661
CASE REPORTS
Metastatic Malignant Melanoma of the Epididymis F. A. HAM MAD, Department of Urology, Selly Oak Hospital, Birmingham
Case Report A 38-year-old Caucasian male presented with a painless swelling of the left scrotum. Physical examination revealed a well defined uniform swelling of the head of the epididymis about 1 cm in diameter, completely separate from the testis. This was diagnosed as a n epididymal cyst and the patient was reassured and discharged. He returned 6 months later because the swelling had increased in size and was tender to palpation. There were no other abnormal physical findings. The only past history of significance was a malignant melanoma of the left shoulder which had been completely excised 8 years previously. An ultrasound scan revealed a solid mass about 2 cm in diameter in the head of the epididymis with a normal testis (Fig.)
About 20 to 25% are malignant but only a few are metastatic (Elsasser, 1977). A survey of the literature has revealed only 42 reported cases of metastatic paratesticular tumours, the majority of which have been included in a review by Powell ef al. (1985). Most of them were metastatic from genitourinary or gastrointestinal primaries. Only 5 cases of paratesticular metastatic malignant melanoma have previously been reported and 3 of these were autopsy findings in patients who had died of disseminated malignant melanomas (Anselmo et al., 1979; Anderson and McGahan, 1986). One of the 2 remaining patients had widespread metastases and in the other case no details were mentioned in the report. An epididymal metastasis from a malignant melanoma in an otherwise apparently healthy patient would seem to indicate the presence of other metastases.
Acknowledgement The author thanks Mr D. J. Farrar and Dr J. A. Banks for allowing him to report their case and Miss Tracey Wakelam for secretarial assistance.
References Anderson, M. W. and McGahan, J. P. (1986). Metastatic melanoma to the epididymis suspected on pre-operative ultrasound. J . Clin. Ultrasound, 14,64446. Anselmo, G., Rizzotti, A. and Gramegna, V. (1979). A metastatic melanoma in the spermatic cord. Br. J . Urol., 51,416. Elsasser, E. (1977). Tumours of the epididymis. Recent results. Cancer Res., 60, 163-175. Powell, B. L., Craig, J. B. and MUSS, H. B. (1985). Secondary malignancies of the penis and epididymis: a case report and review of the literature. J . Clin. Oncol., 3, 1 l(rl16.
Requests for reprints to: F. A. Hammad, P.O.Box 92, Nablus, via Israel.
The scrotum was explored and a n epididymectomy was performed. Histology of the specimen revealed a poorly differentiated malignant melanoma. A CT scan of the chest and abdomen revealed 3 metastases in the small intestine causing sub-acute obstruction. At laparotomy the 3 segments of small intestine involved were resected. Histology again confirmed metastatic malignant melanoma. The patient later developed cerebral metastases, which are being treated by chemotherapy and radiotherapy.
Hypereosinophilia, Cardiomyopathy and Transitional Cell Carcinoma of the Bladder R. KING, RUTH FAIRBROTHER, I. GRANTand K. FARRI NGTON, Departments of Medicine and Haernatology. King George Hospital, Itford
Comment
Case Report
Tumours of the epididymis and spermatic cord account for only 5% of all intra-scrota1 tumours.
A 53-year-old lady presented with weight loss. She had a 6-year h i s t o j of rheumatoid arthritk treated with
662 D-penicillamine. Over the preceding 18 months eosinophilia had been noted, with counts ranging between 0.9 x 109/1and 8.38 x 109/1(743% of total white cell count). D-penicillamine had been stopped but the eosinophilia persisted. There was no history of atopy. On examination she was cachectic. The jugular venous pressure was elevated. She had hepatomegaly and leg oedema. There were no murmurs and no cardiomegaly. Blood pressure was 105/80. Investigations revealed normal serum creatinine and albumin concentrations. Stool microscopy was negative. Bone marrow examinations showed excess eosinophils but no evidence of tumour. 2D echocardiography showed features of a restrictive cardiomyopathy. CT scanning showed bilateral hydronephrosis. Cystoscopy revealed a mass at the base of the bladder. Histology showed poorly differentiated transitional cell carcinoma. Her deterioration continued despite treatment with diuretics, steroids and palliative radiotherapy and she died.
Comment Blood eosinophilia may indicate a variety of underlying systemic conditions. Investigation of our patient revealed no evidence of parasitic infestation, allergy, vasculitis or lymphoma. The eosinophilia was attributed to her transitional cell carcinoma of the bladder. She also had a restrictive cardiomyography probably due to endomyocardial fibrosis (Davies ef al., 1983),which may complicate prolonged eosinophilia of any cause. The association between blood eosinophilia and carcinoma is well recognised (Sataline and Mobley, 1967), the most frequently reported associations being with tumours of mucin-secreting epithelium, namely bronchus, gut, pancreas and uterus (Beeson, 1983). We know of no previously reported association with transitional cell carcinoma of the bladder.
References Cancer and eosinophilia. N.Engl. J. Med., 309,792-793. Davies, J.,Spry,C. J. F.,Sapsford,R.efd (1983). Cardiovascular features of eleven patients with eosinophilic endomyocardial disease. Q. J. Med., 52,23-29. Sataline, L. R. and Mobley, E. (1967). Eosinophilia associated with metastatic carcinoma. Ohio Srute Med. J . , 63, 14741476. Beeson, P. (1983).
Requests for reprints to: K. Farrington, Renal Unit, Lister Hospital, Coreys Mill Lane, Stevenage SGI 4AB.
BRITISH JOURNAL OF UROLOGY
lontophoretic Local Anaesthesia for Bladder Dilatation in the Treatment of Interstitial Cystitis U. A. FONTANELLA, C. A. ROSS1 and R. L. STEPHEN, Division of Urology. Valduce Hospital, Como. Italy; Physion srl, Mirandola, Italy; Institute of Biomedical Engineering, University of Utah. Salt Lake City. USA
Iontophoresis is the active transport of ions into tissues by means of an electric current : Ji = DiACi/ Ax DizeECi/kt,where Ji is the total ionic flux, Di the diffusion coefficient, Ci the concentration, z the valency and E the electrical field (Deister and Kasting, 1986). The first expression on the right side of the equation is Fick’s Law of Diffusion, which approaches zero for bladder mucosa (Teruo et al., 1986). Thus, to achieve significant ionised drug penetration into an intact bladder wall an electrical field is required, a principle that was adapted to perform isobaric overdistension of the bladder in the treatment of non-infective interstitial cystitis.
+
Case Report A female multiparous patient, 38 years old, was referred with worsening symptoms of frequency, urgency, some stress incontinence, nocturia 2 4 times and micturition about 15 times daily. Urodynamic studies demonstrated a bladder capacity of 80-100 ml to painful stimulus, stress incontinence with a further 40-60 ml, elevated endovesical pressures and no vesicoureteric reflux; all urinary cultures were persistently negative and biopsy demonstrated a sub-mucosal, non-specific, inflammatory process. Diazepam and imipramine achieved no objective results, but a 3-month course of oxybutinin improved bladder capacity by about 25%. It was decided to perform bladder dilatation using an uncommon method of bladder anaesthesia, without pre-operative medication of any kind. One hundred ml of salt-free lignocaine HCl 1% and epinephrine C1 1/100,000 were prepared. The patient’s bladder was drained and flushed with distilled water to remove residual urinary ionic “contaminants”; 80 ml of the anaesthetic solution were then infused into the bladder, at which point the patient noted the onset of discomfort/pain. An electrode of positive polarity was inserted into the catheter, a dispersive negative electrode was placed on the abdominal wall and a 15 mA DC current was applied for 10 min from a battery-powered source (equipment supplied by PHYSION srl, Mirandola, Italy). Then followed insertion of a cystoscope, visual inspection (no obvious abnormalities), a deep biopsy into
CASE REPORTS
Metastatic Malignant Melanoma of the Epididymis F. A. HAM MAD, Department of Urology, Selly Oak Hospital, Birmingham
Case Report A 38-year-old Caucasian male presented with a painless swelling of the left scrotum. Physical examination revealed a well defined uniform swelling of the head of the epididymis about 1 cm in diameter, completely separate from the testis. This was diagnosed as a n epididymal cyst and the patient was reassured and discharged. He returned 6 months later because the swelling had increased in size and was tender to palpation. There were no other abnormal physical findings. The only past history of significance was a malignant melanoma of the left shoulder which had been completely excised 8 years previously. An ultrasound scan revealed a solid mass about 2 cm in diameter in the head of the epididymis with a normal testis (Fig.)
About 20 to 25% are malignant but only a few are metastatic (Elsasser, 1977). A survey of the literature has revealed only 42 reported cases of metastatic paratesticular tumours, the majority of which have been included in a review by Powell ef al. (1985). Most of them were metastatic from genitourinary or gastrointestinal primaries. Only 5 cases of paratesticular metastatic malignant melanoma have previously been reported and 3 of these were autopsy findings in patients who had died of disseminated malignant melanomas (Anselmo et al., 1979; Anderson and McGahan, 1986). One of the 2 remaining patients had widespread metastases and in the other case no details were mentioned in the report. An epididymal metastasis from a malignant melanoma in an otherwise apparently healthy patient would seem to indicate the presence of other metastases.
Acknowledgement The author thanks Mr D. J. Farrar and Dr J. A. Banks for allowing him to report their case and Miss Tracey Wakelam for secretarial assistance.
References Anderson, M. W. and McGahan, J. P. (1986). Metastatic melanoma to the epididymis suspected on pre-operative ultrasound. J . Clin. Ultrasound, 14,64446. Anselmo, G., Rizzotti, A. and Gramegna, V. (1979). A metastatic melanoma in the spermatic cord. Br. J . Urol., 51,416. Elsasser, E. (1977). Tumours of the epididymis. Recent results. Cancer Res., 60, 163-175. Powell, B. L., Craig, J. B. and MUSS, H. B. (1985). Secondary malignancies of the penis and epididymis: a case report and review of the literature. J . Clin. Oncol., 3, 1 l(rl16.
Requests for reprints to: F. A. Hammad, P.O.Box 92, Nablus, via Israel.
The scrotum was explored and a n epididymectomy was performed. Histology of the specimen revealed a poorly differentiated malignant melanoma. A CT scan of the chest and abdomen revealed 3 metastases in the small intestine causing sub-acute obstruction. At laparotomy the 3 segments of small intestine involved were resected. Histology again confirmed metastatic malignant melanoma. The patient later developed cerebral metastases, which are being treated by chemotherapy and radiotherapy.
Hypereosinophilia, Cardiomyopathy and Transitional Cell Carcinoma of the Bladder R. KING, RUTH FAIRBROTHER, I. GRANTand K. FARRI NGTON, Departments of Medicine and Haernatology. King George Hospital, Itford
Comment
Case Report
Tumours of the epididymis and spermatic cord account for only 5% of all intra-scrota1 tumours.
A 53-year-old lady presented with weight loss. She had a 6-year h i s t o j of rheumatoid arthritk treated with
662 D-penicillamine. Over the preceding 18 months eosinophilia had been noted, with counts ranging between 0.9 x 109/1and 8.38 x 109/1(743% of total white cell count). D-penicillamine had been stopped but the eosinophilia persisted. There was no history of atopy. On examination she was cachectic. The jugular venous pressure was elevated. She had hepatomegaly and leg oedema. There were no murmurs and no cardiomegaly. Blood pressure was 105/80. Investigations revealed normal serum creatinine and albumin concentrations. Stool microscopy was negative. Bone marrow examinations showed excess eosinophils but no evidence of tumour. 2D echocardiography showed features of a restrictive cardiomyopathy. CT scanning showed bilateral hydronephrosis. Cystoscopy revealed a mass at the base of the bladder. Histology showed poorly differentiated transitional cell carcinoma. Her deterioration continued despite treatment with diuretics, steroids and palliative radiotherapy and she died.
Comment Blood eosinophilia may indicate a variety of underlying systemic conditions. Investigation of our patient revealed no evidence of parasitic infestation, allergy, vasculitis or lymphoma. The eosinophilia was attributed to her transitional cell carcinoma of the bladder. She also had a restrictive cardiomyography probably due to endomyocardial fibrosis (Davies ef al., 1983),which may complicate prolonged eosinophilia of any cause. The association between blood eosinophilia and carcinoma is well recognised (Sataline and Mobley, 1967), the most frequently reported associations being with tumours of mucin-secreting epithelium, namely bronchus, gut, pancreas and uterus (Beeson, 1983). We know of no previously reported association with transitional cell carcinoma of the bladder.
References Cancer and eosinophilia. N.Engl. J. Med., 309,792-793. Davies, J.,Spry,C. J. F.,Sapsford,R.efd (1983). Cardiovascular features of eleven patients with eosinophilic endomyocardial disease. Q. J. Med., 52,23-29. Sataline, L. R. and Mobley, E. (1967). Eosinophilia associated with metastatic carcinoma. Ohio Srute Med. J . , 63, 14741476. Beeson, P. (1983).
Requests for reprints to: K. Farrington, Renal Unit, Lister Hospital, Coreys Mill Lane, Stevenage SGI 4AB.
BRITISH JOURNAL OF UROLOGY
lontophoretic Local Anaesthesia for Bladder Dilatation in the Treatment of Interstitial Cystitis U. A. FONTANELLA, C. A. ROSS1 and R. L. STEPHEN, Division of Urology. Valduce Hospital, Como. Italy; Physion srl, Mirandola, Italy; Institute of Biomedical Engineering, University of Utah. Salt Lake City. USA
Iontophoresis is the active transport of ions into tissues by means of an electric current : Ji = DiACi/ Ax DizeECi/kt,where Ji is the total ionic flux, Di the diffusion coefficient, Ci the concentration, z the valency and E the electrical field (Deister and Kasting, 1986). The first expression on the right side of the equation is Fick’s Law of Diffusion, which approaches zero for bladder mucosa (Teruo et al., 1986). Thus, to achieve significant ionised drug penetration into an intact bladder wall an electrical field is required, a principle that was adapted to perform isobaric overdistension of the bladder in the treatment of non-infective interstitial cystitis.
+
Case Report A female multiparous patient, 38 years old, was referred with worsening symptoms of frequency, urgency, some stress incontinence, nocturia 2 4 times and micturition about 15 times daily. Urodynamic studies demonstrated a bladder capacity of 80-100 ml to painful stimulus, stress incontinence with a further 40-60 ml, elevated endovesical pressures and no vesicoureteric reflux; all urinary cultures were persistently negative and biopsy demonstrated a sub-mucosal, non-specific, inflammatory process. Diazepam and imipramine achieved no objective results, but a 3-month course of oxybutinin improved bladder capacity by about 25%. It was decided to perform bladder dilatation using an uncommon method of bladder anaesthesia, without pre-operative medication of any kind. One hundred ml of salt-free lignocaine HCl 1% and epinephrine C1 1/100,000 were prepared. The patient’s bladder was drained and flushed with distilled water to remove residual urinary ionic “contaminants”; 80 ml of the anaesthetic solution were then infused into the bladder, at which point the patient noted the onset of discomfort/pain. An electrode of positive polarity was inserted into the catheter, a dispersive negative electrode was placed on the abdominal wall and a 15 mA DC current was applied for 10 min from a battery-powered source (equipment supplied by PHYSION srl, Mirandola, Italy). Then followed insertion of a cystoscope, visual inspection (no obvious abnormalities), a deep biopsy into
