Priapism secondary to penile metastasis of rectal cancer

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.

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.

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 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.

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.

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

Penile metastasis in rectal cancer with pathologic complete response after neoadjuvant chemoradiotherapy: The first case report and literature review

RATIONALE

Penile metastasis in rectal cancer is very rare and often originates from prostatic or bladder cancer. The prognosis of penile metastasis is poor and its treatments are more often palliative than curative due to association with disseminated metastases. Pathologic complete response (pCR) in rectal cancer with neoadjuvant chemoradiotherapy (CRT) has been shown to be surrogate marker of favorable long-term outcomes and currently has no report of penile metastasis. Here, we first report isolated penile metastasis in rectal cancer with pCR after neoadjuvant CRT.

PATIENT CONCERN

The patient was a 74-year-old male with metastasis to the glans penis from rectal cancer diagnosed 9 months after abdominoperineal resection. Physical examination revealed palpable multiple nodules on the glans penis.

DIAGNOSIS

Penile biopsy revealed metastatic carcinoma from the rectal cancer.

INTERVENTION

Chemotherapy was started as soon as possible, because patient suffered urinary discomfort by rapid growing metastatic lesions. He is currently receiving palliative chemotherapy with modified FOLFOX-6 (mFOLFOX-6; oxaliplatin with 5-fluorouracil and folinic acid) plus bevacizumab.

OUTCOME

The patient is still alive 4 months after diagnosis with markedly decreased metastatic lesions.

LESSON

We propose that although penile metastasis in rectal cancer with pCR after preoperative neoadjuvant CRT is extremely rare, it might help to start early palliative chemotherapy and clinicians should be aware of this possibility.

Penile Metastasis from Rectal Carcinoma: Case Report and Review of the Literature

Background

Metastasis of rectal cancer to the penis is a very rare condition with less than 40 cases found in the literature.

Case Report

We here report a case of a 41-year-old man who was diagnosed with rectal cancer which later metastasized to the penis. The patient was treated with neoadjuvant radiotherapy, underwent rectal resection, had adjuvant chemotherapy, and, despite that, had penile metastasis 2 years later. Palliative penectomy as well as bilateral orchiectomy with suprapubic cystostomy were performed. The patient died 2 months after the diagnosis. All the previous cases mentioned in the literature are reviewed as well.

Conclusion

The prognosis of penile metastasis from rectal cancer is poor and life expectancy is short. The mechanism of rectal cancer metastasis spread to the penis is unknown. The most acceptable theory is retrograde venous spread. There are several treatment options; however, no single treatment option is associated with superior results.

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

Introduction: Metastases to the penis are rare, but can have severe consequences. The aim of this study was to systematically review the literature in order to gain more information on the presentation and prognosis of this metastatic disease. We reviewed the literature relating to all case reports, series and reviews about penile metastasis, from 2003 to 2013, through a Medline search. We identified 63 articles and 69 patients. Metastases were located on the root (38.8%), the shaft (38.8%) or the glans (22.2%) of the penis. The diagnosis of penile metastasis was made after the primary cancer had been diagnosed. The most common presentation was a single small penile nodule. Ten patients reported priapism. The median survival time after diagnosis of penile metastasis was 10 months (range 6-18 months). A Kaplan-Meier analysis has shown that the patients presenting with priapism and those with metastases from non-urologic tumors have a significantly worse prognosis (age adjusted Log Rank: p=0.037 for priapism vs. no priapism and p=0.045 for urologic vs. non urologic). There are prognostic differences based on the presentation of penile metastases. Survival is substantial and treatment should therefore take into account symptoms improvement and quality of life.

First case of penile metastasis following abdominoperineal resection with VRAM flap reconstruction

Penile metastases are rare in colorectal cancer. We report the first case of such a recurrence in a patient who had undergone an extralevator abdominoperineal resection with vertical rectus abdominis myocutaneous flap perineal reconstruction. The patient was treated with curative intent by total penectomy.

A rare case of metachronous penile and urethral metastases from a rectal mucinous adenocarcinoma

Metastatic lesions in the penis are uncommon in patients with prostate or bladder cancer but penile metastatic lesions from rectal tumours are rare with only 65 cases reported in the literature. We describe the case of a 70-year-old man who developed metastatic lesions within his corpus cavernosum 2 years after being diagnosed and treated for a mucinous adenocarcinoma of the rectum and a year after a wedge resection of an isolated lung metastasis. He proceeded with total penectomy and intraoperatively two skip lesions were also found within the wall of his urethra; histological analysis proved that these were also metastatic lesions. A perineal urethrostomy was formed with the remaining macroscopically healthy urethra. He made a good recovery from his operation and continued his treatment under the oncology team.

Penile metastasis from rectal cancer by PET/CT

It is extremely rare for rectal tumors to metastasize to the penis, and when it occurs, it is associated with poor prognosis. The appearance of penile metastasis from rectal primary tumor on PET imaging has not been widely reported. We report a case of a 70-year-old man with previous history of treated stage III adenocarcinoma of the rectum 26 months ago. The restaging 18F-FDG PET/CT scan demonstrated a hypermetabolic mass at the base of his penile shaft. This lesion was confirmed on core biopsy to be a metastatic adenocarcinoma of colorectal origin consistent with the known primary rectal tumor.

Palpable Penile Metastases: A Bizarre Presentation of Rectal Adenocarcinoma

Metastasis to the penis is an uncommon occurrence, with only about 370 cases reported in the literature to date. The majority of the primary tumors are genitourinary in origin. We report on a patient with undiagnosed disseminated rectal adenocarcinoma, who first presented with lesions of the corporal bodies. A review of the literature indicates that corporeal metastasis as an initial presentation of malignancy is an extremely rare occurrence and carries a very poor prognosis.

Value of positron emission tomography in diagnosing synchronous penile metastasis from urothelial bladder cancer

Metastases to the penis are extremely rare events. Most frequently, penile metastases come from the urogenital system (bladder, prostate) or the rectum-sigmoid colon. Usually painful, penile lesions may be asymptomatic, making diagnosis more challenging. Hence, we report the adding value of ¹⁸F-fludeoxyglucose–positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the detection of penile metastases originating from urothelial carcinoma of the bladder. Arguably, penile metastases must be considered as an advanced disease requiring essentially palliative care. Therefore, accurate staging of clinically localized muscle-invasive bladder cancer is crucial to avoid useless curative intent radical surgery.

Penile metastases treated with partial glansectomy and adjuvant radiotherapy 5 years after an initial diagnosis of rectal cancer

A 61-year-old man with recurrent rectal carcinoma was referred to the urology clinic with two penile lesions. These had negatively affected his quality of life and he underwent a radical circumcision and proximal glansectomy with reconstruction. This case report examines the clinical presentation and surgical treatment of rectal carcinoma metastasising to the penis.

18F-FDG PET/CT in a case of malignant priapism secondary to metastasis from mucoid adenocarcinoma of the cecum

Metastatic tumors of the penis are rare, with priapism as the predominant symptom in a significant number of cases. The genitourinary tract and rectum are the most common primary sites. FDG PET/CT has established role in detection of distant metastasis in various malignancies. The authors describe a case of mucoid adenocarcinoma of cecum, presented with priapism after right hemicolectomy, where FDG PET/CT showed intense tracer uptake throughout the enlarged penis, which was later confirmed as metastatic adenocarcinoma by trucut biopsy.

Metachronous penile metastasis from rectal cancer after total pelvic exenteration

Despite its abundant vascularization and extensive circulatory communication with neighboring organs, metastases to the penis are a rare event. A 57-year-old male, who had undergone total pelvic exenteration for rectal cancer sixteen months earlier, demonstrated an abnormal uptake within his penis by positron emission tomography/computed tomography. A single elastic nodule of the middle penis shaft was noted deep within Bucks fascia. No other obvious recurrent site was noted except the penile lesion. Total penectomy was performed as a curative resection based on a diagnosis of isolated penile metastasis from rectal cancer. A histopathological examination revealed an increase of well differentiated adenocarcinoma in the corpus spongiosum consistent with his primary rectal tumor. The immunohistochemistry of the tumor cells demonstrated positive staining for cytokeratin 20 and negative staining for cytokeratin 7, which strongly supported a diagnosis of penile metastasis from the rectum. The patient is alive more than two years without any recurrence.

A review of penile metastasis

Penile cancer as primary disease is relatively rare in developed countries. The penis is a rare site of metastases in spite of its rich vascularization. Approximately 500 cases have been reported in the literature; almost 70% of primary lesions are of pelvic origin (from genitourinary or recto-sigmoid primary tumors). We describe a case of penile metastasis from lung cancer. The rarity of the event prompted us to also explore related reviews and discuss the incidence, physiopathology, diagnosis and therapy of penile secondary cancer.

Malignant priapism secondary to metastatic prostate cancer: a case report and review of literature

Penile metastasis of cancers from other primary sites is a rare phenomenon that infrequently manifests as malignant priapism. We outline a case of an 84-year-old patient who presented with a 3-month history of painful priapism after radiation therapy for prostate adenocarcinoma. The patient underwent surgical penile exploration and cavernosal biopsy that revealed poorly differentiated cells suggestive of prostate cancer. Postoperative imaging demonstrated extensive regional and distal metastases. A review of the literature on penile metastases returned approximately 400 published cases, with priapism being the initial presentation in 20% to 50% of cases. Regardless of site of origin or subsequent management, most cases have shown very poor prognosis.