AN UNUSUAL CASE OF PENILE METASTASES FROM OSTEOSARCOMA OF FEMUR

CASE REPORT: A 34 year old male, known case of Osteosarcoma of Right knee was referred from medical oncology with complaints of a genital ulcer of 3 months duration. The lesion had started as erosion over the tip of the penis and had gradually progressed in size. It was associated with minimal bleeding and pain on touch. It was not associated with purulent discharge or burning micturition. There was no history of oral ulcers, groin swellings, skin lesions joint pain, trauma or similar lesions in the past. Patient was married for the last 9 years and had 2 children. He denied having pre-marital or extra marital sexual contact. His last sexual contact with his wife was about 6 months back, and there was no history of genital lesions in his wife. Though patient was not a known diabetic or hypertensive he had an undeniably significant medical & surgical history. In 2006, he had been diagnosed with Osteosarcoma of right femur (fig. 1 & 2), and had undergone a limb salvage procedure with prosthetic implant and adjuvant chemotherapy. 2 years later he presented with local recurrence and lung metastases (confirmed by CT guided biopsy) for which he chose to undergo excision of only the locally recurrent lesion (Knee). A year later he presented with multiple unresectable lung metastases and migration of the prosthetic implant for which he underwent right hip disarticulation. 6 months later he presented to us with a genital ulcer. On local examination, patient was circumcised. There was a nodulo-ulcerative lesion of about 3x2cms extending from the external urethral meatus with irregular borders and no visible discharge. On palpation the swelling was firm to hard in consistency, non-tender and did not have any discharge (fig. 3 & 4). Inguinal lymph nodes on both the sides were enlarged, discrete, firm, non-tender, non-fluctuant and 3 in number on either sides. There was no evidence of swelling or discharge at the amputation site. Systemic examination revealed scattered pulmonary crepts while per abdomen, cardiac and nervous system were normal. With thorough investigations we were able to rule out an infective etiology. Having done that, we subjected the patient to an edge-wedge biopsy which confirmed our speculation of metastatic deposits from the primary osteosarcoma (fig. 5 & 6). His blood investigations revealed anemia and normal levels of alkaline phophatase and LDH. Having diagnosed a malignant condition, we referred the patient to medical oncology and urology for further management.