Primary urethral neoplasms: review of 30 cases

Primary urethral carcinoma: A Surveillance, Epidemiology, and End Results data analysis identifying predictors of cancer-specific survival

Objectives

Primary urethral carcinoma (PUC) is rare, accounting for <1% of genitourinary malignancies. Current knowledge regarding is founded upon tertiary care centers reporting their experiences. We aim to identify factors predictive of outcomes using a nationwide registry database.

Materials and Methods

The Surveillance, Epidemiology, and End Results-18 registries database was queried for cases of PUC ranging between 2004 and 2010. To identify PUC cases, ICD-O site code C68.0 was used as a filter, hence identifying PUC with histologic subtypes including urothelial carcinoma (UC), squamous cell carcinoma (SCC), and adenocarcinoma (AC). Tumor characteristics were compared using log-rank analysis, and survival outcomes were compared using Cox proportional hazards models.

Results

A total of 419 PUC cases were identified, 250 (59.7%) male and 169 (40.3%) female patients. The most common histology in men was UC (134, 53.6%), followed by SCC (87, 34.8%) and AC (29, 11.6%). The most common histology in women was AC (79, 46.7%), followed by SCC (43, 25.4%) and UC (42, 24.9%). Log-rank analysis illustrated significant difference in cancer-specific survival (CSS) for T-stage, N-stage, M-stage, and stage of PUC with all histological variants combined (P < 0.001). Multivariate Cox proportional hazards model demonstrated that stage and age were significant for survival, with a risk ratio of 1.033 (95% confidence interval [CI], 1.020-1.046)/year of increased age (P < 0.001) and 3.71 (95% CI, 2.72-5.05) for patients with regional or distant spread.

Conclusions

Knowledge of patient and tumor characteristics that influences survival is paramount in dictating management. The present study illustrates that age and stage are factors significantly associated with CSS in PUC.

Secondary Urethral Malignancies Following Prostate Brachytherapy

OBJECTIVE

To understand urethral secondary malignancies among patients treated with brachytherapy (BRT) for primary prostate cancer.

PATIENTS AND METHODS

Institutional retrospective review identified 13 patients evaluated from 2003 to 2014 with urethral cancer and history of BRT monotherapy for prostate cancer. All patients were biochemically free of their primary disease and radiation-associated secondary malignancies (RASMs) were confirmed pathologically to be histologically distinct from primary tumor. BRT characteristics, patient age, presentation, staging workup, and clinical course were evaluated.

RESULTS

The mean time from BRT to presenting symptoms of hematuria, urinary retention, and/or renal failure was 71 months. Symptom onset to RASM diagnosis interval was 24 months. Mean time from BRT to RASM diagnosis was 95 months. Eighty-five percent of patients had an undetectable prostate-specific antigen level (<0.2 ng/mL) at last follow-up. Types of RASM included sarcomatoid carcinoma (6), small cell carcinoma (2), urothelial carcinoma with squamous differentiation (2), squamous cell carcinoma (1), rhabdomyosarcoma (1), and urothelial carcinoma (1). A majority of patients were diagnosed with advanced disease with either distant metastases (54%) or local progression (23%). Ten patients died during this study period with median time to death after RASM diagnosis of 6 months.

CONCLUSION

RASMs localized to the posterior urethra displayed advanced disease and high mortality rates. Refractory lower urinary tract symptoms, hematuria, and history of prostate BRT should raise suspicion for urethral RASMs. Further studies are warranted to determine patient and disease characteristics that correlate with disease-specific mortality of secondary urethral malignancies.

Carcinome urothélial de l’urètre: une nouvelle observation et revue de la littérature

Le carcinome urothélial de l’urètre masculin est une tumeur exceptionnelle. Nous rapportons une nouvelle observation de carcinome urothélial de l’urètre chez un homme de 64 ans qui avait consulté pour une dysurie. L’urétrocystographie rétrograde et mictionnelle (UCRM) réalisée avait mis en évidence des images de rétrécissement de l’urètre bulbopénien traité par urétroplastie. L’examen histologique de la pièce d’urétrectomie a révélé un carcinome urothélial de l’urètre. Le patient refusa tout traitement complémentaire et survécut 14 mois après le diagnostic.

Prognostic factors in male urethral cancer

BACKGROUND

Male urethral cancer is a rare neoplasm, with the published literature consisting of small single-institution retrospective series. As such, there is no objective analysis of prognostic factors and treatment outcome. The author sought to use the population-based Surveillance, Epidemiology, and End Results (SEER) database to evaluate prognostic factors in male urethral cancer.

METHODS

From 1988 to 2006, 2065 men were identified in the SEER database as having primary urethral cancer. Median follow-up was 2.5 years. Cancer-specific and overall survival was computed using the Kaplan-Meier method, and Cox proportional hazards analysis was used to evaluate patient age at diagnosis, year of diagnosis, race, histologic type, grade, T stage, nodal status, M stage, extent of surgery, and type of radiation as potential significant independent predictors of survival.

RESULTS

Overall survival at 5 and 10 years was 46.2% (95% confidence interval [CI], 43.9-48.6%) and 29.3% (95% CI, 26.6-32.0%), respectively, whereas cancer-specific survival at 5 and 10 years was 68.0% (95% CI, 65.5-70.5%) and 60.1% (95% CI, 57.0-63.2%), respectively. Advanced age, higher grade, higher T stage, systemic metastases, other histology versus transitional cell carcinoma (TCC), and no surgery versus radical resection were predictors of death and death from disease, whereas adenocarcinoma was associated with a lower likelihood of death and death from disease as compared with TCC. In addition, nodal metastasis was a predictor of death. Surgery had a better outcome than radiation for stage T2 -T4 nonmetastatic disease.

CONCLUSIONS

Age, grade, TNM stage, histology, and extent of surgery were predictive of overall and cancer-specific survival.

Clinical outcome of 36 male patients with primary urethral carcinoma: a single center experience

AIM

Retrospective analysis of male urethral carcinoma to assess the best therapeutic approach to the management of this tumor.

METHODS

A review of 36 cases of male urethral carcinoma diagnosed and treated at our center was performed. Clinical features, treatment modality and outcomes were analysed.

RESULTS

The overall median survival time was 55.16 months. The 5-year overall and disease-free survival rate for the cohort was 49% and 23%, respectively. The 5-year survival is 67% for low-stage versus 33% for high-stage tumors and is significantly different (P = 0.001). The survival was 72% for tumors of the distal urethra versus 36% for tumors of the proximal, with a P-value of 0.02.

CONCLUSION

The tumor location and clinicopathological stage were the most important predictors of the disease-free and overall survival. Multimodal approach is necessary for achieving local control especially for proximal and higher stage tumors.

Epithelial differentiation of the lower urinary tract with recognition of the minor prostatic glands

Preservation of tissues in glutaraldehyde-based fixatives allows identification of prostatic glandular secretions without resorting to immunostaining. This has enabled detailed histological assessment of the entire male urethra and bladder and has confirmed prostatic epithelial cells outside the confines of the prostate gland. Male and female lower urinary tracts are also compared. Three intact bladders and penile urethras from radical surgical specimens, tissue from 10 radical prostatectomies, 12 penile urethral biopsy specimens, and 40 samples of of metaplastic bladder mucosa were evaluated after undergoing glutaraldehyde-based fixation (Solufix, Tissugen, Western Australia). All sections were immunostained for prostate-specific antigen (PSA) and high molecular-weight cytokeratin. Selected formalin-fixed samples also were assessed and stained for androgen receptor status, and 10 female control subjects also were evaluated. Prostatic epithelial cells, as recognized by their content of prostate secretory granules (PSG), were identified in almost all periurethral glands seen along the length of the penile urethra. These "minor prostatic glands" were composed entirely of prostatic cells or, more commonly, mixed prostatic and mucinous epithelium. The penile urethra was lined by transitional epithelium, whereas the prostatic urethra was lined by glandular cells with superficial androgen receptor-positive cells that had lost much of their secretory function. Foci of cystitis cystica/glandularis contained prostatic cells in more than half of the cases evaluated, and in all cases PSG secretion in extraprostatic sites was commensurate with PSA secretion. No prostatic secretion was seen in the female control cases, and the female urethra, in contrast to the male urethra, was lined entirely by glycogenated stratified squamous epithelium similar to the epithelium lining the vagina and vulva. This study defines the entity of minor prostatic glands and confirms their extensive normal distribution in the adult male subject. Minimal but persistently elevated levels of serum PSA occuring after successful radical prostatectomy may be related in part to this phenomenon. The female lower urinary tract differs considerably from the male but has similar features related to the lower genital tract.

Therapy and prognosis for male anterior urethral carcinoma: an update

OBJECTIVE

The scarcity of reports evaluating the effect of current treatment strategies for male urethral carcinoma has prompted a review of our recent experience. Since our last report (1980), we have seen 23 patients with this disease.

METHODS

We performed a retrospective chart review of 23 patients seen in our institution between 1979 and 1990 with this type of cancer.

RESULTS

Fifty-two percent of our patients are alive without evidence of disease, after a mean follow-up of fifty months (range, 5 to 156 months). Treatment analysis indicates that distal urethrectomy and partial penectomy are adequate in controlling local disease for tumors arising in the fossa navicularis and penile urethra, respectively, and that en bloc excision of the penis, scrotum, prostate, and bladder together with resection of the inferior pubic rami, using myocutaneous flaps to cover the surgical defect, can provide long-term disease-free survival for patients whose tumor originates in the bulbomembranous urethra. Use of cisplatin-based chemotherapy resulted in a prolonged survival for patients who presented with metastatic disease.

CONCLUSIONS

We conclude that the prognosis for patients with urethral carcinoma has improved, and some of the patients are having a prolonged disease-free survival due, in part, to more effective local and regional control and improved chemotherapy.

Imaging the urethra in men and women

This review describes and illustrates the radiologic techniques, normal anatomy, and common congenital and acquired lesions of the urethra in men and women. Voiding cystourethrography and retrograde urethrography are the most common imaging modalities employed in the diagnosis of anatomic lesions of the urethra. The appearance of the urethra may then dictate the need for further functional evaluation with urodynamic studies. Congenital lesions in men include posterior and anterior urethral valves and duplicated urethra. In women, ectopic insertion of the ureter into the urethra is the usual congenital lesion. Acquired urethral lesions include benign prostatic hypertrophy in men and strictures and diverticula in both men and women.

Non-Hodgkin's lymphoma of the urethra: a rare extranodal entity

We report a rare case of non-Hodgkin's lymphoma of the urethra in a female patient. A review of the literature showed that all such reported cases were described in females, were of varying histologic grade, and presented as a polyp or caruncle. Whether this entity is often localized and has the excellent prognosis of early carcinoma of the urethra will have to be determined by study of more cases.

Phallic reconstruction during exenterative surgery for invasive urethral carcinoma

A technique is described for phallic reconstruction after wide surgical excision of squamous cell carcinoma of the bulbomembranous urethra. Two cases in which this technique was used are presented with followup information at 9 and 12 months.

Localized urethral cancer in women

The results of treatments for localized carcinoma of the urethra were assessed in 21 consecutive women treated at our institutions over a twenty year period. Only one of the tumors was confined to the distal urethra. Eighty-six percent invaded the periurethral tissues and 24% were known to be associated with regional lymph node metastases. Fifty-seven percent were adenocarcinomas. Five patients refused active therapeutic intervention and expired within one to 30 months following diagnosis. Sixteen patients were treated with extirpative surgery, radiation therapy, or combinations of the two. Four are free of disease at one, four, eleven, and 15 years after treatment. Nine developed pelvic recurrences, two developed pelvic recurrences and distant metastases and one developed distant metastases only from six to 72 months (mean, 19 months) after initial treatment. Eight of these 12 patients died at two to 13 months (mean, 8 months) after secondary treatment, two are alive with residual pelvic tumor, and two are clinically free of disease at 7 and 48 months. Only six patients were known to have distant metastases at the time of death and five of these six had adenocarcinomas. Advanced localized urethral cancer in women is difficult to eradicate and usually fatal.

NonHodgkin's lymphoma of the female urethra

A 63-year-old woman presented with a massive proliferative growth in the urethral region. Fine needle aspiration and biopsy revealed nonHodgkin's lymphoma. No other tumor localization was found and complete remission occurred after 3 courses of chemotherapy. Primary localization of a lymphoma to the urethra is rare.

Adenocarcinoma of the male urethra with associated nephrogenic metaplasia. Case report and review of the literature

Nephrogenic metaplasia is an uncommon sequela of chronic bladder irritation. The case described herein represents the second reported in the bulbomembranous urethra of the male. Important questions are raised regarding the premalignant potential of nephrogenic metaplasia. A review of the literature on adenocarcinoma of the male urethra and also of nephrogenic metaplasia of the bladder and urethra is presented.

Carcinoma of deep male urethra

Carcinoma of the deep male urethra is a rare disease. Conservative measures yielding dismal outcomes were standard until 1957, with the report of an 80 per cent five-year survival rate after radical surgery. To assess the value of this surgery, we reviewed all cases of carcinoma of the deep male urethra managed at UCLA Medical Center and its affiliated hospitals between 1952 and 1980. Of the patients managed with radical surgery, 1 died of a myocardial infarction between staged surgical procedures, and 5 died of their disease between twelve and fifty-two months postoperatively (mean survival, 26 months). There were 2 long-term disease-free survivors, yielding a survival rate of 25 per cent. We have also compiled the results of all major series dealing with deep urethral carcinoma published subsequent to the 1957 report. This review of the literature supports the concept that radical extirpative surgery is mandatory in the management of carcinoma of the deep male urethra.

Primary carcinoma of male urethra

Carcinoma of the male urethra is infrequent. To date approximately 600 cases have been reported. We reviewed 16 cases of carcinoma of the male urethra seen at the University of Tennessee and the Memphis Veterans Administration Hospital. The mean patient age was sixty-three years (range 38 to 84). The most common presentation was a palpable mass followed by symptoms of urinary obstruction. Five urethral carcinomas arose distal to the suspensory ligament of the penis while 11 were of bulbar or bulbomembranous origin. The histology was squamous cell carcinoma in 8 patients (50%), mixed squamous and transitional cell carcinoma in 5 (31%), transitional cell carcinoma in 2 (13%), and adenocarcinoma in 1 (6%). The mean patient survival was fifteen months following diagnosis of a proximal urethral tumor and seventy-seven months for tumors arising distally. Neoplasms of the distal urethra can be surgically managed successfully even if regional lymph nodes are involved. The prognosis for proximal urethra tumors remains poor and is best treated by a combination of surgery and radiotherapy.

Radiation therapy for primary carcinoma of the female urethra: a survey over 25 years

Sixty-two patients with primary carcinoma of the female urethra were treated with a combined radiation therapy (high-dose intracavitary vaginal radium and external beam). Treatment was strictly individualized, but an administered tumor dose of 5500-7000 rad (55-70 Gy) was always attempted. Forty-two patients (67.7%) had tumors of the anterior urethra, and in 20 women (32.3%) the posterior urethra was involved. In 19 patients (30.6%) the clinical diagnosis of lymph node involvement was made. The overall 5-year-survival rate was 64.5%. Patients with anterior urethral carcinoma had a higher 5-year-survival rate (71.4%) than patients with posterior carcinoma (50.0%). The favorable results underline the substantial role of radiation therapy for this malignancy.

Primary carcinoma of female urethra

The clinical and morphologic features in 29 cases of primary carcinoma of the female urethra were reviewed. Only 2 of 12 patients treated with radiotherapy are known to have failed; one is dead of disease at one year, and the other is alive with local recurrence at two years. We consider these results sufficiently satisfactory to warrant the continued use of radiotherapy in early-stage lesions, as well as in selected patients who have infiltrating carcinoma. Integrated therapy consisting of 5,000 rad/25 fractions/five weeks, followed in six weeks by radical cystourethrectomy, was used in 7 patients. The low morbidity and absence of operative mortality recommend continuation of this aggressive approach for infiltrating tumors in selected patients.