Indian J Surg Oncol (December 2012) 3(4):299–301 DOI 10.1007/s13193-012-0180-0
CASE REPORT
Penile Metastasis from Carcinoma of Caecum- Unusual Cause of Priapism: A Case Report and Review of Literature Rakesh Kapoor & Anjan Bera & Uma Nahar Saikia & Ritesh Kumar & Divya Khosla & N. Kumar
Received: 14 July 2011 / Accepted: 31 July 2012 / Published online: 9 August 2012 # Indian Association of Surgical Oncology 2012
Introduction Priapism is a pathologic condition of penile erection characterized as prolonged and devoid of sexual stimulation or excitement [1]. Penile metastasis is rare cause of priapism and only limited number of cases reported. In a largest case series of penile metastasis by Alcides Chaux et al. [2] only two cases reported from gastrointestinal tract (sigmoid colon). We report a case of a painful penile metastasis from dissemination of carcinoma caecum.
Case Report Fifty six years old male presented with pain and lump abdomen for 4 months in the year 2010. He was diagnosed to have carcinoma oh caecum and under went right hemicolectomy on 5th June 2010. He received 6 cycle chemotherapy with oxaliplatin and capecitabine which was completed on October 2010. He remained asymptomatic till April 1011 and presented with ulcer over glans penis and swelling of penis (Fig. 1). During examination, found have painful priapism, ulcer over glans and bilateral inguinal node. Histopathological examination from ulcer suggestive metastatic adenocarcinoma (Fig. 2). CT scan showed R. Kapoor (*) : A. Bera : R. Kumar : D. Khosla : N. Kumar Department of Radiotherapy and Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012 e-mail: [email protected] U. N. Saikia Department of Pathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012
multiple lung metastasis and bilateral inguinal lymph node, and replacement of corpora cavernosa tumour by tumour. (Figs. 3 and 4)
Discussion Malignancies of genitourinary tract are the commonest causes of penile metastasise, followed by tumors of the lower gastrointestinal tract and the lungs [2, 3]. The patients frequently presents with signs of priapism. Up to 40 % of patients with penile metastasis can present with priapism[2]. This frequent occurrence of priapism is because of replacement of corpora cavernous by metastatic tumour; with blockage of the venous return and a maintained, painful erection. Hematuria and pain are much less frequent. Symptoms related to urinary obstruction have also been described. Ulceration, penile swellings, and nodularity, have also been reported [4–6]. Urinary obstruction and hematuria may occur because corpora spongiosum involvement. There are several mechanisms by which a tumor can secondarily affect the penis [2]. The most likely routes of spread retrograde venous transport, because there is generous communication between the pelvic venous plexuses and the penile dorsal venous system [4, 7, 8]. This route of spread would explain why penile erectile tissues, mainly corpora cavernosa preferentially involved. Other route of spread is retrograde lymphatic [8]. There is interconnection between lymphatics of base of the bladder, the posterior surface of the prostate, and the lower rectum along with the lymphatics of the penis through the iliac lymph Nodes. This also explains the secondary dissemination from these primary sites to penis especially in those cases affecting the skin of the shaft or foreskin or the penile fascia. Large and loco regionally advanced tumour of prostate, bladder, and lower rectum, directly extends to the penile root or base of
300
Indian J Surg Oncol (December 2012) 3(4):299–301
Fig. 3 Replacement of corpora cavernosa by tumour
Idiopathic priapism; venereal or other infectious ulcerations; tuberculosis; Peyronie’s plaque; and primary, benign, or malignant tumors should be included differential diagnosis
Fig. 1 Ulcer over glans penis and priapism of penis
the shaft [8]. However, this is unlikely mechanism of metastasis from carcinoma caecum. Penile metastases represent an advanced form of aggressive disease and usually appear rather rapidly after recognition and treatment of the primary lesion as in our case [4, 9, 10]. A long interval between the treatment of the primary lesion and the appearance of penile metastases [4], or the penile lesion as the initial and only site of metastasis rarely reported.
Fig. 2 Structure of penis totally replaced by the tumour cell
Treatment Because penile metastatic lesion represents the advanced form of disease, prognosis is dismal. The majority of patients die within 1 year [9, 11]. Complete excision by partial amputation succeeds in removing the entire area of malignant infiltration [12] is the only form of successful treatment may occasionally be possible in the case of solitary nodules or localized distal penile involvement. The prospect for surgical cure is minimal if proximal corporal invasion is present. Dorsal nerve
Fig. 4 CT scan chest showing bilateral multiple lung metastasis
Indian J Surg Oncol (December 2012) 3(4):299–301
section can be used to alleviate pain [13]. Penectomy is occasionally indicated after failure of other modalities to palliate intractable pain [9]. Radiation therapy has generally been unsuccessful, and chemotherapy has not been employed in a sufficient number of cases to warrant definitive recommendations. In our case we have stared chemotherapy with 5-FU, Leucovorin and Oxaliplatin. Patients received three cycles chemotherapy and had relief of pain.
References 1. Pettaway CA, Lynch DF Jr, Davis JW (2007) Tumors of the penis. In: Wein AJ, Kavoussi LR, NovickAlan AC, Partin W, Peters CA (eds) Campbell-Walsh urology, 9th edn. Saunders Elsevier, Philadelphia, pp 959–992 2. Chaux A, Amin M, Cubilla AL, Young RH (2010) Metastatic tumors to the penis: a report of 17 cases and review of the literature. Int J Surg Pathol [10.1177/1066896909350468] Jan [cited 2010 Jan 14] [10 screen]. Available from: URL: http:// ijs.sagepub.com
301 3. Abeshouse BS (1958) Primary and secondary melanoma of the genitourinary tract. S Med J 51:994–1006 4. Abeshouse BS, Abeshouse GA (1961) Metastatic tumors of the penis: a review of the literature and a report of two cases. J Urol 86:99–112 5. McCrea LW, Tobias GL (1958) Metastatic disease of the penis. J Urol 80:489–500 6. Weitzner S (1971) Secondary carcinoma in the penis: report of three cases and literature review. Am Surg 37:563–567 7. Cherian J, Rajan S, Thwaini A, Elmasry Y, Shah T, Puri R et al (2006) Secondary penile tumours revisited. Int Semin Surg Oncol 3:33 8. Paquin AJ Jr, Roland SI (1956) Secondary carcinoma of the penis: a review of the literature and a report of nine new cases. Cancer 9:626–632 9. Mukamel E, Farrer J, Smith RB, de Kernion JB (1987) Metastatic carcinoma for penis: when is total penectomy indicated? Urology 29:15–18 10. Hayes WT, Young JM (1967) Metastatic carcinoma of the penis. J Chron Dis 20:891–895 11. Fischer MA, Patrick A (1999) Secondary penile carcinoma from squamous cell carcinoma of the lung. Can J Urol 6:899–900 12. Spaulding JT, Whitmore WF Jr (1978) Extended total excision of prostatic adenocarcinoma. J Urol 120:188–190 13. Hill JT, Khalid MA (1988) Penile denervation. Br J Urol 61:167
CASE REPORT
Penile Metastasis from Carcinoma of Caecum- Unusual Cause of Priapism: A Case Report and Review of Literature Rakesh Kapoor & Anjan Bera & Uma Nahar Saikia & Ritesh Kumar & Divya Khosla & N. Kumar
Received: 14 July 2011 / Accepted: 31 July 2012 / Published online: 9 August 2012 # Indian Association of Surgical Oncology 2012
Introduction Priapism is a pathologic condition of penile erection characterized as prolonged and devoid of sexual stimulation or excitement [1]. Penile metastasis is rare cause of priapism and only limited number of cases reported. In a largest case series of penile metastasis by Alcides Chaux et al. [2] only two cases reported from gastrointestinal tract (sigmoid colon). We report a case of a painful penile metastasis from dissemination of carcinoma caecum.
Case Report Fifty six years old male presented with pain and lump abdomen for 4 months in the year 2010. He was diagnosed to have carcinoma oh caecum and under went right hemicolectomy on 5th June 2010. He received 6 cycle chemotherapy with oxaliplatin and capecitabine which was completed on October 2010. He remained asymptomatic till April 1011 and presented with ulcer over glans penis and swelling of penis (Fig. 1). During examination, found have painful priapism, ulcer over glans and bilateral inguinal node. Histopathological examination from ulcer suggestive metastatic adenocarcinoma (Fig. 2). CT scan showed R. Kapoor (*) : A. Bera : R. Kumar : D. Khosla : N. Kumar Department of Radiotherapy and Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012 e-mail: [email protected] U. N. Saikia Department of Pathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012
multiple lung metastasis and bilateral inguinal lymph node, and replacement of corpora cavernosa tumour by tumour. (Figs. 3 and 4)
Discussion Malignancies of genitourinary tract are the commonest causes of penile metastasise, followed by tumors of the lower gastrointestinal tract and the lungs [2, 3]. The patients frequently presents with signs of priapism. Up to 40 % of patients with penile metastasis can present with priapism[2]. This frequent occurrence of priapism is because of replacement of corpora cavernous by metastatic tumour; with blockage of the venous return and a maintained, painful erection. Hematuria and pain are much less frequent. Symptoms related to urinary obstruction have also been described. Ulceration, penile swellings, and nodularity, have also been reported [4–6]. Urinary obstruction and hematuria may occur because corpora spongiosum involvement. There are several mechanisms by which a tumor can secondarily affect the penis [2]. The most likely routes of spread retrograde venous transport, because there is generous communication between the pelvic venous plexuses and the penile dorsal venous system [4, 7, 8]. This route of spread would explain why penile erectile tissues, mainly corpora cavernosa preferentially involved. Other route of spread is retrograde lymphatic [8]. There is interconnection between lymphatics of base of the bladder, the posterior surface of the prostate, and the lower rectum along with the lymphatics of the penis through the iliac lymph Nodes. This also explains the secondary dissemination from these primary sites to penis especially in those cases affecting the skin of the shaft or foreskin or the penile fascia. Large and loco regionally advanced tumour of prostate, bladder, and lower rectum, directly extends to the penile root or base of
300
Indian J Surg Oncol (December 2012) 3(4):299–301
Fig. 3 Replacement of corpora cavernosa by tumour
Idiopathic priapism; venereal or other infectious ulcerations; tuberculosis; Peyronie’s plaque; and primary, benign, or malignant tumors should be included differential diagnosis
Fig. 1 Ulcer over glans penis and priapism of penis
the shaft [8]. However, this is unlikely mechanism of metastasis from carcinoma caecum. Penile metastases represent an advanced form of aggressive disease and usually appear rather rapidly after recognition and treatment of the primary lesion as in our case [4, 9, 10]. A long interval between the treatment of the primary lesion and the appearance of penile metastases [4], or the penile lesion as the initial and only site of metastasis rarely reported.
Fig. 2 Structure of penis totally replaced by the tumour cell
Treatment Because penile metastatic lesion represents the advanced form of disease, prognosis is dismal. The majority of patients die within 1 year [9, 11]. Complete excision by partial amputation succeeds in removing the entire area of malignant infiltration [12] is the only form of successful treatment may occasionally be possible in the case of solitary nodules or localized distal penile involvement. The prospect for surgical cure is minimal if proximal corporal invasion is present. Dorsal nerve
Fig. 4 CT scan chest showing bilateral multiple lung metastasis
Indian J Surg Oncol (December 2012) 3(4):299–301
section can be used to alleviate pain [13]. Penectomy is occasionally indicated after failure of other modalities to palliate intractable pain [9]. Radiation therapy has generally been unsuccessful, and chemotherapy has not been employed in a sufficient number of cases to warrant definitive recommendations. In our case we have stared chemotherapy with 5-FU, Leucovorin and Oxaliplatin. Patients received three cycles chemotherapy and had relief of pain.
References 1. Pettaway CA, Lynch DF Jr, Davis JW (2007) Tumors of the penis. In: Wein AJ, Kavoussi LR, NovickAlan AC, Partin W, Peters CA (eds) Campbell-Walsh urology, 9th edn. Saunders Elsevier, Philadelphia, pp 959–992 2. Chaux A, Amin M, Cubilla AL, Young RH (2010) Metastatic tumors to the penis: a report of 17 cases and review of the literature. Int J Surg Pathol [10.1177/1066896909350468] Jan [cited 2010 Jan 14] [10 screen]. Available from: URL: http:// ijs.sagepub.com
301 3. Abeshouse BS (1958) Primary and secondary melanoma of the genitourinary tract. S Med J 51:994–1006 4. Abeshouse BS, Abeshouse GA (1961) Metastatic tumors of the penis: a review of the literature and a report of two cases. J Urol 86:99–112 5. McCrea LW, Tobias GL (1958) Metastatic disease of the penis. J Urol 80:489–500 6. Weitzner S (1971) Secondary carcinoma in the penis: report of three cases and literature review. Am Surg 37:563–567 7. Cherian J, Rajan S, Thwaini A, Elmasry Y, Shah T, Puri R et al (2006) Secondary penile tumours revisited. Int Semin Surg Oncol 3:33 8. Paquin AJ Jr, Roland SI (1956) Secondary carcinoma of the penis: a review of the literature and a report of nine new cases. Cancer 9:626–632 9. Mukamel E, Farrer J, Smith RB, de Kernion JB (1987) Metastatic carcinoma for penis: when is total penectomy indicated? Urology 29:15–18 10. Hayes WT, Young JM (1967) Metastatic carcinoma of the penis. J Chron Dis 20:891–895 11. Fischer MA, Patrick A (1999) Secondary penile carcinoma from squamous cell carcinoma of the lung. Can J Urol 6:899–900 12. Spaulding JT, Whitmore WF Jr (1978) Extended total excision of prostatic adenocarcinoma. J Urol 120:188–190 13. Hill JT, Khalid MA (1988) Penile denervation. Br J Urol 61:167
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