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F-FDG PET/CT in a Case of Malignant Priapism Secondary to Metastasis From Mucoid Adenocarcinoma of the Cecum
Arun Sasikumar, MBBS,* Chidambaram Natarajan Balasubramanian Harisankar, MD,* Anish Bhattacharya, DRM, DNB,* Rakesh Kapoor, MD,Þ and Bhagwant Rai Mittal, MD, DNB* Abstract: 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.
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Key Words: 18F-FDG, PET/CT, malignant priapism, carcinoma cecum
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Received for publication November 24, 2011; accepted January 23, 2012. From the Departments of *Nuclear Medicine and †Radiotherapy, Postgraduate Institute of Medical Education & Research, Chandigarh, India. Conflicts of interest and sources of funding: none declared. Reprints: Anish Bhattacharya, DRM, DNB, Department of Nuclear Medicine, PGIMER, Chandigarh 160012, India. E-mail:
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Clinical Nuclear Medicine
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computed tomography in staging clinically node-negative patients with penile carcinoma. BJU Int. 2009;104:640Y644. Guo Y, Bai RJ, Gao S. FDG PET/CT detects malignant lymphoma invading the penis. Clin Nucl Med. 2011;36:e204Ye206. Kavak K, Aydin M. Unusual urethral F18-FDG accumulation on PET/ CT. Clin Nucl Med. 2009;34:57Y58. Hizli F, Berkmen F. Penile metastasis from other malignancies. A study of ten cases and review of the literature. Urol Int. 2006;76:118Y121. Rees BI. Secondary involvement of the penis by rectal cancer. Br J Surg. 1975;62:77Y79. Haddad FS, Manne RK. Involvement of the penis by rectocolic adenocarcinoma. Report of a case and review of the literature. Dis Colon Rectum. 1987;30:123Y129. Perez LM, Shumway RA, Carson CC III, et al. Penile metastasis secondary to supraglottic squamous cell carcinoma: review of the literature. J Urol. 1992;147:157Y166. Valadez RA, Wheeler JS, Canning JR, et al. Metastatic transitional cell carcinoma to the penis. Urology. 1987;29:394Y397. Chan PT, Be´gin LR, Arnold D, et al. Priapism secondary to penile metastasis: a report of two cases and a review of the literature. J Surg Oncol. 1998;68:51Y59. Park JC, Lee WH, Kang MK, et al. Priapism secondary to penile metastasis of rectal cancer. World J Gastroenterol. 2009;15:4209Y4211. Osther PJ, Løntoft E. Metastasis to the penis. Case reports and review of the literature. Int Urol Nephrol. 1991;23:161Y167. Halac M, Zincirkeser S, So¨nmezoglu K, et al. Fluoro-18 fluorodeoxyglucose positron emission tomography/computerized tomography scans in a patient with penile cancer for appropriate therapeutic strategy. Hell J Nucl Med. 2007;10:113Y115. Dubocq FM, Tefilli MV, Grignon DJ, et al. High flow malignant priapism with isolated metastasis to the corpora cavernosa. Urology. 1998; 51:324Y326.
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FIGURE 1. A 56-year-old man, with a history of mucoid adenocarcinoma of the cecum, presented with priapism 3 months after right hemicolectomy. A distal corpo granular shunt was placed, but priapism persisted and ulcerations developed in the glans penis. The patient underwent 18F fluorodeoxyglucose (FDG) PET/CT to identify any metastatic involvement. The maximum intensity projection image (A) showed multiple foci of FDG uptake in the thorax and both inguinal regions. On the sagittal CT and PET/CT images (B, C), the penis appeared enlarged with diffusely increased tracer uptake. The findings were confirmed on the axial pelvic images (CYF), which also showed involvement of multiple inguinal lymph nodes bilaterally. Trucut biopsy from the penis suggested metastatic adenocarcinoma. Fine needle aspiration from the inguinal lymph nodes was also consistent with metastatic adenocarcinoma. 18F-FDG uptake in the penis has been described in conditions like primary malignancy of penis, lymphoma, and dilated urethra.1Y3 Metastatic tumors of the penis have been previously described but are rare.4 Proximity to the rectum, bladder, and prostate makes them common primary sites for metastatic tumors of the penis.5 Various mechanisms for penile metastasis, like retrograde venous spread, retrograde lymphatic spread, arterial embolism, and local direct extension, have been proposed. Retrograde venous spread from the pudendal area into the dorsal venous system of the penis is considered to be the most likely mechanism.6 This explains why most reports document lesions in the corpora cavernosa, but the glans may be equally involved.7 The main symptoms of metastatic spread to the penis include pain, induration, urethral obstruction, and hematuria. Priapism may also occur and may be the predominant symptom in up to 40% of cases.8 Priapism has been previously described secondary to metastases from genitourinary malignancies9 and rectal carcinoma.10 Penile metastases are unlikely to be solitary, and treatment should focus on palliative control, which may be achieved by radiotherapy, systemic chemotherapy, or in selected refractory cases, surgery.11 FDG PET/CT is helpful in primary penile cancer in detecting lymph nodal involvement.12 Penile metastasis usually indicates widespread metastatic disease,13 and hence FDG PET/CT may be useful to identify other sites of disease involvement and for monitoring treatment response.
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