PENILE
METASTASES FROM
BRONCHOGENIC IGAL SILBER,
CARCINOMA
M.D.
From the Department of Surgery, University of California, Irvine, California
ABSTRACT -A case of secondary penile carcinoma originating in the lung is reported. Modes of metastases to the penis, treatment, prognosis, and a brief review of the literature are given.
Me&tatic carcinoma of the penis is a rare occurrence and usually a late manifestation of the primary disease. A review of the literature revealed 140 cases up to 1961.’ Eberty noted a case of penile metastatic rectal carcinoma in 1870. In 1956 Paquin and Roland’ collected and summarized 55 cases and added 9 cases of their own. McCrea and Tobias in an extensive review in 1958 collected 69 reported cases and added 1 of their own. Among the cases of metastatic carcinoma to the penis, cancer of the urinary bladder was the most common, followed by cancer of the prostate. Metastatic disease to the penis from a primary focus in the lung is rare; we found only 3 reported cases4‘6 and added a fourth. Case Report A fifty-two-year-old white male was admitted to the hospital with a chief complaint of cough, hemoptysis, and shortness of breath of five months’ duration. During this period of time the patient lost 25 pounds. On admission he was in slight respiratory distress. The rest of the examination was within normal limits. Because of urinary symptoms for the last two months, manifested by frequency, burning on urination, and poor stream, the patient was referred to the genitourinary division for consultation. Examination revealed a mass 2.5 cm. in diameter, involving the penile corpora spongiosa and another mass 10 cm. in length involving the corpora cavernosa near the base of the penis. Findings on rectal examination were normal. Laboratory tests revealed a hemoglobin of 11 Gm. per 100 ml., white blood cells 7,300, and blood urea nitrogen 11 mg. per 100 ml. Urinalysis demonstrated 6 to 7 white blood cells, urine cul-
536
ture was negative, and chest x-ray film revealed carcinoma of left bronchus and secondary lesion in left lung. Metastatic series was negative. A urethrogram showed narrowing in the area of the mass around the corpora spongiosa. Cystoscopy revealed a very tight urethra. The bladder interior was normal. A biopsy of the penile mass was obtained under local anesthesia using a Silverman needle. Pathologic examination showed squamous cell carcinoma (Fig. 1). Five weeks after the diagnosis of metastatic carcinoma of the penis the patient died. Postmortem examination revealed bronchogenic carcinoma of the lung with metastasis to various organs. Comment Metastatic disease to the penis may occur in various routes. The following outline shows the different modes of spread: A. Direct extension B. Instrumentation C . Lymphatic Direct Reverse flow 2 degrees to obstructed lymph nodes by tumor D. Venous Direct intercommunications Reverse flow 2 degrees to extramural; mass or increased intra-abdominal pressure E. Arterial Primary, in lung invading artery with tumor emboli Secondary, metastatic lesion to lung. Invasion of artery with emboli Tertiary, metastatic to liver with emboli to lungs; invasion of artery with emboli Paradoxic metastasis, through shunts in heart.
UROLOGY
i
MAY 1976 I
VOLUME VII, NUMBER 5
spread may be divided into four categories which are self-explanatory. Survival
The occurrence of metastasis in the penis carries very poor prognosis, with an average survival after diagnosis of six to seven months.3 Exceptions to this are the cases of Cattell and Mace’ who performed an abdominoperineal resection for carcinoma of rectum and colon. Excision of a metastatic lesion of the penis was done two-andone-half years later, and the patient was alive after nine years. Boyd’ describes a patient who was living two years after the primary cancer and penile metastasis had been excised. The longest survival rate (22.3 months) was among patients with primary rectal lesions with metastases to the penis. In the cases of primary bronchogenic carcinoma of the lung with penile metastasis, the patient reported by Staffieri, &use, and Levit4 survived twenty-five days after diagnosis. Treatment
FIGURE 1. Metastatic lung to penis.
squamous cell carcinoma fi-om
Lymphatic
Via lymphatic may be the case in carcinoma of the prostate or rectum. A portion of the lymphatic drainage of the penis is carried through lymphatics, follows the dorsal vein of the penis, and joins the lymphatic outflow of the prostate to the internal iliac nodes. It is conceivable that metastasis may occur by way of extramural lymphatics to the prostatic plexus. A reversal of the normal direction of flow along the vessels following the dorsal vein could occur with extrinsic pressure or with blockage of nodes draining the prostate.3 In this way, tumor cells could be implanted within the substance of the corpora cavernosa. Venous Batson demonstrated the intercommunication that exists between the pelvic and vertebral veins and the dorsal vein of the penis. Reversal of flow of blood in these channels is possible as a result of extrinsic pressure by tumor mass or straining. _ Arterial Excellent demonstration of this mode of spread is described by Paquin and Rolande2 The arterial
UROLOGY /
MAY 1976 /
VOLUME VII, NUMBER 5
The most common mode of therapy of the penile lesion was suprapubic cystotomy in cases of obstruction and, in a few cases, radical penectomy or local excision of the metastasis. Few patients had x-ray therapy or radium implants. Except for the cases of Cattell and Mace’ and Boyd,8 the different modes of treatment did not change the survival drastically. 13362 Newport Avenue Tustin, California 92680 References 1. ABESHOUSE,B. S., and ABESHOUSE,G. A.:
2. 3. 4.
5.
6.
7.
8.
Metastatic tumors of the penis: a review of the literature and a report of two cases, J. Urol. 86: 99 (1961). PAQUIN,A. J., and ROLAND,S. I. : Secondary carcinoma of the penis, Cancer 9: 626 (1956). MCCREA, L. E., andToems, G. L.: Metastatic disease of the penis, J. Ural. 83: 489 (1958). STAFFIERI, D., KRUSE, H. A., and LEVIT, L.: Metastasis raras de1 cancer de pulmon, Rev. Med. Rosario 33: 24 (1943). RICHTER, H.: Bronchial carcinoma with metastasis in one toe and in penis, Zentralbl. Allg. Pathol. 90: 24 (1953). TRUC, E., LEVALLOIS, M., and PUJOL, A.: Priapism caused by metastasis from a bronchial epithelioma to corpus cavernosum, J. D’urol. 65: 93 (1959). CATTELL, R. B., and MACE, A. J.: Metastasis to the penis from a carcinoma of the rectum, J. A. M. A. 146: 1230 (1951). BOYD, H. L. : Metastatic carcinoma of the penis secondary of the rectum; a review of the literature and a report of of a case, J. Urol. 71: 82 (1954).
537
METASTASES FROM
BRONCHOGENIC IGAL SILBER,
CARCINOMA
M.D.
From the Department of Surgery, University of California, Irvine, California
ABSTRACT -A case of secondary penile carcinoma originating in the lung is reported. Modes of metastases to the penis, treatment, prognosis, and a brief review of the literature are given.
Me&tatic carcinoma of the penis is a rare occurrence and usually a late manifestation of the primary disease. A review of the literature revealed 140 cases up to 1961.’ Eberty noted a case of penile metastatic rectal carcinoma in 1870. In 1956 Paquin and Roland’ collected and summarized 55 cases and added 9 cases of their own. McCrea and Tobias in an extensive review in 1958 collected 69 reported cases and added 1 of their own. Among the cases of metastatic carcinoma to the penis, cancer of the urinary bladder was the most common, followed by cancer of the prostate. Metastatic disease to the penis from a primary focus in the lung is rare; we found only 3 reported cases4‘6 and added a fourth. Case Report A fifty-two-year-old white male was admitted to the hospital with a chief complaint of cough, hemoptysis, and shortness of breath of five months’ duration. During this period of time the patient lost 25 pounds. On admission he was in slight respiratory distress. The rest of the examination was within normal limits. Because of urinary symptoms for the last two months, manifested by frequency, burning on urination, and poor stream, the patient was referred to the genitourinary division for consultation. Examination revealed a mass 2.5 cm. in diameter, involving the penile corpora spongiosa and another mass 10 cm. in length involving the corpora cavernosa near the base of the penis. Findings on rectal examination were normal. Laboratory tests revealed a hemoglobin of 11 Gm. per 100 ml., white blood cells 7,300, and blood urea nitrogen 11 mg. per 100 ml. Urinalysis demonstrated 6 to 7 white blood cells, urine cul-
536
ture was negative, and chest x-ray film revealed carcinoma of left bronchus and secondary lesion in left lung. Metastatic series was negative. A urethrogram showed narrowing in the area of the mass around the corpora spongiosa. Cystoscopy revealed a very tight urethra. The bladder interior was normal. A biopsy of the penile mass was obtained under local anesthesia using a Silverman needle. Pathologic examination showed squamous cell carcinoma (Fig. 1). Five weeks after the diagnosis of metastatic carcinoma of the penis the patient died. Postmortem examination revealed bronchogenic carcinoma of the lung with metastasis to various organs. Comment Metastatic disease to the penis may occur in various routes. The following outline shows the different modes of spread: A. Direct extension B. Instrumentation C . Lymphatic Direct Reverse flow 2 degrees to obstructed lymph nodes by tumor D. Venous Direct intercommunications Reverse flow 2 degrees to extramural; mass or increased intra-abdominal pressure E. Arterial Primary, in lung invading artery with tumor emboli Secondary, metastatic lesion to lung. Invasion of artery with emboli Tertiary, metastatic to liver with emboli to lungs; invasion of artery with emboli Paradoxic metastasis, through shunts in heart.
UROLOGY
i
MAY 1976 I
VOLUME VII, NUMBER 5
spread may be divided into four categories which are self-explanatory. Survival
The occurrence of metastasis in the penis carries very poor prognosis, with an average survival after diagnosis of six to seven months.3 Exceptions to this are the cases of Cattell and Mace’ who performed an abdominoperineal resection for carcinoma of rectum and colon. Excision of a metastatic lesion of the penis was done two-andone-half years later, and the patient was alive after nine years. Boyd’ describes a patient who was living two years after the primary cancer and penile metastasis had been excised. The longest survival rate (22.3 months) was among patients with primary rectal lesions with metastases to the penis. In the cases of primary bronchogenic carcinoma of the lung with penile metastasis, the patient reported by Staffieri, &use, and Levit4 survived twenty-five days after diagnosis. Treatment
FIGURE 1. Metastatic lung to penis.
squamous cell carcinoma fi-om
Lymphatic
Via lymphatic may be the case in carcinoma of the prostate or rectum. A portion of the lymphatic drainage of the penis is carried through lymphatics, follows the dorsal vein of the penis, and joins the lymphatic outflow of the prostate to the internal iliac nodes. It is conceivable that metastasis may occur by way of extramural lymphatics to the prostatic plexus. A reversal of the normal direction of flow along the vessels following the dorsal vein could occur with extrinsic pressure or with blockage of nodes draining the prostate.3 In this way, tumor cells could be implanted within the substance of the corpora cavernosa. Venous Batson demonstrated the intercommunication that exists between the pelvic and vertebral veins and the dorsal vein of the penis. Reversal of flow of blood in these channels is possible as a result of extrinsic pressure by tumor mass or straining. _ Arterial Excellent demonstration of this mode of spread is described by Paquin and Rolande2 The arterial
UROLOGY /
MAY 1976 /
VOLUME VII, NUMBER 5
The most common mode of therapy of the penile lesion was suprapubic cystotomy in cases of obstruction and, in a few cases, radical penectomy or local excision of the metastasis. Few patients had x-ray therapy or radium implants. Except for the cases of Cattell and Mace’ and Boyd,8 the different modes of treatment did not change the survival drastically. 13362 Newport Avenue Tustin, California 92680 References 1. ABESHOUSE,B. S., and ABESHOUSE,G. A.:
2. 3. 4.
5.
6.
7.
8.
Metastatic tumors of the penis: a review of the literature and a report of two cases, J. Urol. 86: 99 (1961). PAQUIN,A. J., and ROLAND,S. I. : Secondary carcinoma of the penis, Cancer 9: 626 (1956). MCCREA, L. E., andToems, G. L.: Metastatic disease of the penis, J. Ural. 83: 489 (1958). STAFFIERI, D., KRUSE, H. A., and LEVIT, L.: Metastasis raras de1 cancer de pulmon, Rev. Med. Rosario 33: 24 (1943). RICHTER, H.: Bronchial carcinoma with metastasis in one toe and in penis, Zentralbl. Allg. Pathol. 90: 24 (1953). TRUC, E., LEVALLOIS, M., and PUJOL, A.: Priapism caused by metastasis from a bronchial epithelioma to corpus cavernosum, J. D’urol. 65: 93 (1959). CATTELL, R. B., and MACE, A. J.: Metastasis to the penis from a carcinoma of the rectum, J. A. M. A. 146: 1230 (1951). BOYD, H. L. : Metastatic carcinoma of the penis secondary of the rectum; a review of the literature and a report of of a case, J. Urol. 71: 82 (1954).
537
