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G.K. BANERJEE, K.P. LIM and N.P. COHEN
Ward 44, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN
Keywords : Penis, adenocarcinoma, metastasis
We report here an interesting presentation of a primary colonic carcinoma in a urological setting. A previously unknown case of colonic carcinoma presented with a lesion in the glans penis which was later diagnosed as a secondary deposit from colonic cancer. Penile involvement has been implicated as a metastatic site in several tumours. Although uncommon, this presentation is not unknown. A literature review of this unusual presentation has been performed and is summarised in the article
J.R.Coll.Edinb., December 2002, 763-764
Metastatic tumours of the penis are rare despite abundant blood supply to the penis. The first case was reported by Eberth in 1870.1 To date, less than 300 cases have been documented in the literature. We report an unusual case of metastatic tumour of the penis in a man with no previously known malignancy in whom the penile lesion was the primary presentation of metastatic colonic carcinoma.
A 55-year-old man presented in November 1999 with a two month history of a painless lump in his glans penis associated with blood staining of his underwear and a non-retractable prepuce. There were no associated systemic complaints. Apart from a history of alcohol abuse there was no significant past medical history. On examination, a hard lump was palpated on the glans penis under the prepuce which was non-retractable. Regional lymph nodes were not palpable and no abnormality was detected on abdominal examination. He underwent circumcision and biopsy of the lesion in the glans. The histopathological report showed features of adenocarcinoma.
Immunohistochemistry demonstrated staining of the cells for carcino-embryionic antigen (CEA), but no staining of the cells for prostate-specific antigen (PSA). This suggested a possible metastasis from a bowel malignancy and excluded a metastasis from prostate cancer. The patient underwent a computerised tomography (CT) scan of abdomen and pelvis and a gastrograffin enema, which confirmed the presence of a circumferential obstructing tumour of the distal colon (Figure 1) and multiple liver metastases. He was treated palliatively with local external beam radiotherapy (20 Gys in five fractions) and four cycles of chemotherapy using 5-FU and folinic acid. An internal colonic stent was inserted to relieve the imminent bowel obstruction (Figure 2). Unfortunately, he only had a partial response to palliative treatment, following which the disease progressed. A subsequent CT scan showed enlargement of the liver metastases. He became clinically jaundiced, developed ascites and, in spite of the internal colonic stent, was re-admitted with large bowel obstruction. He had a loop colostomy performed in June 2000 and died in October 2000.
Figure 1: Gastrograffin enema demonstrating the circumferential obstructing tumour in the distal colon
Figure 2: An internal colonic stent being inserted to relieve the imminent bowel obstruction
Tumour metastases to the penis are rare with less than 300 cases being reported in the literature.2,3,4 In a review article published by Powell et al (1985), out of 218 patients reported in the literature, genito-urinary organs were the commonest site of the primary malignancy.3 Prostate (65 patients) and bladder (65 patients) were the most common, followed by kidney and rectosigmoid.2,3,5 Patients with metastatic tumours of the penis present with a range of symptoms. Priapism is the most frequent clinical feature and was termed malignant priapism by Peacock in 1938. 6,7
The interval between the diagnosis of the primary malignancy and the penile metastases can vary between one-two years.3,4,8,9 Occasionally, metastatic tumours are diagnosed before the primary tumour, as is described in this present case.4,7,9 The modes of metastasis to the penis have been delineated by Paquin and Roland (1956). This includes direct extension via retrograde venous and lymphatic flow, by arterial embolisation, and as a result of instrumentation.3,5,10,11,12
Retrograde venous flow has been regarded as the commonest source of tumour spread. Reversal of the venous flow occurs due to proximal venous occlusion caused by a pelvic-visceral tumour. This results in tumour embolisation in the presence of extensive venous communication.13
Biopsy or fine needle aspiration biopsy is necessary for the diagnosis of a secondary tumour of the penis. Immunohistochemical studies and staining for tumour markers are useful to determine the site of origin.14,15 Some authors have advocated the use of corporeal cavernosography in the diagnosis of penile metastases.16,17,18 While this procedure is of interest, it is of questionable practical benefit.
Treatment of metastatic penile tumours is mainly palliative either in the form of local radiotherapy, surgery or systemic chemotherapy. The treatment is influenced by the size, location and progression of the lesion and also by the nature and prognosis of the primary neoplasm.5 The prognosis is usually poor while survival as long as nine years has been reported in the literature.3,5,10,19 Unfortunately, the majority of patients presenting in this way die within one year.
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Copyright: 11 September 2002
Correspondence: Mr N.P. Cohen, Ward 44, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK Email: nicholas.cohen@arh.grampian.scot.nhs.uk