal swelling that appeared suddenly and persisted for 12 months. The patient's medical history revealed no exposure to asbestos, no previous scrotal surgeries, and no infections. Routine blood tests yielded normal results. On physical examination, a nontender hydrocele was identified, with no palpable masses, leading to an initial clinical diagnosis of a benign hydrocele. A scrotal ultrasound was subsequently requested to determine the aetiology.\u003c/p\u003e \u003cp\u003eA scrotal ultrasound was performed per the departmental protocol via a high-frequency linear transducer. Ultrasound imaging revealed a complex left hydrocele with internal echoes producing a \u0026lsquo;snowstorm\u0026rsquo; appearance. Four hypoechoic, irregular, nodular lesions adhered to the tunica vaginalis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea-d), with the largest nodule measuring 21 mm \u0026times; 19 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). This largest nodule showed internal vascularity on power Doppler interrogation (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). The testes and epididymis appeared sonographically normal in size, shape, and echotexture, with normal arterial and venous vascularity on power Doppler imaging (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). The presence of multiple nodules in the tunica vaginalis raised suspicion of malignancy, and the sonographer issued a cancer alert per departmental policy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe urologist arranged an urgent scrotal MRI scan, which (see Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea \u0026amp; \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb) revealed a large complex left encysted hydrocele with peripheral nodular opacities attached to the wall. The MRI was not specific regarding the nature of the hydrocele or the characterisation of the nodules. MR imaging was extended to include the thorax, abdomen, and pelvis as per the protocol, and no extra-testicular distant spread in the abdomen or locoregional lymphadenopathy was observed. This case was discussed in subsequent urology multidisciplinary team (MDT) meetings, where it was decided to proceed with radical treatment. Thus, a radical left orchiectomy was performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHistopathological analysis of the radical orchiectomy sample revealed large islands of epithelioid cells separated by fine fibrovascular septa, indicating a tightly packed papillary architecture consistent with epithelioid malignant mesothelioma. The tumour cells presented indistinct cell borders, moderately pale eosinophilic cytoplasm, and oval, enlarged nuclei with prominent nucleoli. There was abundant mitotic activity, and areas of necrosis were observed (see Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea-d). Notably, the tumour did not invade adjacent structures, suggesting an early stage of the disease, and the specimen margins were clear. The largest tumour nodule was polypoid, exhibiting surface fibrous degeneration. Immunohistochemistry (IHC) findings revealed that the cells were diffusely positive for CK AE1/3, calretinin, WT1, and vimentin, as well as patchy positivity for CK5/6 and CK7. Focal patchy positivity was also noted for BerEP4. The histological and IHC findings confirmed the diagnosis of malignant mesothelioma (MMTV). The negative markers included mCEA and D2-40.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eGlobally, fewer than 100 reported cases of MMTV have been reported in the available literature, emphasising its rarity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the UK, according to Cancer Research, mesothelioma incidence rates in females have increased by nearly 90% since the early 1990s, whereas rates in males rose by more than 40% from 2017\u0026ndash;2019. Most mesothelioma cases are linked to asbestos exposure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], although some patients have no known history of exposure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The connection between asbestos and tunica vaginalis mesothelioma is particularly unclear, indicating that other factors may contribute to its development in this location. Diagnoses of tunica vaginalis mesothelioma often occur incidentally during surgeries for other scrotal conditions. The uncommon nature of the condition further complicates the collection of comprehensive epidemiological data and contributes to the lack of standardised diagnostic and treatment protocols [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of MMTV presents challenges due to nonspecific clinical manifestations, such as hydrocele or a painless scrotal mass [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These symptoms are also common in several benign conditions, which may lead to delays in diagnosis and further investigation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite its rarity, MMTV shares similar clinical, histological, and molecular characteristics with mesotheliomas found at other sites, including epithelioid and biphasic morphologies, as well as gene mutations, such as NF2 and TP53 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Unfortunately, despite aggressive treatment approaches, the prognosis of the biphasic variant remains poor [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, increasing the degree of clinical suspicion in high-risk patients and achieving the right-rightest result during a scrotal ultrasound examination may improve the MMTV prognosis, similar to that of most cancers.\u003c/p\u003e \u003cp\u003eA vague clinical picture often necessitates a thorough diagnostic approach. Ultrasound is the first-line imaging modality for evaluating scrotal pathology. The rarity of MMTV means that sonographers might lack experience in interpreting its specific ultrasound characteristics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition, the authors believe that the rarity of MMTV may also be attributed to the underreporting of the condition, which can stem from the sonographer's lack of confidence in raising a radiological concern about a potential malignancy when ultrasound-specific features are present. This issue is also compounded by clinicians' low index of suspicion regarding the condition from the outset. Typically, an inconclusive ultrasound finding would warrant a multimodality imaging approach, including computed tomography (CT) scans and magnetic resonance imaging (MRI) scans, to aid in comprehensive evaluation and staging [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Ultimately, histopathological examination through surgical excision or biopsy is essential for confirming the diagnosis of MMTV [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur case highlights the diagnostic importance of detailed ultrasound assessment in the early detection and intervention of MMTV, which can significantly impact patient prognosis. A systematic and thorough evaluation of the tunica vaginalis during the initial ultrasound is crucial for identifying nodules and papillary excrescences, which are key features of MMTV. These excrescences provoke local inflammatory responses that can lead to hydroceles and thickening of the tunica [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The extent of cellular desquamation and debridement varies depending on the degree of inflammation and the aggressiveness of the MMTV subtype, resulting in differing complexities of the ensuing hydrocele [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This emphasises the critical role of the ultrasound operator in early diagnosis and appropriate referral, aligning with the Getting It Right the First Time (GIRFT) initiative of the National Health Service (NHS) in England. Despite the potential of ultrasound for diagnosis, the subtlety of MMTV findings and the absence of specific serum biomarkers require a high suspicion index in any atypical chronic hydrocele case.\u003c/p\u003e \u003cp\u003eImaging modalities such as ultrasound, CT, and MRI are essential for diagnosing MMTV. They are critical for identifying the tumour morphology, assessing local invasion, guiding tissue sampling, and staging the disease [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the sensitivity and specificity of these modalities in diagnosing MMTV are not well established due to the rarity of the disease. While ultrasound is highly sensitive for detecting structural abnormalities, its specificity for diagnosing MMTV is limited because it may not differentiate MMTV from other benign or malignant conditions such as testicular germ cell tumours [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In cases of pleural mesothelioma, ultrasound-guided percutaneous needle biopsy has shown high sensitivity (83.39%) and specificity (100%) for diagnosing malignant mesothelioma [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Based on the findings from pleural mesothelioma and general imaging principles, ultrasound is highly sensitive and has limited specificity. Therefore, the authors recommend that sonographers receive training to enhance or advance their practice in fine needle aspiration cytology and ultrasound-guided biopsy of nodules of the tunica vaginalis within a one-stop rapid-access clinic to expedite the diagnosis of MMTV. This will ensure the collection of comprehensive epidemiological data and contribute to the standardisation of diagnostic and treatment protocols for MMTV. Conversely, the sensitivity and specificity of CT and MRI in diagnosing malignant mesothelioma of the tunica vaginalis have not been well established. However, CT and MRI offer complementary advantages in staging and assessing local invasion. Further research is needed to determine the diagnostic accuracy of these modalities, specifically for MMTV.\u003c/p\u003e \u003cp\u003eThe primary treatment for MMTV is radical orchiectomy, which is often supplemented by adjuvant therapy in aggressive or metastatic cases. This underscores the challenging nature of managing MMTV [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The prognosis varies significantly, with five-year survival rates ranging between 30% and 50% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], further emphasising the need for ongoing research into more effective treatment options.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eScrotal ultrasound is the main imaging technique used to diagnose mesothelial tumours of the tunica vaginalis (MMTV). In our case, the sonographic features indicative of MMTV included multiple nodules along the tunica vaginalis accompanied by a complex hydrocele. Ultrasound practitioners must be aware of these distinct features, thoroughly assess the scrotum, and raise a cancer alert upon their initial observation of these malignant features. In addition, while most cases report a single nodule or papillary excrescence in the tunica vaginalis, our case illustrates a multinodular variant with a chronic complex hydrocele. These findings suggest that MMTV can also present as multiple nodules without prior asbestos exposure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Nina Fielding for providing valuable guidance that aided the publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTATEMENT OF DECLARATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no funding or competing financial interests to disclose, and appropriate informed consent has been obtained for the study.\u003c/p\u003e\u003cp\u003eConsent: The patient consented to the publication of this case report for academic purposes.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrevet, M. (2016). \u003cem\u003eComparative Genetics of Diffuse Malignant Mesothelioma Tumors of the Peritoneumand Pleura, With Focus on BAP1 Expression\u003c/em\u003e. \u003cem\u003e1\u003c/em\u003e(2), 91\u0026ndash;97. https://doi.org/10.1515/PP-2016-0007\u003c/li\u003e\n\u003cli\u003eDrevinskaite, M., Smailyte, G., Kevlicius, L., Patasius, A., \u0026amp; Mickys, U. (2020). Malignant mesothelioma of the tunica vaginalis testis: a rare case and review of literature. BMC Cancer, 20(1). https://doi.org/10.1186/s12885-020-6648-3\u003c/li\u003e\n\u003cli\u003eTiwana, M. S., \u0026amp; Leslie, S. W. (2020). \u003cem\u003eAnatomy, Abdomen and Pelvis, Testicle\u003c/em\u003e. https://www.ncbi.nlm.nih.gov/books/NBK470201/\u003c/li\u003e\n\u003cli\u003eYang, J., Chen, H., Yan, H., Zhang, Y., \u0026amp; Liu, J. (2024). Clinical and ultrasound features of fibrous pseudotumor of tunica vaginalis of the testis: eight cases and literature review. \u003cem\u003eFrontiers in Oncology\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e. https://doi.org/10.3389/fonc.2024.1485723.\u003c/li\u003e\n\u003cli\u003eBri, L. \u0026amp; Kern, I. (2020). Clinical significance of histologic subtyping of malignant pleural mesothelioma. AME Publishing Company. https://doi.org/10.21037/tlcr.2020.03.38\u003c/li\u003e\n\u003cli\u003eLiu, H., Dong, L., Xiang, L.-H., Xu, G., Wan, J., Fang, Y., Ding, S.-S., Jin, Y.-Q., Sun, L.-P., \u0026amp; Xu, H. (2022). Multiparametric ultrasound for the assessment of testicular lesions with negative tumoral markers. \u003cem\u003eAsian Journal of Andrology\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(1), 50\u0026ndash;57. https://doi.org/10.4103/aja202235\u003c/li\u003e\n\u003cli\u003eEmile, S. H., Balata, M., Elfallal, A. H., \u0026amp; Abdelnaby, M. (2019). Malignant Mesothelioma of the Tunica Vaginalis: Incidental Diagnosis of a Rare Condition. \u003cem\u003eIndian Journal of Surgery\u003c/em\u003e, \u003cem\u003e81\u003c/em\u003e(1), 80\u0026ndash;82. https://doi.org/10.1007/S12262-018-1778-4\u003c/li\u003e\n\u003cli\u003eMishra, K., Siddiquee, S., \u0026amp; Mislang, A. R. (2023). A rare presentation of malignant mesothelioma of the tunica vaginalis managed with immunotherapy and review of the literature. Clinical Case Reports, 11(6). https://doi.org/10.1002/ccr3.7610\u003c/li\u003e\n\u003cli\u003eZhang, N., Fu, N., Peng, S., \u0026amp; Luo, X. (2017). Malignant mesothelioma of the tunica vaginalis testis: a case report and literature review.. Molecular and clinical oncology. https://doi.org/10.3892/mco.2017.1450\u003c/li\u003e\n\u003cli\u003eSahu, R. K., Ruhi, S., Al-Goshae, H. A., Bhattacharjee, B., Bhattacharya, S., Khan, J., Goyal, M., Syed, A., Jangde, R. K., Ekasari, W., Nagdev, S., Widyowati, R., \u0026amp; Jeppu, A. K. (2023). Malignant mesothelioma tumours: molecular pathogenesis, diagnosis, and therapies accompanying clinical studies. Frontiers in Oncology, 13. https://doi.org/10.3389/fonc.2023.1204722\u003c/li\u003e\n\u003cli\u003eNazar, T., Gopalakrishnabhaktan, A., et al. (2024). Testicular mesothelioma disguised as hydrocele: A case report. Journal of Medical Case Reports.\u003c/li\u003e\n\u003cli\u003eChekol, S. S., \u0026amp; Sun, C.-C. (2012). Malignant mesothelioma of the tunica vaginalis testis: diagnostic studies and differential diagnosis. \u003cem\u003eArchives of Pathology \u0026amp; Laboratory Medicine\u003c/em\u003e, \u003cem\u003e136\u003c/em\u003e(1), 113\u0026ndash;117. https://doi.org/10.5858/ARPA.2010-0550-RS\u003c/li\u003e\n\u003cli\u003eLadevaia, C., D\u0026rsquo;Agnano, V., Pagliaro, R., Nappi, F., Lucci, R., Massa, S., Bianco, A., \u0026amp; Perrotta, F. (2024). Diagnostic accuracy of ultrasound-guided percutaneous pleural needle biopsy for malignant pleural mesothelioma. \u003cem\u003eJournal of Clinical Medicine\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e. https://doi.org/10.3390/jcm13092600\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"North Cumbria Integrated Care NHS Foundation Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Epithelioid malignant mesothelioma, scrotal ultrasound, chronic hydrocele.","lastPublishedDoi":"10.21203/rs.3.rs-6346910/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6346910/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMalignant mesothelioma of the tunica vaginalis (MMTV) is rare and accounts for less than 3% of all mesothelioma cases. Diagnosing MMTV is challenging because of its nonspecific clinical and radiological presentation. A 69-year-old male with no history of asbestos exposure, scrotal surgeries, or infections was initially suspected to have a large hydrocele on clinical examination. The ultrasound scan revealed turbid fluid with internal echoes and multiple hypoechoic, nodular adherent lesions in the tunica vaginalis. A subsequent MRI scan revealed a large complex encysted hydrocele with peripheral nodular opacities attached to the wall. Histopathology and immunohistochemistry confirmed a malignant epithelioid neoplasm that was positive for Pan-CK (AE1/3, calretinin, WT1, vimentin. CK5/6, CK7 and BerEP4), confirming the diagnosis of epithelioid MMTV. Consequently, MMTV should be suspected during scrotal ultrasound when multiple hypoechoic nodules accompanied by a chronic complex hydrocele are observed along the tunica vaginalis.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","manuscriptTitle":"Ultrasound Presentation of Epithelioid Malignant Mesothelioma of the Tunica Vaginalis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 06:58:14","doi":"10.21203/rs.3.rs-6346910/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"787450fc-ab2f-42a4-a497-86696600ddc6","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46474975,"name":"Preventive Medicine"},{"id":46474976,"name":"Urology \u0026 Nephrology"},{"id":46474977,"name":"Oncology"},{"id":46474978,"name":"Nuclear Medicine \u0026 Medical Imaging"}],"tags":[],"updatedAt":"2025-04-10T06:58:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-10 06:58:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6346910","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6346910","identity":"rs-6346910","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}