Urethral carcinoma in women: results of treatment with primary radiotherapy

Primary urethral carcinoma: Recommendations of the oncology committee of the French Urology Association

Primary urethral carcinoma (PUC) is defined as a tumor process arising within the urethra, with no history of other urinary tract localization or synchronous tumor of the urinary tract. The most common histological types are urothelial carcinoma (UC), squamous cell carcinoma (SCC) and adenocarcinoma (AC). In men, UC predominates, while AC is rare. In women, AC affects around one in two patients, while EC and UC are equally divided between the remaining cases. Diagnosis is often delayed, and requires endoscopic examination with biopsies. MRI is the gold standard for local staging. FDG-PET scan can help in cases of doubt about regional or distant extension. The prognosis remains unfavorable despite aggressive surgical treatment. Multimodal management combining surgery, radiotherapy and chemotherapy appears to improve prognosis in severe forms.

Urethral cancer: a comprehensive review endorsed by the Global Society of Rare Genitourinary Tumours

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.

A case report: Female primary urethral carcinoma presenting as vulval mass

INTRODUCTION

Primary urethral carcinoma is a rare disease with overall poorer outcomes in the past. It is relatively more uncommon in female sex.

CLINICAL PRESENTATION

We present a case of a female with primary urethral carcinoma that presented atypically as a vulval mass without any features of storage, voiding lower urinary tract symptoms, or gross haematuria.

DISCUSSION

As primary urethral carcinoma is rare in occurrence, prospective studies are limited so as the recommendations to guide treatment options. Treatment recommendations are still on development from different small-scale studies as well as from data in higher volume centers. Management options depends on location, extent, histology of the lesion as well as on sex of the patient and fitness of the patient.

CONCLUSION

Early diagnosis and treatment with multidisciplinary consult and multimodality will improve the overall survival rate and quality of life of the patients.

A brief review on the diagnostic and therapeutic principles of primary urethral cancer

Objective

Primary urethral carcinoma (PUC) is a rare malignant carcinoma but with limited therapeutic options. This review aims to provide an overview of the current strategies on this patient settings.

Methods

Recent literature ranging from January 1987 and December 2021 was assessed through PubMed search to assess the diagnostic and therapeutic principles of PUC.

Results

A complete of examination including cystoscopy, imaging, and biopsy should be conducted for these patients. Once diagnosed, the clinical decision of PUC should be made according to the tumor location, pathological pattern, and extent of the tumor. For patients with superficial and distal urethral lesions, organ sparing approaches or radical reconstructive procedures can be utilized. While for more advanced disease or nodal involvement, an optimal multimodal treatment strategy consisted of surgery and radiochemotherapy should be adopted. For patients with urothelial carcinoma of the prostate, the management including transurethral resection of the prostate followed by bacille Calmette-Guerin or radical cystoprostatectomy should depend on the infiltration depth of PUC.

Conclusion

A complete of examination is important for the diagnosis of PUC. The management of PUC should be determined by the location, pathological pattern, and extent of the tumor. More multi-institutional collaborations should be held to investigate better treatment modalities for PUC.

Urethral Masses

Urethral and periurethral masses in women include both benign and malignant entities that can be difficult to clinically differentiate. Primary urethral carcinoma is rare and the optimal treatment modality may vary depending on the stage at presentation. Because cancer-free survival is poor, clinicians shouldhave a high index of suspicion when evaluating a urethral mass. Some benign-appearing urethral masses may be safely observed. Surgical resection is an effective option that should be used based on patient preference and symptoms, and for suspicious lesions.

Current Perspectives on the Diagnosis and Management of Primary Urethral Cancer: A Systematic Review

Primary urethral cancer (PUC) is a rare but highly aggressive malignancy that causes malignant urethral obstruction. We conducted a literature review using PubMed to identify original research studies that assessed the diagnosis and management of primary urethral cancer. PUC affects men more than women, is more common in African Americans than Caucasians, and is associated with history of chronic inflammation and irritation of the urinary tract. Patients suspected of PUC should undergo a complete work-up including cystoscopy, magnetic resonance imaging, and biopsy. In men and women, surgical monotherapy ranging from organ-sparing to more radical reconstructive procedures has adequate survival rates for early stage PUC and has been shown to be similarly as effective as radiation monotherapy, while multimodal therapy has become the standard of treatment for advanced stage PUC. Salvage surgery or radiation therapy has been linked with increased survival rates. Nodal involvement at the time of diagnosis is a negative prognosticator and should be treated with multimodal therapy. Further prospective studies with greater sample sizes and standardized clinical trials would allow for greater consistency in evaluating the different treatment modalities for PUC.

European Association of Urology Guidelines on Primary Urethral Carcinoma-2020 Update

CONTEXT

Primary urethral carcinoma (PUC) is a rare cancer accounting for <1% of all genitourinary malignancies.

OBJECTIVE

To provide updated practical recommendations for the diagnosis and management of PUC.

EVIDENCE ACQUISITION

A systematic search interrogating Ovid (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

EVIDENCE SYNTHESIS

Urothelial carcinoma of the urethra is the predominant histological type of PUC (54-65%), followed by squamous cell carcinoma (16-22%) and adenocarcinoma (10-16%). Diagnosis of PUC depends on urethrocystoscopy with biopsy and urinary cytology. Pathological staging and grading are based on the tumour, node, metastasis (TNM) classification and the 2016 World Health Organization grading systems. Local tumour extent and regional lymph nodes are assessed by magnetic resonance imaging, and the presence of distant metastases is assessed by computed tomography of the thorax/abdomen and pelvis. For all patients with localised distal tumours (≤T2N0M0), partial urethrectomy or urethra-sparing surgery is a valid treatment option, provided that negative intraoperative surgical margins can be achieved. Prostatic Ta-Tis-T1 PUC can be treated with repeat transurethral resection of the prostate and bacillus Calmette-Guérin. In prostatic or proximal ≥ T2N0 disease, neoadjuvant cisplatin-based chemotherapy should be considered prior to radical surgery. All patients with locally advanced disease (≥T3N0-2M0) should be discussed within a multidisciplinary team. In men with locally advanced squamous cell carcinoma, curative radiotherapy combined with radiosensitising chemotherapy can be offered for definitive treatment and genital preservation. In patients with local urethral recurrence, salvage surgery or radiotherapy can be offered. For patients with distant metastatic disease, systemic therapy based on tumour characteristics can be evaluated.

CONCLUSIONS

These updated European Association of Urology guidelines provide up-to-date guidance for the contemporary diagnosis and management of patients with suspected PUC.

PATIENT SUMMARY

Primary urethral carcinoma (PUC) is a very rare, but aggressive disease. These updated European Association of Urology guidelines provide evidence-based guidance for clinicians treating patients with PUC.

Treatment and Outcomes of Primary Urethra Cancer

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.

Contemporary Management of Primary Distal Urethral Cancer

Primary urethral cancer is one of the rare urologic tumors. Distal urethral tumors are usually less advanced at diagnosis compared with proximal tumors and have a good prognosis if treated appropriately. Low-stage distal tumors can be managed successfully with a surgical approach in men or radiation therapy in women. There are no clear-cut indications for the choice of the most appropriate treatment modality. Organ-preserving modalities have shown effective and should be used whenever they do not compromise the oncological safety to decrease the physical and psychological trauma of dismemberment or loss of sexual/urinary function.

Management of Urethral Recurrences: Urothelial and Nonurothelial

This article discusses the diagnostic and therapeutic options in the management of urethral cancer recurrence in patients treated with urethral sparing cystectomy as well as those who had urethral preservation following primary urethral carcinoma.

The "decay" of brachytherapy use in tumors of the oral cavity: A population-based patterns of care and outcomes analysis from 1973 to 2012

PURPOSE

We aimed to evaluate if use of brachytherapy (BT) is associated with improved survival in patients with oral cavity cancer who do not receive surgery and to analyze patterns of care.

METHODS AND MATERIALS

We queried the Surveillance, Epidemiology, and End Results database for patients who received radiation therapy for squamous cell carcinoma of the oral cavity between 1973 and 2012. Patients were grouped by treatment modality: external beam radiotherapy alone vs. external beam radiotherapy + BT. Surgical patients were excluded. Trends in BT utilization over the study period and patterns of care were analyzed. Propensity scores were generated, and a nearest-neighbor matching algorithm was used to balance the 2 groups. Cox regression modeling was used to estimate the effect of BT on overall survival. Sensitivity analysis was conducted to estimate the effect of unmeasured confounders on the analysis.

RESULTS

Of 5,161 patients with squamous cell carcinoma of the oral cavity who received radiotherapy, 12% of patients received BT. The rate of BT use has decreased by 0.58% per year (p < 0.001). Factors that predicted for omission of radiation therapy included age ≥ 65 years (adjusted odds ratio [aOR], 0.56; p < 0.001), regional nodal disease (aOR, 0.57; p < 0.001), and black race (aOR, 0.45; p < 0.001). Use of BT was associated with a decreased risk of death (hazard ratio, 0.75; p < 0.001).

CONCLUSIONS

The use of BT is associated with improved survival in oral cavity tumors treated with definitive radiotherapy. Rates of BT utilization have declined by 0.58% per year and are currently very low.

High-dose-rate interstitial brachytherapy for female peri-urethral cancer

Purpose

Peri-urethral cancer (PUC) in females is a rare malignancy. Surgery is not usually contemplated due to associated morbidity. Radiation therapy (RT) can be employed in the form of interstitial brachytherapy (IBT) alone for early lesions, and external beam radiation therapy (EBRT) with or without IBT for advanced lesions. We report our first experience in the literature to evaluate the role of high-dose-rate (HDR) IBT in female PUC.

Material and methods

Between 2008 and 2013, 10 female patients with PUC (5 primary and 5 recurrent) were treated with HDR-IBT with or without EBRT at our center. Size of the lesion ranged from 1.5 cm to 5.0 cm. A 2-3 plane free-hand implant was performed using plastic catheters. The prescribed dose of HDR-IBT was 42 Gy in 14 fractions for brachytherapy alone (5 patients), and 18-21 Gy for the boost along with EBRT (5 patients). Patients were followed up regularly for assessment of disease control and toxicity.

Results

At a median follow up of 25 months, six patients were disease free at their last follow up. Four patients developed recurrence: 2 at inguinal nodes, 1 at local site, and 1 at both local as well as inguinal nodes. Moist desquamation was the commonest acute toxicity observed in all 5 patients treated with IBT alone, which healed within 4 weeks’ time. Overall, grade II delayed complication rate was 30%.

Conclusions

Though small sample size, the results of our study have shown that HDR-IBT provides good loco-regional control with acceptable toxicity for female PUC.

The contemporary management of primary urethral carcinoma

Primary urethral cancer is a rare malignancy; the most common histological subtype is squamous cell carcinoma. The aetiology of this cancer is similar to penile cancer and the human papilloma virus (HPV) is thought to be an important factor in tumourigenesis. Surgery with or without chemoradiotherapy is the accepted treatment for primary urethral cancer. Current practice supports penile-sparing surgery, to maximise functional and psychological outcomes. We have reviewed the literature to summarise the pathogenesis and management of primary urethral cancer.

Management of advanced primary urethral carcinomas

Primary urethral carcinoma (PUC) is a rare malignancy accounting for <1% of genitourinary cancers, with a predilection for men and African-Americans. The sites and histology of urethral carcinoma vary by gender and anatomical location. Squamous cell carcinoma is most common among both genders but adenocarcinomas are noted in 15-35% of cases among women. Obstructive or irritative symptoms and haematuria are common modes of presentation. Clinical evaluation includes cystourethroscopy with biopsy and examination under anaesthesia. Magnetic resonance imaging provides a highly effective method to image the primary tumour while defıning the potential involvement of surrounding structures. Most tumours are localised, with regional metastases to nodal sites seen in up to 30% of cases in both genders, while distant metastases at presentation are rare (0-6%), but occur in up to 40% of cases with recurrent disease. Among men, the two most important prognostic factors are disease location and stage. Low-stage tumours (T1-2) and tumours involving the fossa navicularis or the penile urethra have a better prognosis than higher stage tumours (>T2 or N+) and lesions involving the bulbomembranous urethra. In women, in addition to stage and location, the size of the tumour has also prognostic implications. While surgery and radiation therapy (RT) are of benefit in early stage disease, advanced stage PUC requires multimodal treatment strategies to optimise local control and survival. These include induction chemotherapy followed by surgery or RT and concurrent chemoradiation with or without surgery. The latter strategy has been used successfully to treat other human papillomavirus-related cancers of the vagina, cervix and anus and may be of value in achieving organ preservation. Given the rarity of PUC, prospective multi-institutional studies are needed to better define the optimal treatment approach for this disease entity.

EAU guidelines on primary urethral carcinoma

CONTEXT

The European Association of Urology (EAU) Guidelines Group on Muscle-Invasive and Metastatic Bladder Cancer prepared these guidelines to deliver current evidence-based information on the diagnosis and treatment of patients with primary urethral carcinoma (UC).

OBJECTIVE

To review the current literature on the diagnosis and treatment of patients with primary UC and assess its level of scientific evidence.

EVIDENCE ACQUISITION

A systematic literature search was performed to identify studies reporting urethral malignancies. Medline was searched using the controlled vocabulary of the Medical Subject Headings database, along with a free-text protocol.

EVIDENCE SYNTHESIS

Primary UC is considered a rare cancer, accounting for <1% of all malignancies. Risk factors for survival include age, tumour stage and grade, nodal stage, presence of distant metastasis, histologic type, tumour size, tumour location, and modality of treatment. Pelvic magnetic resonance imaging is the preferred method to assess the local extent of urethral tumour; computed tomography of the thorax and abdomen should be used to assess distant metastasis. In localised anterior UC, urethra-sparing surgery is an alternative to primary urethrectomy in both sexes, provided negative surgical margins can be achieved. Patients with locally advanced UC should be discussed by a multidisciplinary team of urologists, radiation oncologists, and oncologists. Patients with noninvasive UC or carcinoma in situ of the prostatic urethra and prostatic ducts can be treated with a urethra-sparing approach with transurethral resection and bacillus Calmette-Guérin (BCG). Cystoprostatectomy with extended pelvic lymphadenectomy should be reserved for patients not responding to BCG or as a primary treatment option in patients with extensive ductal or stromal involvement.

CONCLUSIONS

The 2013 guidelines document on primary UC is the first publication on this topic by the EAU. It aims to increase awareness in the urologic community and provide scientific transparency to improve outcomes of this rare urogenital malignancy.

Locally advanced female urethral adenocarcinoma of enteric origin: the role of adjuvant chemoradiation and brief review

Primary female urethral adenocarcinoma (FUA) is rare and has a poor prognosis. The common manifestations include urethrorrhagia, urinary frequency, dysuria, urethral obstructions, focal tenderness, and urinary tract infection. These symptoms are neither diagnostic nor pathognomonic; therefore, a delay in diagnosis and even a misdiagnosis is hardly uncommon. The histogenesis of FUAs may have derived from urethritis glandularis, Mullerian ducts, Skene's glands, or mixed origins. Tumors of different embryologic origins displayed heterogeneous pathological morphology and immunohistochemistical phenotypes. Because of its rarity and the lack of large-scale studies, there is no current consensus on the optimal treatment of urethral adenocarcinomas. Here, we report two cases of locally advanced FUA of enteric origin. They manifested as slightest warning symptoms of urinary tract infection and stress urinary incontinence, respectively. One patient died of disease progression 2 months after curative operation. The other patient underwent surgery followed by adjuvant irinotecan-containing chemoradiation, and the effect was at least modest. Hence, we recommend adjuvant chemoradiation in locally advanced FUA. Individualizing cancer care of chemoregimens in accordance with the tumor origins may probably be beneficial in FUAs.

Successful management of female urethral carcinoma with radiation therapy and concurrent chemotherapy

► Successful treatment of locally advanced urethral carcinoma with chemoradiation as evidenced by patients alive NED at 90 and 47 months. ► 45 Gy of external beam RT followed by 15-25 Gy of interstitial brachytherapy. ► Concurrent chemotherapy with 5-fluorouracil and cisplatin.

Non-surgical treatment of primary female urethral cancer

Primary carcinomas of the female urethra are extremely rare, with an annual incidence of less than ten in one million. Currently, there is no consensus regarding management of this malignancy. However, there have been several case reports demonstrating the efficacy of chemoradiation in the treatment of female urethral cancer. In this report we present two cases of female primary urethral adenocarcinoma that were treated by concomitant chemotherapy and external beam radiotherapy, followed by interstitial brachytherapy.

Carcinoma of the urethra: radiation oncology

Urethral cancer is a rare but aggressive neoplasm. Early-stage distal lesions can be successfully treated with a single modality. Results for definitive radiotherapy using either or both external beam radiation therapy and brachytherapy have shown excellent cure rates in men and women. The primary advantage of radiotherapy is organ preservation. Advanced tumors, however, have poor outcomes with single modality treatment. Results have been improved using a combination of radiotherapy and chemotherapy, chiefly 5-fluorouracil and mitomycin C. Although literature is limited to case reports because of the rarity of the disease, the markedly improved results compared with older results of surgery with or without radiation warrant consideration.

[Treatment of primary urethral carcinoma. Guidelines from the French Urological Association. Cancer committee]

The litterature dealing with the treatment of primary uretral carcinoma is very limited. Most of it is based on small series, case report or expert opinions. These guidelines are level IV. The treatment modality is mainly based on the lesion topography and not on the histology. For anterior T1 or 2 lesions, surgery is the most often used modality. In women, radiotherapy might be an attractive option. For more advanced lesions, the combination of radiotherapy and chemotherapy is the standard of care. The optimal protocol remains to be defined. Intradiverticular lesions in women are mainly adenocarcimoma. Surgery only is often inadequate.

Radiation therapy in urinary cancer: state of the art and perspective

Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.

[Urethral cancer: report of three cases and review of the literature]

OBJECTIVE

To review the various clinical forms of female urethral cancer in the light of three clinical cases with a review of the corresponding treatment guidelines.

METHOD

The authors report three cases of female urethral cancer. Case 1 consisted of squamous cell carcinoma in a 56-year-old woman with no particular history. Case 2 was a urothelial tumour arising in a urethral diverticulum in a 60-year-old smoker. Case 3 was a 69-year-old woman patient with invasive urothelial carcinoma.

RESULTS

Case 1 was treated by segmental urethrectomy with no adjuvant therapy and a favourable course. Case 2 was treated by anterior pelvic exenteration with no adjuvant therapy. This patient relapsed in the form of peritoneal carcinomatosis two years later and died. Case 3 was initially treated by anterior pelvic exenteration followed by a chemoradiotherapy combination after local recurrence with a favourable course.

CONCLUSION

There are many clinical presentations and histological forms of female urethral cancer. Localized distal lesions can be treated by simple circumferential resection. The treatment of other lesions comprises anterior pelvic exenteration and platinum- or M-VAC-based chemoradiotherapy. The main prognostic factors for these tumours are their size, histological type, site and the presence of pelvic lymph node extension.

Urethral transitional cell carcinoma in a cat

A 15-year-old, male neutered cat was referred for investigation of dysuria. A retrograde urethrography was performed which showed two space-occupying masses within the lumen of the mid-to-proximal urethra. Exploratory coeliotomy revealed two urethral masses. Segmental urethrectomy was performed to resect the mass, and the lower urinary tract was reconstructed by vesico-urethral anastomosis. Histopathology showed the mass to be a transitional cell carcinoma with incomplete surgical margins. Tumour regrowth was suspected when dysuria was found approximately 318 days after surgery. Clinical signs were palliated by radiation using weekly fractions of 6 Gy for three weeks. The cat died of unknown causes 386 days postoperatively.