Vol. 106, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
ADENOID CYSTIC CARCINOMA OF COWPER'S GLAND: CASE REPORT A. AI DEN CARPENTER*
JOHN R. BERNARDO, JR.
From the Department of Surgery, Rhode Island Hospital, Providence, Rhode Island
Histological examination of an asymptomatic perineal mass discovered by rectal examination revealed adenoid cystic carcinoma, probably originating in Cowper's gland. Seventeen cases of primary carcinoma of Cowper's gland have been reported.1 Review of the literature reveals no previous cases of primary adenoid cystic carcinoma of this gland. CASE REPORT
The patient, a 57-year-old man, consulted his physician because of redness and swelling of the left great toe. History was unremarkable except for several episodes of acute arthralgia of the right shoulder and the left hip. There was no history of urogenital or rectal symptoms and the patient's weight was stable. Family history was unremarkable. Examination revealed a moderately obese middle-aged man who was normotensive. The proximal interphalangeal joints of several fingers contained tophi-like masses and the left first metatarsal phalangeal joint was tender to palpation and hyperemic. Rectal examination revealed a small, hard, fixed mass in the midline infraprostatic region clearly separated from the prostate and moderately tender to palpation. The prostate itself was symmetrical, firm and not enlarged. Most laboratory tests, including blood urea nitrogen, alkaline and acid phosphatase, were normal. However, urinalysis showed 1 plus protein and 200 plus red blood cells, occasional granular casts and 5 to 8 white blood cells per high power field. Serum uric acid was 12.0 mg. per cent. Chest x-ray was unremarkable; the excretory urogram showed a filling defect within the left renal pelvis. Sigmoidoscopy and transrectal biopsy of the mass were done on the second day of hospitalization. No intraluminal lesions were found and the mass was easily palpable through the anterior Accepted for publication December 1970. * Current address: 62 Columbian St., South Weymouth, Massachusetts 02188. 1 Keen, M. R., Golden, R. L., Richardson, J. F. and Melicow, M. M.: Carcinoma of Cowper's gland treated with chemotherapy. J. Urol., 104: 854, 1970.
rectal wall, below the prostate. Microscopic examination of the biopsy specimen revealed an infiltrating tumor, arranged in anastomosing cords, formed by cells with little cytoplasm and dark nuclei. Within the cell nests, acellular pseudo-glandular spaces were seen, filled with mucus or hyalin (figs. 1 and 2). The tumor infiltrated the perineural spaces and grew between the skeletal muscle bundles at the periphery. The mass was excised via a perinea! approach on the fifth day of hospitalization. The patient was given spinal anesthesia and placed in an exaggerated Buie position. A midline incision was made over the mass, which then was removed by blunt and sharp dissection. The mass was about 6 by 6 cm. and extended to both ischial tuberosities, to the rectum posteriorly and to the urethra anteriorly. It was necessary to shear the mass off the urethra anteriorly, into which a catheter had been inserted preoperatively. Posteriorly the rectal mucosa was compressed by the lesion and, in the process of removing it, a rectal wall tear was produced. The main body of the tumor was wrapped in the musculature of the urogenital diaphragm. In some places it was possible to slip the muscle fibers around the tumor; in others it was necessary to incise the muscle. The rectal rent was repaired and the wound was closed in layers, reapproximating the urogenital diaphragm as closely as possible. The wound was drained. Histological examination revealed a round piece of tissue 5 cm. in diameter. The surface was slightly ragged owing to remnants of fibromuscular tissue (fig. 3). Basically, the specimen was formed by a globular mass covered by a thin capsule. The cut surface showed a firm, lobulated, whitish-tan tissue, marked by small yellowish pin-point sized foci and translucent gray areas. Microscopic features were identical to those of the biopsy specimen. The tumor was not encapsulated and it infiltrated the nearby structures and extended to the surgically resected margins in several places. Convalescence was uneventful. Retrograde pyelography on the eleventh day of hospitalization showed a probable calculus within the left
CARPENTER AND BERNARDO
Fm. 1. Tumor infiltrating fibromuscular stroma. Arrow points to infiltration of perineural spaces
Fm. 2. Tumor cells show cribriform pattern with pseudo-glandular arrangement. Cystic spaces were filled with basophilic mucoid material.
renal pelvis and left pelviolithotomy was done 6 days later. The calculus was composed of uric acid. Convalescence was again uneventful except for fever. Clinical and laboratory tests showed no evidence of infection. Gantrisin was discontinued and the patient was afebrile within 24 hours and remained so until discharge from the hospital, after 32 days.
The patient received 3,500R through 2 portals to the perineum on an outpatient basis. Five years following completion of x-ray therapy he is clinically free of malignancy. DISCUSSION
Cowper's glands arise as diverticula from the epithelial lining of the urogenital sinus. Each
ADENOID CYSTIC CARCINOMA OF COWPER'S GLAND
Fm. 3. Cut surface of excised tumor. Note well-circumscribed appearance . .il;Iusc!e infiltration was present. gland is made up of several lobules held together a fibrous investment. Each lobule consists of a number of acini, lined columnar epithelial cells. The glands are encased in fibroelastic to deliver a tissue which compresses the mucus that becomes part of the clear, spermatic fluid. 2 Adenoid carcinoma is a rare type of adenocarcinoma, derived from glandular or ductal epithelium and occurring within mucusabout the head and neck. Fin,t secreting described and termed a by Billroth3 it also has been called adenomyoepithelioma" and adenocystic basal cell carcinoma. 5 Foote and Frazel1 6 preferred the term adenoid carcinoma as used Ewing. 7 The structural range that would be encomgland carcinoma is unknown but, because the glands are mucus-secreting, 2 Campbell, M. F.: 2nd ed. Philadelphia: W. B Saunders Co., p. 1963. 3 Billroth, T.: Beobachtungeu i.iber Geschwiilste der Speicheldriisen. Arch. Path. Anat., 17: 357,
1859. 4 Bauer, W. H. and Fox, R. A.: Adenomyoepithelioma (cylindroma) of palatal mucous glands. Arch. Path., 39: 96, 1945. 5 Stein, I. and Geschickter, C. F.: Tumors of the parotid gland. Arch. Surg., 28: 1934. 6 Foote, F. W., Jr. and Frazell, E. : Tumors of the major salivary glands. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. IV, fasc. 11, 1954. 7 Ewing, J.: Neoplastic Diseases; A Treatise on Tumors, 4th ed. Philadelphia: W. B Saunders Co., 1942. -
there should be no theoretical to postulating an adenoid carcinoma from this source. 8 The prognosis for patients with this tumor ic; in doubt. Dockerty and stated that there is an extremely high rate of recurrence, even after radical operative On the other hand, Smout and French cited 2 tumorn of the parotid gland invasion who survived 8 and 12 years respectively with no evidence of local recurrence or metastases. 10 However, most reports seem to indicate that it is a lethal and that most die or have recurrences within years. ,SUMMARY
A originating in gland, is Extirpation of the tumor, followed survival of resulted in an more than 5 years. Dr. Andrew G. Plattley gave advice aud the patient was referred by Dr. E. K. Land-
Jr. Foote, F. W. Jr.: Personal communication. Dockerty, B. and C. W.: "Cyiindroma" (adenocarcinoma, type). of two cases with Surg;ery, 1.3: 1943. 10 Smout, M. S. and French, A. J. of pseudoadenomatous basal-cell Arch. Path., 72: 107, 1961. 8