Prognosis of men with penile metastasis and malignant priapism: a systematic review

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database

BACKGROUND

Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies.

OBJECTIVES

To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI).

MATERIALS AND METHODS

We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis.

RESULTS

Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p < 0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p < 0.05).

CONCLUSION

Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Stereotactic Radiotherapy for Penile Metastasis: Case Report and Systematic Literature Review

INTRODUCTION

Penile metastases (PMs) are a rare clinical presentation mainly related to advanced stages of disease. Considering the low incidence, an optimal treatment approach has not yet been defined; surgery, chemotherapy, and radiotherapy (RT) are different options used in the vast majority with palliative intent. The advances in modern RT can represent an innovative tool in PM management and a curative option. This paper aimed to report the case of a PM patient treated with stereotactic body radiotherapy (SBRT) and perform a systematic literature review of current evidence on the RT approach to PM.

CASE PRESENTATION

We reported the case of an 80-year-old patient with PM from primary bladder cancer. Following the surgical approach for the primary tumor, evidence of PM was shown, and the patient was admitted to SBRT treatment on PM after an adjuvant RT course on the pelvis. A 25 Gy in 5-fraction SBRT treatment was performed, and a complete clinical response was shown at the first follow-up. A PubMed/MEDLINE and Embase systematic review was carried out. The search strategy terms were [("penile metastasis"/exp OR "penile metastasis" OR (penile AND ("metastasis"/exp OR metastasis))) AND ("radiotherapy"/exp OR radiotherapy)] and only original articles up to October 24, 2023 were considered.

CONCLUSION

A total of 174 studies were obtained using the previously mentioned search strategy, and the analysis was performed on 15 papers obtained following the complete selection process. All reported evidence was focused on the palliative approach of PM, showing good results in terms of symptom control. The potential role of modern RT in the management of PM has yet to be defined. The reported case showed the feasibility and the clinical impact of SBRT in PM treatment.

International case series of metastasis to penis

Objectives

To evaluate clinical characteristics associated with survival in patients with metastases to the penis.

Methods

After approval by the IRB, records of collaborating centres in Leuven, London, Rostock, Amsterdam and Tampa were screened for men presenting with metastatic disease to penis. Multivariate logistic regression analyses were used to identify covariables associated with survival. We analysed clinical data on 34 patients.

Results

Primary sites were most frequently prostate (n = 14, 41%) and bladder (n = 9, 26%). Twenty-eight of 34 (82%) presented with metachronous penile metastases, and 11 (32%) patients had penile metastases as the sole metastatic site. Penile metastatic locations were most frequently in the corpora (n = 18; 53%). Seven (21%) patients with penile metastases had priapism on presentation. Systemic therapy was frequent and variable (chemotherapy n = 12; immunotherapy n = 5; hormones n = 3). Local management included either surgery (n = 10) or RT (n = 8). Twelve- and 24-month overall survival rate were 67% and 35%, respectively. No clinical parameter including primary histology, synchronous or metachronous metastases or priapism showed statistical survival benefit or detriment.

Conclusion

Metastasis to penis arises most frequently from pelvic primaries. Priapism does not appear to correlate with survival in this large, well-defined series.

The Current Challenges in Diagnosing and Treating Malignant Priapism: A Comprehensive Review

Malignant priapism (MP) is defined as a condition of persistent erection of the penis without sexual stimulation due to the neoplastic process of the cavernous sinus and the efferent veins. The effectiveness of established therapeutic recommendations in priapism was ineffective in MP. Modalities of therapy for MP varied from medication treatment, nonsurgical treatment, surgical treatment, and radiotherapy. Despite aggressive surgical management combined with radiation therapy, chemotherapy, or targeted therapy, the survival rate remains low. Therefore, the treatment is usually palliative, focusing on the patient's quality of life improvement and symptom relief.

Malignant priapism: case report and update on management protocols

Background

Malignant priapism, a rare disease with only about 500 reported cases to date, consists of persistent erection secondary to invasion or metastasis of a primary neoplasm. While treatment guidelines for priapism in non-malignant cases have been established, there is currently no guideline for treating malignant priapism. Herein, we describe three cases of malignant priapism and suggest a step-by-step approach for clinical management.

Case Description

This study reports three cases of malignant priapism resulting from advanced genitourinary cancers. All patients experienced a sub-acute progression of penile pain and ultimately underwent palliative penectomy, resulting in sustained symptom relief.

Conclusions

Treatment of malignant priapism needs to be individualized to the needs of the patient. No matter the primary or secondary nature of the disease, current data suggest that malignant priapism is associated with poor outcomes and emphasis should be put on palliative care. Similar to previous cases, our cases died shortly after the diagnosis of malignant priapism. Conventional procedures such as shunting may not necessarily provide symptom relief in these patients. Although new radiation techniques have shown favorable outcomes, penectomy should be considered the last resort in clinical management. Revisions to the existing management guidelines for priapism are necessary to address its occurrence in malignant contexts.

Malignant priapism secondary from metastatic renal carcinoma: Case report: "Malignant Priapism from Kidney Neoplasm"

Malignant priapism (MP) is defined as a condition of persistent erection of the penile without sexual stimulation due to malignant cell invasion to the cavernous sinus and the efferent veins. We present a case of a man, 63 years old, with previous history of high-grade renal carcinoma pT3N0M0 had been through radical nephrectomy, diagnosed with MP secondary from metastatic renal carcinoma. The management of this case was aspiration of corpora cavernosa and distal shunting with the Al-Ghorab procedure, then continued to total penectomy and perineostomy.

A Case of Penile Metastasis from Prostate Cancer, Identified by 68Ga-PSMA PET/CT, Mimicking Peyronie's Disease: A Diagnostic Challenge

A 70-year-old man with high-risk prostate cancer (PCa) received radiation therapy and androgen deprivation therapy (ADT). The patient developed penile tenderness, compatible with Peyronie's disease upon physical examination. An ultrasound revealed a matching hypoechoic plaque and a thrombus in the vena dorsalis profunda, which were treated with anticoagulants. A follow-up ultrasound showed no abnormalities. Despite the use of analgesics, the patient suffered from persistent pain, later accompanied by an increasing PSA level of up to 7.5 ng/mL, despite ADT. 68Ga-PSMA PET/CT showed a PSMA uptake consistent with PCa penile metastasis. Due to severe pain and the presence of metastatic PCa, the patient was referred for penectomy. Histopathological analysis confirmed metastases originating from the PCa. This case underscores the importance of 68Ga-PSMA PET/CT in diagnosing PCa metastases and vigilance towards urogenital symptoms as potential indicators of metastases, despite the rarity of penile metastases.

Penile metastasis secondary to urothelial bladder cancer

Penile metastasis is extremely rare. The most common neoplasms that spread to the external male genital area are bladder and prostate cancer. The diagnosis usually begins with the appearance of penile symptoms. Further examination usually reveals metastasis to other organs, which worsens the patient prognosis. We present a case report of an 80-year-old patient who was accidently diagnosed with metastatic high-grade urothelial cancer during a male circumcision. Further diagnostic process revealed a disseminated neoplastic disease. Whole-body computed tomography (CT) scan often reveals disseminated neoplastic disease, which is the cause of high mortality in secondary penile neoplasms.

Priapism in a Patient with Rectal Adenocarcinoma

BACKGROUND

Priapism is a very rare complication of malignancy and is usually accompanied by locally advanced or widely metastatic disease. We describe a case of priapism arising in a 46-year-old male with localised rectal cancer that was responding to therapy.

CASE PRESENTATION

This patient had just completed two weeks of neoadjuvant, long-course chemoradiation when he presented with persistent painful penile erection. Assessment and diagnosis were delayed for more than 60 h, and although a cause could not be determined from imaging, a near complete radiological response of the primary rectal cancer was seen. His symptoms were refractory to urologic intervention and were associated with extreme psychological distress. He re-presented shortly thereafter with extensively metastatic disease in the lungs, liver, pelvis, scrotum, and penis; additionally, multiple venous thromboses were identified, including in the dorsal penile veins. His priapism was not reversible and was associated with a considerable symptom burden for the remainder of his life. His malignancy did not respond to first-line palliative chemotherapy or radiation, and his clinical course was further complicated by obstructive nephropathy, ileus, and genital skin breakdown with a suspected infection. We initiated comfort measures, and he ultimately died in hospital less than five months after his initial presentation.

CONCLUSION

Priapism in cancer is usually related to tumour infiltration of the penis and corporal bodies resulting in poor venous and lymphatic drainage. The management is palliative and can include chemotherapy, radiation, surgical shunting, and potentially penectomy; however, conservative penis-sparing therapy may be reasonable in patients with limited life expectancy.

Metachronous isolated penile metastasis from sigmoid colon adenocarcinoma: A case report

BACKGROUND

Sigmoid colon adenocarcinoma has a high incidence among gastrointestinal tumors, and it very rarely metastasizes to the penis. The literature reports that the prognosis after penile metastasis is generally poor, with a median survival of about 9 mo. Metachronous isolated metastasis to the penis originating from sigmoid colon adenocarcinoma has not been reported so far. Here, we report a case of sigmoid colon adenocarcinoma with isolated penile metastasis occurring 2 years after surgery. The mass was pathologically confirmed as metastatic adenocarcinoma, and oral chemotherapy with capecitabine was given after surgery. The tumor did not recur during the 2-year follow-up period.

CASE SUMMARY

A 79-year-old man presented to the urology department with "a mass located at the root of the penis since 1 mo". Enhanced computed tomography (CT) examination suggested a 12 mm × 10 mm × 9 mm nodule at the root of the right penile corpus cavernosum. Cranial, pulmonary, and abdominal CT; and bone scan did not show any tumorigenic lesions. The carcinoembryonic antigen (CEA) level was slightly elevated (6.01 ng/mL, reference value 0-5 ng/mL). The patient had undergone laparoscopic radical sigmoidectomy for sigmoid colon cancer 2 years ago. The postoperative pathology showed moderately differentiated adenocarcinoma of the sigmoid colon, and the stage was PT2N0M0. The penile mass was removed under general anesthesia. The postoperative pathology showed adenocarcinoma, and immunohistochemistry showed CDX2(+), CK20(+), and Villin(+). Based on the medical history, he was diagnosed with penile metastasis from sigmoid colon adenocarcinoma. The CEA level returned to normal (3.34 ng/mL) 4 d after surgery. Oral chemotherapy with capecitabine was given subsequently, and tumor recurrence was not found during the 2-year follow-up period.

CONCLUSION

To our knowledge, this is a rare case of metachronous isolated penile metastasis from sigmoid colon adenocarcinoma. The penis is a potential site of metastasis of colon adenocarcinoma, and the possibility of metastasis should be considered in patients with a history of colon cancer who present with a penile mass. Solitary penile metastasis can be removed surgically, in combination with chemotherapy, and it may have good long-term outcomes.

A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment

Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.

Review of Ischemic and Non-ischemic Priapism

PURPOSE OF REVIEW

Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition.

RECENT FINDINGS

Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.

A Case Report and Review of the Literature of Penile Metastasis From Rectal Cancer

Background

Metastatic involvement of the penis in cases of rectal cancer is exceptionally rare condition. Our clinical case report and review of the literature will contribute in complementing currently limited data on penile metastasis from rectal cancer.

Case report

We report a case of a 64-year-old male diagnosed with penile metastasis from rectal cancer. The patient was treated with neoadjuvant chemoradiotherapy followed by total mesorectal excision (TME). However, penile metastasis developed 3 years later, clinically presenting as penile pain and solid formations along the entire length of the penis with visible tumor in the head of the penis. The amputation of penis was performed, and adjuvant chemotherapy was prescribed. The patient survived only 6 months.

Conclusion

Penile metastasis from rectal cancer in most cases is a lethal pathology that indicates wide dissemination of oncological disease and has a very poor prognosis. Aggressive surgical treatment is doubtful in metastatic disease as this will negatively affect the quality of life.

Brachytherapy for oligometastatic prostate cancer to the penis

The origin of penile metastases is in 70% of cases from primary pelvic cancers (genitourinary and recto-sigmoid primary tumors). The prognosis is poor and it is often associated with synchronous bone metastases at the time of diagnosis. We present the case of a 61-year-old patient who developed a penile induration 7 years after radical prostatectomy followed by adjuvant external beam radiation therapy for high-risk prostatic adenocarcinoma. Biopsies confirmed the metastatic localization and a detailed assessment failed to find any further remote lesions. Faced with this penile oligometastatic prostate cancer, we proposed an ablative treatment based on interstitial multi-catheter high-dose rate brachytherapy. At the six-month follow-up, clinical examination and ⁶⁸Ga-PSMA-11-PET confirmed a complete response of the penile tumor without new lesion at a distance.

Case report of metastatic prostate cancer masquerading as squamous cell carcinoma on the tip of the penis

We present a 76-year old man with a two year history of Gleason 9 prostate cancer (PCa) presenting with penile pain, erythema, and a fungating mass on the glans. Imaging at initial PCa diagnosis revealed confined disease. His prostate cancer was previously treated with radiation and androgen deprivation therapy (ADT) with initial laboratory response via prostate specific antigen (PSA) levels, however his PSA began to rise six months following cessation of ADT. Shared decision making resulted in partial penectomy for symptomatic management. Computed tomography (CT) and bone scan performed after surgery were not definitive for metastatic disease.

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Prostatic adenocarcinoma metastasis to the penis is a rare occurrence.

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Presentation can mimic that of squamous cell carcinoma.

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Treatment is often focused on improving quality of life.

Successful Treatment of Malignant Priapism by Radiotherapy: Report of a Case, Review of the Literature, and Treatment Recommendations

Malignant priapism is a condition of painful induration and erection of the penis secondary to metastatic infiltration by a neoplasm. This condition is associated with a poor prognosis. We report on a case of an 87-year-old man who presented with a painful, partially erected penis subsequent to a diagnosis of metastatic Gleason 4+5 prostate cancer. Magnetic resonance imaging (MRI) showed diffuse bilateral infiltration of his corpora cavernosa. The core biopsy of the penile nodule revealed it to be a poorly differentiated carcinoma consistent with prostatic origin. The patient's symptoms were completely resolved after treatment with high-dose palliative conformal radiotherapy (40Gy in 16 fractions). We systemically reviewed clinical reports of palliative radiotherapy for malignant priapism with the aim to gain more information on the management of this rare condition.

Radiotherapy is effective in the management of rare penile metastases: Two case reports

Penile metastasization is an uncommon condition, mostly derived from primitive advanced abdominal cancers, with disabling symptoms. Palliative treatment, in reason of poor prognosis patients, is frequently surgical with destructive management. We report two cases of penile metastasis, from primitive prostatic adenocarcinoma and primitive urothelial carcinoma, effectively managed with radiation treatment at our institution. A three-dimensional conformal radiation therapy with 42Gy to the planning target volume in 14 fractions was delivered. Radiation treatment was safely delivered, with low toxicity profile and achieved adequate symptoms control without compromising genitourinary functions. Radiation therapy should be considered in management of rare penile metastases.

Patient with penile metastasis from prostate cancer and survival over 5 years: A case report with longitudinal evaluation using computed tomography and magnetic resonance imaging

Penile metastasis of malignant tumors is a very rare condition, often occurring as a part of systemic metastases, and is therefore associated with a poor prognosis. Although there have been reports of magnetic resonance imaging findings of penile metastasis, longitudinal imaging changes have not been presented previously. We report a case of a 80-year-old male patient with penile metastasis from prostate adenocarcinoma. First magnetic resonance imaging demonstrated multiple penile nodules in the left corpus cavernosum corpora cavernosa, and these nodules were fused and across the septum of the penis, forming an enlarged, diffusely spreading mass on the follow-up exam 5 years later. In this case, a longitudinal evaluation of magnetic resonance imaging demonstrated the course of the extension of the rare penile metastasis.

Penile secondary lesions: a rare entity detected by PET/CT

While penile metastases are rare, PET/CT has facilitated their detection. We aimed to describe penile secondary lesions (PSL) identified by PET/CT. We reviewed 18F-FDG and Ga68-PSMA PET/CT records performed in a single center during May 2012-March 2020, for PSL. Of 16,774 18F-FDG and 1,963 Ga68-PSMA-PET scans, PSL were found in 24(0.13%) men with a mean age of 74. PSMA detected PSL in 12 with prostate cancer; FDG identified PSL in 4 with lymphoma, 3 with colorectal cancer, 2 with lung cancer, and one each with bladder cancer, pelvic sarcoma, and leukemia. Mean SUVmax of PSL was 7.9 ± 4.2 with focal uptake in 13(54%). Mean lesion size was 16.5 ± 6.8 mm; 8 at the penile root, 4 along the shaft, and 1 at the glans. CT detected loss of the penile texture in 15(63%). PSL were observed only during relapse or follow-up of disseminated disease. Among those with prostate cancer, PSA varied widely. Fifteen (62.5%) died, at a mean 13.3 ± 15.9 months following PSL demonstration, nine had non-prostate malignancies. PET/CT identified and characterized PSL in a fraction of cancer patients, most commonly those with prostate cancer. PSL universally surfaced in advanced disease, and signaled high mortality, especially in non-prostate cancers.

Malignant Priapism - What Do We Know About It?

Malignancy as an etiological factor involved in priapism pathogenesis is rare. Malignant priapism (MP) can arise as a result of penile tumor invasion, either from primary penile tumors or from metastatic penile tumors, or due to hematological malignancies. Non-urological penile metastases are associated with significant worse prognosis compared to urological penile metastases, the appearance of priapism in such cases affecting even more the prognosis and the survival of these patients. Patients diagnosed with hematological malignancies and priapism present significant higher survival rates compared to those who develop MP in the context of a non-hematological malignancy, this being related to the fact that hematological malignancies are more sensitive to chemo- and radiotherapy. Most malignant priapism cases are ischemic; therefore the management should be based on the initial steps of the IP therapeutic protocol. Considering the trigger factor that has led to the priapic event specific oncologic treatment can be added as well.

Malignant priapism: Review of the report in three decades

Introduction:

Priapism is one of the few critical male urological emergencies. There are two main types of priapism, low flow/venous and high flow/arterial priapism. Malignant priapism is a rare subtype of low flow priapism usually secondary to pelvic malignancy, but other extra-pelvic primary cancers cannot be completely excluded.

Aim:

To assess and highlight the poor prognosis of malignant priapism, with a view to directing management towards both symptomatic relief and improving patients’ quality of life.

Method:

All reports of malignant priapism between 1998 and 2018 were searched and assessed focusing on the primary cancer, duration of complaint, associated symptoms, method of management and prognosis.

Conclusion:

Malignant priapism is a rare form of ischaemic priapism, resistant to successful therapies utilized in the management of other forms of ischaemic priapism. Urological cancers are the most common primaries implicated with the most commonly associated symptoms being pain and urinary symptoms. In the absence of any evidence based guidelines and reliably successful treatment options, clinicians should aim to employ supportive treatment strategies including adequate analgesia.

Level of evidence:

level4

Solitary Penile Metastasis of Prostate Cancer on 18F-Fluciclovine PET/CT Imaging in a Patient With PSA of 1 ng/mL

An 85-year-old asymptomatic man with suspected biochemical recurrence of prostate cancer underwent an F-fluciclovine PET/CT scan, which revealed a solitary suspicious tracer uptake in the dorsal right corporal body of the proximal pendulous penis. The patient underwent ultrasound-guided fine-needle aspiration of the penile lesion, which revealed metastatic prostate cancer. The patient had definitive external beam radiation therapy 3 years before the examination. At the time of scan, the prostatic-specific antigen (PSA) was only 1.0 ng/mL, although the PSA doubling time was 2.6 months. It is unusual to detect a solitary penile metastasis in a patient with a low level of PSA.

Early penile-only metastasis of urothelial bladder carcinoma

Penile metastasis rarely occurs as a unique and early distant recurrence of urothelial bladder carcinoma. A 77-year-old male underwent a radical cystoprostatecomy for a pT3a urothelial bladder cancer. Preoperative imaging workup concluded to a disease confined to the bladder. The patient consulted 5 months later for a penile induration. Computed tomography imaging revealed a suspicious penile nodule with no other nodal or visceral lesion. Total penectomy after a confirmatory biopsy confirmed the infiltration of the corpora cavernosa, the corpus spongiosum and the urethra by a urothelial metastasis of bladder cancer. Distant recurrences after radical surgery for locally advanced bladder cancer may occur as a unique early metastasis located to the penis.

We hereby present the case of a 77-year-old male who presented with a recurrence of his bladder carcinoma located solely to the penis. This was confirmed by dedicated imaging. The patient had undergone a radical cystoprostatectomy for an invasive bladder tumor 5 months earlier. The imaging workup performed preoperatively concluded that the tumor was confined to the bladder. The definitive pathological report concluded then to a complete resection of the bladder tumor.

A rare case of penile metastases from small cell prostate cancer

We present a case of an 83-year-old-male with painless penile nodules several months after he was diagnosed with pure prostatic small cell carcinoma. Penile doppler ultrasound and magnetic resonance imaging demonstrated solid nodules in both corpora cavernosa. Fine-needle aspiration of the nodules with immunohistochemical examination confirmed prostatic small cell carcinoma origin of metastases. Small cell carcinoma of the prostate is a rare disorder accounting for less than 1% of all prostate cancers, the penis being an uncommon site for metastasis. An extremely low number of cases of penile metastases from prostatic small cell carcinoma has been reported to date in the literature.

Role of MRI in Staging of Penile Cancer

Penile cancer is one of the male-specific cancers. Accurate pretreatment staging is crucial due to a plethora of treatment options currently available. The 8^th edition American Joint Committee on Cancer-Tumor Node and Metastasis (AJCC-TNM) revised the staging for penile cancers, with invasion of corpora cavernosa upstaged from T2 to T3 and invasion of urethra downstaged from T3 to being not separately relevant. With this revision, MRI is more relevant in local staging because MRI is accurate in identifying invasion of corpora cavernosa, while the accuracy is lower for detection of urethral involvement. The recent European Urology Association (EAU) guidelines recommend MRI to exclude invasion of the corpora cavernosa, especially if penis preservation is planned. Identification of satellite lesions and measurement of residual-penile-length help in surgical planning. When nonsurgical treatment modalities of the primary tumor are being considered, accurate local staging helps in decision-making regarding upfront inguinal lymph node dissection as against surveillance. MRI helps in detection and extent of inguinal and pelvic lymphadenopathy and is superior to clinical palpation, which continues to be the current approach recommended by National Comprehensive Cancer Network (NCCN) treatment guidelines. MRI helps the detection of "bulky" lymph nodes that warrant neoadjuvant chemotherapy and potentially identify extranodal extension. However, tumor involvement in small lymph nodes and differentiation of reactive vs. malignant lymphadenopathy in large lymph nodes continue to be challenging and the utilization of alternative contrast agents (superparamagnetic iron oxide), positron emission tomography (PET)-MRI along with texture analysis is promising. In locally recurrent tumors, MRI is invaluable in identification of deep invasion, which forms the basis of treatment. Multiparametric MRI, especially diffusion-weighted-imaging, may allow for quantitative noninvasive assessment of tumor grade and histologic subtyping to avoid biopsy undersampling. Further research is required for incorporation of MRI with deep learning and artificial intelligence algorithms for effective staging in penile cancer. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2020;51:1612-1629.

Malignancy: A Rare, Important and Poorly Understood Cause of Priapism

INTRODUCTION

Priapism is rare yet has the potential to inflict significant suffering on patients, often with lasting consequences such as erectile dysfunction, corporal muscle necrosis, and a loss of sexual function. Although rare, it is a pathology that has received little focus in the literature, particularly that caused by malignancy, and it is in this form that the long-term prognosis becomes particularly poor.

AIM

This review looks at malignant priapism in detail moving from the etiology and pathogenesis through investigations and management to provide an up-to-date picture.

METHODS

In so doing, more than 30 articles are reviewed and examined from databases such as PubMed. Significant cases are provided as examples to provide a comprehensive review of a topic that receives little attention but can cause significant patient morbidity.

MAIN OUTCOME MEASURE

The main outcome measure was the use of aspiration, sympathomimetics, and surgery as the main treatment modalities and how each one is used with regard to both the underlying etiology of the priapism and also the prognosis. We look at the need for treatment and how that relates to quality of life and erectile function thereafter.

RESULTS

Solid tumor invasion-both primary and secondary-and hematologic malignancies represent the key etiologies of malignant priapism and aggressive treatment is needed. Recovery of erectile function can occur if intracavernosal phenylephrine is quickly administered or distal shunts are placed; however, the prognosis is often poor, and subsequent chemotherapy treatment is often required.

CONCLUSION

The importance of a clear history and examination cannot be understated, and although the prognosis is often poor, this review hopes to give clinicians better understanding to be able to recognize malignancy as a potential cause of priapism. Ralph O, Shroff N, Johnson MJ, et al. Malignancy: A Rare, Important and Poorly Understood Cause of Priapism. J Sex Med 2021; 9:312-319.

Penile metastasis from recurrent sarcoma in a teenager: a case report

BACKGROUND

Metastatic tumors of the penis are uncommon, and fewer than 500 cases have been reported since 1870. Most penile secondary tumors originate in organs of the genitourinary tract, followed by the gastrointestinal tract. Primary tumors of sarcoma origin are extremely rare. Herein, we present a teenager who had recurrent sarcoma of the right femur with penile metastasis.

CASE PRESENTATION

The 20-year-old male patient was diagnosed with sarcoma of the right femur when he was 16 days old. He was stable following combination chemotherapy with the VAC regimen (vincristine, adriamycin, and cyclophosphamide) and debulking surgery. In January 2018, five months ago, he presented with right leg pain and swelling, and a recurrent tumor was found. Following excision of the tumor showed recurrent sarcoma. However, 2 months after the operation, right thigh swelling with tenderness occurred. A firm nodule on the glans of the penis was also noted. Penile metastasis was suspected and a biopsy was performed. The final pathology report disclosed pleomorphic sarcoma with penile metastasis. Symptoms including priapism and inguinal lymph node enlargement progressed rapidly within 2 weeks. He also complained of voiding difficulty with urine retention. The patient died 35 days after admission due to pneumonia with septic shock.

CONCLUSION

Penile metasitasis largely occurs from organs in the pelvis. To the best of our knowledge, this is the first case of a teenager with a secondary penile tumor, metastasizing from sarcoma of the bone. It presented as a palpable mass, and then progressed into priapism. The patient had a dismal prognosis and the symptoms progressed faster than his physicians anticipated.

Painful Penile Plaques: A Rare Case Report of Rectal Adenocarcinoma with Cutaneous Metastasis to the Penis

Despite the rich vascularization of the penis and its close proximity to other pelvic organs, cutaneous manifestations of metastatic disease to the penis are an uncommon occurrence. Penile lesions suspected for malignancy should alert clinicians to differentiate between primary and secondary tumors. While the majority of metastatic malignancies arise from the genitourinary tract, we present a unique case report of a 51-year-old male with penile metastasis of primary rectal adenocarcinoma. A thorough diagnostic evaluation was performed including imaging studies, colonoscopy, as well as penile biopsies with associated immunohistochemistry panel. The patient was diagnosed with penile metastases secondary to invasive rectal adenocarcinoma. Due to the aggressive nature of the patient's presentation, systemic chemotherapy was initiated for palliative measures as the patient declined any radical surgical intervention.

Penile metastasis of colon carcinoma: A rare case report

Despite being one of the most common primary tumors in the world, colon cancer only metastasizes to the penis in singular cases.

We report the case of a 53 year-old male presenting with hematuria, pain and induration of the penis 2 and half years after the diagnosis of left colon cancer. CT scan demonstrated involvement of the corpus spongiosum and corpora cavernosa with enlarged external inguinal lymph nodes and asymptomatic metastasis in the liver and lungs.

The finding of a penile lesion in a cancer patient is an alarming sign and should indicate a disseminated disease. The prognosis of penile metastasis is poor.

Metastasis in penile corpus cavernosum from esophageal squamous carcinoma after curative resection: a case report

Background

Metastasis in penile corpus cavernosum from esophageal squamous carcinoma is a rare but fatal disease, which was reported in cases without series studies.

Case presentation

An 84-year-old male smoker, who had a history of curative resection of esophageal squamous carcinoma 12 months before, presented with aggressive dysuria and penis pain for 1 month. Ultrasonic guided biopsy diagnosed metastatic squamous carcinoma from the primary in the esophagus. The accurately modulated conformal radiotherapy and non-steroidal antiinflammatory drugs achieved to alleviate the penis pain temporarily. But the disease progressed and disseminated in a short period. He died of multiple metastases and cancer cachexia in 4 months.

Conclusions

Primary esophageal cancer metastasis to penile corpus cavernosum refers to short onset time of metastasis, extensive dissemination, bad response to treatment and poor prognosis. Palliative therapy to patients with the disease could achieve temporary local symptom relief, but not prolong survival time. More research is necessary to understand the underlying mechanism of esophagheal metastasis.