1608178 © 1990 S. Karger AG, Basel 0302-2838/90/0182-0156S2.75/0
Eur Urol 1990;18:156-159
Early ‘Invasive’ Malignant Melanoma of the Gians penis and the Male Urethra Report of a Case and Review of the Literature
Günter Primus3, Hans Peter Soyerh, JosefSmolleb, Georg Mertl3, Karl Pummer3, Helmut KerP “Urology Unit, General Hospital of Graz, and bDepartment of Dermatology, University of Graz, Austria
Key Words. Penile neoplasms melanoma • Pathology therapy Abstract. A 40-year-old male with early ‘invasive’ malignant melanoma of the glans penis and meatus urethrae externus is presented. Early stages of primary melanoma of the glans penis and the male urethra are distinctly rare and are often clinically indistinguishable from penile lentigo, melanosis and melanocytic nevus on the genitalia. In order to avoid large and useless surgery on such a delicate location we propose a punch biopsy with subsequent histological examination prior to definitive surgical procedure. Whereas malignant melanoma of the penis with a thick Breslow index is treated with extended surgical management, only local excision of the tumor without groin dissection was performed in our patient.
Fewer than 100 cases of primary malignant melanoma arising in the male urethra or penis have been accumulated in the literature [ 1, 2, 4, 5, 7-18, 20-22, 24-26, 29, 30, 32, 34, 37-50], Undoubtedly, many go unreported. Although malignant melanoma is one of the rarer tumors of the male urethra and penis, these locations are the most common sites of origin in the genitourinary tract. The diagno sis is usually late, recurrence is early and widespread métastasés are frequent. This confirms the consensus of available reports that, irre spective of the type of therapy used, prognosis is poor in patients with malignant melanoma of the penis and urethra. Although it has been pointed out that these tumors are relatively radioresistant, preoperative radiation therapy may be useful as a sterilization proce dure to prevent viable tumor spill at the time of operation. Informa tion regarding appropriate treatment of this malignancy is derived from the review of single case reports and small series. A case of an early stage of malignant melanoma of the glans penis and male urethra is presented with special emphasis on clini cal and histopathological findings.
Case Report Clinical History For 2 years a 40 year-old male patient had observed a pigmented macule on his glans penis rapidly increasing in the last 3 months.
Clinical Finding On the glans penis situated around the meatus urethrae externus there is a broad, asymmetrical, poorly circumscribed, unevenly brown pigmented, flat lesion, which merges in the distal part of the male urethra. Pathologic Finding The histopathological findings of the glans penis and of the male urethra were identical. There was a broad, asymmetrical, not sharply circumscribed lesion characterized by an increased number of atypical melanocytes appearing singly and in nests of various sizes and shapes all within the epidermis and within the urethral epithelium. Atypical melanocytes in single units and nests were scattered mainly in the lower part, but sometimes also at every level of the epidermis and the urethral epithelium (fig. 1, 2). The atypical mela nocytes reveal loss of cohesion, hyperchromatic nuclei, variation in nuclear size and shape, increased nuclearxytoplasmic ratios and prominent nucleoli. In serial sections the continuity with the overly ing epidermis and urethral epithelium cannot always be demonstrated and some single tumor cells extend into the papillary dermis and the lamina propria indicating focal ‘microinvasion’ (fig. 3). Only in these areas a very sparse inflammatory cell infiltrate can be observed. Treatment Local excision of the lesion - the diagnosis of early invasive malignant melanoma was already established by histopathological examination of a 4-mm punch biopsy - was performed in general anesthesia in bloodlessness with a security distance of 1 cm together Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
Introduction
Early ‘Invasive’ Malignant Melanoma of Gians penis and Male Urethra
157
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Fig. 1. Melanoma in situ of the glans penis. Note an increased number of atypical melanocytes, both single and in nests within the lower part of the epidermis. HE X 250. Fig. 2. Melanoma in situ of the distal part of the male urethra. Numerous atypical melanocytes are scattered throughout the hyper plastic urethral epithelium sometimes including upper layers. HE X 100.
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Fig. 3. Early ‘invasive’ malignant melanoma of the male urethra. There is a markedly increased number of atypical melanocytes arranged as solitary units and in nests within all levels of the epithelium. Notice that a few atypical melanocytes are present within the lamina propria. HE X 250. Fig. 4. Penis 1 month after excision of the malignant melanoma. A new orifice (arrow) was formed by everting urethra.
Discussion Cancers of the penis other than epidermoid carcinomas are very rare and, except for basal cell carcinoma, generally have a poor prognosis [35]. Of 1,200 malignant melanomas treated at MemorialSloan Kettering Cancer Center, only 2 were of penile origin. The peak incidence is seen in the sixth to seventh decade [5, 50]. In the advanced stages of disease patients may present with symptoms of Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
with the first part of the distal urethra in a length of about 2 cm. The basis and the surroundings of the resection were coagulated careful ly. Histological examination, however, revealed excision of the tumor in the distal urethra not in sano. Therefore a further part of the distal urethra was resected and this specimen was histologically free of melanoma. A new orifice was made by everting urethra (fig. 4). Convalescence was uneventful; after removing the catheter the patient voided well. He was discharged in good condition.
158
munotherapy [21, 24] or injection of 13lI-Lipiodol [13] after opera tive treatment, but their effects were limited. We propose a conservative surgical management, for early ‘inva sive’ malignant melanoma of the glans penis and the male urethra, especially when the patients are young and fully active in sexual life. However, in the literature, there are only a few reported 5-year sur vivors [16, 25, 32, 37]. In general prognosis is poor and most patients die within 3 years due to distant métastasés. As with malig nant melanoma on other locations the early detection and sufficient surgical treatment is of crucial importance for successful control of penile and urethral melanoma.
References 1 Abeshouse, B.S.: Primary and secondary melanoma of the geni tourinary tract. Sth. med. J. 51: 994-1006 (1958). 2 Alferez, F.J.D.; Corali, M.T.F.; Medierò, J.G.; Gomez, J.M.: Melanoma maligno de pene: presentacion de dos casos. Actas Urol. Esp. 7: 473-476 (1983). 3 Ariel, I.M.: Malignant melanoma of the male genital system; in Ariel, Malignant melanoma, pp. 507-511 (Appleton-CenturyCrofts, New York 1981). 4 Baruah, B.D.; Dutta, A.: Malignant melanoma of the penis. J. Indian med Ass. 62: 354-356 (1974). 5 Begun, F.P.: Grossmann, H.B.; Diokno, A.C.; Sogani, P.C.: Malignant melanoma of the penis and male urethra. J. Urol. 132: 123-125 (1984). 6 Bhawan, J.; Cahn, T.M.: Atypical penile lentigo. J. Dermatol. Surg. Oncol. 10: 99-100 (1984). 7 Blech, M.; Miersch, W.D.; Koelmel, K.F.; Truss, F.: Penismelanome. Urologe 25: 166-169 (1986). 8 Bobin, J.Y.; Gaude, J.M.; Bailly, C; Gerard, J.P.; Mayer, M.: Les mélanomes malins primitifs de l’urètre: à propos de 4 cas. J. Urol. 89: 105-109 (1983). 9 Bracken, R.B.; Diokno, A.C.: Melanoma of the penis and the urethra: two case reports and review of the literature. J. Urol. Ill: 198-200 (1974). 10 Casselman, J.; Maes, D.: Malignant melanoma of the glans penis. Acta urol. belg. 55: 467-471 (1987). 11 Cricco, R.P.; Lindert, D.J.; Belis, J.A.: Carcinoma of the penis. Sth. med. J. 73: 758-760 (1980). 12 Das Gupta, T.; Grabstald, H.: Melanoma of the genitourinary tract. J. Urol. 93: 607-614 (1965). 13 Ellis, H.; White, W.F.: Malignant melanoma of the penis: endo lymphatic therapy with 131-1 Lipiodol. Br. J. Surg. 55: 238-241 (1968). 14 Fernandez Madrigal, F.; Junquera Villa, J.M.: Primary mela noma of the male urethra. A review of the literature. Actas Urol. Esp. 8: 221-224 (1984). 15 Fronstin, M.H.; Hutcheson, J.B.: Malignant melanoma of the penis: a report of two cases. Br. J. Urol. 41: 324-326 (1969). 16 Geelhoed, G.W.; Myers, G.H., Jr.: Primary melanoma of the male urethra. J. Urol. 109: 634-637 (1973). 17 Girgis, A.S.; Bergman, H.; Rosenthal, H.; Solomon, L.: Unusual penile malignancies in circumcised je wish men. J Urol 100:696702 (1973). 18 Gojaseni, P.; Nitiyant, P.: Malignant melanoma of the penis: report of a case treated by surgery and chemotherapy. Br. J. Urol. 44: 143-146 (1972). Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
urinary irritation, obstruction, hematuria, and occasionally melanuna. Malignant melanomas present clinically as a blue-black to red dish-brown pigmented papule, plaque or ulceration on the glans penis, less frequently it is found on the prepuce. Our case is an example that also on the glans penis, as on other sites of the skin, malignant melanoma in its very early stage represents a flat, asym metrical, more or less sharply circumscribed macule with a diameter between 5 and 10 mm composed of different hues of brown. The clinical differential diagnoses include junctional melanocytic nevus, penile melanosis, penile lentigo and furthermore ‘atypical pig mented penile macules’, recently described by Leicht et al. [28; see also 3, 19, 31, 33]. These completely benign lesions are often clini cally indistinguishable from malignant melanoma. Therefore, in order to establish a definitive diagnosis and to avoid large and use less surgical removal in any case of suspected pigmented genital lesion a punch biopsy with subsequent histologic examination should be performed. The histological examination of the punch biopsy specimen as well as of the excisional biopsy specimen from our patient revealed the characteristic features of melanoma in situ [23, 31]. In multiple serial sections a few atypical melanocytes could be detected in the papillary dermis and the lamina propria and therefore the diagnosis of early ‘invasive’ malignant melanoma was established. Indepen dent of the diagnosis of early ‘invasive’ malignant melanoma the patient’s prognosis is good especially if no regressive phenomena with fibrosis, teleangiectases and macrophages in a thickened papil lary dermis are observed. Although malignant melanoma can arise in all anatomic sites in the urethra from the meatus to the prostatic urethra, the fossa navicularis and meatus are most frequently involved [5, 20, 50]. Surgery is the primary mode of treatment, with radiotherapy and chemotherapy being of only adjunctive or palliative benefit. For stage I melanoma (localized lesion without métastasés) and stage II melanoma (métastasés confined to one regional area), adequate excision of the primary tumor by partial or total penis amputation together with en bloc bilateral ilioinguinal node dissection offers the greatest prospectus for cure [3, 18, 19, 25, 33, 34]. Surgical removal of a superficial nodule is indicated when the lesion is considered localized disease and the patient is determined to be apparently free of disease in other sites and organs. Positive aspiration cytology may avoid risk from ill-judged surgical procedures and indicate appro priate palliative treatment of the disease [36]. Bracken and Diokno [9] cite the high local and regional failure rate in patients with clinically localized penile and male urethral melanoma managed with conservative penectomy or without bilat eral ilioinguinal lymphadenectomy and recommend aggressive sur gery. Early hematogenous and lymphatic dissemination is characteris tic of malignant melanoma, which may originate from the penis or the urethra. With the exception of very early ‘invasive’ malignant melanoma, the most common therapy of penile and urethral melanoma is radi cal surgery. Radiation therapy and chemotherapy may be helpful adjuncts to surgery. Rothenberger [38] reported a case of malignant melanoma of the penis treated with Neodym-YAG-laser, but he failed to produce a superior result. In a very limited number of tumors Bobin [8] performed an amputation of the penis with a per ineal urethrostomy completed by interstitial irradiation with irid ium-192 and inguinal lymphadenectomy. Other authors tried im
Primus/Soyer/Smolle/Mertl/Pummer/Kerl
Early ‘Invasive’ Malignant Melanoma of Gians penis and Male Urethra
37 Reid, J.D.: Melanocarcinoma of the penis. Report of a case. Cancer 10: 359-362 (1957). 38 Rothenberger, K.; Hofstetter, A.; Pensel, J.; Keiditsch, E.: Neodymium-YAG laser therapy of malignant tumors of the penis. Case report of a malignant melanoma. Fortschr. Med. 100: 1806-1808 (1982). 39 Sanders, T.J.; Venable, D.D.; Sanusi, I.D.: Primary malignant melanoma of the urethra in a black man: a case report. J. Urol. 135: 1012-1014 (1986). 40 Schneiderman, C.; Simon, M.A.; Levine, R.M.: Malignant mela noma of the penis. J. Urol. 93: 615-617 (1965). 41 Senga, Y.; Furuhata, A.; Murakami, M.; Kameyama, K: A case of malignant melanoma of the penis. Hinyokika Kiyo 29: 10791083 (1983). 42 Shanik, G.D.; Jagoe, S.W.: Case report: malignant melanoma of the penis. Ir. J. med Sci. 145: 207-208 (1976). 43 Somlai, B.; Zalatnay, A.: Malignant melanoma localized on the penis. Orv. Hétil. 128: 149-151 (1987). 44 Stein, B.S.; Kendall, A.R.: Malignant melanoma of the genito urinary tract. J. Urol. 132: 859-868 (1984). 45 Talerman, A.: Malignant melanoma of the penis. Urol. int. 27: 66-80 (1972). 46 Taeuber, H.; Hartmann, A.A.: Das maligne Melanom des Penis. Hautarzt 28: 239-240 (1977). 47 Terada, Y.; Takayasu, H.: Malignant melanoma of the male ure thra. Br. J. Urol. 48: 390 (1976). 48 Tyrrell, H.J.; Melanotic tumor of the urethra. Proc. Pathol. Soc. Dublin 4: 194 (1971). 49 Von Krauss, J.; Heinrichs, H.J.; Reiss, C.J.; Müller, R.: Primäre maligne Melanome seltener Lokalisationen. Teil I: Maligne Me lanome des Hamtraktes und des männlichen Genitale. Dt. Gesundhwes. 35: 36-38 (1980). 50 Weiss, J.; Elder, D.; Hamilton, R.: Melanoma of the male ure thra: surgical approach and pathological analysis. J. Urol. 128: 382-385 (1982).
Günter Primus, MD Urologische Abteilung des Landeskrankenhauses Graz Auenbniggerplatz 1 A-8036 Graz (Austria)
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19 Gross, S.D.: A system of surgery; 6th ed., voi. 2, p. 834 (Saun ders, Philadelphia 1982). 20 Guinn, G.A.; Ayala, A.G.: Male urethral cancer: report of 15 cases including a primary melanoma. J. Urol. 103: 176-179 (1970). 21 Jaeger, N.; Wirtler, H.; Tschubel, K.: Acral lentiginous mela noma of the penis. Eur. Urol. 8: 182-184 (1982). 22 Jorda, E.; Verdeger, J.M.; Moragon, M.; Galan, A.; Sanchez, M.D.; Castells, A.: Desmoplastic melanoma of the penis. Letter. J. Am. Acad. Derm. 16: 619-620 (1987). 23 Kerl, H.; Hoedl, S.; Kresbach, H.; Stettner, H.: Diagnosis and prognosis of the early stages of cutaneous malignant melanoma; in Burghardt, Holzer, Clinics in oncology, voi. 1, pp 433-453 (Saunders, Philadephia 1982). 24 Khezri, A.A.; Dounis, A.; Roberts, J.B.M.: Primary malignant melanoma of the penis: two cases and a review of the literature. Br. J. Urol 51: 147-150 (1979). 25 Kokotas, N.S.; Kallis, E.G.; Fokitis, P.J.: Primary malignant melanoma of male urethra. Urology 18: 392-394 (1981). 26 Königsberg, H.A.; Gray, G.F.; Benign melanosis and malignant melanoma of penis and male urethra. Urology 7: 323-326 (1976). 27 Kopf, A.W.; Bart, R.S.: Tumor conference 43: Penile lentigo. J. Dermatol. Surg. Oncol. 8: 637-639 (1982). 28 Leicht, S.; Youngberg, G.; Diaz-Miranda, C.: Atypical pig mented penile macules. Archs Derm. 124: 1267-1270 (1988). 29 Lozano, J.L.; Mayayo, E.; Trobat, F.; Rodriquez, J.L.; Rey, A.: Malignant melanoma of the penis associated with other types of melanosis. A propos of an isolated case. J. Urol. 92: 365-368 (1986). 30 Luechtrath, H.; Schmich, H.R.: Malignant melanoma of the penile fossa navicularis. Urologe 23: 285-287 (1984). 31 Maize, J.C.; Ackerman, A.B.: Pigmented lesions of the skin. Clinicopathological correlations (Lea & Febiger, Philadelphia 1987). 32 Oldbring, J.; Mikulowski, P.: Malignant melanoma of the penis and the male urethra. Report of nine cases and review of the literature. Cancer 59: 581-587 (1987). 33 Pack, G.T.: The pigmented mole and the malignant melanoma. CA 12: 11-26 (1962). 34 Paul, E.: Lentigo maligna an der Gians penis. Differenzierung mit einer neuen Methode. Hautarzt 27: 599-602 (1976). 35 Persky, L.; deKemion, J.: Carcinoma of the penis. CA 36: 258273 (1986). 36 Piscioli, F.; Polla, E.; Pusiol, T.; Zumiani, G.; Cristofolini, M.: Aspiration cytology of cutaneous metastatic melanoma and epi dermoid carcinoma of the penis. Am. J. Dermatopathol. 8: 472477 (1986).
159
Eur Urol 1990;18:156-159
Early ‘Invasive’ Malignant Melanoma of the Gians penis and the Male Urethra Report of a Case and Review of the Literature
Günter Primus3, Hans Peter Soyerh, JosefSmolleb, Georg Mertl3, Karl Pummer3, Helmut KerP “Urology Unit, General Hospital of Graz, and bDepartment of Dermatology, University of Graz, Austria
Key Words. Penile neoplasms melanoma • Pathology therapy Abstract. A 40-year-old male with early ‘invasive’ malignant melanoma of the glans penis and meatus urethrae externus is presented. Early stages of primary melanoma of the glans penis and the male urethra are distinctly rare and are often clinically indistinguishable from penile lentigo, melanosis and melanocytic nevus on the genitalia. In order to avoid large and useless surgery on such a delicate location we propose a punch biopsy with subsequent histological examination prior to definitive surgical procedure. Whereas malignant melanoma of the penis with a thick Breslow index is treated with extended surgical management, only local excision of the tumor without groin dissection was performed in our patient.
Fewer than 100 cases of primary malignant melanoma arising in the male urethra or penis have been accumulated in the literature [ 1, 2, 4, 5, 7-18, 20-22, 24-26, 29, 30, 32, 34, 37-50], Undoubtedly, many go unreported. Although malignant melanoma is one of the rarer tumors of the male urethra and penis, these locations are the most common sites of origin in the genitourinary tract. The diagno sis is usually late, recurrence is early and widespread métastasés are frequent. This confirms the consensus of available reports that, irre spective of the type of therapy used, prognosis is poor in patients with malignant melanoma of the penis and urethra. Although it has been pointed out that these tumors are relatively radioresistant, preoperative radiation therapy may be useful as a sterilization proce dure to prevent viable tumor spill at the time of operation. Informa tion regarding appropriate treatment of this malignancy is derived from the review of single case reports and small series. A case of an early stage of malignant melanoma of the glans penis and male urethra is presented with special emphasis on clini cal and histopathological findings.
Case Report Clinical History For 2 years a 40 year-old male patient had observed a pigmented macule on his glans penis rapidly increasing in the last 3 months.
Clinical Finding On the glans penis situated around the meatus urethrae externus there is a broad, asymmetrical, poorly circumscribed, unevenly brown pigmented, flat lesion, which merges in the distal part of the male urethra. Pathologic Finding The histopathological findings of the glans penis and of the male urethra were identical. There was a broad, asymmetrical, not sharply circumscribed lesion characterized by an increased number of atypical melanocytes appearing singly and in nests of various sizes and shapes all within the epidermis and within the urethral epithelium. Atypical melanocytes in single units and nests were scattered mainly in the lower part, but sometimes also at every level of the epidermis and the urethral epithelium (fig. 1, 2). The atypical mela nocytes reveal loss of cohesion, hyperchromatic nuclei, variation in nuclear size and shape, increased nuclearxytoplasmic ratios and prominent nucleoli. In serial sections the continuity with the overly ing epidermis and urethral epithelium cannot always be demonstrated and some single tumor cells extend into the papillary dermis and the lamina propria indicating focal ‘microinvasion’ (fig. 3). Only in these areas a very sparse inflammatory cell infiltrate can be observed. Treatment Local excision of the lesion - the diagnosis of early invasive malignant melanoma was already established by histopathological examination of a 4-mm punch biopsy - was performed in general anesthesia in bloodlessness with a security distance of 1 cm together Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
Introduction
Early ‘Invasive’ Malignant Melanoma of Gians penis and Male Urethra
157
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Fig. 1. Melanoma in situ of the glans penis. Note an increased number of atypical melanocytes, both single and in nests within the lower part of the epidermis. HE X 250. Fig. 2. Melanoma in situ of the distal part of the male urethra. Numerous atypical melanocytes are scattered throughout the hyper plastic urethral epithelium sometimes including upper layers. HE X 100.
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Fig. 3. Early ‘invasive’ malignant melanoma of the male urethra. There is a markedly increased number of atypical melanocytes arranged as solitary units and in nests within all levels of the epithelium. Notice that a few atypical melanocytes are present within the lamina propria. HE X 250. Fig. 4. Penis 1 month after excision of the malignant melanoma. A new orifice (arrow) was formed by everting urethra.
Discussion Cancers of the penis other than epidermoid carcinomas are very rare and, except for basal cell carcinoma, generally have a poor prognosis [35]. Of 1,200 malignant melanomas treated at MemorialSloan Kettering Cancer Center, only 2 were of penile origin. The peak incidence is seen in the sixth to seventh decade [5, 50]. In the advanced stages of disease patients may present with symptoms of Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
with the first part of the distal urethra in a length of about 2 cm. The basis and the surroundings of the resection were coagulated careful ly. Histological examination, however, revealed excision of the tumor in the distal urethra not in sano. Therefore a further part of the distal urethra was resected and this specimen was histologically free of melanoma. A new orifice was made by everting urethra (fig. 4). Convalescence was uneventful; after removing the catheter the patient voided well. He was discharged in good condition.
158
munotherapy [21, 24] or injection of 13lI-Lipiodol [13] after opera tive treatment, but their effects were limited. We propose a conservative surgical management, for early ‘inva sive’ malignant melanoma of the glans penis and the male urethra, especially when the patients are young and fully active in sexual life. However, in the literature, there are only a few reported 5-year sur vivors [16, 25, 32, 37]. In general prognosis is poor and most patients die within 3 years due to distant métastasés. As with malig nant melanoma on other locations the early detection and sufficient surgical treatment is of crucial importance for successful control of penile and urethral melanoma.
References 1 Abeshouse, B.S.: Primary and secondary melanoma of the geni tourinary tract. Sth. med. J. 51: 994-1006 (1958). 2 Alferez, F.J.D.; Corali, M.T.F.; Medierò, J.G.; Gomez, J.M.: Melanoma maligno de pene: presentacion de dos casos. Actas Urol. Esp. 7: 473-476 (1983). 3 Ariel, I.M.: Malignant melanoma of the male genital system; in Ariel, Malignant melanoma, pp. 507-511 (Appleton-CenturyCrofts, New York 1981). 4 Baruah, B.D.; Dutta, A.: Malignant melanoma of the penis. J. Indian med Ass. 62: 354-356 (1974). 5 Begun, F.P.: Grossmann, H.B.; Diokno, A.C.; Sogani, P.C.: Malignant melanoma of the penis and male urethra. J. Urol. 132: 123-125 (1984). 6 Bhawan, J.; Cahn, T.M.: Atypical penile lentigo. J. Dermatol. Surg. Oncol. 10: 99-100 (1984). 7 Blech, M.; Miersch, W.D.; Koelmel, K.F.; Truss, F.: Penismelanome. Urologe 25: 166-169 (1986). 8 Bobin, J.Y.; Gaude, J.M.; Bailly, C; Gerard, J.P.; Mayer, M.: Les mélanomes malins primitifs de l’urètre: à propos de 4 cas. J. Urol. 89: 105-109 (1983). 9 Bracken, R.B.; Diokno, A.C.: Melanoma of the penis and the urethra: two case reports and review of the literature. J. Urol. Ill: 198-200 (1974). 10 Casselman, J.; Maes, D.: Malignant melanoma of the glans penis. Acta urol. belg. 55: 467-471 (1987). 11 Cricco, R.P.; Lindert, D.J.; Belis, J.A.: Carcinoma of the penis. Sth. med. J. 73: 758-760 (1980). 12 Das Gupta, T.; Grabstald, H.: Melanoma of the genitourinary tract. J. Urol. 93: 607-614 (1965). 13 Ellis, H.; White, W.F.: Malignant melanoma of the penis: endo lymphatic therapy with 131-1 Lipiodol. Br. J. Surg. 55: 238-241 (1968). 14 Fernandez Madrigal, F.; Junquera Villa, J.M.: Primary mela noma of the male urethra. A review of the literature. Actas Urol. Esp. 8: 221-224 (1984). 15 Fronstin, M.H.; Hutcheson, J.B.: Malignant melanoma of the penis: a report of two cases. Br. J. Urol. 41: 324-326 (1969). 16 Geelhoed, G.W.; Myers, G.H., Jr.: Primary melanoma of the male urethra. J. Urol. 109: 634-637 (1973). 17 Girgis, A.S.; Bergman, H.; Rosenthal, H.; Solomon, L.: Unusual penile malignancies in circumcised je wish men. J Urol 100:696702 (1973). 18 Gojaseni, P.; Nitiyant, P.: Malignant melanoma of the penis: report of a case treated by surgery and chemotherapy. Br. J. Urol. 44: 143-146 (1972). Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 9:42:05 AM
urinary irritation, obstruction, hematuria, and occasionally melanuna. Malignant melanomas present clinically as a blue-black to red dish-brown pigmented papule, plaque or ulceration on the glans penis, less frequently it is found on the prepuce. Our case is an example that also on the glans penis, as on other sites of the skin, malignant melanoma in its very early stage represents a flat, asym metrical, more or less sharply circumscribed macule with a diameter between 5 and 10 mm composed of different hues of brown. The clinical differential diagnoses include junctional melanocytic nevus, penile melanosis, penile lentigo and furthermore ‘atypical pig mented penile macules’, recently described by Leicht et al. [28; see also 3, 19, 31, 33]. These completely benign lesions are often clini cally indistinguishable from malignant melanoma. Therefore, in order to establish a definitive diagnosis and to avoid large and use less surgical removal in any case of suspected pigmented genital lesion a punch biopsy with subsequent histologic examination should be performed. The histological examination of the punch biopsy specimen as well as of the excisional biopsy specimen from our patient revealed the characteristic features of melanoma in situ [23, 31]. In multiple serial sections a few atypical melanocytes could be detected in the papillary dermis and the lamina propria and therefore the diagnosis of early ‘invasive’ malignant melanoma was established. Indepen dent of the diagnosis of early ‘invasive’ malignant melanoma the patient’s prognosis is good especially if no regressive phenomena with fibrosis, teleangiectases and macrophages in a thickened papil lary dermis are observed. Although malignant melanoma can arise in all anatomic sites in the urethra from the meatus to the prostatic urethra, the fossa navicularis and meatus are most frequently involved [5, 20, 50]. Surgery is the primary mode of treatment, with radiotherapy and chemotherapy being of only adjunctive or palliative benefit. For stage I melanoma (localized lesion without métastasés) and stage II melanoma (métastasés confined to one regional area), adequate excision of the primary tumor by partial or total penis amputation together with en bloc bilateral ilioinguinal node dissection offers the greatest prospectus for cure [3, 18, 19, 25, 33, 34]. Surgical removal of a superficial nodule is indicated when the lesion is considered localized disease and the patient is determined to be apparently free of disease in other sites and organs. Positive aspiration cytology may avoid risk from ill-judged surgical procedures and indicate appro priate palliative treatment of the disease [36]. Bracken and Diokno [9] cite the high local and regional failure rate in patients with clinically localized penile and male urethral melanoma managed with conservative penectomy or without bilat eral ilioinguinal lymphadenectomy and recommend aggressive sur gery. Early hematogenous and lymphatic dissemination is characteris tic of malignant melanoma, which may originate from the penis or the urethra. With the exception of very early ‘invasive’ malignant melanoma, the most common therapy of penile and urethral melanoma is radi cal surgery. Radiation therapy and chemotherapy may be helpful adjuncts to surgery. Rothenberger [38] reported a case of malignant melanoma of the penis treated with Neodym-YAG-laser, but he failed to produce a superior result. In a very limited number of tumors Bobin [8] performed an amputation of the penis with a per ineal urethrostomy completed by interstitial irradiation with irid ium-192 and inguinal lymphadenectomy. Other authors tried im
Primus/Soyer/Smolle/Mertl/Pummer/Kerl
Early ‘Invasive’ Malignant Melanoma of Gians penis and Male Urethra
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Günter Primus, MD Urologische Abteilung des Landeskrankenhauses Graz Auenbniggerplatz 1 A-8036 Graz (Austria)
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