Melanoma of the penis and the urethra: 2 case reports and review of the literature

Melanoma of glans penis and urethra: A case report and systematic review of the literature of a rare and complex neoplasm

OBJECTIVE

To evaluate the features and prognosis of melanoma of glans penis and urethra, with the presentation of a significant case report.

MATERIALS AND METHODS

A systematic literature review was performed using the MEDLINE (PubMed) and Cochrane Libraries databases to identify all cases of male mucosal melanoma reported.

RESULTS

Two hundred fifty-two patients with male mucosal primary melanoma were found. Glans penis and fossa navicularis as primary site includes the 81.6% of all lesions considered. Median Breslow's depth is 2.1 mm, whereas nine in situ melanomas have been reported. At the diagnosis, the disease was at a non-localized stage in 21.4% for glans penis melanomas and 11.7% urethral lesions, respectively. The 2 and 5-year survival for glans melanoma is 62.5% and 38.4%; higher rates were observed in the 2012-2020 period (76% and 58.8%, respectively). Two-year survival for urethral melanomas is 66.7%, while 5-year survival is 12.5%. 22 patients survived over 5 years with a Breslow's depth reported always < 3.3 mm.

CONCLUSION

Melanoma of the glans penis and urethra is a rare neoplasm associated with a poor prognosis, however recent reports show higher survival rates. Surgery remains the mainstay for a localized disease. Taking into account the small number of cases reported, topical imiquimod seems to be a valid non-surgical alterative for melanoma in situ. The use of immunotherapy and targeted therapy should be considered only in an adjuvant setting according to the recommendations of cutaneous melanoma; however, additional clinical data on male mucosal melanoma are needed to draw definitive conclusions.

Penile melanoma: a pathological report of two cases

BACKGROUND

Penile melanoma (PM) is a rare tumor, accounting for less than 2% of all penile cancers. PM can occur on the surface of the glans, foreskin, and opening of the urethra. Furthermore, PM primarily affects older individuals and is not associated with sun exposure. Currently, there is no specific staging system for genitourinary tract melanomas, so these tumors are typically staged using the criteria for cutaneous melanoma. Limited data in the literature suggests that PM generally has a poor clinical prognosis.

CASE PRESENTATION

Here, we describe two cases of PM. The first case affected a 62-year-old male who presented with hematuria and a painful tumor in the distal urethra, leading to a suspicion of penile cancer. The second case involved a 68-year-old male who noticed a rapidly evolving dark spot on his foreskin. Histological analysis confirmed the presence of melanoma in both patients. The tumors showed a diffuse and strong PRAME-positivity and lacked BRAF mutation in both cases. Additionally, the second tumor harbored an activating CKIT mutation. An enhanced PD-L1 expression was observed in both tumors.

CONCLUSIONS

We presented two rare forms of mucosal melanoma and highlighted the entities in the differential diagnosis. Based on our experience PRAME is a helpful marker for making the diagnosis of PM, and PD-L1 can predict the success of the immunotherapy. We also emphasize the need for an organ-specific staging system for PMs.

Genitourinary melanoma: An overview for the clinician

Genitourinary (GU) melanoma is a rare presentation of melanoma accounting for approximately 0.5% of all melanomas. GU melanomas include primary melanomas of the vulva, vagina, uterine cervix, ovary, penis, scrotum, urethra, bladder, ureter, and kidney. These melanomas are often diagnosed in advanced stages and stigma is thought to contribute to delays in presentation. As the likely diagnosing provider, it is imperative that dermatologists, urologists, and gynecologists are aware of these uncommon sites of presentation. While there have been major advances in the treatment of melanomas as a whole in the last 10 years, their applications to GU melanomas have often been overlooked. GU melanomas have not been included in many of the major phase III clinical trials which brought contemporary advanced treatments to market and the prognoses for GU melanomas remain poor. Due to the rarity of GU melanomas, much of the literature provides generalized recommendations across multiple different organs affected by GU melanomas or omits certain topics, making it difficult to appreciate the fundamentals of the individual presentations. This review aimed to provide background information on the pathogenesis and epidemiology of the different sites of GU melanomas and categorize data specific to the presentation, staging, treatment, and prognosis of each type of GU melanoma to guide the clinician. It was also meant to encourage a multidisciplinary approach to the management of these patients as it spans the expertise of surgical oncologists, medical oncologists, radiation oncologist, dermatologists, urologists, and gynecologists.

Hepatic Metastasis Revealing a Melanoma of the Penis: Case Report

Melanoma of the penis is a rare tumor with a poor prognosis. We report the case of a 73-year-old patient with no significant medical history, admitted for deterioration of the general condition and bilateral inguinal lymph nodes. An abdominal ultrasound and thoraco-abdomino-pelvic CT (computed tomography) scan revealed metastatic liver nodules, the tumoral nature of which was confirmed by an anatomopathological examination. Further clinical examination revealed papular and ulcerated lesions of the penis located at the urethral meatus and glans penis. These lesions were biopsied and histologically assessed as melanoma. The contribution of imaging in penile tumors is generally not useful for diagnosis as clinical examination is key. However, it has its place in the assessment of locoregional and distant extension. In our case, it was the distant lesions that helped orient the diagnosis. The patient underwent immunotherapical treatment and is still alive 19 months after the diagnosis.

Identification of distinct genomic features reveals frequent somatic AHNAK and PTEN mutations predominantly in primary malignant melanoma presenting in the ureter

BACKGROUND

Primary malignant melanoma of the ureter is extremely rare. Genetic variants to the increased risk of developing the disease have not yet been investigated.

METHODS

Tumour mutation profiling for primary malignant melanoma of the ureter was performed by whole-exome sequencing. Immunohistochemistry was performed to verify histopathological features and the variants of predisposing genes and driver mutation genes. Furthermore, we conducted a literature review and Surveillance, Epidemiology and End Result-based study by searching public databases.

RESULTS

We identified 38 somatic single nucleotide variants and 9 somatic insertions and deletions (INDELs) in tumour specimens. After filtering with the Cancer Gene Census database, seven predisposing genes and two driver mutation genes were identified. Moreover, the immunohistochemical profile showed that tumour cells were positive for Melan-A, melanoma gp100 human melanoma black 45 (HMB45), S100 beta and P53. The expression levels of two driver mutation genes (phosphatase and tensin homolog (PTEN) and desmoyokin (AHNAK) and five predisposing genes (AT-rich interaction domain 1B (ARID1B), catalase, eukaryotic translation initiation factor 4 gamma 3 (EIF4G3), ANK3 and collagen type I) were significantly downregulated in tumour tissues compared to paracancerous tissues. In the literature review and Surveillance, Epidemiology and End Results-based study, patients with primary malignant melanoma of the urinary tract had worse clinical outcomes than patients with primary urothelial carcinoma after 1:2 propensity score matching (P = 0.010). Additionally, Cox multivariate analysis for patients with primary malignant melanoma of the urinary tract indicated that distant metastasis (hazard ratio = 1.185; P = 0.044) was an independent predictor for overall survival, and tumour focality (hazard ratio = 0.602; P = 0.017) and non-surgery (hazard ratio = 0.434; P = 0.003) were independent factors for tumour progression.

CONCLUSIONS

Our study is the first to provide evidence that the distinct phenotypes of primary malignant melanoma of the ureter may be due to different genetic variations. The prognosis of primary malignant melanoma of the urinary tract was poorer than that of primary urothelial carcinoma of the urinary tract.

Anorectal and Genital Mucosal Melanoma: Diagnostic Challenges, Current Knowledge and Therapeutic Opportunities of Rare Melanomas

Mucosal melanomas (MM) are rare tumors, being less than 2% of all diagnosed melanomas, comprising a variegated group of malignancies arising from melanocytes in virtually all mucosal epithelia, even if more frequently found in oral and sino-nasal cavities, ano-rectum and female genitalia (vulva and vagina). To date, there is no consensus about the optimal management strategy of MM. Furthermore, the clinical rationale of molecular tumor characterization regarding BRAF, KIT or NRAS, as well as the therapeutic value of immunotherapy, chemotherapy and targeted therapy, has not yet been deeply explored and clearly established in MM. In this overview, focused on anorectal and genital MM as models of rare melanomas deserving of a multidisciplinary approach, we highlight the need of referring these patients to centers with experts in melanoma, anorectal and uro-genital cancers treatments. Taking into account the rarity, the poor outcomes and the lack of effective treatment options for MM, tailored research needs to be promptly promoted.

Systematic Review of Surgical Treatment and Outcomes After Local Surgery of Primary Cutaneous Melanomas of the Penis and Scrotum

BACKGROUND

Few data exist to guide surgical management and counseling about local recurrence after surgery of primary male genital melanoma.

OBJECTIVE

To compile all available data on local recurrence rates after surgery of primary cutaneous melanoma of the penis and scrotum.

MATERIALS AND METHODS

A systematic review of PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Excerpta Medica database (EMBASE), and Web of Science identified all surgically treated penile and scrotal melanomas that reported local recurrence status and follow-up time.

RESULTS

One hundred twenty-seven melanomas from 74 manuscripts were included. Eighty-six percent of melanomas were located on the penis, and 14% were located on the scrotum. Average follow-up time was 35.7 months. Scrotal melanomas were predominantly treated with organ-sparing surgeries (16/18, 88.9%), whereas penile melanomas were treated more often with amputation (61/109, 56.0%). Overall, local recurrence rate was 15.7% (20/127). Local recurrence rates for penile cases were 18.8% (9/48) after organ-sparing surgery versus 13.1% (8/61) for amputative surgery. Local recurrence rates were 66.7% (4/6) after positive surgical margins versus 10.2% (5/49) after negative surgical margins.

CONCLUSION

Local recurrence rates are high after both organ-sparing and amputative surgery of primary cutaneous melanoma of the penis and scrotum. There is a need to standardize reporting for this rare tumor, as more complete data are necessary to develop consensus guidelines for surgical management of male genital melanoma.

Red nodular melanoma of the penile foreskin: A case report and literature review

The penis is an extremely rare primary site for malignant melanomas, and the clinical presentation may vary greatly. We herein present the case of a 71-year-old male patient who presented with a 6-year history of two slow growing, asymptomatic red macules on the penile foreskin. On physical examination, the mobility of the foreskin was good, and there was no metastasis on computed tomography and magnetic resonance imaging. The patient underwent segmental circumcision for treatment and histological diagnosis, and the histological examination revealed a malignant melanoma. As cancer cells were identified at the edge of the tissue specimen and computed tomography-positron emission tomography revealed increased uptake of ¹⁸F-fluorodeoxyglucose in the penis, wider resection and a right sentinel lymph node biopsy were performed; both specimens came back negative. Two years after the surgery, there has been no evidence of locoregional recurrence or distant metastases. The aim of this report is to alert physicians to include melanoma in the differential diagnosis of red-pigmented lesions of the penile foreskin.

Malignant Melanoma of the Penis. A Report of Four Cases

Malignant melanoma (MM) of the penis is a rare neoplasia. We report 4 cases by a retrospective survey of all cases of MM observed at the Istituto Nazionale Tumori of Milano from 1967 to 1988. The problem of the therapeutic approach is still unsolved. Therefore, any case is useful for a better knowledge of the natural history of this disease.

A case report of primary malignant melanoma of male urethra with distinct appearance in multiple regions

A 66-year-old man presented with macrohematuria. Cystoscope examination found a 5 mm nodular tumor at external urethral orifice and multiple papillary tumors at fossa navicularis of urethra; those are non-black colored. Transurethral resection of the urethra tumor was performed, and pathologically diagnosed as malignant melanoma. Image examinations showed no lymphadenopathy and metastasis. Accordingly, total penectomy was conducted to remove the remaining tumors, resulting in surgically curative resection. After the operation, monthly interferon-β injection into inguinal region has been administered as adjuvant therapy, resulting in no recurrence at 6 months after penectomy.

Malignant melanoma of the penis and urethra: one case report

We present a case of a patient with malignant melanoma of the glans penis and urethra, which was found in a 53-year-old man with nonhealing ulcerative penile lesion and bilateral, clinically palpable inguinal lymphadenopathies at diagnosis. A diagnostic biopsy showed the characteristics of a melanoma. We treated the patient with total penectomy and bilateral inguinal lymph node dissection. After surgery, chemotherapy with bleomycin, vincristine and cisplatin and immunotherapy with thymosin injection were started. No recurrence or metastasis occurred during the 3 years after the operation. Melanoma of the penis is very rare, and early diagnosis is important because the patient prognosis is very poor.

Recurrent malignant melanoma of the penis

We report the case of a 72-year-old man with arcal-lentiginous type melanoma of the penis who had undergone local excision and bilateral inguinal lymphadenectomy but developed recurrence at the subcoronal ridge of the glans penis. To our knowledge, this is the 10th reported case in English published studies. We believe this case demonstrates the importance of close follow-up postoperatively and to beware of the recurrence of penile melanoma in patients without total penectomy.

[Melanoma of the penis: 6 cases]

BACKGROUND

Melanomas of the penis are rare tumors of poor prognosis.

METHODS

Six cases of melanoma of the penis, followed between 1975 and 2002, were retrospectively reviewed. We collected the data on epidemiological, clinical and pathologic factors, treatment and follow-up.

RESULTS

The mean age was 44 years. The time to diagnosis was 2 years. Two patients had general predisposing factors for melanoma, and 3 patients local predisposing factors. Two patients had partial penectomy and 4 patients had conservative excision. One patient had local recurrence, and another had metastatic course resulting in death. Five patients out of 6 were alive and disease free at time of the study, with a 24 month follow-up.

DISCUSSION

The identified risk factors for the development of penile melanoma are melanosis and pre-existing nevus. Delayed diagnosis explains the usually bad prognosis. Classical surgical treatment used to be radical, but recently, conservative surgery has been proposed. For an early diagnosis, genital melanosis requires surgical excision, when technically feasible, and any atypical lesion of the penis should be submitted to a biopsy.

[Penile adenoma: clinical case]

Penile melanoma is a very uncommon neoplasm, being reported less than 60 cases. Event yet it outlines not few doubts about its diagnosis and treatment, and in advanced stages represents a challenge for the future since it prognosis is awful at short time. In the present article, its presented a glans melanoma diagnosed and treated at our Service. We make a brief revision of the literature and some basic issues on the management of this entity when it's localized in penis, since in the cases in which it extends far from this organ is yet oncological field.

Primary genitourinary melanoma

OBJECTIVES

To describe the presentation, management, and clinical outcome of patients with genitourinary melanoma.

METHODS

We identified 14 patients with genitourinary melanoma treated at Memorial Sloan-Kettering Cancer Center, New York and Tripler Army Medical Center, Honolulu, Hawaii. The presentation, surgical treatment, disease progression, and outcome of these patients were reviewed. Survival was analyzed, using the Kaplan-Meier product limit method.

RESULTS

The presentation and management of patients with genitourinary melanoma were varied. Overall, the prognosis was poor, with a median survival of 43 months, and only 3 patients were alive, without disease, at last follow-up. Our findings confirm a poor prognosis in patients with this rare disease.

CONCLUSIONS

Genitourinary melanoma is a rare form of the disease with an unfavorable clinical outcome. Less than one third of patients survive long term, although patients with scrotal melanomas may have a better prognosis.

[Malignant neoplasms of the penis]

OBJECTIVE

To assess the behaviour and management of these uncommon neoplasias.

MATERIAL AND METHODS

Between March 1975 and July 1999, a total of 95 malignant neoplasias of the penis were diagnosed and treated by our unit. Patients mean age was 62 years (28 to 87 years). A retrospective analysis of any associated lesions, biological behaviour of the various neoplasias, as well as therapies used is carried out.

RESULTS

The squamous carcinoma of the penis (SCP) is the most frequent pathohistological entity entailing 78 cases (82%), followed by verrucous carcinoma (VC) 13 cases (13.5%), basal cells carcinoma 1 case, and melanoma, lymphoma and penile metastasis 1 case each. There is a significant presence of associated lesions with marked predominance of phimosis. The most frequent reason for the call is an injury of the penis (74 cases; 78%). Treatment was mainly partial penectomy (51 patients; 53.7%), followed by conservative treatment in 28 cases (30%). Inguinal lymphadenectomy was performed in 13 patients (14%), due to either a positive nodular biopsy or a persistent adenopathy following antibiotic therapy.

CONCLUSIONS

Neoplasias showing superior biological behaviour are basal cell carcinoma of the penis, and verrucous carcinoma. Prognosis in SCP is based on pathological status and node involvement. Patients with pT1 tumours showed no metastatic adenopathies after follow-up regardless of cytological grading, and are therefore candidates to watchful waiting with regular monitoring. Melanoma of the penis is a highly aggressive tumour due to its high metastatic capacity with a poor prognosis.

Primary malignant melanoma of the urethra: a clinicopathologic analysis of 15 cases

The clinical and pathologic features of 15 primary urethral melanomas occurring in patients (nine women and six men) age 44 to 96 years (mean age, 73 yrs) are described. In the men the tumor involved the distal urethra. In eight women it involved the distal urethra, usually the meatus; both the distal and proximal urethra were involved in one woman. The tumors were typically polypoid and ranged from 0.8 to 6 cm (mean, 2.6 cm) in maximum dimension. A vertical growth phase was present in all tumors, with a prominent nodular component in seven of them. A radial growth phase was seen in nine tumors. The depth of invasion ranged from 2 to 17 mm. The tumors had diffuse, nested, storiform, or mixed growth patterns. The neoplastic cells typically had abundant eosinophilic cytoplasm, large nuclei with prominent nucleoli, and brisk mitotic activity. Melanin pigment was seen in 12 tumors but was conspicuous in only six. At the time of diagnosis, 13 tumors were confined to the urethra and two patients had lymph node metastasis. Nine patients died of disease 13 to 56 months after initial diagnosis and treatment, and one patient had a local recurrence at 4 years and subsequently died of sepsis 1 year later. Three patients were alive and well at 11 months, 23 months, and 7 years. One patient died at the time of the initial operation, and one died of a ruptured aortic aneurysm at 3 years without evidence of melanoma at autopsy. Primary malignant melanomas of the urethra, one fifth of which are amelanotic, must be included in the differential diagnosis of a number of primary neoplasms that involve the urethra, including transitional cell carcinoma, sarcomatoid carcinoma, and sarcomas. Conventional prognostic factors, such as depth of invasion or tumor stage, do not seem to play as important a role in predicting survival as the mucosal location and the nodular growth present frequently in these tumors.

Malignant melanoma of the penis

A case of malignant melanoma of the penis is herein reported. Malignant melanoma of the penis is rare and accounts for a small percentage of malignant melanomas and of malignant penile lesions. The diagnosis is often delayed by the patient's reluctance to consult a physician and by the intrinsic difficulty in clinical diagnosis of such a rare neoplasm. The surgical treatment is not standardized and is shortly discussed. In general, prognosis is poor and most patients die within a few years due to distant metastasis.

Penile malignant melanoma in association with squamous cell carcinoma of the penis

We report a case of malignant melanoma of the penis in association with penile squamous cell cancer. Previous regional lymphadenectomy did not prevent subsequent development of regional recurrence. This clinical presentation and the literature are discussed.

Primary malignant melanoma of male urethra

A case of primary malignant melanoma of the male urethra is reported. Treatment included partial urethrectomy, bilateral inguinal and iliac lymphadenectomy, and post-surgical systemic chemotherapy. After thirty-six months, the patient is alive with cutaneous, pelvic lymph node, and gastric metastases.

Malignant melanoma of the penis

Malignant melanoma of the penis is rare and accounts for only a small percentage of penile carcinomas. We report the largest series and the longest followup of patients with this disease. The tumor usually presents as a small, brown or black lesion, often ulcerating, on the glans penis. Stage I disease (confined to the penis) can be treated conservatively by distal penectomy and results in excellent survival. Palpable inguinal lymph nodes and nodes associated with thick cutaneous lesions require surgical exploration. Stages II (node positive) and III (metastatic) diseases carry a poor prognosis, mainly because of the lack of effective adjuvant systemic therapy.

Primary malignant melanoma of the male urethra

Primary malignant melanoma of the male urethra is a rare disease, with only 24 cases previously reported in the literature, including 1 black patient. We describe 2 additional patients with primary malignant melanoma of the urethra, one of whom was a black man. The literature is reviewed briefly and treatment recommendations are discussed.

Malignant melanoma of the penis and male urethra: 4 case reports and literature review

Malignant melanomas of the penis and male urethra are uncommon lesions. We report 3 new cases of male urethral melanoma and 1 case of penile melanoma, bringing the total numbers of reported cases to 26 and 57, respectively. The literature is reviewed, and biological, histopathological and therapeutic considerations are analyzed.

Malignant melanoma of penis

We report a case of malignant melanoma of the penis. Appropriate staging of these rare cancers is discussed in light of current views of the biology of malignant melanoma arising at other skin sites, and the implications of Breslow thickness for management are considered. There is no good evidence in the literature that extirpation of the entire penis offers the only hope of cure for stage I penile melanoma.

Malignant melanoma of the penis and male urethra. Report of nine cases and review of the literature

Nine cases of primary malignant melanoma of the penis and male urethra are presented. The age range of the patients was 57-77 years. Five patients had intermittent bleeding, one had pain, and three were asymptomatic. Six patients had the melanoma on the glans or prepuce and three in the urethra; two presented with inguinal lymph node metastases. Penile amputation was performed in six patients, local excision in three, groin dissection in four, and one was given radiotherapy. Postoperative metastases were seen in eight patients, four of whom were treated with surgery, alone or in combination with radiotherapy, and one with chemotherapy. Two patients are still living, at 2 and 14 years after diagnosis, respectively. Seven patients have died of their tumors, five of them within 2 years. This confirms the consensus of available reports that, irrespective of what type of therapy is used, prognosis is poor in patients with malignant melanoma of the penis and urethra.

Malignant melanoma of prepuce: case report

A 58 year old man presented with what seemed to be a simple penile lesion, but which on subsequent histological examination proved to be a malignant melanoma. The lesion was excised by circumcision. No further treatment was considered to be necessary.

Primary malignant melanoma of the urethra in a black man: a case report

We report a unique occurrence of primary urethral melanoma in a black man. The biological relationships to melanocyte/melanin site densities or to precursor mucosal lesions are discussed as possible etiological factors in the occurrence of this rare neoplasm.

Malignant melanoma of the penis and male urethra

We report 3 new cases of penile and 2 of male urethral melanoma, increasing the total numbers of reported cases to 56 and 23, respectively.

Melanoma of the male urethra: surgical approach and pathological analysis

Primary urethral melanoma in male subjects is rare and optimum therapy has not been established. We described a male patient with a primary urethral melanoma that arose in a precursor nevus and was treated by excision, bilateral groin dissections and postoperative radiation therapy. Urinary and sexual functions have been maintained. We review the previously reported cases of urethral melanoma in male subjects. The biologic relationship of melanoma to precursor lesions in mucosal sites is discussed.

Primary malignant melanoma of the penis. Two cases and a review of the literature

Two cases of primary malignant melanoma of the penis are reported and 35 cases from the world literature are reviewed. The tumour most commonly started in the glans penis and less frequently from the prepuce. The microscopic appearances were identical with those of tumours arising elsewhere in the skin. A comparison is made between the incidence of melanoma of the penis and melanoma occurring elsewhere on the body surface. Evaluation of the best treatment was difficult because the total number of cases was small and the methods of treatment and results so variable. It would seem that the prognosis of malignant melanoma of the penis is generally poor, although there are sufficient examples of long-term survival after total amputation in Stage I disease to suggest that this radical treatment is justified.

Epidemiology of cancer of the penis

World-wide incidences of penile cancer are reviewed and epidemiologic factors including ciecumcision, hygiene, phimosis, smegma, irritation, infection, veneral disease, viruses, environment, race, immune response, trauma, and age are discussed. The lowest rates appear in groups practicing infant circumcision and in areas where standards of sexual hygiene are high.

Benign melanosis and malignant melanoma of penis and male urethra

Malignant melanoma of the penis and male uretha are unusually aggressive tumors which only rarely are cured by radical surgery. Melanosis of the penis may be confused with malignant melanoma, and we report a case of melanosis originally diagnosed and treated as melanoma with survival for twenty years. We contrast this with another case of malignant penile melanoma with a fatal outcome.

Staging carcinoma of the penis

Presently there are six clinical staging systems in use for carcinoma of the penis. We propose a method which compares these systems by means of a check list type of format. With the aid of this device, any penile carcinoma can readily be staged in terms of all six systems. Advantages of multiple system staging include comparing series of patients which have been discussed only in terms of a single staging system and selecting the appropriate therapeutic modality in terms of the stage of disease.