Clinical Oncology (1992) 4:130-131 © 1992 The Royal College of Radiologists

Clinical Oncology

Case Report Metastasis to the Penis from Malignant Melanoma: Case Report and Review of the Literature S. M. Sagar 1'2 and S. Retsas 2 D e p a r t m e n t s of t R a d i o t h e r a p y and 2Medical Oncology, T h e W e s t m i n s t e r Hospital, L o n d o n , U K

Major Sites

Abstract. A case of metastatic malignant melanoma to the shaft of the penis is described and the literature reviewed to collate the incidence of primary sites which metastasize to the penis. Less than 260 cases of metastasis to the penis have been reported. Of these, 76% are from genitourinary primary sites and 17% are from gastrointestinal primary sites but only one case of metastatic melanoma to the penis has been previously reported. The described case presented with painful priapism while receiving combination chemotherapy for metastatic disease. A C T scan demonstrated a deposit in the left corpora cavernosa and needle aspiration cytology of a plaque attached to the shaft confirmed malignant melanoma ceils. Palliation of the painful priapism was achieved by treatment with radiotherapy using large doses per fraction. Retrograde venous or lymphatic spread may have been the cause of a metastasis at this site. Prognosis is very poor.


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Keywords: Melanoma; Metastasis; Penis; Radiotherapy

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INTRODUCTION Metastases to the penis are extremely rare and less than 260 cases have been reported (Fig. 1). Primary melanoma of the penis is rare but well described [1-3] but, to the best of our knowledge, secondary melanoma to the shaft of the penis has only once been previously reported [4] and no details of diagnosis and management were presented. In a series of 1150 cases seen in this unit between 1975 and 1990 by one of the authors (S.R.), the penis has been the site of metastasis in only two patients. One case developed a metastasis of the penile skin, but the case to be described was complicated by a metastasis to the corpora cavernosa which resulted in priapism.

Correspondence and offprint requests to: Dr S. M. Sagar, Radiation Oncologist, Cancer Treatment and Research Foundation of Nova Scotia, 5280 University Avenue, Halifax, Nova Scotia B3H 1V7, Canada•

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Fig. 1. a---c. Incidence of metastases to the penis according to primary site (Compiled from: Gillatt [6];

Powell et al. [7]; Escribano et al. [8]; Karanjia et al. [9]; Matthewman et al. [10]; Mukamel et al. [11]; Savion et al. [12]; Valadez et al. [13]; Adjiman et al [14]; Kelleher et al. [15]; Perez-Mesa and Oxenhandler [16]; Ucar et al. [17].

Metastasis to the Penis from Malignant M e l a n o m a

CASE REPORT A 41-year-old male presented in April 1989 with an enlarging pigmented lesion on the inner aspect of his left thigh accompanied by left inguinal lymphadenopathy. H e proceeded to a wide excision of the skin lesion and block dissection of the inguinal nodes. Histological examination showed a malignant m e l a n o m a with infiltration to Clark's level III but the thickness could not be accurately assessed. Inguinal node metastases were present and infiltrated the skin of the groin. In N o v e m b e r 1989, the patient complained of dyspnoea and low back pain. H e was referred to this unit and staging investigations revealed a left pleural effusion and a metastasis to the third l u m b a r vertebra. T h e lumbar spine was treated with palliative radiotherapy and combination c h e m o t h e r a p y utilizing the DJV3-F regime of dacarbazine, carboplatin, vinblastine, vindesine, vincristine and fotemustine [5] was c o m m e n c e d . Back pain resolved and the pleural effusion was reduced. In March 1990, the patient complained of pain in the left inguinal canal, penis and perineum. O n examination, the penis and p e r i n e u m were indurated and tender. Early priapism was present and a single plaque was fixed to the left side of the base of the penis. A contrast-enhanced C T scan demonstrated a lobulated low density area in the left corpora cavernosa extending to the glans but not to the crura or bulb (Fig. 2). L y m p h a d e n o p a t h y and scarring in the left inguinal region was seen but no further evidence of disease in the a b d o m e n or pelvis. Needle aspiration of the penile plaque revealed multiple m e l a n o m a cells. A palliative course of radiation was administered in order to control pain and priapism. T h e volume included the prostate, corpus spongiosum, corpora cavernosa and the scrotum. Radiation was administered with a 6 M e V linear accelerator to a field size of 15 x 17 cm utilizing parallel opposed beams. Large doses per fraction were administered in view of the intrinsic radioresistance of m e l a n o m a cells displayed by their

Fig. 2. CT scan through the penis (with contrast). A lobulated low density area in the corpora cavernosa on the left side is demonstrated (M). Needle aspiration confirmed malignant melanoma. There is lymphadenopathy in the left inguinal region with scarring in the subcutaneous tissues.

large shoulder on cell survival curves. T h e patient received 6 Gy midline once a week to a total dose of 18 Gy. Pain was relieved and the penile induration resolved. A transient brisk e r y t h e m a of the scrotum and p e r i n e u m was experienced but resolved within 2 weeks.

DISCUSSION Metastases to the penis m a y present with priapism; diffuse swelling and pain in the penis and perineum; dysuria and haematuria [4]. Multifocal, painless nodules over the corpora cavernosa or glans m a y also occur [14]. Priapism is usually a s y m p t o m of infiltration of the corpora cavernosa causing sinus thrombosis, but compression of the dorsal vein outflow by a mass lesion or neural infiltration may also be the cause [4,7,18]. The differential diagnosis includes Peyronie's disease, infective scar tissue and baematological disorders [17]. Cavernosography has been used to confirm the diagnosis and to assess the extent of disease [8] but it is not crucial and m a y be complicated by h a e m a t o m a , abscess or fibrosis [18]. W e found that the C T scan defined the metastasis anatomically and needle aspiration cytology confirmed the tissue diagnosis. Considering that m e l a n o m a has a propensity for widespread metastases, it is curious that a metastasis to the penis has only been reported once before. It is interesting that the patient had secondaries in his lumbar spine which m a y have predisposed to retrograde venous spread through the plexus of Batson, pudendal veins and dorsal veins of the penis [4]. Alternatively, retrograde lymphatic spread from the left inguinal region m a y have occurred [18]. M a n a g e m e n t of metastases to the penis is usually aimed at palliation of symptoms. The m o d e of treatment depends on the histology and extent of metastases. Surgery [11] and chemotherapy [10] have been used. In our case of metastatic m e l a n o m a which progressed in the penis while on chemotherapy, radiotherapy was the appropriate palliative procedure. The usefulness of radiotherapy in the palliation of this distressing condition has been described with respect to other types of penile metastases [6,7,13,16]. Dose and fractionation are individualized to the histological type and extent of disease and care should be taken to ensure local s y m p t o m control without causing a severe acute radiation reaction. The prognosis of metastatic t u m o u r s is partly dependent on the histological type; in the case of Stage III melan o m a , 15% survive 2 years on chemotherapy [19,20]. With few exceptions, regardless of the histological type, the prognosis of a case with a metastasis to the penis is poor, most patients surviving less than 6 m o n t h s [4,8,13].


References 1. Oldbring J, Mikulowski P. Malignant melanoma of the penis and male urethra: report of nine cases and review of the literature. Cancer 1987; 59:581-7. 2. Myskow MW, Going J J, McLaren KM, et al. Malignant melanoma of penis. J Urol 1988; 139:81%8. 3. Stillwell TJ, Zincke H, Gaffey TA, et al. Malignant melanoma of the penis. J Urol 1988; 140:72-5. 4. Abeshouse BS, Abeshouse GA. Metastatic tumors of the penis: a review of the literature and a report of two cases. J Urol 1961; 86:99112. 5. Retsas S, Bayliss M, Sheikh N, et al. Chemotherapy of malignant melanoma; the European experience. Rev Med Interne 1990; 11 Suppl 2. 6. Gillatt DA. Secondary carcinomatous infiltration of the penis: palliation with radiotherapy. Br J Surg 1985; 72:763-4. 7. Powell BL, Craig JB, Hyman BM. Secondary malignancies of the penis and epididymis: a case report and review of the literature. J Clin Oncol 1985; 3:110-6. 8. Escribano G, Allona A, Burgos FJ, et al. Cavernosography in diagnosis of metastatic tumors of the penis: 5 new cases and a review of the literature. J Urol 1987; 138:1174-7. 9. Karanjia ND, King H, Schweitzer FAW. Metastases to the penis from carcinoma of the stomach. Br J Urol 1987; 60:368-75. 10. Matthewman PJ, Oliver RTD, Woodhouse CRJ, et al. The role of chemotherapy in the treatment of penile metastases from carcinoma of the bladder. Eur Urol 1987; 13:3102. 11. Mukamel E, Farter J, Smith RB, et al. Metastatic carcinoma to penis: when is total penectomy indicated? Urology 1987; 29:158. 12. Savion M, Livne PM, Mor C, et al. Mixed carcinoma of the prostate with penile metastases and priapism. Eur Urol 1987; 13:351-2. 13. Valadez RA, Wheeler JS, Canning JR, et al. Metastatic transitional cell carcinoma to penis. Urology 1987; 29:394-7. 14. Adjiman S, Flam TA, Zerbib M, et al. Delayed nonurothelial metastatic lesions to the penis: a report of two cases. Euro Urol 1989; 16:391-2. 15. Kelleher JP, Ashpole R, Pengelly AW. Penile plaque: a presentation of metastatic renal carcinoma. Br J Urol 1989; 64:428. 16. Perez-Mesa C, Oxenhandler R. Metastatic tumors of the penis. J Surg Oncol 1989; 42:11-5. 17. Ucar FJA, Robles JE, Isa WA, et al. Secondary carcinoma of the penis: a report of three new cases. Eur Urol 1989; 16:308-9. 18. Haddad FS. Letter to the Editor. Re: Cavernosography in diagnosis of metastatic tumors of the penis. J Urol 1989; 141:959-60. 19. Retsas S, Stockdale A, Nicholl J. Impact of chemotherapy on survival of patients with metastatic malignant melanoma: results of 240 patients treated at the Westminster Hospital [abstrast]. Third European Conference on Clinical Oncology; Stockholm. 1985:235. 20. Retsas S. Disseminated melanoma: for chemotherapy or biotherapy? Results of 328 patients treated with chemotherapy at the Westminster Hospital. Handbook of the Second International Conference on Melanoma; Venice: Fondazione Giorgio Cini, 1989:321.

Received for publication August 1990 Accepted December 1990

Metastasis to the penis from malignant melanoma: case report and review of the literature.

A case of metastatic malignant melanoma to the shaft of the penis is described and the literature reviewed to collate the incidence of primary sites w...
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