Spongious Penile Metastasis from Urothelial Carcinoma of the Bladder: A Case Report and Literature Review

Abstract

Penile metastases are exceedingly rare and are typically secondary to genitourinary malignancies such as bladder or prostate cancer. Their diagnosis is often delayed and associated with a poor prognosis. We report the case of a 49-year-old patient who had been managed in 2016 for a urothelial carcinoma of the bladder, treated with a radical cyst prostatectomy and Bricker-type urinary diversion (pT2N0M0). Nine years later, he presented with a painful swelling of the penis evolving over three months. MRI and CT imaging revealed a tumoral process involving the corpus spongiosum and the penile urethra, with trans-parietal extension and an inguinal lymphadenopathy, without evidence of bladder recurrence. Histological and immunohistochemically analyses were consistent with a urothelial carcinoma. The patient underwent a penectomy with right inguinal lymph-node dissection, followed by concomitant chemo radiotherapy. Conclusion: Penile metastases of urothelial origin are rare but represent severe complications of urothelial carcinomas. They may occur many years after cyst prostatectomy.

Keywords

Penile; Cancer; Metastasis; Bladder; Young Patient

INTRODUCTION

Penile metastases of tumoral Origin are extremely rare [1].They were first described by Eberth in 1870 [2].

To date, 504 cases of metastatic cancers to the penis have been reported in the literature, 70% of which originate from primary tumors of the genitourinary tract [1].

The interval between the primary tumor and the onset of penile metastasis ranges from 3 to 60 months, and the time between the diagnosis of penile metastasis and death varies from 0.25 to 18 months [3].The prognosis is poor, with survival rarely exceeding 20 months [4-5].

Given the rarity of this spongiosum localization and the variability in its time of onset, this article aims to contribute to the existing literature, highlight the importance of prolonged surveillance, and discuss the diagnostic and therapeutic challenges associated with this condition.

CASE PRESENTATION

The patient is a we report the case of a 49-year-old man, a former heavy consumer of tobacco and alcohol who had been abstinent for more than fifteen years. His medical history was notable for a urothelial carcinoma of the bladder diagnosed in 2016, for which he underwent a radical cyst prostatectomy with a Bricker urinary diversion. The tumor was staged as pT2N0M0. Postoperative recovery was uneventful, with no significant sequelae, and follow-up had remained unremarkable for several years.

Nine years after the surgery, the patient presented with a painful swelling of the penis, without reporting any other associated symptoms. Physical examination confirmed a penile mass that was indurated and tender on palpation, with no palpable peripheral lymphadenopathy. His general condition remained preserved (ECOG 1).

A pelvic MRI was performed, revealing a tumoral process centered on the corpus spongiosum and the penile urethra, with parietal extension and associated inguinal lymphadenopathy [Figures 1-2].

Figure 1: Sagittal MRI scan showing métastasis in the corpus cavernous (red arrow).

Figure 2: Séquence T2 dans la section coronographe de la lésion pénienne sur la flèche rouge.

A thoraco-abdominopelvic CT scan conducted during the same period confirmed infiltration of the corpus spongiosum, the corpora cavernosa, and the penile urethra, with no additional abnormalities detected elsewhere [Figure 3].

Figure 3: The basic axial contrast CT images (A and B) revealed the penile lesion in the corpus spongiosum (arrow).

A penile biopsy was subsequently performed. Histopathological analysis demonstrated an undifferentiated malignant tumor consistent with carcinoma. Immunohistochemically staining showed diffuse positivity for CK8/18, CK20, and GATA3, heterogeneous positivity for CK5/6, and negativity for CD117. This immunoprofile, in conjunction with the morphological features, confirmed the diagnosis of urothelial carcinoma with a micro papillary component [Figure 4].

Figure 4: (A) Atypical urothelial masses (HES x100). (B) Immunohistochemically study showing GATA3 expression by tumor cells. (C): Infiltration. Of the penis by a carcinomatous proliferation arranged in masses (HES x40).

The case was discussed at a multidisciplinary urology tumor board. Given the extent of the tumor and its aggressive profile, a penectomy with right inguinal lymph node dissection was recommended, followed by concomitant chemo radiotherapy. The patient tolerated the treatment well, and the immediate clinical course was considered favorable.

DISCUSSION

Penile metastases originating from primary bladder cancer are extremely rare and account for approximately 30-34% of all reported penile metastatic lesions [1]. Their incidence after radical surgery is exceptional, estimated at around 1% [6]. They most commonly develop within the corpora cavernosa rather than the corpus spongiosum [5].

In most patients, recurrence presents as distant metastases, whereas local recurrences represent only about 30% of cases [7].

The first symptom is often pain, followed by induration or a palpable mass in 51% of cases [1]. Other signs have also been reported, including: priapism (27%), urinary symptoms such as bleeding, hematuria, incontinence, or irrigative/obstructive symptoms (27%), pain (17%), urinary retention (13%), cutaneous lesions (11%) [1,8].According to the literature, penile metastases usually occur within an average of 8 months following surgery, although much longer intervals have been described, reaching up to ten years [9]. V. Talavera et al. reported two cases diagnosed 10 years and 2 years after radical cystectomy for bladder cancer [10].

Several mechanisms of metastatic spread have been proposed, including direct tumor extension, retrograde venous, arterial, lymphatic, or iatrogenic dissemination [1, 4, and 8].

Currently, retrograde venous spread is considered the most likely mechanism. It is favored by altered blood flow in the deep dorsal vein of the penis due to neoplastic compression and by the numerous anastomoses between the vesical, prostatic, and internal pudendal venous systems. Arterial dissemination remains possible but is considered rare, given the low incidence of penile metastases from distant primary tumors. Iatrogenic dissemination may occur in bladder or prostate tumors; in such cases, the initial location is usually spongious rather than cavernous, which is far less frequent, as in our patient [5].

Although penile metastases may be clinically evident, imaging is essential to evaluate the extent of disease, the degree of cavernous infiltration, and to guide therapeutic decisions, particularly when surgical amputation is considered [5,8].

Magnetic resonance imaging (MRI) remains the gold standard for local assessment [8].

Histological and immunohistochemically confirmation is mandatory, particularly through the expression of GATA3 [11], which generally mirror the phenotype of the primary bladder tumor. In our case, the lesion expressed GATA3+, as well as CK8/18, CK20, and CK5/6.

From a therapeutic standpoint, no standardized recommendations exist. The best outcomes have been reported following surgical interventions such as partial or total penectomy [11].

According to several published cases, treatment should be guided by the characteristics of the primary tumor and its sensitivity to chemotherapy. Radiotherapy and chemotherapy may be used with palliative or adjuvant intent [8].

In our patient, adjuvant concurrent chemo radiotherapy was administered, resulting in a favorable clinical course.

CONCLUSION

Secondary urothelial cancers of the penis are rare but represent severe complications of urothelial carcinomas. Their diagnosis should be considered in the presence of any penile lesion. Their occurrence can be delayed, even several years after radical cyst prostatectomy, which highlights the importance of careful surveillance and thorough clinical examination. Given the poor prognosis, early and multidisciplinary management is essential.

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