BLADDER
EPITHELIAL
METASTATIC
TO GLANS
JOHN P. TUTTLE,
JR., M.D.*
STEPHEN
NEOPLASMS PENIS
N. ROUS, M.D.”
RAYMOND C. KINZEL,
M.D.
From the Department of Surgery (Urology), Michigan State University and Ingham Medical Center, Lansing, Michigan
ABSTRACT -A rare case of bladder tumor metastatic to the glans penis is presented. It is thefifth such case in the literature. Clinical aspects and review of the literature are presented.
Epithelial neoplasms of the urinary bladder are the second most common malignancy of the genitourinary system in adult males, and these tumors are notorious for distant organ metastases.’ However, secondary involvement of the glans penis is exceedingly rare with only 4 cases of such tumors metastatic to the glans penis reported in the urologic literature to 1961and none since.2 The purpose of this article is to review the literature of epithelial bladder tumors metastasizing to the glans penis and to report an additional case. Case Report An eighty-seven-year-old Caucasian male was admitted to the hospital with frequency, dysuria, and total gross hematuria of three days’ duration in July, 1974. This same patient had been first seen in 1970 and after a complete urologic evaluation for painless hematuria, a small papillomatous transitional cell bladder carcinoma had been transurethrally resected (grade I; Jewett’s Stage A). The patient, however, was then lost to follow-up during the four-year interim. Drip infusion urograms with nephrotomograms in July, 1974, showed chronic inflammatory changes of the left kidney, marked contracture of the urinary bladder with intrinsic filling defects, *Present address: Department of Urology, Medical University of South Carolina, Charleston, South Carolina.
80
and bilateral hydroureters from obstruction at the ureterovesical junctions. At cystoscopy recurrent bladder tumor involving the trigone and bladder neck with extension into the prostatic urethra was found. The tumor mass was transurethrally resected down to bladder muscle. Microscopically, most of the neoplastic elements were in broad sheets, some in bundles and anastomosing cords, separated by a fibrous connective septa of varying thickness. Individual tumor cells varied in size and shape, some being larger with hyperchromatic nuclei and prominent nucleoli. Mitotic figures were encountered along with areas of necrosis, stromal fibrosis, and invasion into the muscle wall (grade III, Jewett’s Stage B2). Bone and liver scans were negative for metastatic involvement. Because of the patient’s age palliative radiation therapy was elected over radical cystectomy and urinary diversion, and during the following weeks 7,000 rads of radiation were delivered to the pelvis. In November, 1974, the patient was readmitted with dysuria, lower abdominal pain, and total gross hematuria of one weeks duration. Repeat cystoscopy demonstrated a diffuse tumor involvement of the entire bladder wall that appeared to be beyond the possibility of total transurethral resection. At this time a 10 mm. by 4 mm. rubbery hard violaceous papule containing a painless, clean, shallow ulcer with indurated rolling borders was noted on the dorsum of the
UROLOGY
/
JULY 1976
/
VOLUME
VIII,
NUMBER
1
FIGURE 1. Biopsy of the lesion of the glans penis *under low power; original mgnijication X 100.
glans penis alongside the coronal sulcus. Microscopic examination of the biopsied lesion revealed lymphatic permeation of the corium by ovoid tumor cells with vesicular nuclei and moderate abundant pale staining cytoplasm, comparable to cells from the patient’s urinary bladder carcinoma (Fig. 1). The patient’s condition continued to deteriorate, and a few days later he succumbed to hemorrhage and sepsis. Autopsy was not obtained. Comment Because of the extreme rarity of bladder epitheha1 carcinoma metastasizing to the glans penis, there is little on the subject in urologic literature. In 1961 Abeshouse and Abeshouse’ presented a comprehensive review of all malignancies metastatic to the penis, and they reported only 4 cases metastatic to the glans penis. In this review 105 of 140 reported cases of metastatic tumors to the penis originated from a primary neoplasm of the genitourinary tract with the urinary bladder being the organ most often harboring the primary lesion (43 cases). Metastatic bladder carcinoma to the penis was reported in both corpora cavernosa (25 cases), both corpora cavernosa and corpus spongiosum (5 cases), one corpus cavernosum (6 cases), the glans penis (4 cases), and the prepuce (2 cases). Whitmore believes that single or multiple nodules in the cavernosa are the most common
UROLOGY
/ JULY 1976
/ VOLUME VIII, NUMBER 1
form of penile metastases, with involvement of both the corpora and the glans next most common and metastases to the glans, cavernosa, and spongiosum rarest of all. He also believes that the bladder is the likeliest primary source for penile metastases with primary lesions in the rectum, prostate, and kidney following in that order. Proposed pathways by which malignant bladder cells may spread to the penis are direct extension, arterial dissemination, retrograde venous spread, and retrograde lymphatic extension.4 The case reported in this article represents the only additional case of bladder epithelial tumors metastatic to the glans penis found in urologic literature since the review by Abeshouse and Abeshouse.’ Department of Urology Medical University of South Carolina Charleston, South Carolina 29401 (DR. ROUS) References “Ca” A Cancer Journal for Clinicians, American Cancer Society 25: 10 Jan./Feb. (1975). ABESHOUSE, B. S., and ABESHOUSE, G. A.: Metastatic tumors of the penis. A review of the literature and a report of two cases, J. Urol. 86: 99 (1961). WHITMORE, W. F., JR. : Tumors of the penis, urethra, scrotum and testes, in Campbell, J. F., and Harrison, J. H., Ed.: Urology, 3rd. ed., Philadelphia, W. B. Saunders Co., 1970, vol. 2, chap. 30, p. 1190. DEELEY, T. J., and MORRISON, R.: Secondary carcinoma of the penis from carcinoma of the bladder, Br. J. Ural. 47: 388 (1960).
81
EPITHELIAL
METASTATIC
TO GLANS
JOHN P. TUTTLE,
JR., M.D.*
STEPHEN
NEOPLASMS PENIS
N. ROUS, M.D.”
RAYMOND C. KINZEL,
M.D.
From the Department of Surgery (Urology), Michigan State University and Ingham Medical Center, Lansing, Michigan
ABSTRACT -A rare case of bladder tumor metastatic to the glans penis is presented. It is thefifth such case in the literature. Clinical aspects and review of the literature are presented.
Epithelial neoplasms of the urinary bladder are the second most common malignancy of the genitourinary system in adult males, and these tumors are notorious for distant organ metastases.’ However, secondary involvement of the glans penis is exceedingly rare with only 4 cases of such tumors metastatic to the glans penis reported in the urologic literature to 1961and none since.2 The purpose of this article is to review the literature of epithelial bladder tumors metastasizing to the glans penis and to report an additional case. Case Report An eighty-seven-year-old Caucasian male was admitted to the hospital with frequency, dysuria, and total gross hematuria of three days’ duration in July, 1974. This same patient had been first seen in 1970 and after a complete urologic evaluation for painless hematuria, a small papillomatous transitional cell bladder carcinoma had been transurethrally resected (grade I; Jewett’s Stage A). The patient, however, was then lost to follow-up during the four-year interim. Drip infusion urograms with nephrotomograms in July, 1974, showed chronic inflammatory changes of the left kidney, marked contracture of the urinary bladder with intrinsic filling defects, *Present address: Department of Urology, Medical University of South Carolina, Charleston, South Carolina.
80
and bilateral hydroureters from obstruction at the ureterovesical junctions. At cystoscopy recurrent bladder tumor involving the trigone and bladder neck with extension into the prostatic urethra was found. The tumor mass was transurethrally resected down to bladder muscle. Microscopically, most of the neoplastic elements were in broad sheets, some in bundles and anastomosing cords, separated by a fibrous connective septa of varying thickness. Individual tumor cells varied in size and shape, some being larger with hyperchromatic nuclei and prominent nucleoli. Mitotic figures were encountered along with areas of necrosis, stromal fibrosis, and invasion into the muscle wall (grade III, Jewett’s Stage B2). Bone and liver scans were negative for metastatic involvement. Because of the patient’s age palliative radiation therapy was elected over radical cystectomy and urinary diversion, and during the following weeks 7,000 rads of radiation were delivered to the pelvis. In November, 1974, the patient was readmitted with dysuria, lower abdominal pain, and total gross hematuria of one weeks duration. Repeat cystoscopy demonstrated a diffuse tumor involvement of the entire bladder wall that appeared to be beyond the possibility of total transurethral resection. At this time a 10 mm. by 4 mm. rubbery hard violaceous papule containing a painless, clean, shallow ulcer with indurated rolling borders was noted on the dorsum of the
UROLOGY
/
JULY 1976
/
VOLUME
VIII,
NUMBER
1
FIGURE 1. Biopsy of the lesion of the glans penis *under low power; original mgnijication X 100.
glans penis alongside the coronal sulcus. Microscopic examination of the biopsied lesion revealed lymphatic permeation of the corium by ovoid tumor cells with vesicular nuclei and moderate abundant pale staining cytoplasm, comparable to cells from the patient’s urinary bladder carcinoma (Fig. 1). The patient’s condition continued to deteriorate, and a few days later he succumbed to hemorrhage and sepsis. Autopsy was not obtained. Comment Because of the extreme rarity of bladder epitheha1 carcinoma metastasizing to the glans penis, there is little on the subject in urologic literature. In 1961 Abeshouse and Abeshouse’ presented a comprehensive review of all malignancies metastatic to the penis, and they reported only 4 cases metastatic to the glans penis. In this review 105 of 140 reported cases of metastatic tumors to the penis originated from a primary neoplasm of the genitourinary tract with the urinary bladder being the organ most often harboring the primary lesion (43 cases). Metastatic bladder carcinoma to the penis was reported in both corpora cavernosa (25 cases), both corpora cavernosa and corpus spongiosum (5 cases), one corpus cavernosum (6 cases), the glans penis (4 cases), and the prepuce (2 cases). Whitmore believes that single or multiple nodules in the cavernosa are the most common
UROLOGY
/ JULY 1976
/ VOLUME VIII, NUMBER 1
form of penile metastases, with involvement of both the corpora and the glans next most common and metastases to the glans, cavernosa, and spongiosum rarest of all. He also believes that the bladder is the likeliest primary source for penile metastases with primary lesions in the rectum, prostate, and kidney following in that order. Proposed pathways by which malignant bladder cells may spread to the penis are direct extension, arterial dissemination, retrograde venous spread, and retrograde lymphatic extension.4 The case reported in this article represents the only additional case of bladder epithelial tumors metastatic to the glans penis found in urologic literature since the review by Abeshouse and Abeshouse.’ Department of Urology Medical University of South Carolina Charleston, South Carolina 29401 (DR. ROUS) References “Ca” A Cancer Journal for Clinicians, American Cancer Society 25: 10 Jan./Feb. (1975). ABESHOUSE, B. S., and ABESHOUSE, G. A.: Metastatic tumors of the penis. A review of the literature and a report of two cases, J. Urol. 86: 99 (1961). WHITMORE, W. F., JR. : Tumors of the penis, urethra, scrotum and testes, in Campbell, J. F., and Harrison, J. H., Ed.: Urology, 3rd. ed., Philadelphia, W. B. Saunders Co., 1970, vol. 2, chap. 30, p. 1190. DEELEY, T. J., and MORRISON, R.: Secondary carcinoma of the penis from carcinoma of the bladder, Br. J. Ural. 47: 388 (1960).
81
