Female urethral carcinoma

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.

Brachytherapy for cancer of the female urethra

Carcinoma of the female urethra is uncommon. The review of literature and our own experience indicates that early distal urethral cancers (squamous and adenocarcinoma) can be treated either with surgery (70-80% 5-year survival) or with radiotherapy (brachytherapy) with excellent results (75% 5-year survival). Early proximal or entire urethral cancers (squamous and adenocarcinoma), if treated surgically, will require exenterative procedures. Alternatively, these cancers can be treated with a combination of external beam and brachytherapy with or without chemotherapy with good results and preservation of organs. Surgery can be used for failures or persistent tumors. Advanced cancers require a multimodality approach, and a combination of radiation and chemotherapy appears to be the optimal way to treat these patients-with surgery to be used for biopsy-proven persistent tumors or recurrences.

Localized urethral tumors in women: indications for conservative versus exenterative therapies

The objectives of this retrospective review were to evaluate patient and tumor characteristics, survival, patterns of failure and sequelae of therapy for women with urethral carcinoma. Primary urethral carcinoma was diagnosed in 33 women referred to the Washington University Medical Center and the Mallinckrodt Institute of Radiology, Radiation Oncology Center from November 1959 through June 1988. Treatment consisted of surgery alone in 6 patients, surgery and irradiation in 7, and irradiation alone in 20. Median followup was 4.7 years. The 5-year overall and progression-free survivals for all patients were 41% and 36%, respectively. Tumor location, size and T stage were predictive for survival. No patient with a lesion of greater than 4 cm. survived at 5 years if treated with irradiation alone, surgery alone or irradiation and nonexenterative surgery. Exenterative surgery plus irradiation was curative in 1 of 4 patients. Pelvic failures occurred in approximately 50% of all patients. Severe complications of therapy occurred in 30% of the patients treated with irradiation alone, 1 of 7 treated with surgery and irradiation, and 0 of 6 treated with surgery only. Surgery only or irradiation only may be curative in patients with lesions less than 2 cm. Larger lesions require a combination of surgery and irradiation.

Carcinoma of the female urethra: a review of results with radiation therapy

Low stage female urethral carcinoma is curable by radiation therapy alone and is amenable to brachytherapy techniques whereby high doses of irradiation can be delivered safely. A 60 to 80 per cent 5-year survival rate with preservation of bladder function and control can be expected with good radiotherapeutic techniques. Except for stage Tis or early stage T1 lesions of the anterior urethra that can be treated with limited surgical excision, irradiation should be considered as an alternative to more extensive surgery for low stage bulky lesions. While there has been some success with radiation therapy alone for advanced disease, the cure rate probably can be improved with a combined approach using surgery, radiation therapy and possibly chemotherapy.

Carcinoma in diverticulum of female urethra

A case of carcinoma originating in a diverticulum of the urethra in a female patient is presented. A review of 143 cases of carcinoma of the female urethra treated from 1948 to 1984 at The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston disclosed 6 additional patients with diverticular carcinoma. Analysis of their clinical features, treatments--various combinations of primary excision, radiotherapy, and chemotherapy--and survival results indicate that survival is primarily a function of grade. Only 40 cases of carcinoma in urethral diverticula are recorded in the world literature. The majority are adenocarcinomas, and the most frequent presenting symptoms are dysuria, frequency, and urgency. Radiotherapy successfully established long-term control of the disease with low morbidity in all of our patients who had low-grade tumors.

Squamous cell cancer of female urethra. Successful treatment with chemoradiotherapy

We report the case of a seventy-four-year-old woman with advanced squamous cell carcinoma of the urethra who achieved complete biopsy-proved regression of the tumor for more than thirty months after therapy with 5-fluorouracil, mitomycin-C, and radiotherapy.

Radiation therapy in primary carcinoma of the female urethra. II. An update on results

Analysis of 21 patients with primary carcinoma of the female urethra who were treated by radiation only, from 1961 to 1980, is presented. Of 21 patients studied, 14 were treated for curative intent, 6 for palliation, and 1 patient did not finish the treatment as planned. For the curative group, radiation treatment was highly individualized and integrated with a special interest in brachytherapy. The authors were able to obtain excellent local control and subsequent 5-year-disease-free survival in Stage I, II, IIIA, IIIB, IIIC, and IV. The overall local control was 11 of 14 (78%) while achieving 77% 5-year disease-free survival. The bladder neck involvement continues to be a therapeutic problem and represents the only failure site. Factors responsible for the prognosis of this cancer are the extent of the cancer (clinical stage), location, individualization, and integration of the external beam and brachytherapy. Involvement of the vulva or vagina did not alter the good outcome, but involvement of the bladder neck, bladder, parametrium, and inguinal node represented a poor prognosis. Palliative irradiation treatment for those whose diseases were beyond cure can only offer a short-term, symptom-free result in 70% (5 of 7) of cases treated. No major complications occurred as a consequence of radiation treatment. Sample cases, particularly with brachytherapy and dosimetric analysis, are discussed.

Adenocarcinoma arising in female urethral diverticulum

Cancer arising from a female urethral diverticulum is rare, and because of its rarity, a review of the medical literature reveals significant nonuniformity in its management. We report an additional 2 cases of this disease, one of which has an even rarer feature of being mucin-producing. The management of our 2 cases is presented in detail and in line with the management of female urethral cancer. From our extensive literature search, diverticulectomy alone showed poor results with the highest rate of recurrence (67%). Extensive surgery, either in the form of cystourethrectomy or anterior exenteration, offered results comparable with those of combined therapy (diverticulectomy and full course of irradiation for early cases; preoperative irradiation followed by cystourethrectomy for late cases). Individualization of radiation treatment and cooperative effort between urologist and radiation oncologist are essential if best results are to be achieved.

Carcinoma of the female urethra: reassessment of modes of therapy

Of 15 women with primary urethral carcinoma 2 had tumors confined to the urethra and were managed successfully by an operation. Of the 9 patients with tumor extending to the surrounding structures 6 (67 per cent) died of complications related to inadequate control of the primary tumor. The last 4 patients had stage D1 disease or greater at initial diagnosis and died of distant metastases. Our current approach for patients with locally advanced disease is combined brachytherapy and operation in an effort to eradicate the primary tumor, since morbidity and mortality result from failure to control the local tumor.

Impressions on floor of female bladder: "the female prostate"

The "female prostate" denotes an impression on the base of the female bladder resembling the enlarged male prostate radiographically. Though the finding is widely recognized, confusion exists as to its significance. The differential diagnosis is moderately extensive, and includes retroverted uterus, anterior vaginal tumors, urethral and bladder floor tumors, benign and malignant bony pelvic lesions, urethral diverticulum, and postsurgical changes. Several cases are presented illustrating the previously mentioned causations. An impression on the floor of the female bladder should not be routinely dismissed as inconsequential without thorough evaluation.

Primary carcinoma of the female urethra

Experience in the diagnosis and management of 39 female patients with primary carcinoma of the urethra is described. The condition presents to both gynaecological and urological units and has a relatively good prognosis provided that it is diagnosed quickly. There must be, however, a clinical awareness of the condition in those patients presenting with non-specific urological symptoms. Radiotherapy is the treatment of choice using interstitial implants for the superficial tumours and external beam for the deeper tumours. Surgery alone is possible in only a small number of cases, it being reserved mainly for recurrent or resistant disease.

Radiation treatment of primary carcinoma of the female urethra

Because of the rarity of the primary carcinoma of the female urethra, there has been limited experience of individual institutions in management of this disease. Treatment by radiation alone required radium implant skill in early cases and individualized consideration for integrating external and internal irradiation in more advanced cases. From 1961 to 1975 a total of 16 women with histologically verified primary urethral carcinoma were given radiation treatment at the University of Maryland Hospital. Six of 16 patients were primarily treated for palliation only and 10 were receiving curative radiation treatment. The results show an excellent local control in anterior urethral disease (3/3), entire urethral disease (2/3) and urethral disease with involvement of vulva and/or vagina (3/3). Bladder neck, parametrial, inguinal lymph node, or paraortic involvement represents a poor prognosis and failure is close to 100%. Eight of 10 patients who were treated with aggressive radium alone or combination of external irradiation and interstitial therapy show complete control of disease (80%). Total dosage between 5500 to 6500 rad appears to be adequate to control the disease. Palliative treatment by irradiation alone can only offer a short term symptom-free result, and should be considered as an occasional alternative modality of choice.

Primary carcinoma of the female urethra

The clinical and morphological features in 81 cases of carcinoma of the female urethra were reviewed. The over-all 5 and 10-year survival rate for the entire group was 32 per cent. Survival expectations for patients with squamous carcinoma, transitional cell carcinoma and adenocarcinoma were similar when analyzed according to stage and all cell types appeared to respond equally to irradiation. Prognosis was related directly to the clinical stage of the disease. A plea is made for more accurate assessment of the disease status. The high incidence of local recurrence noted for all forms of single modality therapy (46 to 64 per cent) suggests the need for clinical trials with combination preoperative irradiation followed by definitive surgical procedures.