SARCOMAS OF THE PENIS
International Braz J Urol
Official Journal of the Brazilian Society of Urology
Vol. 31 (3): 245-250, May - June, 2005
DEEP-SEATED SARCOMAS OF THE PENIS
ALBERTO A. ANTUNES, LUCIANO J. NESRALLAH, PIERRE D. GONCALVES, YURI A.
FERREIRA, JOAO C. CAMPAGNARI, MIGUEL SROUGI
Portuguese Beneficence Hospital of Sao Paulo and Syrian Lebanese Hospital, Sao Paulo, SP, Brazil
Mesenchymal neoplasias represent 5% of tumors affecting the penis. Due to the rarity of
such tumors, there is no agreement concerning the best method for staging and managing these patients.
Sarcomas of the penis can be classified as deep-seated if they derive from the structures
forming the spongy body and the cavernous bodies. Superficial lesions are usually low-grade and
show a small tendency towards distant metastasis. In contrast, deep-seated lesions usually show behavior
that is more aggressive and have poorer prognosis.
The authors report 3 cases of deep-seated primary sarcomas of the penis and review the
literature on this rare and aggressive neoplasia.
Key words: penis; sarcoma; neoplasm metastasis
Int Braz J Urol. 2005; 31: 245-50
Cancer of the penis is infrequent, with an
incidence ranging from 0.6 to 1/100,000 patients in
developed countries. Epidermoid carcinoma is the
dominant histological type; however, other tumors,
including basal cell carcinoma and melanoma, can
be found as well (1). Malignant and benign
mesenchymal tumors represent 5% of tumors
affecting this organ (2).
The sarcomas of the penis can be classified
as superficial or deep-seated according to the tissues
from which they derive (3). Superficial lesions rarely
reach deep tissues, are usually low-grade and show a
small tendency to distant metastases. In contrast, deep-
seated lesions, which include those originating from
the glans, those involving the smooth muscle of the
spongy and/or cavernous bodies, and those
representing advanced lesions that were initially
superficial, usually show more aggressive behavior
and have poorer prognosis (4).
In the present study, the authors report 3 cases
of primary deep-seated sarcomas of the penis and
review the literature on this rare and aggressive
A 61-year old Caucasian man presented
penile pain and a tumor at the base of the penis for 60
days. Physical examination of the penis revealed a
constant state of semi-erection, which the patient
reported as having started 30 days earlier. On
palpation, a tumor mass with hardened consistency
was observed in the pre-pubic region measuring
approximately 5 cm in diameter and extending to the
right cavernous body and perineal region.
Laboratory tests, chest x-ray and abdominal
ultrasound (USG) were normal. Magnetic resonance
imaging (MRI) of the pelvis showed a solid infiltrative
mass at the base of the penis and signs suggestive of
SARCOMAS OF THE PENIS
thrombosis in the cavernous bodies (Figure-1). There
was no evidence of enlarged lymph nodes.
The patient underwent emasculation (Figure-
2) and definitive suprapubic cystostomy with closure
of the urethral stump at the level of the membranous
urethra due to the perineal extension of the tumor.
There were no postoperative complications and the
patient was discharged from the hospital on the 4th
postoperative day. Pathological examination revealed
leiomyosarcoma involving the cavernous bodies and
extending to the deep perineal planes (Figure-3).
Surgical margins were free from neoplasia.
One month following surgery, patient
presented respiratory stress and the radiological
examination revealed the presence of bilateral
pulmonary nodules and metastases characteristics.
Chemotherapy was then started with adriamycin,
ifosfamide and dimethy-l-triazeno-imidazol-
carboxamide (DTIC). Upon completion of
chemotherapy, the patient presented a reduction in
pulmonary lesions but he died in the eighth
Figure 1 – Magnetic resonance imaging. The coronal T1-
weighted image of the base of the penis shows an infiltrative
tumor leading to destruction of cavernous bodies (arrows).
Figure 2 – Emasculation. Resection of the entire penis and
Figure 3 – Leiomyosarcoma of the penis (HE, X100).
SARCOMAS OF THE PENIS
A 56-year old man complained of a painful
perineal tumor for 2 months. Physical examination
revealed a fixed perineal mass measuring
approximately 6.0 cm in diameter.
Pelvic computerized tomography revealed a
solid nodule measuring 6.5 cm with involvement of
cavernous bodies. Laboratory tests were normal, as
were radiological examinations of the chest and
Emasculation was performed with closure of
the urethral stump followed by definitive cystostomy.
The patient evolved with no intercurrences and was
discharged from the hospital on the 5th postoperative
The pathological examination revealed
leiomyosarcoma of cavernous bodies with
involvement of surgical margins. The patient was then
referred to adjuvant radiotherapy, however he
complained of respiratory stress and control exams
evidenced pulmonary nodules suggestive of
metastases at the end of the treatment. Systemic
chemotherapy was indicated, but the patient died in
the 9th postoperative month.
A 72-year old man presented perineal
discomfort with increasing severity for approximately
6 months, especially during sexual intercourse. He
reported the appearance of a tumor in the penis 30
days earlier. Physical examination revealed a
hardened mass measuring approximately 8.0 x 8.0 cm
located at the base of the penis, infiltrating to the
cavernous bodies and extending to the perineum.
Laboratory tests were normal and pelvic
ultrasound showed no abnormalities. Abdominal and
pelvic computerized tomography showed a solid
lesion in cavernous bodies measuring 5.9 cm in
diameter. MRI allowed a more accurate assessment
of the local extension to the perineum (Figure-4).
There was no evidence of enlarged lymph nodes in
the chest x-ray.
The patient underwent emasculation where
an extensive involvement was observed in the
perineum and right ischiorectal fossa. Again,
suprapubic definitive cystostomy was performed.
There were no postoperative complications and the
patient was discharged from hospital on the 5th
The pathological study together with an
immunohistochemical analysis revealed a
fibrohistiocytic sarcomatous tumor (Figure-5) with
imprecise limits located 0.8 cm from the surgical
margins. The patient received adjuvant radiotherapy;
however, pulmonary metastasis was diagnosed in the
3rd postoperative month. The patient received
Figure 4 – Magnetic resonance imaging. Coronal T1-weighted
image shows tumor in soft tissues affecting the root of the right
cavernous body and extending to the pubis.
Figure 5 – Malignant fibrohistiocytoma of the penis.
Immunohistochemical analysis for CD-68 (X400).
SARCOMAS OF THE PENIS
chemotherapy, which was unsuccessful, and died on
the 6th postoperative day.
It is estimated that less than 5% of soft tissue
sarcomas originate from the urogenital tract, and they
represent only 1 to 2% of neoplasias in this system
(5). In the present study, we present 3 cases of deep-
seated sarcomas of the penis in patients aged between
56 and 72 years old that were diagnosed based on
clinical presentation and pelvic imaging studies. The
cases reflect the lesion’s aggressive characteristics
leading to death after a mean period of 7.6 months
despite aggressive surgical treatment and adjuvant
Despite being rare, some characteristics
relative to the pattern of recurrence and metastatic
dissemination for sarcomas of the penis have been
well established. Local recurrence seems to be a
frequent phenomenon, and total amputation of the
penis should be considered even for superficial lesions
(6). On the other hand, regional metastases appear to
occur less frequently, and if there is no apparent lymph
nodal disease, lymphatic dissection is not
recommended (7). The most frequent sites of distant
metastases are the lungs, liver and brain (8).
The best treatment method for sarcomas is
complete resection of the tumor. One study showed
that no patient with retroperitoneal sarcoma had
survived beyond 5 years when the sarcomas had not
been not completely resected, while the 5-year
survival rate for patients who underwent complete
resection was 48% (9). When investigating 43
patients with urogenital sarcoma, Russo et al. (10)
reported that complete tumor resection was possible
in 72% of the cases, and 58% had disease-free
margins. Survival rates after 3 and 5 years were 55%
and 40% respectively. Another factor that contributes
to the poor prognosis in these patients is the fact
that no effective response to adjuvant therapy has
been obtained up to this moment. Radiotherapy has
been used for final control in local disease for
unresectable tumors and for patients with positive
margins, with chemotherapy being reserved for cases
of disseminated disease. In the series by Russo et
al. (10), no patient with disseminated disease was
fully responsive to the use of several chemotherapy
Some previously described prognostic factors
can help to predict the biological behavior of sarco-
mas of the penis (10). These factors are lesion size
(larger or smaller than 5 cm), extension of invasion
(superficial vs. deep-seated), complete resection of
the lesion, presence or absence of metastatic disease
and expression of the retinoblastoma gene (11).
Two of the 3 cases described in this study
were diagnosed as leiomyosarcoma. In 1994, 14
cases of deep-seated leiomyosarcomas of the penis
were reviewed (12). The lesions were primarily
treated with local excision (3), amputation (8),
external radiotherapy (2) and chemotherapy (1), and
patients were followed during a period from 1 to 72
months (mean 16 months). Eight patients died during
follow-up. Among the patients treated by radical
surgery (amputation), 3 developed disseminated
disease and 4 died from the disease. All patients
treated with chemotherapy or radiotherapy had local
recurrence, with 2 of them presenting disseminated
More recently, Fetsch et al. (13) reported 14
cases of leiomyosarcoma of the penis from a single
center. Ages ranged from 43 to 62 years old (mean
51). The penile shaft was the most frequently
affected site. The size of the lesions ranged between
0.5 and 6 cm. Nine tumors were superficial, 2 had
undetermined location, and 3 were deep-seated.
Immunohistochemical analysis was available for 9
patients (64%), and immunoreactivity for desmin
was present in all such cases. Mean follow-up was
12 years and 11 months, and, of 9 patients (64%)
with available information, 3 had multiple local
recurrences, 2 of which were subsequently treated
by wide local excision and partial penectomy. The
third patient refused treatment and developed distant
metastasis 10 months after the fourth recurrence. The
main prognostic factors were the lesion’s depth and
The third case was diagnosed as a
fibrohistiocytic sarcoma. Despite being the sarcoma
that is more frequently described in the elderly, this
histological type rarely involves the urogenital tract
SARCOMAS OF THE PENIS
(14). Only 2 cases of malignant fibrohistiocytoma
have been described up to the present time (15,16).
These tumors usually display an aggressive behavior
tending to lymphatic dissemination (15,17). Regional
lymphadenectomy apparently does not benefit those
patients with sarcomas of the penis without evidence
of lymphatic dissemination, however it is highly
recommended for patients with this type of tumor. In
the presence of metastases, chemotherapy seems to
present some benefits (18).
Other types of penile sarcoma have been
described in the literature. According to records from
the Armed Forces Institute of Pathology, Kaposi’s
sarcoma is the most common histological type,
surpassing the cases of leiomyosarcoma by a 2:1 ratio.
In contrast to the latter, the Kaposi’s sarcomas are
strongly reactive to CD34 and CD31 and do not show
desmin expression. Finally, sarcomatoid carcinomas
must always be remembered when a penile sarcoma
is diagnosed. The immunohistochemical analysis for
keratin pattern and extension can distinguish between
both tumors (13).
Though radical surgery with negative margins
is the treatment that provides the best results, our
patients quickly evolved to disseminated disease, with
the lungs being the most frequent site for metastasis.
When a perineal urethrostomy is impossible, and if
the patient’s clinical conditions allow, performing a
continent urinary shunt might make social living more
acceptable for these patients, since they would not
have to use a cystostomy bag (19).
The authors conclude that sarcomas of penis
are rare tumors and usually have poor prognosis when
they involve deep-seated lesions. The analysis of
prognostic factors can help to identify those patients
at higher risk for disease progression. The complete
tumor resection with negative surgical margins
whenever possible seems to offer the best chances of
healing. No effective treatment for disseminated
disease has been developed up to the present time.
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Received: January 17, 2005
Accepted after revision: May 3, 2005
Dr. Alberto Azoubel Antunes
Rua Três de Maio, 17/31
São Paulo, SP, 04044-020, Brazil
Phone: + 55 11 5573-5385