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Cigliola A, Prakash G, Li R, Oualla K, Gupta S, Kamat AM, Chahoud J, Necchi A, Spiess PE. Current Status and Challenges in Rare Genitourinary Cancer Research and Future Directions. Curr Oncol Rep 2024; 26:977-990. [PMID: 38847974 DOI: 10.1007/s11912-024-01554-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 08/25/2024]
Abstract
PURPOSE OF REVIEW In contemporary urological practice, managing rare genitourinary (GU) malignancies presents significant challenges, necessitating a comprehensive understanding of their unique characteristics and tailored treatment approaches. RECENT FINDINGS Rare GU malignancies, whether per se, variants of common histologies, or common tumors in uncommon locations, often lack widely available clinical guidelines. Consequently, treatment decisions are frequently based on empirical evidence, risking suboptimal outcomes. However, recent advances in molecular profiling, targeted therapies, and immunotherapy offer promising avenues for improving management strategies and patient outcomes. This review provides a comprehensive overview of some rare GU malignancies encountered in clinical practice, including their distinct pathological features, current management approaches, and ongoing research directions. Understanding the complexities of these rare tumors and implementing multidisciplinary treatment strategies are essential for optimizing patient care and improving survival outcomes.
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Affiliation(s)
- Antonio Cigliola
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | - Gagan Prakash
- Department of Uro-Oncology, Tata Memorial Hospital, Mumbai, India
| | - Roger Li
- Department of GU Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Karima Oualla
- Department of Medical Oncology, Centre Hospitalier Universitaire Hassan II, Fes, Morocco
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Ashish M Kamat
- Department of Urology Under Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jad Chahoud
- Department of Uro-Oncology, Tata Memorial Hospital, Mumbai, India
| | - Andrea Necchi
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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García-Perdomo HA, Dávila-Raigoza AM, Summers E, Billingham L, Necchi A, Griffiths G, Spiess PE. Urethral cancer: a comprehensive review endorsed by the Global Society of Rare Genitourinary Tumours. BJU Int 2024; 134:175-184. [PMID: 38587299 DOI: 10.1111/bju.16334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To determine the effectiveness and adverse effects of urethrectomy alone or as part of multimodal therapy (MMT). METHODS A comprehensive search was conducted across MEDLINE (OVID), EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL) databases, from their inception to the present date. The study cohort comprised individuals aged 16 years and older diagnosed with urethral tumours at any stage who underwent either isolated urethrectomy or urethrectomy as an integral component of MMT. RESULTS Ninety-two studies comprising 25 480 patients met the inclusion criteria. Surgical outcomes for urethral cancer vary considerably, with 5-year overall survival (OS) ranging from 10% to 68% based on disease extent, approach, and gender. Radiotherapy (RT) alone provides 5-year OS of approximately 40%. Combined regimens provide better outcomes compared to single modalities, including reduced recurrence and enhanced survival. However, trimodal therapy showed survival benefits only for urothelial subtypes, indicating the need to tailor management according to cancer type. MMT with neoadjuvant chemotherapy prior to surgery demonstrated the most consistent survival gains. CONCLUSIONS The management of urethral cancer demands a nuanced, personalised approach, accounting for factors such as tumour location, sex, and tumour stage. MMT combining surgery, chemotherapy and RT has shown the ability to enhance outcomes in advanced disease. More extensive collaborative studies through specialised centres are imperative to advance evidence-based protocols and refine treatment in order to improve survival.
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Affiliation(s)
- Herney Andrés García-Perdomo
- UROGIV Research Group, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | | | - Ellie Summers
- Cancer Research U.K., Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Lucinda Billingham
- Cancer Research U.K., Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Andrea Necchi
- Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Gareth Griffiths
- Cancer Research U.K., Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Philippe E Spiess
- Department of Genitourinary Oncology and Tumor Biology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Urology and Oncology, University of South Florida, Tampa, FL, USA
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3
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Phillips L, Lundholm C, Almqvist C, Skarin Nordenvall A, Nordenskjöld A. Risk of Urological Cancer Among Boys and Men Born with Hypospadias: A Swedish Population-based Study. EUR UROL SUPPL 2023; 57:51-59. [PMID: 38020521 PMCID: PMC10658418 DOI: 10.1016/j.euros.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Hypospadias is a common genital malformation among boys. Studies indicate that hypospadias is associated with a higher risk of testicular cancer. Other forms of urological cancer may be linked to hypospadias via a mutual aetiology, hormonal dysfunction, or hypospadias complications, but this has not yet been studied. Objective To investigate the association between hypospadias and testicular cancer and the risk of other urological cancers among individuals born with hypospadias. Design setting and participants The study used a population-based male cohort born in Sweden in 1964-2018. Exposure was hypospadias diagnosis in national registers. Outcomes were defined using the Swedish Cancer Register. An extended cohort born from 1940 was used to study cancers among older men. Biological brothers and fathers were linked to investigate familial coaggregation. Outcome measurements and statistical analysis Associations were assessed using Cox proportional-hazards regression analysis, with results presented as hazard ratios. Results and limitations We found that hypospadias was associated with a higher risk of testicular cancer (hazard ratio 2.04, 95% confidence interval 1.42-2.92), especially for proximal hypospadias, but did not observe any clear familial coaggregation of hypospadias and testicular cancer. Hypospadias was associated with Wilms' tumour in childhood. We also found an association between hypospadias and bladder and urethral cancers, but not prostate cancer. The number of cases with hypospadias was small and the results for cancers among older men may be impacted by limitations in register coverage. Conclusions Our study supports the hypothesis of a higher risk of testicular cancer for men with hypospadias, especially with proximal phenotypes. Hypospadias may also be associated with a higher risk of lower urinary tract cancers, although this requires further investigation in older cohorts. Patient summary Boys and men in whom the opening of the urethra is not at the end of the penis (called hypospadias) at birth are at higher risk of developing testicular cancer, although their overall risk is still low. They may also have a higher risk of developing other forms of cancer in the urinary tract.
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Affiliation(s)
- Lottie Phillips
- Department of Women’s and Children’s Health and Center of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Lundholm
- Deparment of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Almqvist
- Deparment of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Skarin Nordenvall
- Deparment of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women’s and Children’s Health and Center of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
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Zhang JQ, Duan Y, Wang K, Zhang XL, Jiang KH. Metachronous urothelial carcinoma in the renal pelvis, bladder, and urethra: A case report. World J Clin Cases 2023; 11:3062-3069. [PMID: 37215428 PMCID: PMC10198092 DOI: 10.12998/wjcc.v11.i13.3062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/06/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Urothelial carcinoma (UC) is a common malignancy of the urinary system that can occur anywhere from the renal pelvis to the proximal urethra. Most UCs are in the bladder and have multifocal growth. Upper urinary tract UC (UTUC), which occurs in the renal pelvis or ureter, accounts for only 5% to 10% of UCs.
CASE SUMMARY In March 2015, a 70-year-old male who initially presented to a local hospital with a complaint of painless hematuria was diagnosed with UTUC of the right renal pelvis. The doctors administered radical nephroureterectomy and bladder cuff excision. Although the doctors recommended intravesical chemotherapy and regular follow-up, he rejected this advice. In December 2016, the patient presented at our hospital with dysuria. We identified UC in the residual bladder and administered radical cystectomy and left cutaneous ureterostomy. In November 2021, he presented again with urethral bleeding. We detected urethral UC as the cause of urethral orifice bleeding and administered radical urethrectomy. Since then, he has visited regularly for 6-mo follow-ups, and was in stable condition as of December 2022.
CONCLUSION UTUC is prone to seeding and recurrence. Adjuvant instillation therapy and intense surveillance are crucial for these patients.
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Affiliation(s)
- Jian-Qing Zhang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Yu Duan
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Kun Wang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Xiao-Li Zhang
- Department of Biomedicine, Guizhou University, Guiyang 550025, Guizhou Province, China
| | - Ke-Hua Jiang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
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Takahashi H, Potretzke TA, Kawashima A, Cheville JC, Masuoka S, Kim B. Imaging of the Bulbourethral (Cowper) Gland: Abnormalities and Differential Diagnosis. Radiographics 2022; 42:2037-2053. [PMID: 36149823 DOI: 10.1148/rg.220099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Normal Cowper glands and ducts are imperceptible at imaging. However, abnormalities of the Cowper glands and ducts are increasingly seen owing to increasing use of cross-sectional imaging. In this article, the authors present a comprehensive review of the normal anatomy of the Cowper glands and ducts and the clinical and imaging findings of conditions that affect them in an effort to help lead to appropriate diagnosis and management. A Cowper duct syringocele is a congenital or acquired dilatation of the Cowper duct in the bulb of the corpus spongiosum. Retrograde urethrography is the standard test to diagnose a communicating (open) Cowper duct syringocele, and MRI is used for further morphologic assessment. Cowperitis refers to inflammation of the gland and/or duct, and recurrent cowperitis is usually associated with an underlying syringocele, a urethral fistulous connection to the Cowper gland, or a perianal fistula. MRI allows detection of the underlying structural abnormality and the superimposed inflammation. Cowper stones are typically radiopaque and are found in both the Cowper gland and duct. A Cowper gland HHhemorrhagic cyst may be incidentally detected at MRI of the prostate, and follow-up MRI may be required to ensure evolution of hemorrhage and exclude an underlying neoplasm. Cowper gland carcinoma is rare and includes adenocarcinoma and adenoid cystic carcinoma subtypes. Transperineal US may be used for initial evaluation and CT and/or MRI are necessary for further characterization and staging. Cowper gland hyperplasia is a rare entity with few previous reports that may be incidentally detected at imaging and may mimic malignancy. ©RSNA, 2022.
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Affiliation(s)
- Hiroaki Takahashi
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Theodora A Potretzke
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Akira Kawashima
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - John C Cheville
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Sota Masuoka
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Bohyun Kim
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
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Calderón Cortez JF, Territo A, Fontana M, Gaya JM, Sanguedolce F, Palou J, Huguet J, Breda A. Primary urethral carcinoma: Results from a single center experience. Actas Urol Esp 2022; 46:70-77. [PMID: 35120853 DOI: 10.1016/j.acuroe.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/26/2020] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND AIM OF THE STUDY Primary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. MATERIALS AND METHODS Medical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN+ with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease (<T2) and/or more distal tumors underwent urethrectomy or partial penectomy. Kaplan-Meier curves were evaluated for analysis of overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). RESULTS A total of 13 male patients with anterior PUC were studied retrospectively. Total penectomy was performed in 7 cases, while partial urethrectomy was performed in 5 cases, and partial penectomy in 1 case. Of the 7 patients who underwent total penectomy, 5 underwent radical cystectomy with bilateral inguinal lymphadenectomy. Three patients were treated with neoadjuvant systemic chemotherapy, of which 2 were cT3N+ and 1 was cT3N0. The predominant histologic subtype was squamous cell carcinoma (SCC), found in 7 patients (53.8%), while urothelial carcinoma (UC) was present in 5 patients (38.5%) and a malignant fibro-histiocytoma in 1 case. Most patients were diagnosed at advanced stages of the disease, with T2 tumors in 15.4% and T3 tumors in 46.2% of the cases. Median follow-up was 24 months (range 1-294). After surgical treatment, 8 patients (61.5%) presented disease recurrence after a median of 6.3 months, with a 5-year RFS of 58% ± 14%. The 5-year OS rate was 50% ± 14% while the 5-year CSS rate was 66% ± 13%. CONCLUSION Given its rarity, urethral carcinoma should be treated in a referral center. Treatment options include a radical approach or penile-preserving surgery (urethrectomy or partial penectomy) in cases of localized disease. Due to the high recurrence rate, strict follow-up is mandatory.
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Affiliation(s)
- J F Calderón Cortez
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Territo
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain.
| | - M Fontana
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J M Gaya
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - F Sanguedolce
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Palou
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Huguet
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Breda
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
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Lee W, Yu J, Lee J, Kim YS, Hong B. Clinical features and oncological outcomes of primary female urethral cancer. J Surg Oncol 2022; 125:907-915. [DOI: 10.1002/jso.26790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Wonchul Lee
- Department of Urology Hallym University Dongtan Sacred Heart Hospital Hwaseong Korea
| | - Jesang Yu
- Department of Radiation Oncology Kosin University Gospel Hospital Busan Korea
| | - Jae‐Lyun Lee
- Department of Oncology, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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8
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Calderón Cortez JF, Territo A, Fontana M, Gaya JM, Sanguedolce F, Palou J, Huguet J, Breda A. Primary urethral carcinoma: Results from a single center experience. Actas Urol Esp 2021; 46:S0210-4806(21)00096-6. [PMID: 34332811 DOI: 10.1016/j.acuro.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/24/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIM OF THE STUDY Primary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. MATERIALS AND METHODS Medical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN + with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease ( RESULTS A total of 13 male patients with anterior PUC were studied retrospectively. Total penectomy was performed in 7 cases, while partial urethrectomy was performed in 5 cases, and partial penectomy in 1 case. Of the 7 patients who underwent total penectomy, 5 underwent radical cystectomy with bilateral inguinal lymphadenectomy. Three patients were treated with neoadjuvant systemic chemotherapy, of which 2 were cT3N + and 1 was cT3N0. The predominant histologic subtype was squamous cell carcinoma (SCC), found in 7 patients (53.8%), while urothelial carcinoma (UC) was present in 5 patients (38.5%) and a malignant fibro-histiocytoma in 1 case. Most patients were diagnosed at advanced stages of the disease, with T2 tumors in 15.4% and T3 tumors in 46.2% of the cases. Median follow-up was 24 months (range 1-294). After surgical treatment, 8 patients (61.5%) presented disease recurrence after a median of 6.3 months, with a 5-year RFS of 58%±14%. The 5-year OS rate was 50%±14% while the 5-year CSS rate was 66%±13%. CONCLUSIóN: Given its rarity, urethral carcinoma should be treated in a referral center. Treatment options include a radical approach or penile-preserving surgery (urethrectomy or partial penectomy) in cases of localized disease. Due to the high recurrence rate, strict follow-up is mandatory.
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Affiliation(s)
- J F Calderón Cortez
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - A Territo
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - M Fontana
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España.
| | - J M Gaya
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - F Sanguedolce
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - J Palou
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - J Huguet
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - A Breda
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
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Jacob J, Necchi A, Grivas P, Hughes M, Sanford T, Mollapour M, Shapiro O, Talal A, Sokol E, Vergilio JA, Killian J, Lin D, Williams E, Tse J, Ramkissoon S, Severson E, Hemmerich A, Ferguson N, Edgerly C, Duncan D, Huang R, Chung J, Madison R, Alexander B, Venstrom J, Reddy P, McGregor K, Elvin J, Schrock A, Danziger N, Pavlick D, Ross J, Bratslavsky G. Comprehensive genomic profiling of histologic subtypes of urethral carcinomas. Urol Oncol 2021; 39:731.e1-731.e15. [PMID: 34215504 DOI: 10.1016/j.urolonc.2020.12.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Carcinoma of the urethra (UrthCa) is an uncommon Genitourinary (GU) malignancy that can progress to advanced metastatic disease. METHODS One hundred twenty-seven metastatic UrthCa underwent hybrid capture-based comprehensive genomic profiling to evaluate all classes of genomic alterations (GA). Tumor mutational burden was determined on up to 1.1 Mbp of sequenced DNA, and microsatellite instability was determined on 114 loci. PD-L1 expression was determined by IHC (Dako 22C3). RESULTS Forty-nine (39%) urothelial (UrthUC), 31 (24%) squamous (UrthSCC), 24 (19%) adenocarcinomas NOS (UrthAC), and 12 (9%) clear cell (UrthCC) were evaluated. UrthUC and UrthSCC are more common in men; UrthAC and UrthCC are more common in women. Ages were similar in all 4 groups. GA in PIK3CA were the most frequent potentially targetable GA; mTOR pathway GA in PTEN were also identified. GA in other potentially targetable genes were also identified including ERBB2 (6% in UrthUC, 3% in UrthSCC, and 12% in UrthAC), FGFR1-3 (3% in UrthSCC), BRAF (3% in UrthAC), PTCH1 (8% in UrthCC), and MET (8% in UrthCC). Possibly reflecting their higher GA/tumor status, potential for immunotherapy benefit associated with higher tumor mutational burden and PD-L1 staining levels were seen in UrthUC and UrthSCC compared to UrthAC and UrthCC. Microsatellite instability high status was absent throughout. CONCLUSIONS Comprehensive genomic profiling reveals GA that may be predictive of both targeted and immunotherapy benefit in patients with advanced UrthCa and that could potentially be used in future adjuvant, neoadjuvant, and metastatic disease trials.
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Affiliation(s)
- Joseph Jacob
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY
| | | | | | - Michael Hughes
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY
| | - Thomas Sanford
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY
| | - Mehdi Mollapour
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY; SUNY Upstate Medical University Department of Biochemistry and Molecular Biology, Syracuse, NY
| | - Oleg Shapiro
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jeffrey Ross
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY; Foundation Medicine, Cambridge, MA
| | - Gennady Bratslavsky
- SUNY Upstate Medical University, Department of Urology, Syracuse, NY; SUNY Upstate Medical University Department of Biochemistry and Molecular Biology, Syracuse, NY.
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Castiglione F, Alnajjar HM, Christodoulidou M, Albersen M, Parnham A, Freeman A, Jameson C, Mitra A, Nigam R, Malone P, Muneer A. Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre. Eur Urol Focus 2019; 7:163-169. [PMID: 30853605 DOI: 10.1016/j.euf.2019.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/05/2019] [Accepted: 02/25/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary squamous cell carcinoma (SCC) of the male proximal urethra is an aggressive and rare urogenital malignancy. OBJECTIVE To review the surgical management and outcomes for male proximal urethral SCCs within a single centre and to suggest an algorithm for the surgical management of these rare tumours. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective study of patients undergoing surgery for male proximal urethral SCC within a single tertiary academic centre managing rare genital tumours. Ten patients with a histological diagnosis of proximal urethral SCC were identified from an institutional database over a period of 10 yr with a median follow-up of 22.5 mo (standard deviation±25.77 mo). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Pathological staging, surgical treatment, and neoadjuvant and adjuvant treatment were recorded. Complications according to the Clavien-Dindo classification and overall survival rates were recorded. Kaplan-Meier curves were used for overall survival. RESULTS AND LIMITATIONS A total of 10 patients were identified of whom eight underwent panurethrectomy and radical prostatectomy. Radical inguinal lymphadenectomy was performed in five patients, which confirmed bilateral metastatic disease. Perioperative complications were reported in six patients (Clavien I and II). Within 6 mo of surgery, 90% of patients developed distant metastatic disease. Nine patients died of urethra cancer during the follow-up. One patient is still on follow-up. The median overall follow-up was 13.92 mo (range: 5-91 mo). At 5 yr, cancer-specific/overall survival was 10%. A limitation of this study is the retrospective design, which is unavoidable for such a rare disease. CONCLUSIONS Radical surgery allows local disease control, but despite neo/adjuvant treatment, proximal urethral SCC is associated with poor survival outcomes and progression to distant metastatic disease within 6 mo. PATIENT SUMMARY Proximal urethral squamous cell carcinoma is a rare cancer in men which is often detected late. Patients often present with problems such as voiding, urethral bleeding, or a palpable mass. Aggressive surgery allows local control, but despite this the overall survival is poor. Adjuvant and neoadjuvant radiochemotherapy can improve survival. Multicentric randomised trials are needed to identify the correct treatment modality.
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Affiliation(s)
- Fabio Castiglione
- Department of Urology, University College London Hospital, London, UK; NIHR Biomedical Research Centre, University College London Hospital, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Maarten Albersen
- Department of Urology, University College London Hospital, London, UK
| | - Arie Parnham
- Department of Urology, University College London Hospital, London, UK
| | - Alex Freeman
- Department of Pathology, University College London Hospital, London, UK
| | - Charles Jameson
- Department of Pathology, University College London Hospital, London, UK
| | - Anita Mitra
- Department of Oncology, University College London Hospital, London, UK
| | - Raj Nigam
- Department of Urology, University College London Hospital, London, UK
| | - Peter Malone
- Department of Urology, University College London Hospital, London, UK
| | - Asif Muneer
- Department of Urology, University College London Hospital, London, UK; NIHR Biomedical Research Centre, University College London Hospital, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.
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Kisa E, Semiz HS, Küçük Ü, İlbey YÖ. Metastatic primary urothelial carcinoma of the prostatic urethra: A case report. Urologia 2018; 86:161-164. [PMID: 30373476 DOI: 10.1177/0391560318808631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Primary carcinomas of the urethra differ by location and histologic subtype. Primary urethral cancer of the proximal urethra is rare and aggressive tumor with a high propensity for regional and distant metastases. CASE DESCRIPTION In this case report, we present primary urothelial carcinoma of the prostatic urethra, diagnosed by transrectal ultrasound-guided biopsy of the prostate and having multiple metastases at the time of diagnosis. Metastatic patients were initiated chemotherapy according to the histological type of urethral cancer. CONCLUSION Urothelial carcinomas of the urethra are rarely seen, and therefore there is no standard treatment regimen for early-stage or metastatic disease. Gemcitabine-, platinum-, and taxane-based treatments are used in the metastatic stage.
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Affiliation(s)
- Erdem Kisa
- Tepecik Training and Research Hospital, İzmir, Turkey
| | | | - Ülkü Küçük
- Tepecik Training and Research Hospital, İzmir, Turkey
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12
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Female Urethra Adenocarcinoma. Clin Genitourin Cancer 2018; 16:e263-e267. [DOI: 10.1016/j.clgc.2017.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/24/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022]
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13
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Torbrand C, Håkansson U, Ehrnström R, Liedberg F. Diagnosing Distal Urethral Carcinomas in Men Might Be Only the Tip of the Iceberg. Clin Genitourin Cancer 2017; 15:e1131-e1135. [DOI: 10.1016/j.clgc.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/09/2017] [Indexed: 10/19/2022]
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Hartman R, Kawashima A. Lower tract neoplasm: Update of imaging evaluation. Eur J Radiol 2017; 97:119-130. [PMID: 29102424 DOI: 10.1016/j.ejrad.2017.10.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 01/13/2023]
Abstract
Cancers of the lower urinary tract can arise from the bladder, urachus or urethra. Urothelial carcinoma of the bladder (UCB) is the most common of these. The presentation of bladder, urachal and urethral cancers can differ but many result in hematuria as an initial indication. The diagnosis and staging of these cancers often necessitate radiologic imaging often in the form of cross-section CT urography or MR urography. The following article reviews the specific nature of lower tract cancers and their imaging.
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Affiliation(s)
- Robert Hartman
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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Zhang M, Adeniran AJ, Vikram R, Tamboli P, Pettaway C, Bondaruk J, Liu J, Baggerly K, Czerniak B. Carcinoma of the urethra. Hum Pathol 2017; 72:35-44. [PMID: 28827100 DOI: 10.1016/j.humpath.2017.08.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/26/2017] [Accepted: 08/10/2017] [Indexed: 01/05/2023]
Abstract
Primary carcinomas of the urethra are rare and poorly understood lesions; hence, their clinical and pathologic spectrum is not completely defined. We analyzed a series of 130 primary urethral tumors and classified 106 of them as primary urethral carcinomas. The age at diagnosis of patients with primary urethral carcinomas ranged from 42 to 97 years (mean, 69.4 years; median, 70 years). There were 73 male and 33 female patients with a ratio of 2.2:1. In male patients, the tumors most frequently developed in the bulbous-membranous segment of the urethra. In female patients, the entire length of the urethra was typically involved. Microscopically, they were poorly differentiated carcinomas with hybrid squamous and urothelial features and developed from precursor intraepithelial conditions such as dysplasia and carcinoma in situ, which were frequently present in the adjacent urethral mucosa. High-risk human papilloma virus infection could be documented in 31.6% of these tumors. Follow-up information was available for 95 patients. Twenty-three patients died of the disease with a mean and median survival of 39 and 21 months, respectively. Urethral carcinomas are aggressive tumors with a high propensity for regional and distant metastases with mean and median survival of 39 and 21 months, respectively. Our observations have important implications for the management of patients with primary carcinoma of the urethra by defining them as a unique entity linked to human papilloma virus infection.
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Affiliation(s)
- Miao Zhang
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | | | - Raghunandan Vikram
- Department of Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Pheroze Tamboli
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Curtis Pettaway
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Jolanta Bondaruk
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Jinsong Liu
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Keith Baggerly
- Department of Bioinformatics and Computational Biology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States
| | - Bogdan Czerniak
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, United States.
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Abstract
BACKGROUND Urethral cancer is a rare malignancy, representing <1% of all malignancies. Optimal management, due to its rarity, presents as a treatment dilemma for physicians. There is a lack of consensus regarding treatment as large randomized trials cannot be performed; thus, optimal management decisions rely on study of retrospective cases. This is a review of our institutional experience with urethral cancer treated with various treatment modalities. METHODS A retrospective chart review was performed on 31 patients treated for primary cancer of the urethra from 1958 to 2008. The patients were stratified by sex, histologic type, stage, date of diagnosis, type of treatment, and last follow-up. Early stage cases were designated as Tis-T2N0M0 and advanced cases were designated as T3-4, N+ or M+. Analysis was performed based on clinical stage, treatment modalities and outcomes. RESULTS Fourteen early stage cases and 17 advanced stage cases of urethral cancer were analyzed. The majority of early stage cases occurred in men (M:F=8:6) and the majority of advanced stage cases occurred in women (M:F=5:12). The most common histology was squamous cell carcinoma for both early and advanced stage cases. Surgery was the preferred modality of treatment for early stage cases (surgery used in 13 cases vs. chemo/radiotherapy used in 1 case) while for advanced cases, radiation ±chemotherapy was commonly used. Overall survival for this series was 45% at mean follow-up of 7 years. Eight of the 14 cases of early stage cancer remained disease free at last follow-up. Comparatively, only 5 of 17 with advanced cancers had no apparent disease at last follow-up. All but one of those patients were treated with combined modality therapy. CONCLUSIONS Patients with early stage urethral cancers do well with single modality therapy, whereas patients who present with advanced cancers may benefit from combined modality therapy. More extensive study is required to recommend a particular treatment protocol. However, in this rare malignancy, institutional experiences provide the best evidence currently due to the lack of multi-institutional trials.
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17
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Heller DS. Lesions of the Female Urethra: A Review. J Gynecol Surg 2015. [DOI: 10.1089/gyn.2014.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Debra S. Heller
- Department of Pathology & Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, NJ
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Li A, Fang W, Zuo X, Zhang F, Li W, Lu H, Liu S, Wang H, Zhang B. Transurethral holmium laser vaporization to the urethral tumour through a ureteroscope. Can Urol Assoc J 2015; 8:E913-5. [PMID: 25553166 DOI: 10.5489/cuaj.2026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We present 2 cases of urethral cancers: one is recurrent bladder transitional cell carcinoma accompanied by urethral metastatic carcinoma located on the right side of verumontanum, and the other is primary bladder and metastatic urethral adenocarcinoma. The urethral tumour was treated by transurethral holmium laser vaporization to the urethral tumour through a ureteroscope and the bladder tumour was treated with transurethral resection and degeneration of the bladder tumour (TURD-Bt). After the second or third therapy, patients were free of urethral or bladder tumour recurrence; they also did not experience urethral stricture or urinary incontinence during the 24- to 36-month follow-up. Transurethral holmium laser vaporization and TURD-Bt could be performed to treat non-invasive urethral cancer accompanied with bladder cancer and preserve the urethra and bladder.
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Affiliation(s)
- Aihua Li
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Wei Fang
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Xiaoming Zuo
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Feng Zhang
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Weiwu Li
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Honghai Lu
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Sikuan Liu
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Hui Wang
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
| | - Binghui Zhang
- Department of Urology, Yangpu Hospital, School of Medicine, Tongji University Shanghai, China
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Hammer-Hansen N, Høyer S, Jensen JB. Occult distal urethral carcinoma presenting as metastatic carcinoma in the inguinal lymph nodes. Scand J Urol 2014; 49:79-80. [DOI: 10.3109/21681805.2014.967811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nanoparticle albumin-bound-Paclitaxel in the treatment of metastatic urethral adenocarcinoma: the significance of molecular profiling and targeted therapy. Case Rep Urol 2014; 2014:489686. [PMID: 25202467 PMCID: PMC4151539 DOI: 10.1155/2014/489686] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/06/2014] [Indexed: 01/05/2023] Open
Abstract
Primary urethral cancer is rare and accounts for only 0.003% of all malignancies arising from the female genitourinary tract. Due to the rarity of this disease, no consensus exists regarding the optimal therapeutic approach. Nanoparticle albumin-bound-paclitaxel has been shown to be effective in the treatment of a number of malignancies including metastatic breast, pancreatic, and bladder cancer. We present a 67-year-old woman with advanced metastatic urethral adenocarcinoma resistant to two lines of chemotherapy (ifosfamide/paclitaxel/cisplatin and irinotecan/5-fluorouracil/leucovorin) that showed a dramatic response to nanoparticle albumin-bound-paclitaxel. This is the first case report to document the use and efficacy of nanoparticle albumin-bound-paclitaxel in the treatment of unresectable metastatic urethral cancer.
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Chang CF, Hsu SN, Chien ST, Wang CT, Ni YJ, Hsu CW, Mei JT. Urethral Metastasis from Rectal Adenocarcinoma: A Case Report and Review of the Literature. Low Urin Tract Symptoms 2014; 7:162-5. [PMID: 26663732 DOI: 10.1111/luts.12069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/15/2014] [Accepted: 05/25/2014] [Indexed: 12/18/2022]
Abstract
CASE A 73-year-old man with Dukes' C adenocarcinoma of the rectum, pT3N2bM0, stage IIIB, presented with voiding difficulties including poor stream and terminal dribbling for one month. The patient was under careful surveillance and had no postoperative recurrence. Physical examination revealed a palpable irregular nodular lesion (0.5 × 0.5 cm(2)) at the penile-scrotal junction. He underwent urethroscopy, which showed a cauliflower lesion in the pendulous urethra. Transurethral resection was performed and histopathologic and immunochemical staining demonstrated a metastatic moderately differentiated urethral adenocarcinoma from the colorectal primary. OUTCOME His voiding disorder improved significantly post-operation and he commenced second-line chemotherapy combined with regional radiotherapy. Follow-up urethrocystoscopy and abdominal computed tomography demonstrated no recurrence or metastatic disease. His tumor marker remained within the normal range for 12 months. CONCLUSION Urethral metastasis from primary colon cancer is extremely rare. This disease, with its various atypical presentations, presents a diagnostic challenge to the clinician. In patients with recurrent or persistent lower urinary tract symptoms, further urologic workup including thorough history taking, physical examination, and imaging surveys is warranted.
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Affiliation(s)
- Chun-Feng Chang
- Division of Urology, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Shun-Neng Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shang-Tao Chien
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Chian-Ting Wang
- Division of Urology, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Ying-Jui Ni
- Division of Urology, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Ching-Wen Hsu
- Division of Urology, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Jian-Tai Mei
- Division of Urology, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
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Syvänen KT, Taimen P, Salminen A, Kuusisto K, Boström PJ. Bulbourethral gland adenocarcinoma in a 25-year-old man without comorbidities: Radical resection of proximal urethrae with Mitrofanoff-type appendicovesicostomy. Scand J Urol 2013; 48:405-9. [DOI: 10.3109/21681805.2013.852622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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