LEUKEMIC
INFILTRATION
EMERSON
L. KNIGHT,
GREGORY
J. POST,
ROCCO
JR., M.D.
P. P. SINHA, STANLEY
M.D.
A. MORABITO,
OF PENIS
M.D.
J. KANDZARI,
M.D.
M.D.
From the Divisions of Urology and Radiation Therapy, West Virginia University Medical Center, Morgantown, West Virginia
ABSTRACT - Leukemic infiltration of the urinary tract is most common in the kidneys. Other areas are involved much less frequently. We report a case of leukemic infiltration of the penis.
A seventy-two-year-old black man was referred to our department for evaluation of an ulcerative lesion on his penis. The lesion had been present for two or three months, was thought to be a carcinoma of the penis, and was virtually painless. The patient had been circumcised. He was known to have had chronic lymphocytic leukemia for eight years and was on intermittent therapy for this disease. He gave no history of venereal disease. Physical examination revealed an elderly black man in no acute distress. There were multiple posterior cervical, submental, and supraclavicular lymph nodes palpable as well as huge matted, nontender nodes in both axillary and inguinal regions. The penis was markedly swollen, with a large ulcerating area behind the corona that was foul smelling and purulent (Fig. 1A). The prostate was enlarged (l+), nontender, and non-nodular. Laboratory results revealed a hemoglobin of 8.7 Gm.000 ml. White blood cell count was 107,000, with 98 per cent lymphocytes. Blood urea nitrogen, creatinine, and electrolytes were within normal limits. Erythrocyte sedimentation rate was 48 mm. per hour, and platelet count was 94,000 per cubic centimeter. Urine culture grew greater than lo5 Proteus morganii. Chest x-ray film and intravenous pyelogram were normal. A biopsy of the penile lesion revealed lymphoid infiltration consistent with lymphocytic leukemia (Fig. 1B). A bone marrow aspiration was packed with mature and fairly mature lymphocytes consistent with chronic lymphocytic leukemia.
UROLOGY
/ JULY 1979
/ VOLUME
XIV, NUMBER
1
In view of the histology of the lesion the patient was referred to radiation oncology for treatment. He received 5,500 rads of cobalt to the penis over two treatment courses, with shrinkage of the tumor to approximately 40 per cent of its original size (Fig. 1C). However, because of persistent ventral ulceration and swelling, he had radioactive iridium-192 ribbon implants to the area approximately 1.5 months after the initial radiation treatments (Fig. 1D). One week later however he was readmitted to the hospital in fulminant congestive heart failure and died. Comment Leukemic infiltration of the urinary tract occurs most frequently in the kidneys. Various autopsy series revealed involvement of this organ in from 58 to 63 per cent of cases.‘p2 According to Meyer3 two varieties occur - one in which nodules are found on gross examination and another in which the kidney is diffusely infiltrated by leukemic cells. Often, however, the diagnosis is not made prior to death because the lesions are frequently asymptomatic, as was evidenced by Watson, Sauer, and Sodugor’ who found a 13.5 per cent incidence clinically versus 58.6 per cent incidence at autopsy. The prostate is the second most common organ in the genitourinary tract invaded by leukemic deposits. Symptoms of urinary tract obstruction develop as the result of rapid enlargement of the prostate. Sudden onset of urinary difficulties often resulting in complete retention may be the presenting feature of the
83
FIGURE 1. (A) ( ross appeartr~ve q pnile lesion; (B) photomicrograph showing lymphoid infiltration consistent with lympl’rocytic leukelrlia; (i: lczsion after external cobalt radiation therapy; and (0) needles in persistent lesion _for ir~5xrtion of iridium 1‘bllons.
generalized diserlse process. hdet (1: any young man presenting with obstrI[ctive symptoms or urinary retentioli and a large prostate on rectal examination should alert one 1,) consider a leukemic proce:;j. The ureters, l;ladder, testicles, and penis are involved to a much lesser degree. 1,4 Penile involvt’rnent of leukemi:~ may present as priapism, witl[ the mechanism I hought to be thrombosis of thz venous spaces (:f the corpora cavernosa. Howltver, this complic ition is actually rare in leuk(:mic patients, Wil 11large series reporting 0.62 pthr cent’ and 0.65 #en-cent5 incidence. Necrosis or ulceration of the lIenis due to leukemic infiltration is rare. We w:re unable to find any case report similar to 01rrs in the literature. Meyer3 ,.llluded to a case of gangrene of the penis seconirlary to leukemic nfiltration in the French literature. Treatment muit, of course, be c!.hrected at the primary disease process. Leuken&: infiltrates
84
have been sensitive to local radiation therapy,6 and in our case we achieved good results with this modality. We recommend local radiation therapy to ulcerative or necrotic lesions of the penis secondary to leukemic infiltrates, while the generalized disease process should be treated with chemotherapeutic agents. Morgantown, West Virginia 26506 (DR. KANDZARI) References 1. Watson EM, Sauer HR, and Sodugor MG: Manifestations of the lymphoblastomas in the genitourinary tract, J. Ural. 61: 626 (1949). 2. Kirshbaum TD, and Preuss FS: Leukemia, Arch. Intern. Med. 71: 777 (1943). 3. Meyer LM: Pathology of the genitourinary tract in leukemia, Ural. Cutan. Rev. 45: 693 (1941). 4. Pentecost CL, and Pizzolato P: Involvement of the genitourinary tract in leukemia, J. Ural. 55 725 (1945). 5. Lower WE, and Christopher LA: Priapism in leukemia, Cleve. Clin. Q. 12: 133 (1945). 6. Atkinson K, Thomas PR%I, Peckham MJ, and McElwain TJ: Radiosensitivity of the acute leukaemic infiltrate, Eur. J. Cancer 12: 535 (1976).
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
INFILTRATION
EMERSON
L. KNIGHT,
GREGORY
J. POST,
ROCCO
JR., M.D.
P. P. SINHA, STANLEY
M.D.
A. MORABITO,
OF PENIS
M.D.
J. KANDZARI,
M.D.
M.D.
From the Divisions of Urology and Radiation Therapy, West Virginia University Medical Center, Morgantown, West Virginia
ABSTRACT - Leukemic infiltration of the urinary tract is most common in the kidneys. Other areas are involved much less frequently. We report a case of leukemic infiltration of the penis.
A seventy-two-year-old black man was referred to our department for evaluation of an ulcerative lesion on his penis. The lesion had been present for two or three months, was thought to be a carcinoma of the penis, and was virtually painless. The patient had been circumcised. He was known to have had chronic lymphocytic leukemia for eight years and was on intermittent therapy for this disease. He gave no history of venereal disease. Physical examination revealed an elderly black man in no acute distress. There were multiple posterior cervical, submental, and supraclavicular lymph nodes palpable as well as huge matted, nontender nodes in both axillary and inguinal regions. The penis was markedly swollen, with a large ulcerating area behind the corona that was foul smelling and purulent (Fig. 1A). The prostate was enlarged (l+), nontender, and non-nodular. Laboratory results revealed a hemoglobin of 8.7 Gm.000 ml. White blood cell count was 107,000, with 98 per cent lymphocytes. Blood urea nitrogen, creatinine, and electrolytes were within normal limits. Erythrocyte sedimentation rate was 48 mm. per hour, and platelet count was 94,000 per cubic centimeter. Urine culture grew greater than lo5 Proteus morganii. Chest x-ray film and intravenous pyelogram were normal. A biopsy of the penile lesion revealed lymphoid infiltration consistent with lymphocytic leukemia (Fig. 1B). A bone marrow aspiration was packed with mature and fairly mature lymphocytes consistent with chronic lymphocytic leukemia.
UROLOGY
/ JULY 1979
/ VOLUME
XIV, NUMBER
1
In view of the histology of the lesion the patient was referred to radiation oncology for treatment. He received 5,500 rads of cobalt to the penis over two treatment courses, with shrinkage of the tumor to approximately 40 per cent of its original size (Fig. 1C). However, because of persistent ventral ulceration and swelling, he had radioactive iridium-192 ribbon implants to the area approximately 1.5 months after the initial radiation treatments (Fig. 1D). One week later however he was readmitted to the hospital in fulminant congestive heart failure and died. Comment Leukemic infiltration of the urinary tract occurs most frequently in the kidneys. Various autopsy series revealed involvement of this organ in from 58 to 63 per cent of cases.‘p2 According to Meyer3 two varieties occur - one in which nodules are found on gross examination and another in which the kidney is diffusely infiltrated by leukemic cells. Often, however, the diagnosis is not made prior to death because the lesions are frequently asymptomatic, as was evidenced by Watson, Sauer, and Sodugor’ who found a 13.5 per cent incidence clinically versus 58.6 per cent incidence at autopsy. The prostate is the second most common organ in the genitourinary tract invaded by leukemic deposits. Symptoms of urinary tract obstruction develop as the result of rapid enlargement of the prostate. Sudden onset of urinary difficulties often resulting in complete retention may be the presenting feature of the
83
FIGURE 1. (A) ( ross appeartr~ve q pnile lesion; (B) photomicrograph showing lymphoid infiltration consistent with lympl’rocytic leukelrlia; (i: lczsion after external cobalt radiation therapy; and (0) needles in persistent lesion _for ir~5xrtion of iridium 1‘bllons.
generalized diserlse process. hdet (1: any young man presenting with obstrI[ctive symptoms or urinary retentioli and a large prostate on rectal examination should alert one 1,) consider a leukemic proce:;j. The ureters, l;ladder, testicles, and penis are involved to a much lesser degree. 1,4 Penile involvt’rnent of leukemi:~ may present as priapism, witl[ the mechanism I hought to be thrombosis of thz venous spaces (:f the corpora cavernosa. Howltver, this complic ition is actually rare in leuk(:mic patients, Wil 11large series reporting 0.62 pthr cent’ and 0.65 #en-cent5 incidence. Necrosis or ulceration of the lIenis due to leukemic infiltration is rare. We w:re unable to find any case report similar to 01rrs in the literature. Meyer3 ,.llluded to a case of gangrene of the penis seconirlary to leukemic nfiltration in the French literature. Treatment muit, of course, be c!.hrected at the primary disease process. Leuken&: infiltrates
84
have been sensitive to local radiation therapy,6 and in our case we achieved good results with this modality. We recommend local radiation therapy to ulcerative or necrotic lesions of the penis secondary to leukemic infiltrates, while the generalized disease process should be treated with chemotherapeutic agents. Morgantown, West Virginia 26506 (DR. KANDZARI) References 1. Watson EM, Sauer HR, and Sodugor MG: Manifestations of the lymphoblastomas in the genitourinary tract, J. Ural. 61: 626 (1949). 2. Kirshbaum TD, and Preuss FS: Leukemia, Arch. Intern. Med. 71: 777 (1943). 3. Meyer LM: Pathology of the genitourinary tract in leukemia, Ural. Cutan. Rev. 45: 693 (1941). 4. Pentecost CL, and Pizzolato P: Involvement of the genitourinary tract in leukemia, J. Ural. 55 725 (1945). 5. Lower WE, and Christopher LA: Priapism in leukemia, Cleve. Clin. Q. 12: 133 (1945). 6. Atkinson K, Thomas PR%I, Peckham MJ, and McElwain TJ: Radiosensitivity of the acute leukaemic infiltrate, Eur. J. Cancer 12: 535 (1976).
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
