International Urology and Nephrology 23 (2), pp. 161--167 (1991)
Metastasis to the Penis Case Reports and Review of the Literature P. J. OSTHER, E. LONTOFT Department of Urology, Odense University Hospital, Odense, Denmark (Received May 9, 1990)
Metastasis to the penis is rare, despite rich vascularization and complex circulation. Less than 200 cases have been reported. Three new cases of penis metastasis
from primary tumours in the bladder and prostate, respectively, are described. The most common symptoms are penile induration and swelling. Treatments, all of which must be considered merely palliative, consist of local tumour excision, radiation therapy, cytostatic and hormone therapy, possibly with partial or total penis amputation. The prognosis is poor, irrespective of the therapy and site of the primary tumour. More than 80 ~ of the patients die within six months after the occurrence of penis metastasis, as a result of disseminated cancer disease.
Introduction Metastasis to the penis is rare despite rich vascularization and extensive circulatory communication between the penis and neighbouring organs; the latter often being the site of malignant tumours. Less than 200 cases have been reported in the present century. Abeshouse and Abeshouse [1] published a comprehensive review of the literature in 1961 covering a total of 140 cases. Since then, only a few cases have been reported in the literature [2, 11, 21, 25]. Seventy-five per cent of the metastases to the penis originate from primary tumours in the urogenital tract. Three new case histories of such patients will be presented. Furthermore, the metastatic mechanisms, clinical picture, diagnosis and differential diagnosis, treatment and prognosis will be the object of comment.
Case reports Case 1. A 66-year-old man, who had been subjected to cystectomy 2 8 9 months earlier with the establishment of a Bricker bladder due to low differentiated transitional-cell bladder carcinoma grade IV, T3 with the turnout adhering to the rectum. Radiation treatment commenced after operation. Presenting with a 5
VSP, Utrecht .4kad~miai Kiad6, Budapest
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Osther, L o n t o f t : M e t a s t a s i s to the penis
1 x 1 cm large ulceration, an underlying tumour on the glans penis at the site o f the meatus was found, without other signs of metastasis from the bladder tumour. Biopsy from the tumour showed metastasis from the bladder carcinoma. Partial penis amputation was then carried out, and microscopy demonstrated the edges of resection to be free from carcinoma. Radiation treatment was re-commenced, and extended to include the stump of the penis. Two months later the patient developed extensive metastasis in the scar of the abdomen, at the same time X-ray examination of the chest showed metastasis to the lungs. The patient died three weeks later. Case 2. A 76-year-old man, who had been subjected to transurethral resection due to adenocarcinoma of the prostate some 3-4 months earlier, no additional treatment. There had been some diffuse swelling of the penis for a few weeks prior to the present admission, and at the time of hospitalization the patient had suffered from priapism for two days. Operation according to the method of Ebbehoj was carried out twice without effect, after which broken, turnout-like material was removed from the corpora cavernosa, using a sharp curette. Microscopic examination of the material showed metastasis from the prostatic adenocarcinoma. X-ray of the chest revealed multiple lung metastases. The patient was then treated with Androcur, and an indwelling catheter was inserted because o f urine retention. Discharged after 30 days with the indwelling catheter for continued treatment with Androcur, no swelling or pain in the penis was noted. He was re-admitted some 6 8 9 months later as the catheter continued to clog owing to tissue debris. A suprapubic catheter was inserted by means of cystotomy. However, his condition deteriorated rapidly and the patient died. Diagnosis at post mortem examination: adenocarcinoma of the prostate with metastasis to the lungs, liver and pleurae. The penis was not examined. Case 3. A 78-year-old man, who four years previously had been subjected to transurethral prostate resection due to symptoms arising from the prostate. Histological examination demonstrated highly differentiated adenocarcinoma of the prostate. No additional treatment was given. A slowly enlarging swelling had appeared on the glans penis over the last year, together with increasing low-back pain and pain in the right hip. Biopsy from the tumour on the glans penis revealed metastasis from cancer of the prostate. Bone scintigraphy as well as X-ray of the spine, hips, pelvis and chest showed changes compatible with metastasis from cancer of the prostate. The patient was given hormone treatment (Buserelin) which reduces serum testosterone to castration level. The effects were good, inasmuch as pain relief was achieved after one week of treatment, and at control examination four months later the patient was still free from pain and showed no signs of progression of the metastases.
International Urolo#y and Nephrology 23, 1991
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Primary tumours
Seventy-five per cent of metastases to the penis originate from primary malignant tumours in the neighbouring urogenital organs [1, 9, 14, 18]. Of these, malignant bladder tumours comprise roughly 30~, and cancer of the prostate about 25~ [1]. Primary tumours situated in the kidneys constitute almost 10~ and in the testes roughly 7 ~ [1, 12]. Gastrointestinal tumours are responsible in about 20~ [4], the majority of them being recto-sigmoidal cancers. Tumours of the lungs, lymphatic system, skin and locomotor apparatus are very rarely responsible for metastases to the penis. A review of the primary tumours is given in Table 1. Table 1 Metastasis to the penis Primary tumours Bladder Prostate Colon Kidney Testis Lungs Bone Skin Other
Per cent 33 27 18 9 7 3 1.5 0.5 1
Metastasis to the penis is a manifestation occurring late in the course of the disease in respect of all types of tumour, and is often associated with disseminated disease. Metastatic mechanisms
There is no obvious explanation as to why metastasis to the penis is so rare, taking into consideration that the penis is an end organ in respect of the arterial, venous and lymphatic systems, and that it has a complex circulation; further, the fact that it is situated in close relationship to neighbouring organs with a high frequency of malignant tumours. The presumed metastatic mechanisms will therefore be reviewed. 1. Direct spread Direct growth from malignant tumours in the bladder, prostate and rectum to the bulbus penis (corpus spongiosum) and crura penales (corpora cavernosa) has been described in very few cases [1, 18]. This mode of spreading may only 5*
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Osther, L o n t o f t : M e t a s t a s i s to the penis"
explain the presence of tumours in the proximal part o f the penis (pars fixa), but not solitary or multiple metastases in the distal part o f the corpora cavernosa, as is most often seen. 2. Retrograde venous spread Retrograde venous metastasis to the penis is presumably the mechanism occurring most frequently [1, 18]. The widespread communication between the venous plexuses around the bladder, prostate and rectum, on the one hand, and the dorsal vein, on the other, constitute the background for this type o f metastasis. There are two possible mechanisms. (a) The blood stream in the abovementioned area may - due to pressure from the turnout or growth into the blood vessels - turn around, so that a permanent retrograde flow occurs. (b) Intermittent retrograde flow in the above-mentioned area may occur with sudden increase in the intra-abdominal pressure (cough, sneeze, employment of intraabdominal pressure). The tumour cells can be transported in this manner to the penis from the organs in question. 3. Retrograde lymphatic spread Retrograde lymphatic spread can take place to the penis via the superficial and deep-lying lymphatic vessels in the same manner as with venous spreading [1, 181. 4. Direct spreading via the arteries The spreading of tumour cells via the arterial system is thought to be the most common pathway in respect o f a number of tumours [2]. However, with regard to metastasis to the penis, this method of spreading is considered to play only a minor role [1, 18]. This would explain why metastasis to the penis from sarcomas, which are known to metastasize in this manner, are extremely rare, even when due regard is taken of the fact that sarcomas themselves are relatively rare [1 ]. 5. Spread by means of implantation and employment of instruments The implantation of tumour cells transported by the urine presumably plays a minor role in cases of metastasis to the penis, inasmuch as metastases rarely or never originate from nor include the urethral mucosa. Further, metastases to the corpora spongiosum are in practice only seen when the corpus cavernosa, glans penis or praeputium are also involved [1, 9, 14, 18]. In addition, gpread through the use o f instruments in the urethra (cystourethroscopy, transurethral resections) can also be repudiated in this manner. International Urology and Nephroloyy 23, 1991
Osther, L o n t o f t : M e t a s t a s i s to the penis
165
The above-mentioned possible mechanisms of metastasis are all based on mechanical aspects; however, it should be borne in mind that immunological mechanisms are of importance in the occurrence of metastasis [5].
Clinical picture Patients with metastasis to the penis are often marked by disseminated malignant disease, and therefore in a poor general state of health. The primary tumours, and with these metastases to the penis, occur most frequently in the age group 60 to 80 [1]. Metastases are, on the whole, similar irrespective of the primary tumour. They often present as multiple infiltrative nodules (approx. 60~). Solitary turnout nodules are, however, observed, whereas the ulcerative type is uncommon and occurs most often when the glans penis is involved [1]. In roughly 65~ of all cases of metastasis to the penis, the metastasis is located in both corpora cavernosa, and in about 15~o to only one of these. The glans penis is involved in 10~ of these cases, and is often found as diffuse infiltrations in the corpora cavernosa also. The praeputium is involved in less than 10~ of cases [1, 10, 22]. In contrast to metastasis to the penis, primary penis tumours are in the great majority of cases (94~) localized to the glans penis, frenulum or sulcus coronarius [7]. The most common symptoms of metastasis to the penis are penile induration and diffuse or localized swelling. Actual priapism is reported in the literature with considerably varying frequencies [1, 6, 24]. It is the result of either direct ingrowth into the veins of the penis or of tumours in the corpora cavernosa, giving rise to thrombosis or congestion of the circulation [1 ]. Pain is not a typical symptom. An uncharacteristic feeling of discomfort in the perineum when sitting down is frequently reported, and should therefore be the object of further examination. Pain is localized partly to the pars pendularis and partly to the perineum. Perianal pain may be triggered by tumour formation in the penis. Haematuria and symptoms of urinary obstruction are somewhat unspecific symptoms, although belonging to the overall picture [1, 10].
Diagnosis and differential diagnosis The diagnosis is made by biopsy. It is essential to obtain biopsy material as early as possible in order to differentiate between metastasis to the penis and primary tumours, since the latter have a considerably better prognosis [7]. Differential diagnosis includes primary malignant tumours and benign tumours of the penis, syphilitic chancre, idiopathic priapism, Peyronie's disease, candidiasis, tuberculosis of the penis and other specific and non-specific inflammations. The extent of the metastatic process in the penis can be visualized by means of cavernosography [12, 15]. International Urology and Nephrology 23, 1991
166
Osther, Lontoft: Metastasis to the penis
Treatment and prognosis
Treatment depends on the general condition of the patient, the site and extent of the primary tumour, as well as on the extent of the metastasis, and lastly on symptomatology. The various methods of treatment, all of which must be considered as palliative, consist of local excision of the tumour, radiation therapy, cytostatic treatment and partial or total amputation of the penis. In cases of metastasis from carcinoma of the prostate, oestrogen or related hormone therapy, possibly castration, can be attempted. When urinary tract obstruction is present, procedures designed to alleviate this condition may be of value [1, 22]. There is little experience with the use of cytostatics, but the use of this therapy must depend on the type of primary tumour, and the general condition of the patient [6]. Irrespective of whether the primary tumour is situated in the bladder, prostate, kidneys, rectum or other organs, the great majority (more than 80%) of patients with metastasis to the penis die within six months; the latter is an expression of disseminated cancer disease [1, 9, 14, 18]. Even so, reports have been published on survival for up to nine years after the occurrence of metastasis to the penis [1]. Conclusion
Due to the poor prognosis of metastasis to the penis, where more than 80% of the patients die within six months irrespective of the primary tumour and also of the therapy, conservative treatment is advisable. Early biopsy is indicated in order to distinguish between metastasis to and primary turnouts of the penis. Amputation of the penis is inadvisable as it is of no prognostic importance and mutilates the patient. Cases with ulceration and irritating secretion can, however, necessitate such a procedure. Urinary obstruction may require operation to alleviate this condition.
References 1. Abeshouse, B. S., Abeshouse, G. A.: Metastatic tumors of the penis: a review of the literature and a report of two cases. 3". UroL, 86, 99 (1961). 2. Anderson, W . A . D . , Scotti, T. M.: Synopsis of Pathology. 10th edition. C. V. Mosby, St. Louis 1980, pp. 247-250. 3. Bosch, P. C., Forbes, K. A., Kollin, J., Golji, H., Miller, J. B.: Secondary carcinoma of the penis. J. UroL, 132, 990 (1984). 4. Callen, J. P., Gruber, G. G., Giannini, J. M. : Metastatic colonic adenocarcinoma to the glans penis. Int. J. DermatoL, 9, 540 (1982). 5. Currie, G.: Cancer and the Immune Response. 2nd edition. Edward Arnold, London 1980.
6. Garnick, M. B., Skarin, A. T., Steele, G. D.: Metastatic carcinoma of the penis: Complete remission after high dose methotrexate chemotherapy. J. UroL, 122, 265 (1979). International Uroloyy and Nephrology 23, 1991
Osther, Lontoft: Metastasis" to the penis
167
7. Jensen, M. S.: Cancer penis. Copenhagen, F. A. D. L. 1976 (Thesis). 8. Jepsen, J. M., Pedersen, J. K., Andersen, J.: Cancer of the prostate with metastasis to the penis. Ugeskr. Laeger., 143, 2236 (1981). 9. Kumar, P. P., Newland, J. R.: Metastatic carcinoma of the penis. J. Nat. Med. Assoc., 1, 55 (1980). 10. Kyriakidis, A., Papacharalambous, G., Economaeos, G.: Metastatic carcinoma of the penis: case report. Acta Urol. Belg., 4, 702 (1979). 11. Lund, F.: Priapism caused by metastasis to the penis. Ugeskr. Laeger., 123, 346 (1961). 12. May, F., Hirtl, H. : Das Cavernosogramm. Urol. Int., 2, 120 (1955). 13. McCrea, L. E., Karafin, L.: Carcinoma of the prostate with metastasis to the prepuce. J. Urol., 106, 588 (1971). 14. Narayana, A. S., Loening, S. A., Olney, L., Howard, D., Culp, D. A. : Metastatic tumors of the penis. Eur. Urol., 5, 262 (1979). 15. Ney, C., Miller, H. L., Friedenberg, R. M. : Various applications of corpus cavernosography. Radiology, 119, 69 (1976). t6. Oka, M., Nakashima, K.: Carcinoma of the prostate with metastasis to the skin and glans penis. Br. J. Urol., 54, 61 (1982). 17. Ordonez, N. G., Ayala, A. G., Bracken, R. B.: Renal cell carcinoma metastatic to penis. Urology, 4, 417 (1982). 18. Paquin, A. J., Roland, S. I.: Secondary carcinoma of the penis. Cancer, 9, 626 (1956). 19. Patel, N. B., Ward, J. N.: Carcinoma of prostate metastatic to prepuce and glans penis. Urology, 3, 269 (1978). 20. Robey, E. L., Schellhammer, P. F.: Four cases of metastasis to the penis and a review of the litarature. J. Urol., 132, 992 (1984). 21. Smehaug, J.: Metastases to the penis from carcinoma of the prostate. Stand. J. UroL Nephrol., 13, 205 (1979). 22. Spreen, S. A., Keys, R. H., Evans, A. I.: Acute urinary retention secondary to metastatic prostatic carcinoma to the penis: a case report. J. Urol., 113, 59 (1975). 23. Tan, H. T., Vishniavski, S.: Carcinoma of the prostate with metastasis to the prepuce. J. Urol., 106, 588 (1971). 24. Trulock, T. S., Wheatley, J. K., Walton, K. N. : Secondary tumors of the penis. Urology, 6, 563 (1981). 25. Wolf, H., Madsen, P. O.: Metastases to the external genitalia from carcinoma of the prostate: a report of two cases. J. Urol., 99, 198 (1968).
International Urology and Nephrology 23~ 1991
Metastasis to the Penis Case Reports and Review of the Literature P. J. OSTHER, E. LONTOFT Department of Urology, Odense University Hospital, Odense, Denmark (Received May 9, 1990)
Metastasis to the penis is rare, despite rich vascularization and complex circulation. Less than 200 cases have been reported. Three new cases of penis metastasis
from primary tumours in the bladder and prostate, respectively, are described. The most common symptoms are penile induration and swelling. Treatments, all of which must be considered merely palliative, consist of local tumour excision, radiation therapy, cytostatic and hormone therapy, possibly with partial or total penis amputation. The prognosis is poor, irrespective of the therapy and site of the primary tumour. More than 80 ~ of the patients die within six months after the occurrence of penis metastasis, as a result of disseminated cancer disease.
Introduction Metastasis to the penis is rare despite rich vascularization and extensive circulatory communication between the penis and neighbouring organs; the latter often being the site of malignant tumours. Less than 200 cases have been reported in the present century. Abeshouse and Abeshouse [1] published a comprehensive review of the literature in 1961 covering a total of 140 cases. Since then, only a few cases have been reported in the literature [2, 11, 21, 25]. Seventy-five per cent of the metastases to the penis originate from primary tumours in the urogenital tract. Three new case histories of such patients will be presented. Furthermore, the metastatic mechanisms, clinical picture, diagnosis and differential diagnosis, treatment and prognosis will be the object of comment.
Case reports Case 1. A 66-year-old man, who had been subjected to cystectomy 2 8 9 months earlier with the establishment of a Bricker bladder due to low differentiated transitional-cell bladder carcinoma grade IV, T3 with the turnout adhering to the rectum. Radiation treatment commenced after operation. Presenting with a 5
VSP, Utrecht .4kad~miai Kiad6, Budapest
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Osther, L o n t o f t : M e t a s t a s i s to the penis
1 x 1 cm large ulceration, an underlying tumour on the glans penis at the site o f the meatus was found, without other signs of metastasis from the bladder tumour. Biopsy from the tumour showed metastasis from the bladder carcinoma. Partial penis amputation was then carried out, and microscopy demonstrated the edges of resection to be free from carcinoma. Radiation treatment was re-commenced, and extended to include the stump of the penis. Two months later the patient developed extensive metastasis in the scar of the abdomen, at the same time X-ray examination of the chest showed metastasis to the lungs. The patient died three weeks later. Case 2. A 76-year-old man, who had been subjected to transurethral resection due to adenocarcinoma of the prostate some 3-4 months earlier, no additional treatment. There had been some diffuse swelling of the penis for a few weeks prior to the present admission, and at the time of hospitalization the patient had suffered from priapism for two days. Operation according to the method of Ebbehoj was carried out twice without effect, after which broken, turnout-like material was removed from the corpora cavernosa, using a sharp curette. Microscopic examination of the material showed metastasis from the prostatic adenocarcinoma. X-ray of the chest revealed multiple lung metastases. The patient was then treated with Androcur, and an indwelling catheter was inserted because o f urine retention. Discharged after 30 days with the indwelling catheter for continued treatment with Androcur, no swelling or pain in the penis was noted. He was re-admitted some 6 8 9 months later as the catheter continued to clog owing to tissue debris. A suprapubic catheter was inserted by means of cystotomy. However, his condition deteriorated rapidly and the patient died. Diagnosis at post mortem examination: adenocarcinoma of the prostate with metastasis to the lungs, liver and pleurae. The penis was not examined. Case 3. A 78-year-old man, who four years previously had been subjected to transurethral prostate resection due to symptoms arising from the prostate. Histological examination demonstrated highly differentiated adenocarcinoma of the prostate. No additional treatment was given. A slowly enlarging swelling had appeared on the glans penis over the last year, together with increasing low-back pain and pain in the right hip. Biopsy from the tumour on the glans penis revealed metastasis from cancer of the prostate. Bone scintigraphy as well as X-ray of the spine, hips, pelvis and chest showed changes compatible with metastasis from cancer of the prostate. The patient was given hormone treatment (Buserelin) which reduces serum testosterone to castration level. The effects were good, inasmuch as pain relief was achieved after one week of treatment, and at control examination four months later the patient was still free from pain and showed no signs of progression of the metastases.
International Urolo#y and Nephrology 23, 1991
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163
Primary tumours
Seventy-five per cent of metastases to the penis originate from primary malignant tumours in the neighbouring urogenital organs [1, 9, 14, 18]. Of these, malignant bladder tumours comprise roughly 30~, and cancer of the prostate about 25~ [1]. Primary tumours situated in the kidneys constitute almost 10~ and in the testes roughly 7 ~ [1, 12]. Gastrointestinal tumours are responsible in about 20~ [4], the majority of them being recto-sigmoidal cancers. Tumours of the lungs, lymphatic system, skin and locomotor apparatus are very rarely responsible for metastases to the penis. A review of the primary tumours is given in Table 1. Table 1 Metastasis to the penis Primary tumours Bladder Prostate Colon Kidney Testis Lungs Bone Skin Other
Per cent 33 27 18 9 7 3 1.5 0.5 1
Metastasis to the penis is a manifestation occurring late in the course of the disease in respect of all types of tumour, and is often associated with disseminated disease. Metastatic mechanisms
There is no obvious explanation as to why metastasis to the penis is so rare, taking into consideration that the penis is an end organ in respect of the arterial, venous and lymphatic systems, and that it has a complex circulation; further, the fact that it is situated in close relationship to neighbouring organs with a high frequency of malignant tumours. The presumed metastatic mechanisms will therefore be reviewed. 1. Direct spread Direct growth from malignant tumours in the bladder, prostate and rectum to the bulbus penis (corpus spongiosum) and crura penales (corpora cavernosa) has been described in very few cases [1, 18]. This mode of spreading may only 5*
International Urology and Nephroloay 23, 1991
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Osther, L o n t o f t : M e t a s t a s i s to the penis"
explain the presence of tumours in the proximal part o f the penis (pars fixa), but not solitary or multiple metastases in the distal part o f the corpora cavernosa, as is most often seen. 2. Retrograde venous spread Retrograde venous metastasis to the penis is presumably the mechanism occurring most frequently [1, 18]. The widespread communication between the venous plexuses around the bladder, prostate and rectum, on the one hand, and the dorsal vein, on the other, constitute the background for this type o f metastasis. There are two possible mechanisms. (a) The blood stream in the abovementioned area may - due to pressure from the turnout or growth into the blood vessels - turn around, so that a permanent retrograde flow occurs. (b) Intermittent retrograde flow in the above-mentioned area may occur with sudden increase in the intra-abdominal pressure (cough, sneeze, employment of intraabdominal pressure). The tumour cells can be transported in this manner to the penis from the organs in question. 3. Retrograde lymphatic spread Retrograde lymphatic spread can take place to the penis via the superficial and deep-lying lymphatic vessels in the same manner as with venous spreading [1, 181. 4. Direct spreading via the arteries The spreading of tumour cells via the arterial system is thought to be the most common pathway in respect o f a number of tumours [2]. However, with regard to metastasis to the penis, this method of spreading is considered to play only a minor role [1, 18]. This would explain why metastasis to the penis from sarcomas, which are known to metastasize in this manner, are extremely rare, even when due regard is taken of the fact that sarcomas themselves are relatively rare [1 ]. 5. Spread by means of implantation and employment of instruments The implantation of tumour cells transported by the urine presumably plays a minor role in cases of metastasis to the penis, inasmuch as metastases rarely or never originate from nor include the urethral mucosa. Further, metastases to the corpora spongiosum are in practice only seen when the corpus cavernosa, glans penis or praeputium are also involved [1, 9, 14, 18]. In addition, gpread through the use o f instruments in the urethra (cystourethroscopy, transurethral resections) can also be repudiated in this manner. International Urology and Nephroloyy 23, 1991
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165
The above-mentioned possible mechanisms of metastasis are all based on mechanical aspects; however, it should be borne in mind that immunological mechanisms are of importance in the occurrence of metastasis [5].
Clinical picture Patients with metastasis to the penis are often marked by disseminated malignant disease, and therefore in a poor general state of health. The primary tumours, and with these metastases to the penis, occur most frequently in the age group 60 to 80 [1]. Metastases are, on the whole, similar irrespective of the primary tumour. They often present as multiple infiltrative nodules (approx. 60~). Solitary turnout nodules are, however, observed, whereas the ulcerative type is uncommon and occurs most often when the glans penis is involved [1]. In roughly 65~ of all cases of metastasis to the penis, the metastasis is located in both corpora cavernosa, and in about 15~o to only one of these. The glans penis is involved in 10~ of these cases, and is often found as diffuse infiltrations in the corpora cavernosa also. The praeputium is involved in less than 10~ of cases [1, 10, 22]. In contrast to metastasis to the penis, primary penis tumours are in the great majority of cases (94~) localized to the glans penis, frenulum or sulcus coronarius [7]. The most common symptoms of metastasis to the penis are penile induration and diffuse or localized swelling. Actual priapism is reported in the literature with considerably varying frequencies [1, 6, 24]. It is the result of either direct ingrowth into the veins of the penis or of tumours in the corpora cavernosa, giving rise to thrombosis or congestion of the circulation [1 ]. Pain is not a typical symptom. An uncharacteristic feeling of discomfort in the perineum when sitting down is frequently reported, and should therefore be the object of further examination. Pain is localized partly to the pars pendularis and partly to the perineum. Perianal pain may be triggered by tumour formation in the penis. Haematuria and symptoms of urinary obstruction are somewhat unspecific symptoms, although belonging to the overall picture [1, 10].
Diagnosis and differential diagnosis The diagnosis is made by biopsy. It is essential to obtain biopsy material as early as possible in order to differentiate between metastasis to the penis and primary tumours, since the latter have a considerably better prognosis [7]. Differential diagnosis includes primary malignant tumours and benign tumours of the penis, syphilitic chancre, idiopathic priapism, Peyronie's disease, candidiasis, tuberculosis of the penis and other specific and non-specific inflammations. The extent of the metastatic process in the penis can be visualized by means of cavernosography [12, 15]. International Urology and Nephrology 23, 1991
166
Osther, Lontoft: Metastasis to the penis
Treatment and prognosis
Treatment depends on the general condition of the patient, the site and extent of the primary tumour, as well as on the extent of the metastasis, and lastly on symptomatology. The various methods of treatment, all of which must be considered as palliative, consist of local excision of the tumour, radiation therapy, cytostatic treatment and partial or total amputation of the penis. In cases of metastasis from carcinoma of the prostate, oestrogen or related hormone therapy, possibly castration, can be attempted. When urinary tract obstruction is present, procedures designed to alleviate this condition may be of value [1, 22]. There is little experience with the use of cytostatics, but the use of this therapy must depend on the type of primary tumour, and the general condition of the patient [6]. Irrespective of whether the primary tumour is situated in the bladder, prostate, kidneys, rectum or other organs, the great majority (more than 80%) of patients with metastasis to the penis die within six months; the latter is an expression of disseminated cancer disease [1, 9, 14, 18]. Even so, reports have been published on survival for up to nine years after the occurrence of metastasis to the penis [1]. Conclusion
Due to the poor prognosis of metastasis to the penis, where more than 80% of the patients die within six months irrespective of the primary tumour and also of the therapy, conservative treatment is advisable. Early biopsy is indicated in order to distinguish between metastasis to and primary turnouts of the penis. Amputation of the penis is inadvisable as it is of no prognostic importance and mutilates the patient. Cases with ulceration and irritating secretion can, however, necessitate such a procedure. Urinary obstruction may require operation to alleviate this condition.
References 1. Abeshouse, B. S., Abeshouse, G. A.: Metastatic tumors of the penis: a review of the literature and a report of two cases. 3". UroL, 86, 99 (1961). 2. Anderson, W . A . D . , Scotti, T. M.: Synopsis of Pathology. 10th edition. C. V. Mosby, St. Louis 1980, pp. 247-250. 3. Bosch, P. C., Forbes, K. A., Kollin, J., Golji, H., Miller, J. B.: Secondary carcinoma of the penis. J. UroL, 132, 990 (1984). 4. Callen, J. P., Gruber, G. G., Giannini, J. M. : Metastatic colonic adenocarcinoma to the glans penis. Int. J. DermatoL, 9, 540 (1982). 5. Currie, G.: Cancer and the Immune Response. 2nd edition. Edward Arnold, London 1980.
6. Garnick, M. B., Skarin, A. T., Steele, G. D.: Metastatic carcinoma of the penis: Complete remission after high dose methotrexate chemotherapy. J. UroL, 122, 265 (1979). International Uroloyy and Nephrology 23, 1991
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International Urology and Nephrology 23~ 1991
