|Year : 2010 | Volume
| Issue : 4 | Page : 585-586
Symptomatic intracranial metastasis in penile carcinoma
Aliasgar V Moiyadi1, Hemant B Tongaonkar2, Ganesh K Bakshi2
1 Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, India
2 Uro-oncology Services, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, India
|Date of Web Publication||31-Dec-2010|
Aliasgar V Moiyadi
Room 48, Main Bldg, Tata Memorial Hospital, E Borges Rd, Parel, Mumbai- 400 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Distant metastases in penile cancers are rare, especially metachronous symptomatic intracranial metastasis. A middle-aged patient presented to us with an intracranial mass 2 years after being treated for penile cancer. Given the rarity of metastasis and the diagnostic dilemma along with the need for relief of neurological symptoms, it was excised and found to be a metastatic deposit. We discuss the case and review the relevant literature.
Keywords: Brain metastasis, intracranial metastasis, penile cancers
|How to cite this article:|
Moiyadi AV, Tongaonkar HB, Bakshi GK. Symptomatic intracranial metastasis in penile carcinoma. Indian J Urol 2010;26:585-6
| Introduction|| |
Penile cancer is primarily a locoregional disease. Treatment is focused toward the control of the primary and nodal disease. Systemic metastases occur in advanced cases, the commonest sites being lung, liver, and bone. , Intracranial metastases from carcinoma penis are extremely rare. The exact incidence is unknown probably because of underdiagnosis and under-reporting. Presence of an intracranial mass is often life-threatening and warrants prompt treatment to relieve the raised intracranial pressure. Surgery remains the mainstay of treatment of large symptomatic intracranial, metastases especially if the histological diagnosis is unsure, as is the case in penile cancers where intracranial metastases are uncommon.
| Case Report|| |
A middle-aged male presented with a 10-day history of significantly discomforting headaches associated with progressive right upper limb weakness. Two years ago, he had been diagnosed with penile carcinoma and had undergone a partial penectomy with right groin node dissection at another hospital. Details of histology were unfortunately not available. He had remained asymptomatic till his current illness. On examination, he had papilloedema and right upper limb monoparesis. The penile stump was clean. There was an 1-cm left inguinal node which on fine-needle-aspiration yielded metastatic cells. CT abdomen-pelvis and chest X-ray were normal. MRI brain revealed a well-circumscribed, lobulated intra-axial mass in the left perisylvian area [Figure 1]. Differentials of a secondary versus a malignant primary tumor were considered. In view of his progressive neurological deterioration and reasonable diagnostic dilemma (given the rarity of symptomatic cerebral metastases in penile cancers), the mass was excised. He had a transient postoperative deterioration, which improved over 2 weeks. Histology revealed metastasis from squamous cell carcinoma [Figure 2].
|Figure 1 :MRI brain (a - T1 axial, b - T2 axial, c - post-contrast T1 axial, d - post-contrast T1 coronal) showing a well-delineated right perisylvian mass appearing hypointense on T1, hyperintense on T2 images with a shaggy enhancing wall all around. Perilesional edema is noted on the T2 images|
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|Figure 2 :Photomicrographs showing a tumor comprising of sheets of tumor cells (a-H and E ×100) with large areas of necrosis (b-H and E ×40; arrow marks the areas of necrosis). The tumor shows a well-demarcated border with the adjacent brain parenchyma (c-H and E ×200). The tumor cells are polygonal in shape with distinct cytoplasmic outline with no identifiable keratin. Mitoses are noted (d-H and E ×400; arrow head for mitosis).|
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He subsequently received whole brain radiotherapy (30 Gy/10 fractions) and palliative external beam radiotherapy to the left groin. At the 3-month follow-up, he remained clinically controlled.
| Discussion|| |
Clinically symptomatic cerebral metastases in penile cancers are extremely uncommon. Our search of literature revealed only three reports. Lutterbach et al .  reported a case of right frontal metastasis developing in a patient with initially diagnosed early penile cancer. After treatment of the primary, he developed local recurrence which was salvaged. This was followed by pulmonary and subsequently liver and retroperitoneal nodal metastases. He then developed cranial metastases. In spite of aggressive treatment, the patient finally succumbed to disseminated disease. The second report describes the presence of brain metastases at autopsy in a patient with disseminated disease and multiple other sites of metastases.  A third autopsy report on 14 cases of penile cancer describes 2 with brain metastases.  These scattered reports suggest that if and when brain metastases develop, they are often preceded by other metastases. The incidence of brain metastases may be higher if more frequent cranial imaging is performed. Presence of an intracranial mass in patients with a known primary generally raises the suspicion of a metastasis. However imaging is not foolproof, with both false negatives and false positives well known.  In primaries with a high propensity for cranial metastases (like lung cancer), clinicoradiological correlation often suffices in labeling an intracranial mass as a metastasis. However in cancers which rarely metastasize to the brain (like penile cancer), one must be extremely cautious in labeling a mass as metastatic especially if it is metachronous and solitary. Our patient with penile cancer had a 2-year disease-free interval prior to presenting with the intracranial mass. In such cases, tissue diagnosis becomes essential unless the patient is severely disabled or has disseminated disease. Symptomatic and large, solitary intracranial metastases should generally be excised if accessible and safe. Not only does it provide tissue for diagnosis, it also relieves symptoms of raised pressure and can relieve neurological deficits, besides prolonging survival.  Metastases are generally well circumscribed, noninfiltrating, and amenable to safe complete resection. Although our patient did not have a PET scan (in view of logistical issues), his abdominal CT scan and chest X-ray were normal. Progressive neurological symptoms and a reasonable diagnostic dilemma warranted surgery with an acceptable neurological outcome. How much this would translate into a survival advantage remains a matter of conjecture. Role of chemotherapy in advanced cases is still to be established. ,,
| Acknowledgment|| |
The author would like to thank Dr. Epari Sridhar, department of Pathology, for reviewing the histology and providing the photomicrographs.
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[Figure 1], [Figure 2]