[Extra peritoneal anterior pelvic exenteration with total urethrectomy and vaginectomy for bladder and urethra cancer - clinical case and review of literature]

The anterior pelvic exenteration is technically demanding surgical intervention carried out in advanced malignant genito-urethral process origin. It is characterized by a high percentage of intra and postoperative complications. They can be reduced through new surgical techniques, such as extra peritoneal approach to perform this operation. We present a clinical case of 56 years old patient with adenocarcinoma of the urethra/bladder established histologically by TUR (Transurethral) - biopsy. Of the clinical and imaging studies - data for the invasion to the anterior vaginal wall. The patient is after Total Hysterectomy with bilateral salpingo oophorectomy on the occasion of the fibroids in the uterus. After a routine preoperative preparation, we did: extra peritoneal anterior pelvic exenteration with total urethrectomy and vaginectomy. Bilateral extra peritoneal ureterocutaneostomy with "JJ" stents. Bilateral extra peritoneal pelvic lymph dissection. Our clinical case, proves the thesis of many authors about the benefits of extra peritoneal approach for anterior pelvic exenteration. Reduce significantly the intra/post-operative complications, hospital stay and a time to follow postoperative therapy. We consider that the extra peritoneal approach for radical surgery should be applied whenever possible in the interest of the health of the patient.

Palliative intralesional interleukin-2 treatment in dogs with urinary bladder and urethral carcinomas

AIM

The investigation of the influence of intralesional interleukin-2 (IL-2) on the clinical course and tumor progression in dogs suffering from urinary bladder and urethral carcinomas.

MATERIALS AND METHODS

Medical records of 25 dogs diagnosed with advanced transitional cell carcinomas (TCC) were retrospectively reviewed. In 14 dogs, intralesional IL-2 treatment was performed by transabdominal ultrasound-guided injection. Seven dogs underwent cytoreductive surgery, followed by IL-2 injection into the tumor bed. All dogs received long-term non-steroidal anti-inflammatory drugs.

RESULTS

Adverse effects associated with IL-2 treatment were not observed. At re-examination, 17 dogs showed marked clinical improvement and regression of tumor size. Four dogs were in complete remission.

CONCLUSION

Intralesional IL-2 application is a safe and minimally-invasive palliative treatment option in dogs suffering from advanced transitional cell carcinoma when surgical cure is impossible. Prognosis depends on tumor localization and feasibility of concomitant cytoreductive surgery.

[Primary adenocarcinoma of the male urethra]

We present a case of a 43-year-old man treated for urethral stricture. Cystoscopy showed unusual tissue in the posterior urethra. Biopsies showed adenocarcinoma which was positive for cytokeratins 7 and 20 and negative for prostate specific antigen. Immunohistochemistry in this case was important for the diagnosis, primary urethral adenocarcinoma.

Clinicopathologic significance of high signal intensity on diffusion-weighted MR imaging in the ureter, urethra, prostate and bone of patients with bladder cancer

RATIONALE AND OBJECTIVES

The aim of this study was to determine the clinicopathologic significance of high-intensity areas in the ureter, urethra, prostate, and bone incidentally found on diffusion-weighted magnetic resonance imaging (DWI) for the staging of bladder cancer.

MATERIALS AND METHODS

Axial and sagittal DWI and T2-weighted imaging of the pelvis were evaluated in 157 patients with bladder cancer. Two observers assessed T2-weighted imaging with DWI independently. The observers pointed out 67 areas showing abnormal high signal intensity on DWI in the ureter (n = 17), urethra (n = 8), prostate (n = 20), and bone (n = 22). Of the 67 high-intensity areas, 33 lesions were confirmed histopathologically (ureter, n = 10; urethra, n = 7; prostate, n = 16), and 22 bone lesions were diagnosed using T1-weighted imaging and follow-up computed tomography. Thus, 55 lesions were evaluable for correlation with DWI findings.

RESULTS

Of the 55 high-intensity areas, 28 (53%) were synchronous or metastatic urothelial cancer or invasion of urothelial cancer. The remaining 27 (47%) were a ureteral clot in one, a ureteral stone granuloma in one, prostatic cancer in six, granulomatous prostatitis in three, and normal red bone marrow in 16.

CONCLUSIONS

DWI is useful to comprehend the extent of bladder cancer and to detect incidentally coexisting diseases. Other imaging, endoscopic, and clinical findings would be useful to reduce false positivity.

Metastatic transitional cell carcinoma in proximal humerus of a dog

Transitional cell carcinoma (TCC) was diagnosed in the proximal humerus of a dog that was presented with persistent right forelimb lameness with no clinical signs of urinary tract involvement. A diagnosis of TCC was made from surgical biopsy of the humeral lesion with subsequent necropsy revealing the prostatic urethra as the primary site of the tumor.

Prostatic nephrogenic adenoma. Case report

OBJECTIVE

We present a case of prostatic urethra nephrogenic adenoma as an incidental finding following transurethral resection of the prostate.

METHOD/RESULT

It is an incidental diagnosis of nephrogenic adenoma of prostatic urethra in a 50-year-old male operated for benign prostatic hyperplasia by means of transurethral resection.

CONCLUSIONS

Nephrogenic adenoma is an infrequent and benign lesion of the urinary tract, associated with a previous history of trauma or irritation on the urothelium. Predisposing factors include infections, calculi, surgery, trauma and kidney transplantation.

Carcinosarcoma of female urethra with melanocytic differentiation

Carcinosarcoma arising from the female urethra is rare. We report an unusual case of urethral carcinosarcoma from a female patient with melanocytic differentiation. The tumor consists of a high-grade papillary serous carcinoma with psammoma bodies and a mesenchymal component with area of heterologous (cartilaginous) element. More interestingly, there are epithelioid tumor cells containing melanin pigment. On immunohistochemical stains, the epithelioid tumor cells are positive for S100, HMB45 and Mart-1, but negative for cytokeratin. This case represents an unusual carcinosarcoma with areas of melanocytic differentiation. Such rare tumors have been occasionally reported in the breast, uterus, kidney, and lung. These cases demonstrate the capacity of tumor cells to differentiate into divergent elements, supporting the concept of pluripotent tumor stem cells.

Villous adenoma of the urinary bladder: a case report

Villous adenomas of the urinary tract are rare, in contrast to urothelial neoplasms. Most reports were scattered individual cases. Only two case series of this entity have been published. The histopathology is identical to that of the much more common villous adenoma of the gastrointestinal tract. The authors reported a case of urinary bladder villous adenoma in a 41-year-old Thai patient who complained of hematuria for one day without any other symptom. Cystoscopic examination revealed a papillary growth at the bladder neck associated with marked degree of bullous edema and bilateral mild hydroureters. The clinical diagnosis was urothelial carcinoma. Transurethral resection was performed Histologic examination revealed typical features of villous adenoma. The tumor showed identical immunohistochemical profile to colonic villous adenoma. The patient has been well for more than a year after tumor removal.

Management of adenocarcinoma of the female urethra: case report and brief review

INTRODUCTION

We present a case of a differentiated adenocarcinoma of the female urethra, which caused dysuria and voiding dysfunction.

MATERIALS AND METHODS

A 54-year-old female presented with dysuria and the sensation of incomplete voiding.

RESULTS

An ultrasound-guided biopsy showed a urethral carcinoma. A magnetic resonance imaging (MRI) scan showed a high-stage tumor. The patient had a pelvic exenteration. The patient was free of disease after 2 years of follow up.

CONCLUSION

Urethral carcinoma is a rare malignancy. A biopsy is necessary to make a diagnosis. MRI is the best imaging for tumor staging. Small tumors are treated with a single modality option including sparing surgery or radiotherapy. Advanced disease should be treated with a multimodality of options including neoadjuvant radiotherapy given concomitantly with chemotherapy followed by surgery.

[Case of primary amelanotic malignant melanoma of the female urethra]

We report a rare case of primary amelanotic malignant melanoma of the female urethra. A 58-year-old female with complaint of nodule on the external urethral meatus was referred to our hospital. Pathological diagnosis of the biopsy specimen from the nodule was malignant melanoma. Computed tomography of the chest and abdomen as well as bone scan showed no evidence of metastasis. Sentinel biopsy from the inguinal lymph nodes revealed no metastasis. Thereafter, the patient underwent radical urethrectomy, whose limits of resection were the bulbocavernosal muscles bilaterally, the arch of the pubic symphysis anteriorly, the anterior vaginal wall posteriorly, and the urethra up to the level of the bladder neck superiorly. The histopathological diagnosis was amelanotic malignant melanoma of the urethra. The patient had received six cycles of DAV-Feron (dacarbazine, nimustine, vincristine, and interferon-beta) in an adjuvant setting, and there is no sign of recurrence 25 months after operation.

Urethral carcinoma and hyperplasia in male and female B6C3F1 mice treated with 3,3',4,4'-tetrachloroazobenzene (TCAB)

B6C3F1 mice chronically exposed to 3,3',4,4'-tetrachloroazobenzene (TCAB), a contaminant of dichloroaniline-derived herbicides, developed a number of neoplastic and nonneoplastic lesions, including carcinoma of the urinary tract. Groups of fifty male and fifty female B6C3F1 mice were exposed by gavage to TCAB at dose levels of 0, 3, 10, and 30 mg/kg five days a week for two years. Control animals received corn oil:acetone (99:1) vehicle. Decreased survival of male mice in the mid-dose group and of male and female mice in the high-dose groups was related mainly to the occurrence of urethral transitional cell (urothelial) carcinoma and resulting urinary obstruction. Increased urethral transitional cell carcinomas were seen in all treated male groups in a dose-related manner as well as in the females treated with 30 mg/kg TCAB. Administration of TCAB was also associated with increased transitional cell hyperplasia of the urethra. Most nonneoplastic lesions of the urogenital tract were considered secondary to local invasion and urinary obstruction by the urethral transitional cell carcinomas. The mechanism of tumor induction is uncertain, but the high frequency of tumors in the proximal urethra of male mice suggests that the neoplasms result from the exposure of a susceptible population of urothelial cells to a carcinogenic metabolite of TCAB.

[A case of primary urethral adenocarcinoma accompanied by vaginal wall infiltration in which the CA19-9 level was very high]

A 55-year-old woman had urinary frequency and a constant urge to urinate. Computed tomography confirmed a urethral tumor, and transurethral biopsy confirmed adenocarcinoma. She visited our hospital to undergo treatment, and we performed an anterior pelvic excenteration. On histology, the tumor had spread to the bladder, urethra, and vagina. However, the majority of the tumor was located in the bladder and urethra, a duct with intestinal metaplasia was present around the urethra, and carcinoma in situ was seen in the urethral mucosa. Based on the above findings, the patient was diagnosed as having primary urethral adenocarcinoma. No tumor cells were seen in the resection stump. Six months after surgery, the patient developed bone metastasis, followed by peritoneal and pleural dissemination, as well as multiple lung metastases. The patient died nine months after surgery. In the present patient, the carbohydrate antigen (CA) 19-9 level changed with the clinical course, and it was a useful marker. Urethral tumor is relatively rare. A urethral tumor accompanied by vaginal wall infiltration is likely to be mistaken for a primary vaginal tumor. It was very difficult to identify the primary organ in our case. To the best of our knowledge, the present patient is the sixth reported case of primary urethral carcinoma accompanied by vaginal wall infiltration in Japan. The six reported cases are compared and analyzed.

Prospective study of transitional cell carcinoma in the prostatic urethra and prostate in the cystoprostatectomy specimen

OBJECTIVES

To prospectively evaluate the incidence of transitional cell carcinoma (TCC) in the prostatic urethra and prostate in the cystoprostatectomy specimen, investigate characteristics of bladder tumours in relation to the risk of involvement of the prostatic urethra and prostate and examine the sensitivity of preoperative loop biopsies from the prostatic urethra.

MATERIAL AND METHODS

Preoperatively, patients were investigated with cold cup biopsies from the bladder and transurethral loop biopsies from the bladder neck to the verumontanum. The prostate and bladder neck were submitted to sagittal whole-mount pathological analysis.

RESULTS

The incidence of TCC in the prostatic urethra and prostate in the cystoprostatectomy specimen was 29% (50/175 patients). Age, previous bacillus Calmette-Guérin treatment, carcinoma in situ (Cis) in the cold cup mapping biopsies and tumour grade were not associated with the risk of TCC in the prostatic urethra/prostate. Cis, multifocal Cis (> or = 2 locations) and tumour location in the trigone were significantly more common in cystectomy specimens with TCC in the prostatic urethra and prostate: 21/50 (42%) vs 32/125 (26%), p=0.045; 20/50 (40%) vs 27/125 (22%), p=0.023; and 20/50 (40%) vs 26/125 (21%), p=0.01, respectively. Preoperative resectional biopsies from the prostatic urethra in the 154 patients analysed identified 31/47 (66%) of patients with TCC in the prostatic urethra/prostate, with a specificity of 89%. The detection of stromal-invasive and non-stromal involvement was similar: 66% and 65%, respectively.

CONCLUSIONS

The incidence of TCC in the prostatic urethra and prostate was 29% (50/175) in the cystoprostatectomy specimen. Preoperative biopsies from the prostatic urethra identified 66% of patients with such tumour growth. Our findings suggest that preoperative cold cup mapping biopsies of the bladder for detection of Cis add little extra information with regard to the risk of TCC in the prostatic urethra and prostate.

[A patient with a primary malignant lymphoma surrounding the female urethra]

A 90-year-old female patient presented with dysuria. She was treated with partial excision of the mass protruding from the urethral meatus. Pathological examination revealed non-Hodgkin's malignant lymphoma of the B-cell type. The patient received a total of 42.4 Gy extrabeam irradiation. Our patient was disease-free for 14 months. We reviewed 25 cases of this rare entity reported previously.

Urethral carcinosarcoma from bladder carcinosarcomatous lesions: analysis of clinicopathological features

Carcinosarcoma (CS) of the bladder is a rare malignancy of the genitourinary tract that is highly aggressive with unfavorable prognoses. Data regarding the epidemiological and clinicopathological characteristics of CS of the urinary bladder have been limited due to the low reported incidence of the tumor. In particular, there is little evidence on recurrence patterns and surveillance after definitive surgical therapy. In this case report, we describe a urethral recurrence of CS after radical cystoprostatectomy for CS of the bladder. The goal of this case report is to review our current understanding of the pathological and recurrence patterns of patients with CS of the urinary bladder in order to better define postoperative care for patients with CS of the bladder.

Endometrioid adenocarcinoma in urethrovaginal septum: a diagnostic pitfall

Primary endometrioid adenocarcinoma developed at urethrovaginal septum has not been reported. A 61-yr-old woman presented with recurrent urinary tract infection. She had received hormone replacement treatment with estrogen and progesterone for 5 yr. A pinpoint ulceration at slightly elevated anterior vaginal wall was found and biopsy revealed endometrioid adenocarcinoma. Magnetic resonance imaging showed the 4.3 cm sized mass in urethrovaginal septum. She has undergone anterior pelvic exenteration, pelvic lymph node dissection, and urostomy with ileal conduit. Microscopic finding of the pathology revealed endometrioid adenocarcinoma. Co-existence of endometriosis was not identified. Tumor at urethrovaginal septum was difficult to be detected till growing to be bulky, because of vaginal axis, misunderstanding of the tumor as symphysis pubis, no definitive symptom, and its rarity. This is the first reported case of extraovarian endometrioid adenocarcinoma developed at the urethrovaginal septum. Understanding normal functional anatomy and meticulous physical examination are essential to detect this rare tumor in the urethrovaginal septum.

[Primary adenocarcinoma of the female urethra treated by multimodal therapy]

A 64-year old female presented with urinary retention. Physical examination revealed a firm mass on the anterior vaginal wall. Magnetic resonance imaging showed a tumor surrounding the urethra, which invaded to the vesical triangle and the anterior vaginal wall. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were elevated, but squamous cell carcinoma antigen and prostate specific antigen were within normal limits. Pathological examinations of the transurethral and transvaginal needle biopsy specimen suggested mucinous adenocarcinoma. First, the patient received local chemoradiotherapy and systemic chemotherapy using a fluoropyrimidine drug TS-1 and cisplatin. The tumor markers declined to within normal limits after this preoperative therapy. Then she underwent total cysto-urethrectomy with anterior vaginal wall resection, pelvic lymphadenectomy, and urinary diversion with ureterocutaneous fistula. Histopathological examination of the surgical specimen showed mutinous adenocarcinoma invading to the vesical triangle and the anterior vaginal wall. No metastasis was found in the lymph nodes. The final diagnosis was urethral adenocarcinoma, pT4N0, Stage IV. Five months after surgery, local recurrence and distant metastases appeared, and she died 14 months after surgery.

[Endoscopic electroexcision of benign urethral tumors in children]

Endoscopic treatment was performed in 17 boys aged 4 months-16 years with benign new growths of the posterior urethra: false polyps (n = 11), fibroepithelial polyps (congenital--4, acquired--1), fetal rabdomyoma of the urethra and urinary bladder (n = 1). Acquired fibroepithelial polyp was detected in a patient who previously had resection and urethral anastomosis for posttraumatic stricture and long-term preventive catheterization. A leading symptom of the disease in 8 patients was infravesical obstruction. Most complete diagnostic information was provided by urethroscopy. All the patients were treated with endoscopic electroexcision of the tumors with coagulation of their bases. In a child with fetal rabdomyoma a vesicular part of the tumor was removed transvesically. Histological examination of the false polyps identified epithelium-covered granulation tissue. Fibroepithelial polyps were represented with mature connective tissue covered with urothelium. Recovery was achieved in all the patients. Benign urethral tumors should be considered in differential diagnosis in children as one of rare causes of infravesical obstruction. Most of the neoplasms are represented by congenital and acquired polyps of connective tissue of various maturity covered with transitory epithelium. False polyps may be an initial stage of the development of fibroepithelial acquired polyp. Factors of a higher risk of acquired urethral polyps are secondary trauma of urethral mucosa in device investigations and manipulations as well as chronic inflammation. A method of choice in the treatment of benign urethral neoplasms is endoscopic electroexcision which in some cases can be made with transvesicular approach.

[A case of left urothelial carcinoma with multiple bone metastasis, liver metastasis and right adrenal metastasis successfully treated with combination chemotherapy of gemcitabine and carboplatin]

The patient was a 53-year-old male. He had been admitted to another hospital with a complaint of left sciatica. He was referred to our hospital for further examination and therapy. He was diagnosed as left urothelial carcinoma with multiple bone metastasis, liver metastasis and right adrenal metastasis. He was treated with combination chemotherapy of gemcitabine and carboplatin (1,000 mg/m2 day 1 and AUC 2 day 1, respectively) biweekly. After the ninth course, a significant tumor reduction was obtained, and has been maintained. He has been treated on an outpatient basis because of no grade 3 or severer adverse reactions. We report an effective case of biweekly chemotherapy with gemcitabine and carboplatin in the treatment of advanced urothelial carcinoma.

[Primary malignant melanoma of the male urethra: a case report]

A 70-year-old man presented with hematuria and urodynia. A hemorrhagic black tumor and surrounding tan-colored flat lesions were observed at the distal urethra on urethroscopy. Atypical cells consistent with malignant melanoma were noted in urinary cytologic samples. Total penectomy and prostatectomy were performed with negative surgical margin. Because of negative sentinel biopsy of inguinal lymph nodes, further lymph nodes exploration was omitted. However, recurrent tumors at the perineal region and metastases to pelvic lymph nodes appeared four months after surgery, and he died eleven months later.

Fine needle aspiration of urethral recurrence of urothelial carcinoma after radical cystectomy presenting as a perineal mass: a case report

BACKGROUND

Recurrence of urothelial (transitional cell) carcinoma in the urethra after cystectomy for invasive urothelial carcinoma is relatively uncommon. It is also uncommon for the recurring urethral tumor to present as a painful perineal mass. Fine needle aspiration (FNA) can be used to evaluate such perineal lesions and confirm tumor recurrence.

CASE

A 5-cm-diameter mass was found in the perineum of a 63-year-old man 1 year after radical cystoprostatectomy for invasive urothelial carcinoma of the urinary bladder. The mass was detected on pelvic computed tomographic scanning. FNA cytology showed numerous urothelial carcinoma cells of high grade displaying squamous cell differentiation mimicking the histopathologic findings of the primary tumor found on cystectomy. Diagnosis of recurrent urothelial carcinoma was rendered. The FNA in this case spared the patient an open biopsy.

CONCLUSION

Mass lesions arising in the perineum of patients who underwent cystectomy for urothelial carcinoma should raise the suspicion of urothelial carcinoma recurrence. Evaluation of perineal masses for recurrence of urothelial carcinoma can be made on FNA without the need for open biopsy.

[Case of local recurrence of the periurethral proximal-type epithelioid sarcoma successfully treated by repeated regional excision]

Proximal-type epithelioid sarcomas are rare soft tissue neoplasms occuring in the soma or thigh and often repeat recurrence and metastasis. We present a case of locally recurrenced proximal-type epithelioid sarcoma that could be treated by regional excision alone. A 62-year-old man visited our institute for a growing mass in the perineal region. Computed tomography (CT) showed a periurethral tumor 22 x 13 mm in diameter in the perineal region. The tumor was excised regionally, and the pathological examination with immunohistochemical staining revealed that the tumor was proximal-type epithelioid sarcoma. Local recurrence of the tumor occurred 2 years 7 months later without any metastatic lesion, and regional excision was performed again. Pathological diagnosis was proximal type epithelioid sarcoma and it was identical to the primary tumor. The patient is free of the disease 1 year after the second surgery of the tumor.

Pathological Guidelines for Orthotopic Urinary Diversion in Women With Bladder Cancer: A Review of the Literature

PURPOSE

Before the early 1990s total urethrectomy at radical cystectomy for bladder cancer in women was considered the standard of care. As our understanding of the natural history of urethral urothelial carcinoma in women has improved, neobladders have been increasingly created in carefully selected women with bladder cancer. We reviewed the literature regarding the incidence of urethral involvement, the risk factors for urethral involvement and the incidence of urethral recurrence in women undergoing orthotopic urinary diversion for bladder cancer.

MATERIALS AND METHODS

A comprehensive literature review was performed regarding the natural history of urethral tumor involvement by urothelial carcinoma, risk factors and the incidence of urethral recurrence following radical cystectomy and orthotopic diversion in women with bladder cancer.

RESULTS

Urethral tumor involvement occurs in approximately 12% of female patients with bladder cancer undergoing radical cystectomy for high grade, invasive urothelial carcinoma. Preoperative involvement of the bladder neck or anterior vaginal wall with urothelial carcinoma is an important risk factor for urethral tumor involvement. Intraoperative frozen section analysis of the proximal urethra is an appropriate and reliable method of identifying female candidates for orthotopic diversion. The rate of secondary tumor recurrence in the retained urethra of women following radical cystectomy and orthotopic urinary diversion is low but the condition requires long-term followup.

CONCLUSIONS

Orthotopic urinary diversion can be performed safely in appropriately selected women with bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence. Preoperative bladder neck involvement is an important risk factor for urethral involvement but not an absolute contraindication to orthotopic diversion should intraoperative frozen section of the proximal urethra be without evidence of malignancy.

[A case of adenocarcinoma in female urethral diverticulum]

A 49-year-old woman presented with complaints of dysuria and gross hematuria. Vaginal examination revealed an elastic-soft mass beneath the anterior vaginal wall. Urine cytology was positive. Urethrocystoscopy, magnetic resonance imaging and computed tomographic scan revealed a localized urethral diverticular tumor. Transurethral resection of the tumor was performed and the histopathologic finding was adenocarcinoma. Transvaginal urethral diverticulectomy was performed. Histopathological examination showed that the tumor arose in the urethral diverticulum and the proximal margin was positive. She had local recurrence at six months after the operation, and cystourethrectomy was performed. Six months after the operation, she had no evidence of recurrence. We review 18 cases of urethral diverticular carcinoma in Japan.

Behavior of urothelial carcinoma with respect to anatomical location

PURPOSE

Urothelial carcinoma is a disease of the entire urothelium. Recent molecular insights suggest that the biology of some upper urinary tract and bladder urothelial carcinoma differ. These differences may affect tumor phenotype. Observational studies conflict as to the significance of anatomical location on the behavior of urothelial carcinoma. We compared the biological outcome in a large series of urothelial carcinoma with respect to anatomical location.

MATERIALS AND METHODS

We analyzed urothelial carcinoma in 425 patients treated at 4 centers according to stage and anatomical location, including the bladder in 275, the ureter in 67 and the renal pelvis in 79. Relapse surveillance was performed for a median of 46 months (range 2 to 216). A separate invasive bladder urothelial carcinoma population was also included to pathologically balance upper and lower tract urothelial carcinoma cases to allow behavioral comparisons.

RESULTS

As a whole, upper urinary tract urothelial carcinoma is more invasive and worse differentiated than bladder cancer (chi-square test p<0.0001 and 0.015, respectively). In pathologically matched cohorts recurrence to less aggressive disease, progression to more advanced disease and death occurred in 37%, 40% and 44% of patients with bladder urothelial carcinoma, and in 41%, 44% and 43% of those with upper urinary tract urothelial carcinoma, respectively. Multivariate analysis revealed that tumor stage and grade (Cox p=0.0001 and 0.012, respectively) but not location were associated with behavior.

CONCLUSIONS

Urothelial carcinoma behaves identically in the upper and lower urinary tracts when stage and grade are considered. The majority of tumors relapse within 5 years of excision. The current move to minimally invasive/nephron sparing techniques for urothelial carcinoma of the upper urinary tract appears safe. Care could be analogous to that for bladder urothelial carcinoma.

Squamous Cell Carcinoma In Situ in a Female Urethral Diverticulum

There have been less than 100 reported cases of carcinoma in a female urethral diverticulum, with only 10 of these cases being squamous cell carcinoma (SCC). The course of this disease is frequently aggressive, despite multimodality treatment, and most patients die within 2 to 3 years. To our knowledge, carcinoma in situ of the female urethral diverticulum has not been reported to date, and thus, optimal treatment is not well defined. A 41-year-old woman was found to have SCC in situ without evidence of invasive carcinoma after diverticulectomy. She elected close observation and remains disease-free at 2 years. A brief overview is given of the presentation, management, and outcomes of urethral diverticular carcinoma.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

Primary melanoma of the urethra: a rare neoplasm of the urinary tract

Primary melanomas of the genitourinary tract are rare and constitute less than 1% of all melanomas. Since the clinical presentation of urethral melanoma is similar to commoner urothelial carcinomas, there is frequent delay in diagnosis. A 65-year-old female presented with bleeding per urethra for 1 month. Cysto-urethroscopy showed a gray-white polypoidal tumor in the distal urethra. A biopsy from the tumor showed sheets of cells with moderate cytoplasm, and central vesicular nucleus with prominent nucleolus. Immunohistochemistry for HMB-45 and S-100 protein was positive in the tumor cells. A diagnosis of urethral melanoma was made and radical cysto-urethrectomy with total hysterectomy was done. There was no residual tumor in the urethra; however, sections from bladder neck showed pagetoid spread of melanoma cells in urothelium. No melanocytic lesion was found elsewhere, and a diagnosis of primary melanoma of urethra was rendered. Urethral melanomas are rare tumors, having clinical presentation similar to much commoner urothelial neoplasms. Due to the poor prognosis, the clinician and the pathologists should keep this diagnosis in mind when dealing with urethral tumors with unusual morphology.

Male urethral cancer

A 55 years old man presented with long standing voiding obstructive symptoms like poor stream, frequency of micturition, straining at micturition and a sense of incomplete evaluation since 2002. He was clinically diagnosed a case of stricture urethra. Later he developed a swelling in the penoscrotal region with retention of urine in March 2005 and was treated by dilatation. But on removal of the catheter he developed retention again for several times and ultimately for gross periurethral sepsis, urinary diversion was required in May 2005. In October 2005, biopsy from the scrotal abscess wall established the diagnosis of urethral carcinoma. In November 2005 extensive penoscrotectomy was done followed by chemo-radiotherapy. But the prognosis was so bad that the patient died in November 2006. Urethral carcinoma is a rare disease diagnosed in the department of urology, Mymensingh Medical College Hospital, the prognosis of which is also poor even after extensive operations.

Leiomyomas of the female urethra and bladder: a report of five cases and review of the literature

Through the experience of five cases of leiomyoma developed in the female bladder and urethra with a review of the literature, we have made an effort to characterize the association of symptom with the size and location of the tumor and demonstrate an appropriate treatment. The study population was composed of patients who underwent surgery for bladder or urethral leiomyoma in our hospital from March 1990 to April 2005. Their medical records were reviewed retrospectively concerning the symptom, size and location of leiomyoma, the result of cystoscope and radiological examination, surgical method, pathologic report, complications, and recurrence. Four cases were diagnosed as urethral leiomyoma and one case as bladder leiomyoma. All patients with urethral leiomyoma were admitted for the chief complaint of a palpable tumor. When the tumor size was small, if it was located on the lateral side of the urethra, it was asymptomatic, but if located in the midline, it presented irritative or obstructive symptom. When it was big, if located on the lateral side, it presented irritative rather than obstructive symptom, and if located in the midline, it presented obstructive symptom. One case of bladder leiomyoma was discovered incidentally during ultrasonic exam. In all five cases, surgical removal was performed and complications or recurrence were not detected afterwards. Bladder and urethral leiomyomas are very rare and cause diverse manifestations from asymptomatic to irritative or obstructive symptom. It is presumed that the location and size of the tumor are associated with symptom. Unless it is the case with severe hemorrhage or obstructive acute renal failure, immediate surgery is not required. However, it is desirable to distinguish leiomyoma from malignant or other benign tumors by surgical biopsy or removal.

Prognostic Factors for Metastatic Urothelial Carcinoma Treated with Cisplatin and 5-Fluorouracil-Based Regimens

OBJECTIVES

We have previously shown that a combination of infusion cisplatin and high-dose 5-fluorouracil/leucovorin (P-HDFL) has moderate activity and acceptable toxicity in patients with metastatic urothelial carcinoma. The present study sought to identify factors that predict for patient survival after treatment with P-HDFL-based regimens.

METHODS

The outcomes of 79 patients (median age 69 years) with metastatic urothelial cancer treated in two Phase II trials, including P-HDFL and paclitaxel plus P-HDFL, were updated. The log-rank test and multivariate Cox proportional hazard models were used to identify the prognostic factors predicting for survival.

RESULTS

The median follow-up duration was 38.9 months (range 10.2 to 89.0). A Karnofsky performance status scale of less than 80% (hazard ratio 2.6, 95% confidence interval 1.5 to 4.6), presence of visceral metastasis (hazard ratio 2.3, 95% confidence interval 1.3 to 4.1), and alkaline phosphatase level of 220 U/L or greater (hazard ratio 2.5, 95% confidence interval 1.3 to 4.5) were three significant risk factors predicting for poor survival in the Cox proportional hazard model. The three factors weighted approximately the same and were independent of each other. The median survival for patients with three, one or two, and no risk factors was 4.6, 13.2, and greater than 81.8 months, respectively (P <0.001).

CONCLUSIONS

The Karnofsky performance status scale, presence of visceral metastasis, and alkaline phosphatase level were independent risk factors for survival in patients with metastatic urothelial carcinoma treated with cisplatin and 5-fluorouracil-based regimens.

Phase II trial of pemetrexed as second-line therapy in patients with metastatic urothelial carcinoma

PURPOSE

The purpose of this single-center phase II study was to determine the activity of pemetrexed administered as second-line therapy in patients with advanced urothelial carcinoma.

METHODS

Patients with advanced urothelial carcinoma that had relapsed after receiving perioperative chemotherapy, or progressed on first-line chemotherapy for metastatic disease, were eligible for enrollment. Patients received pemetrexed 500 mg/m(2) every 21 days along with folic acid and vitamin B12 supplementation.

RESULTS

A total of 13 patients were enrolled. An objective response was achieved in 1/12 evaluable patients for an overall response rate of 8% (90% upper limit 29%). This level of activity did not meet criteria for expansion based on the pre-defined optimal 2-stage Simon design and the trial was concluded. Treatment was generally well tolerated, however, 2/13 patients developed febrile neutropenia. Non-hematologic grade > or = 3 toxicity was rare.

CONCLUSIONS

Pemetrexed as second-line therapy in advanced urothelial carcinoma is associated with modest activity. The role of this novel antifolate in chemotherapy-naïve patients warrants further investigation.

Incidence of primary urethral carcinoma in the United States

OBJECTIVES

Primary urethral carcinoma is rare, and the demographic correlates of its incidence have not been examined using population-based data.

METHODS

The National Cancer Institute Surveillance, Epidemiology, and End Results database was used to identify persons diagnosed with primary urethral carcinoma from 1973 to 2002. During this period, the Surveillance, Epidemiology, and End Results program included population-based tumor registries in nine geographic areas that represented approximately 10% of the U.S. population. The incidence rates were tabulated for the major histologic subtypes according to age, sex, and race.

RESULTS

Primary urethral carcinoma was identified in 1075 men and 540 women, with an annual age-adjusted incidence rate of 4.3 per million and 1.5 per million, respectively. The annual incidence rate increased with age to a peak of 32 per million men and 9.5 per million women in the 75 to 84-year age group. The rate was 5.0 per million and 2.5 per million for African Americans and whites, respectively. The histologic types were transitional cell carcinoma in 888 patients (55%), squamous cell carcinoma in 348 (21.5%), and adenocarcinoma in 265 (16.4%). The incidence of the three primary histologic types varied by race and sex.

CONCLUSIONS

In the United States, the incidence of urethral carcinoma is relatively higher in men and African Americans, with a histologic profile differing from that previously described.