Mr Harper and colleagues1 (January 2002 JRSM) report an unusual case of colonic adenocarcinoma presenting with a penile metastasis. We have studied the pathology of secondary neoplasms of the genitourinary tract in a series of some 27 000 necropsies at the Royal London Hospital2,3. Secondary malignancies of the penis are much less common than those of other sites in the genitourinary tract: there were 425 secondary tumours of the kidney, 155 of the bladder, 24 of the prostate, 14 of the testis, and only 5 of the penis. These 5 cases were from necropsies of men who died between the ages of 51 and 74 years. 2 were metastatic pancreatic adenocarcinomas, 2 were metastatic transitionalcell carcinomas of the bladder, and 1 a prostatic adenocarcinoma that reached the bulb of the penis by direct spread. The histological appearances were of diffuse infiltration, by tumour cells, of the vascular spaces of the corpora cavernosum and spongiosum. All had metastatic disease elsewhere. Vascular spread seems to be the usual route of metastases to the penis, though their rarity in so vascular an organ suggests that it is an unpermissive environment for tumour growth4.

Aims The incidence, presentation and macroscopic and histological features of secondary neoplasms of the male genital tract are described with reference to their differential diagnosis. Methods and results A retrospective study of cases from the Royal London Hospital yielded a total of 31 secondary neoplasms involving the testis: 14 at postmortem examination and 17 surgical specimens. Nine cases were leukaemias: six acute lymphoblastic and two acute myeloid leukaemias in children, and one chronic lymphocytic leukaemia in an adult. The commonest primary sites of metastases to the testis were prostate (six cases), stomach (five cases) and lung (three cases). There were two malignant melanomas and isolated examples of metastases from the adrenal gland (neuroblastoma), cerebellum (medulloblastoma), soft tissue (alveolar rhabdomyosarcoma), pancreas and rectum. Of the metastases from solid tumours, 12 involved the right testis only, three involved the left and four were bilateral. In seven of these cases there were multiple testicular nodules, in seven there was a single mass, and in the rest there was diffuse involvement. Secondary neoplasms represented 4.6% of all testicular neoplasms at autopsy, and 1.6% in surgical specimens. There were five secondary penile neoplasms: two each from the pancreas and prostate and one from the bladder. Two neoplasms metastatic to the spermatic cord, both from a gastric primary, were included in the series. Conclusions Secondary neoplasms of the testis occur with a frequency comparable to other sites in the genitourinary tract, and metastases to the spermatic cord, epididymis, and penis, are rare in comparison. Disseminated neoplasms rarely present initially at this site and are histologically distinctive in adults, but in children they must be distinguished from primary small round blue cell tumours.

Aims: The incidence, anatomical localization and histological appearances of secondary neoplasms of the urinary bladder are described, with emphasis on the points of distinction from primary tumours.Methods and results: A retrospective study of cases at the Royal Hospitals Trust yielded a total of 282 secondary bladder neoplasms, representing 2.3% of all malignant bladder tumours in surgical specimens. The commonest primary sites were the colon (21% of secondary neoplasms), prostate (19%), rectum (12%) and cervix (11%). Most tumours from these sites reached the bladder by direct spread. The most common sites of origin of tumours metastatic to the bladder were stomach (4.3% of all secondary bladder neoplasms), skin (3.9%), lung (2.8%), and breast (2.5%). Secondary tumour deposits were almost always solitary (96.7%), and 54% were located in the bladder neck or trigone. Histologically, 54% of secondary tumours were adenocarcinomas. Immunohistochemical staining patterns with prostate-specific acid phosphatase, prostate-specific antigen, carcinoembryonic antigen, chromogranin and neurone-specific enolase were similar in primary vesical and urachal adenocarcinomas and secondary adenocarcinomas from the gastrointestinal tract.Conclusions: The incidence of secondary bladder tumours is comparable to that of nontransitional cell primary tumours. Few secondary tumours have distinctive histological features, hence knowledge of the history and clinical investigations are particularly important in their diagnosis.

AIM:To report the clinical and histological features and outcome of primary and secondary malignant lymphomas of the urinary bladder.METHODS:Eleven cases of malignant lymphoma of the urinary bladder were obtained from the registry of cases at St Bartholomews and the Royal London Hospitals. The lymphomas were classified on the basis of their morphology and immunophenotype, and the clinical records were reviewed.RESULTS:There were six primary lymphomas: three extranodal marginal zone lymphomas of mucosa associated lymphoid tissue (MALT) type and three diffuse large B cell lymphomas. Of the five secondary cases, four were diffuse large B cell lymphomas, one secondary to a systemic follicular follicle centre lymphoma, and one nodular sclerosis Hodgkins disease. Four patients with secondary lymphoma for whom follow up was available had died of disease within 13 months of diagnosis. Primary lymphomas followed a more indolent course. In one case, there was evidence of transformation from low grade MALT-type to diffuse large B cell lymphoma. The most common presenting symptom was haematuria. Cystoscopic appearances were of solid, sometimes necrotic tumours resembling transitional cell carcinoma, and in one case the tumours were multiple. These cases represented 0.2% of all bladder neoplasms.CONCLUSIONS:Diffuse large B cell lymphoma and MALT-type lymphoma are the most common primary malignant lymphomas of the bladder. Lymphoepithelial lesions in MALT-type lymphoma involve transitional epithelium, and their presence in high grade lymphoma suggests a primary origin owing to transformation of low grade MALT-type lymphoma. Primary and secondary diffuse large B cell lymphomas of the bladder are histologically similar, but the prognosis of the former is favourable.

In recent years, it has been noted that the rate of detection of high-grade uterine cervical abnormalities by screening in the Newham and Tower Hamlets districts have been much lower than the national average. Whilst the national average for the detection rate of moderate and severe dyskaryosis has been around 1.6%, the detection rate in Newham and Tower Hamlets has consistently been substantially lower, at 0.6-1.0%. This discrepancy may be explained on demographic grounds. The ethnic make up of the two districts differs from the national average. Newham has a mixed ethnic structure: Moslem (11%). Asian non-Moslem (12%) and other groups (77%). The population of Tower Hamlets is made up of Moslem (23%), Asian non-Moslem ( 11%) and other groups (66%). In both districts, the rate of detection of moderate and severe dyskaryosis in these population subgroups between 1997 and 1999 was 0.57% for Moslem women, 0.52% for Asian non-Moslem women and 1.18% for other women. This study attempts to confirm the effects of social factors in the differences in rates of detection of cervical intraepithelial neoplasia (CIN) in Newham and Tower Hamlets.