Primary malignant melanoma of the urethra: Report of 9 cases in China

BACKGROUND

Primary urethral melanoma is extremely rare and malignant, and accounts for <1% of all melanoma cases. Here, we aimed to gain more insight into the pathological and follow-up outcomes of patients with this tumor type.

METHODS

We conducted a retrospective analysis of nine patients who had undergone comprehensive treatment at West China Hospital since 2009. Furthermore, we also performed a questionnaire-based survey to determine the quality of life and health statuses of surviving patients.

RESULTS

Most participants were women, and their ages ranged between 57 and 78 years (mean age: 64.9 years). Common clinical presentations included pigmentation, moles, and irregular neoplasms in the urethral meatus with or without bleeding. The final diagnosis was based on pathological and immunohistochemical examination results. All patients underwent regular follow-ups after receiving surgical or non-surgical therapy, such as chemotherapy or radiotherapy.

DISCUSSION/CONCLUSION

Our study revealed that pathological and immunohistochemical tests are crucial for precise diagnosis, especially in asymptomatic patients. Primary malignant urethral melanoma generally has a poor prognosis; therefore, early and accurate diagnosis is imperative. Timely surgical intervention and immunotherapy can help improve patient prognosis. Moreover, an optimistic outlook and family support may augment the clinical management of this disease.

Morphologic spectrum of the epithelial tumors of the male and female urethra

The classification of the epithelial tumors of the male and female urethra includes benign and malignant neoplasms. Primary urethral carcinomas and adenocarcinomas of the accessory glands are the most relevant tumors, both from the morphologic and clinical point of view. An accurate diagnosis, grading and staging are essential for determining adequate treatment strategies and outcome. Information on anatomy and histology of the urethra is of fundamental importance in understanding the morphology of the tumors, including the clinical importance of their location and origin.

[Primary melanoma of female urethra: A case diagnosed in Ouagadougou]

We report a case of primary melanoma of a female urethra diagnosed at a non-metastatic stage in a 48-year-old patient with a history of breast carcinoma treated with radiotherapy and hormone therapy. The patient was consulting for dysuria, hematuria, and perineal pain. The clinical examination found a prolapsed and black mass, developed at the expense of the urethra and located at the anterosuperior part of the vulva. The mass biopsy revealed a proliferation of fusiform and globular cells loaded with black pigment expressing the anti-HMB 45 and PS 100 antibodies. The extension assessment showed an absence of secondary localization. The patient underwent total cystourethrectomy without inguinal lymphadenectomy. There was no recurrence observed on day 100 following the surgery.

Primary mucinous cell adenocarcinoma of female urethra

Primary adenocarcinoma of the female urethra is a rare entity. Its incidence increases with age with the highest rate in women aged more than 65 years. Adenocarcinoma of the urethra is more common among women than men and is associated with a relatively poor prognosis. We report a case of primary adenocarcinoma of the urethra and review the literature with emphasis on the diagnosis, management and outcome of this rare tumour.

The ultrasonographic characteristics of female periurethral solid masses

INTRODUCTION AND HYPOTHESIS

Studies on the imaging of female periurethral masses are sparse, and most are focused on cystic lesions. In this article, we studied female periurethral solid masses and reported their ultrasonographic features.

METHODS

Fifteen women with periurethral solid masses pathologically diagnosed between January 2008 and April 2021 were assessed.

RESULTS

Each patient had only one mass. The pathological types included urethral caruncle (5 patients), urethral leiomyoma (3 patients), urethral malignant tumor (MT) (3 patients), periurethral spindle tumor (3 patients) and cartilage necrosis of pubic symphysis (PS) (1 patient). On ultrasound, all urethral caruncles were located at the urethral meatus. They were hypoechoic/isoechoic and rich in blood flow signal. Each leiomyoma presented as a well-defined hypoechoic mass with an oval shape. The urethral MT had inhomogeneous/isoechoic echoes, with medium to abundant blood flow signal. The spindle cell tumors had regular/irregular shapes, moderate/high density echogenicity and little/rich blood flow signals. The articular cartilage necrosis of PS was regular in shape, with mixed echogenicity and no blood flow.

CONCLUSIONS

Ultrasound imaging is a convenient and useful method to evaluate the morphological characteristics of female periurethral solid masses.

Carcinogenic Susceptibility to N-bis(2-hydroxypropyl)nitrosamine (DHPN) in rasH2 Mice

To evaluate the susceptibility of rasH2 mice to N-bis(2-hydroxypropyl)nitrosamine (DHPN), a potent carcinogen targeting the lung, liver, thyroid, and kidney, male, 6-week old, rasH2 mice and wild-type Iittermates (non-Tg mice) were given DHPN in drinking water at 0, 20 or 200 ppm, and 0 or 200 ppm, respectively, for 26 weeks. The experiment using rasH2 mice given 200 ppm DHPN and non-Tg mice given 200 and 0 ppm DHPN was completed at 20 weeks, since mortality in these groups was remarkably increased due to hemangiosarcomas of the liver. Histologically, tumors developed in the lung and liver in both rasH2 and non-Tg mice treated with DHPN. In addition, proliferative lesions were observed in the forestomach, urethra, and excretory duct of salivary glands in rasH2 mice given 200 ppm DHPN. RT-PCR analysis showed no marked difference in expression of mRNAs for the transgene and the endogenous mouse ras gene between the whole lung tissue containing a neoplasm and normal lung tissue. Our results suggest that rasH2 mice are highly susceptible to DHPN, the target organs including the forestomach, salivary gland and urethra, which have not been found to develop tumors in previous long-term carcinogenicity studies of DHPN in rats and mice.

Incidence rates and contemporary trends in primary urethral cancer

PURPOSE

We assessed contemporary incidence rates and trends of primary urethral cancer.

METHODS

We identified urethral cancer patients within Surveillance, Epidemiology and End Results registry (SEER, 2004-2016). Age-standardized incidence rates per 1,000,000 (ASR) were calculated. Log linear regression analyses were used to compute average annual percent change (AAPC).

RESULTS

From 2004 to 2016, 1907 patients with urethral cancer were diagnosed (ASR 1.69; AAPC: -0.98%, p = 0.3). ASR rates were higher in males than in females (2.70 vs. 0.55), respectively and did not change over the time (both p = 0.3). Highest incidence rates were recorded in respectively ≥75 (0.77), 55-74 (0.71) and ≤54 (0.19) years of age categories, in that order. African Americans exhibited highest incidence rate (3.33) followed by Caucasians (1.72), other race groups (1.57) and Hispanics (1.57), in that order. A significant decrease occurred over time in Hispanics, but not in other race groups. In African Americans, male and female sex-stratified incidence rates were higher than in any other race group. Urothelial histological subtype exhibited highest incidence rate (0.92), followed by squamous cell carcinoma (0.41), adenocarcinoma (0.29) and other histologies (0.20). In stage stratified analyses, T₁N₀M₀ stage exhibited highest incidence rate. However, it decreased over time (-3.00%, p = 0.02) in favor of T_1-4N_1-2M₀ stage (+ 2.11%, p = 0.02).

CONCLUSION

Urethral cancer is rare. Its incidence rates are highest in males, elderly patients, African Americans and in urothelial histological subtype. Most urethral cancer cases are T₁N₀M₀, but over time, the incidence of T₁N₀M₀ decreased in favor of T_1-4N_1-2M₀.

MRI predicts prostatic urethral involvement in men undergoing radical prostatectomy: implications for cryo-ablation of localized prostate cancer

PURPOSE

To determine whether multi-parametric magnetic resonance imaging (mpMRI) can reliably predict proximity of prostate cancer to the prostatic urethra in a contemporary series of men undergoing radical prostatectomy (RP) at two academic centers.

METHODS

Clinical characteristics of consecutive men undergoing pre-operative mpMRI prior to RP and whole-mount axial serial step-sectioned pathology examination at two academic centers between Jun 2016 and Oct 2018 were analyzed retrospectively. Every tumor was characterized by its pathologic minimum distance to the prostatic urethral lumen (pMDUL). Only the cancer closest to the urethra represented the prostatic urethral index lesion. The radiologic minimum distance of the index lesion to the prostatic urethral lumen was measured and noted as ≤ 5 mm versus  > 5 mm. The sensitivity, specificity, positive and negative predicting values (PPV and NPV) and area under the receivers operating characteristics curve (AUC) were calculated for performance of mpMRI for predicting pMDUL ≤ 5 mm.

RESULTS

Of the 163 surgical specimens examined, 112 (69%) exhibited a pMDUL ≤ 5 mm. These men had significantly higher grade group (GG) and advanced pathological and clinical stage. The rates of high PI-RADS score and presence of gross extracapsular extension were also significantly greater for the group with pMDUL ≤ 5 mm. The AUC, sensitivity, specificity, PPV, and NPV were 0.641, 51.8, 76.5, 82.9, and 42.4%, respectively, for mpMRI to predict pMDUL < 5 mm.

CONCLUSIONS

Nearly 70% of men undergoing RP present with tumor within 5 mm of the prostatic urethra. These tumors present higher risk characteristics, and mpMRI exhibited moderate performance and high PPV in their pre-operative detection. Physicians performing partial gland ablation should take these results into consideration during treatment selection and planning.

Villous Adenoma Arising in the Urethra of a Female with Bladder Augmentation History: A Case Report and Review of the Literature

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

The effect of race/ethnicity on histological subtype distribution, stage at presentation and cancer specific survival in urethral cancer

OBJECTIVE

To test the effect of race/ethnicity on histological subtype, stage at presentation, and cancer specific mortality (CSM) in urethral cancer patients.

MATERIAL AND METHODS

Stratified analyses (Surveillance, Epidemiology and End Results [2004-2016]) tested the effect of race/ethnicity on histology and stage. Cumulative incidence-plots and multivariable competing-risks regression models (CRR), addressed CSM, after matching for TNM-stage, histology, age, and gender.

RESULTS

Of 1,904 urethral cancer patients, 71% were Caucasian, 16% African American, 7% Hispanic and 5% other. African Americans were younger (66 years) than Caucasians (73 years) and Hispanics (74 years). In African Americans, adenocarcinoma (25%) and squamous cell carcinoma (SCC; 29%) were more frequent than in Caucasians (12% and 23%) or Hispanics (15% and 20%). African Americans with adenocarcinoma exhibited higher stage than other adenocarcinoma patients. In CRR, African Americans (35%) and Hispanics (29%) exhibited highest and second highest 3-year CSM, even after matching. After further multivariable adjustment of matched CRRs, CSM was higher in Hispanics (HR: 1.93, P= 0.03) and in African Americans (Hazard ratio 1.35, P= 0.07), relative to Caucasians.

CONCLUSION

Race/ethnicity impacts important differences on urethral cancer patients. African American race/ethnicity predisposes to higher rate of SCC and adenocarcinoma. Moreover, African Americans are younger and present with higher stage at diagnoses. Finally, even after most detailed matching for stage, age, gender, and adjustment for treatment and systemic therapy and socioeconomic status, African Americans and Hispanics exhibit higher CSM than Caucasians.

Atezolizumab in locally advanced or metastatic urothelial cancer: a pooled analysis from the Spanish patients of the IMvigor 210 cohort 2 and 211 studies

Background

The studies IMvigor 210 cohort 2 and IMvigor211 evaluated the efficacy of atezolizumab in patients with locally advanced or metastatic urothelial cancer (mUC) upon progression to platinum-based chemotherapy worldwide. Yet, the real impact of this drug in specific geographical regions is unknown.

Materials and methods

We combined individual-level data from the 131 patients recruited in Spain from IMvigor210 cohort 2 and IMvigor211 in a pooled analysis. Efficacy and safety outcomes were assessed in the overall study population and according to PD-L1 expression on tumour-infiltrating immune cells.

Results

Full data were available for 127 patients; 74 (58%) received atezolizumab and 53 (42%) chemotherapy. Atezolizumab patients had a numerically superior median overall survival although not reaching statistical significance (9.2 months vs 7.7 months). No statistically significant differences between arms were observed in overall response rates (20.3% vs 37.0%) or progression-free survival (2.1 months vs 5.3 months). Nonetheless, median duration of response was superior for the immunotherapy arm (non-reached vs 6.4 months; p = 0.005). Additionally, among the responders, the 12-month survival rates seemed to favour atezolizumab (66.7% vs 19.9%). When efficacy was analyzed based on PD-L1 expression status, no significant differences were found. Treatment-related adverse events of any grade occurred more frequently in the chemotherapy arm [46/57 (81%) vs 44/74 (59%)].

Conclusion

Patients who achieved an objective response on atezolizumab presented a longer median duration of response and numerically superior 12 month survival rates when compared with chemotherapy responders along with a more favorable safety profile. PD-L1 expression did not discriminate patients who might benefit from atezolizumab.

Skene's Gland Adenocarcinoma: Borrowing From Prostate Cancer Experience for the Evaluation and Management of a Rare Malignancy

OBJECTIVE

To determine if adenocarcinoma of the Skene's glands in women, which has a histological and immunohistochemical appearance similar to prostate cancer, can be evaluated and managed with the same tools we use for prostate cancer.

METHODS

Serum prostate-specific antigen kinetics, 3D multiparametric (MP) magnetic resonance imaging (MRI), fluciclovine F-18 positron emission tomography (PET), and androgen deprivation therapy (ADT) were employed in a case of Skene's gland adenocarcinoma.

RESULTS

The 3D MP MRI clarified the anatomy of the primary lesion and fluciclovine F-18 PET significantly improved our ability to stage the tumor prompting pelvic lymph node dissection that may have otherwise not been performed. ADT resulted in a significant impact on prostate-specific antigen kinetics despite the patient having a testosterone level in the normal range for a postmenopausal woman.

CONCLUSION

Despite the rarity of Skene's gland adenocarcinoma, we can employ many of the tools at our disposal for the evaluation and management of prostate cancer to benefit the women found to have this malignancy.

A Case study of the radiation therapy treatment of a transitional cell carcinoma of the distal urethra

Urethral carcinoma is a rare urological cancer, accounting for only 1% of malignancies in Australia. The most common histology is transitional cell carcinoma (TCC). The majority of these cancers are treated with surgery. The main purpose of this case study is to describe a novel radiation treatment technique for treatment of this uncommon cancer. This report details organ-preserving treatment for a distal penile urethral cancer using definitive radiation therapy (RT). In May 2016 a 69-year-old male presented to Crown Princess Mary Cancer Centre (CPMCC) with a small TCC of the distal urethra. The patient was offered numerous treatment options, both radical and organ-preserving approaches, and came to a final decision of a course of radiation therapy despite the lack of randomised evidence to guide treatment in this setting. A dose of 66 Gy in 33 fractions from parallel opposed lateral beams was prescribed to the distal penile urethra. This case required an unusual approach to patient set up to allow access for accurate treatment delivery and to maintain patient comfort. The patient tolerated the full course of radiation therapy with expected skin side effects. He has maintained adequate penile function and is currently free from disease at 33 months with ongoing clinical follow-up.

Translabial ultrasound imaging of urethral diverticula

OBJECTIVE

Urethral diverticulum is an uncommon cause of urinary dysfunction in women, with often a significant delay in diagnosis. Urethroscopy and/or magnetic resonance imaging are/is widely used for its identification. Translabial ultrasound is an alternative, particularly since the introduction of three-/four-dimensional imaging. The aim of our study was to review 10 years' experience of urethral diverticula evaluated by translabial ultrasound.

METHODS

We reviewed 4121 patients seen in a tertiary urogynecologic unit between 2008 and 2018. All women were examined using multiplanar translabial ultrasound as well as office urethroscopy. Data regarding demographics, presenting symptoms and findings on clinical examination were collected. Archived ultrasound volumes were analyzed for diverticular location, diameters, complexity and echogenicity as well as tract visualization.

RESULTS

Of our study population, 23 (0.6%) were found to have a major urethral abnormality on translabial ultrasound, 15 of whom were confirmed to have a urethral diverticulum on urethroscopy. Of these, 12 had a cystic component and three were non-cystic on imaging. Mean maximum diameter was 15.3 mm (range, 4-32 mm). In 9/15 there was a simple diverticulum, while in 6/15 it was classified as complex. A communicating tract was seen in 10/15 (67%), and this was located at the 5-7 o'clock position in 7/10 (70%). Mean urethral circumference covered by the diverticulum was 39%.

CONCLUSIONS

Translabial ultrasound is a valid, non-invasive method for the diagnosis of urethral diverticulum. A cystic structure crossing the urethral rhabdosphincter has high predictive value for urethroscopic diagnosis of urethral diverticulum. Multiple hyperechogenic foci may indicate the presence of a small urethral diverticulum. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Urethral diverticular with broadly squamous metaplasia in a patient with urethral diverticular calculi: A case report

RATIONALE

There are already several reports concerning the occurrence of urethral diverticulum (UD) in female patients, but only rarely has a article describing UD combined with UD calculi or squamous carcinoma been published. Moreover, a case with squamous carcinoma and UD calculi at the same time has never been reported, making this the first case report about this condition.

PATIENT CONCERNS

A 43-year-old woman presented to the gynaecology department with a complaint of a hard mass beneath the anterior vaginal wall.

DIAGNOSES

Transvaginal ultrasound (TVU) revealed a UD.

INTERVENTIONS

We performed a standard urethral diverticular excision. Intraoperatively, we identified and removed a stone from the diverticulum. The intraoperative finding of a stone challenged the diagnosis of UD, with subsequent histological examination of biopsy tissue from the mass demonstrating broadly squamous metaplasia.

OUTCOMES

The broadly squamous metaplasia predominantly originated from the stone, and the stone was entirely removed. No complications occurred during the whole follow-up period. Moreover, after the 12-month follow-up, there was no diverticular recurrence or carcinoma metastasis.

LESSONS

UD calculi may be considered a risk factor for female urethra squamous metaplasia, which with the potential of squamous carcinoma, so patients will be advised to treat this condition immediately.

BGJ398, A Pan-FGFR Inhibitor, Overcomes Paclitaxel Resistance in Urothelial Carcinoma with FGFR1 Overexpression

Paclitaxel (PTX) is commonly used to treat urothelial carcinoma (UC) after platinum-based chemotherapy has failed. However, single-agent taxane therapy is not sufficient to inhibit tumor progression and drug resistance in advanced UC. Epithelial-to-mesenchymal transition (EMT) induced by fibroblast growth factor receptor (FGFR)1 signaling has been proposed as a mechanism of PTX resistance, but it is unclear whether this can be overcome by FGFR1 inhibition. The present study investigated whether FGFR1 overexpression contributes to PTX resistance and whether FGFR inhibition can enhance PTX efficacy in UC. The effects of PTX combined with the FGFR inhibitor BGJ398 were evaluated in UC cell lines by flow cytometry; Western blot analysis; cell viability, migration, and colony forming assays; and RNA interference. PTX+BGJ398 induced cell cycle arrest and apoptosis in UC cells with mesenchymal characteristics was accompanied by downregulation of cyclin D1 protein and upregulation of gamma-histone 2A family member X and cleaved poly(ADP-ribose) polymerase. Additionally, PTX+BGJ398 synergistically suppressed UC cell migration and colony formation via regulation of EMT-associated factors, while FGFR1 knockdown enhanced the antitumor effect of PTX. These findings provide a basis for development of effective strategies for overcoming PTX resistance in UC through inhibition of FGFR1 signaling.

Nuclear Factor-κB Promotes Urothelial Tumorigenesis and Cancer Progression via Cooperation with Androgen Receptor Signaling

We investigated the role of NF-κB in the development and progression of urothelial cancer as well as cross-talk between NF-κB and androgen receptor (AR) signals in urothelial cells. Immunohistochemistry in surgical specimens showed that the expression levels of NF-κB/p65 (P = 0.015)/phospho-NF-κB/p65 (P < 0.001) were significantly elevated in bladder tumors, compared with those in nonneoplastic urothelial tissues. The rates of phospho-NF-κB/p65 positivity were also significantly higher in high-grade (P = 0.015)/muscle-invasive (P = 0.033) tumors than in lower grade/non-muscle-invasive tumors. Additionally, patients with phospho-NF-κB/p65-positive muscle-invasive bladder cancer had significantly higher risks of disease progression (P < 0.001) and cancer-specific mortality (P = 0.002). In immortalized human normal urothelial SVHUC cells stably expressing AR, NF-κB activators and inhibitors accelerated and prevented, respectively, their neoplastic transformation induced by a chemical carcinogen 3-methylcholanthrene. Bladder tumors were identified in 56% (mock), 89% (betulinic acid), and 22% (parthenolide) of N-butyl-N-(4-hydroxybutyl)nitrosamine-treated male C57BL/6 mice at 22 weeks of age. NF-κB activators and inhibitors also significantly induced and reduced, respectively, cell proliferation/migration/invasion of AR-positive bladder cancer lines, but not AR-knockdown or AR-negative lines, and their growth in xenograft-bearing mice. In both nonneoplastic and neoplastic urothelial cells, NF-κB activators/inhibitors upregulated/downregulated, respectively, AR expression, whereas AR overexpression was associated with increases in the expression levels of NF-κB/p65 and phospho-NF-κB/p65. Thus, NF-κB appeared to be activated in bladder cancer, which was associated with tumor progression. NF-κB activators/inhibitors were also found to modulate tumorigenesis and tumor outgrowth in AR-activated urothelial cells. Accordingly, NF-κB inhibition, together with AR inactivation, has the potential of being an effective chemopreventive and/or therapeutic approach for urothelial carcinoma. Mol Cancer Ther; 17(6); 1303-14. ©2018 AACR.

[Urethral leiomyoma]

In urology practice, leiomyoma of the urinary bladder is considered a rare tumor. Urethral leiomyoma is even more unusual. This article is a case report of a very rare benign tumor originating from the smooth muscles of the urethra causing obstructive voiding in a woman.

Differential Effects of Histone Acetyltransferase GCN5 or PCAF Knockdown on Urothelial Carcinoma Cells

Disturbances in histone acetyltransferases (HATs) are common in cancers. In urothelial carcinoma (UC), p300 and CBP are often mutated, whereas the GNAT family HATs GCN5 and PCAF (General Control Nonderepressible 5, p300/CBP-Associated Factor) are often upregulated. Here, we explored the effects of specific siRNA-mediated knockdown of GCN5, PCAF or both in four UC cell lines (UCCs). Expression of various HATs and marker proteins was measured by qRT-PCR and western blot. Cellular effects of knockdowns were analyzed by flow cytometry and ATP-, caspase-, and colony forming-assays. GCN5 was regularly upregulated in UCCs, whereas PCAF was variable. Knockdown of GCN5 or both GNATs, but not of PCAF alone, diminished viability and inhibited clonogenic growth in 2/4 UCCs, inducing cell cycle changes and caspase-3/7 activity. PCAF knockdown elicited GCN5 mRNA upregulation. Double knockdown increased c-MYC and MDM2 (Mouse Double Minute 2) in most cell lines. In conclusion, GCN5 upregulation is especially common in UCCs. GCN5 knockdown impeded growth of specific UCCs, whereas PCAF knockdown elicited minor effects. The limited sensitivity towards GNAT knockdown and its variation between the cell lines might be due to compensatory effects including HAT, c-MYC and MDM2 upregulation. Our results predict that developing drugs targeting individual HATs for UC treatment may be challenging.

Urethral hemangioma in a prepubertal female patient: Report of a rare case

RATIONALE

Urethral hemangiomas commonly occur in men or elderly women. We presented a rare case of urethral hemangioma in a prepubertal female patient.

PATIENTS CONCERNS

An 8-year-old girl had the complaints of bloody staining of clothing, a foul perineal odor, and urethral pain. She was brought to our genitourinary outpatient department for survey and a single, 1-cm compressible reddish nodule at the 10-2 o'clock position in the distal urethra was found.

DIAGNOSES

Urethral hemangioma in a prepubertal girl was diagnosed after excision of the urethral nodule.

INTERVENTIONS

Excision with 8 "stay" sutures in the protruding urethral mucosa was performed.

OUTCOMES

Normal micturition without symptom recurrence was noted at the 3-month follow-up.

LESSONS

Urethral hemangioma is also found in prepubertal female patient. Increased physician awareness and early recognition of a urethral hemangioma can avoid unnecessary examinations and patient anxiety. The procedure of excision with 8 "stay" sutures in the protruding urethral mucosa facilitates mobilization from the distal urethra and provides a good surgical view of abnormal proliferative blood vessels. Therefore, the lesion can be removed as clean as possible.

Paraurethral Leiomyoma

BACKGROUND: Paraurethral vaginal leiomyoma is a rare and solid tumor of unknown etiology. We present a case of successfully treated paraurethral leiomyoma. CASE: A 49-year old woman, G4P2A2, was admitted to our clinic with complaints of vaginal mass and dyspareunia. During pelvic examination a 4x4-cm-sized, solid mass with hard consistency was detected at the paraurethral area in the front wall of the vagina. In the histopathological examination the mass was found to be compatible with leiomyoma. CONCLUSION: Paraurethral leiomyoma is a rare, hormone-dependent, benign tumor of mesenchymal origin. Surgical excision is necessary for discrimination from sarcoma. One should be cautious of urethral injury during the excision.

A Challenging Surgical Approach to Locally Advanced Primary Urethral Carcinoma: A Case Report and Literature Review

Primary urethral carcinoma (PUC) is a rare and aggressive cancer, often underdetected and consequently unsatisfactorily treated. We report a case of advanced PUC, surgically treated with combined approaches.A 47-year-old man underwent transurethral resection of a urethral lesion with histological evidence of a poorly differentiated squamous cancer of the bulbomembranous urethra. Computed tomography (CT) and bone scans excluded metastatic spread of the disease but showed involvement of both corpora cavernosa (cT3N0M0). A radical surgical approach was advised, but the patient refused this and opted for chemotherapy. After 17 months the patient was referred to our department due to the evidence of a fistula in the scrotal area. CT scan showed bilateral metastatic disease in the inguinal, external iliac, and obturator lymph nodes as well as the involvement of both corpora cavernosa. Additionally, a fistula originating from the right corpus cavernosum extended to the scrotal skin. At this stage, the patient accepted the surgical treatment, consisting of different phases. Phase I: Radical extraperitoneal cystoprostatectomy with iliac-obturator lymph nodes dissection. Phase II: Creation of a urinary diversion through a Bricker ileal conduit. Phase III: Repositioning of the patient in lithotomic position for an overturned Y skin incision, total penectomy, fistula excision, and "en bloc" removal of surgical specimens including the bladder, through the perineal breach. Phase IV: Right inguinal lymphadenectomy.The procedure lasted 9-and-a-half hours, was complication-free, and intraoperative blood loss was 600 mL. The patient was discharged 8 days after surgery. Pathological examination documented a T4N2M0 tumor. The clinical situation was stable during the first 3 months postoperatively but then metastatic spread occurred, not responsive to adjuvant chemotherapy, which led to the patient's death 6 months after surgery.Patients with advanced stage tumors of the bulbomembranous urethra should be managed with radical surgery including the corporas up to the ischiatic tuberosity attachment, and membranous urethra in continuity with the prostate and bladder. Neo-adjuvant treatment may be advisable with the aim of improving the poor prognosis, even if the efficacy is not certain while it can delay the radical treatment of the disease.

Afatinib Is Active in Platinum-Refractory ERBB-Mutant Urothelial Carcinoma

HER2 or ERBB3 alterations are predictive of afatinib response in refractory urothelial carcinomas.

[A Female Paraurethral Leiomyoma Causing Urinary Retention: A Case Report]

Leiomyoma is a benign smooth muscle tumor which is rarely found in the paraurethral region. We report a case of paraurethral leiomyoma in a 44-year-old female who visited a clinic complaining of urinary retention. Magnetic resonance imaging revealed a 9 cm mass adjacent to the urethra. She was referred to our department. Transvaginal needle biopsy was performed and the histopathological diagnosis was leiomyoma. The mass was completely excised transperitoneally and transvaginally. The resected specimen was 8 × 7 × 4.5 cm in size and 194 g in weight. Histopathological diagnosis was leiomyoma and the tumor cells demonstrated immunoreactivity for estrogen receptors and progesterone receptors. Herpost operative course was uneventful and she gained normal voiding function. In a follow-up after 3 months, there was no evidence of recurrence. We discuss the clinical and pathological features of the paraurethral leiomyoma.

Mucinous Adenocarcinoma of the Male Urethra: A Report of Two Cases

BACKGROUND

Primary malignancies arising in the urethra are rare and, contrary to the other genitourinary malignancies, are more common in female patients. The pathologic diagnosis of primary adenocarcinoma can be challenging due to its rarity and overlapping features with other primary and secondary malignancies. There is no specific immunoprofile to define these adenocarcinomas, but available markers may allow comparison with common secondary tumors. About 30 primary cases have been recorded to date.

CASES

We report 2 cases of primary mucinous adenocarcinoma of the male urethra, one with possible origin from Littrè glands and the other from the prostatic urethra.

CONCLUSION

The available data suggest that this is a heterogeneous group of aggressive tumors and that the optimal management remains to be established.

Prognostic factors and outcomes in primary urethral cancer: results from the international collaboration on primary urethral carcinoma

PURPOSE

To evaluate risk factors for survival in a large international cohort of patients with primary urethral cancer (PUC).

METHODS

A series of 154 patients (109 men, 45 women) were diagnosed with PUC in ten referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank test was used to investigate various potential prognostic factors for recurrence-free (RFS) and overall survival (OS). Multivariate models were constructed to evaluate independent risk factors for recurrence and death.

RESULTS

Median age at definitive treatment was 66 years (IQR 58-76). Histology was urothelial carcinoma in 72 (47 %), squamous cell carcinoma in 46 (30 %), adenocarcinoma in 17 (11 %), and mixed and other histology in 11 (7 %) and nine (6 %), respectively. A high degree of concordance between clinical and pathologic nodal staging (cN+/cN0 vs. pN+/pN0; p < 0.001) was noted. For clinical nodal staging, the corresponding sensitivity, specificity, and overall accuracy for predicting pathologic nodal stage were 92.8, 92.3, and 92.4 %, respectively. In multivariable Cox-regression analysis for patients staged cM0 at initial diagnosis, RFS was significantly associated with clinical nodal stage (p < 0.001), tumor location (p < 0.001), and age (p = 0.001), whereas clinical nodal stage was the only independent predictor for OS (p = 0.026).

CONCLUSIONS

These data suggest that clinical nodal stage is a critical parameter for outcomes in PUC.

Uncommun etiology of pediatric Hematuria: urethral lymphangioma

We report a case of urethral cystic lymphangioma. Hematuria is the revealing symptom. Im our knowledge, is the third case described in literature.

Leiomyoma--a rare benign tumor of the female urethra: a case report

INTRODUCTION

Leiomyoma in the urethra is a rare occurrence. These are rare benign mesenchymal tumors that arise from the smooth muscle of the urethra. Such tumors often appear in females during their reproductive age (from menarche to menopause); the mean age of their appearance is approximately 41 years.

CASE PRESENTATION

We report here a case of a 52-year-old White woman who presented with complaints of sporadic hematuria, dyspareunia, and feeling of nodulation in her vagina.

CONCLUSIONS

Histopathological studies confirmed the urethral leiomyoma, and the surgery completely resolved the original symptoms. Although the average age of occurrence of such tumors in females is about 41 years, the present case involves an older woman of 52 years. Most importantly, the mass was located in the distal urethra, an uncommon site of presentation of leiomyoma in females.

[Case of primary malignant melanoma of the female urethra at age 94 : a case report]

A 94-year-old woman visited a local urological clinic in January 2011 complaining of dysuria and vulvar discomfort that lasted for a month. Clinical examination showed a hematoma-like tumor at the external urethral meatus. She refused an operation. After 2 months, the tumor became hemorrhagic and she was referred to our hospital for operation. A black tumor of fingertip-size was seen at the external urethral meatus. Urinary sediment examination and urine cytology revealed malignant melanoma cells. The tumor showed T1WI high intensity, and T2WI low intensity by magnetic resonance imaging. Collectively, the patient was diagnosed with malignant melanoma. The tumor was extirpated. Pathological diagnosis showed malignant nodular melanoma. However, additional therapy was not performed due to her age and thereafter, the patient was followed up carefully. After 3 months, right inguinal LN swelled, and tumor recurred at the external urethral meatus. She died from multiple metastases 11 months from the initial consultation. We herein report this case of primary malignant melanoma of the female urethra in an elderly patient.

Bowen's Disease Involving the Urethra

Bowen's disease developing on mucous or mucocutaneous regions is clinically called erythroplasia of Queyrat. We report herein a 56-year-old male with Bowen's disease extending from the penis shaft to the glans penis, and urethral meatus. Physical examination revealed bright red velvety plaques on the prepuce and glans penis and an irregularly pigmented scaly lesion on the dorsum of his penis shaft. Histopathological findings of both lesions were compatible with those of Bowen's disease, supporting the concept that erythroplasia of Queyrat and Bowen's disease should be regarded as one clinicopathologic entity. A partial penectomy was finally performed, because tumor cells were pathologically observed in the mucous epithelium of the urethra. Although several therapeutic modalities exist for Bowen's disease on the external genitalia, treatment options are limited when Bowen's disease extends to the urethral meatus. We discussed the recent therapeutic modalities in genital Bowen's disease.

Uretheral invagination of multilocular cystic nephroma; a case report of a new pathologic variant

BACKGROUND

The multilocular cystic nephroma (MLCN) is a unilateral cystic neoplasm of the kidney exhibiting benign biological behavior. The etiology and histopathogenesis of the disease is controversial (dysplastic/hamartomous/neoplastic). MLCNs show bimodal age distribution, with peak incidence occurring at 2-4 years of age and between the fourth and sixth decades. The male to female ratio in patients aged below 4 years is 3:1, which reverses to 1:8 between the fourth and sixth decades.

PATIENTS AND METHODS

A 59-year-old female patient presented with left flank pain and abdominal pain. Ultrasound (US) revealed 220×109×82 mm multiple septated hyperechoic kidney cysts with a semi-solid appearance. MRI showed a 245×119×98 mm multilocular cystic renal mass in the left kidney with hypointense appearance in T1-weighted images and hyperintense in T2-weighted images, and multicystic appearance in ureter projection, the largest portion measuring 17 mm in diameter. Radical nephrectomy was planned with the pre-diagnosis of multilocular cystic nephroma or multicystic renal cell carcinoma.

RESULTS

The patient underwent transperitoneal radical nephroureterectomy. The immunohistopathological examination revealed MLCN with ureteral invagination.

CONCLUSION

The etiology, pathogenesis, and genetic basis of multilocular cystic nephroma are currently unknown. This tumor is confused with cystic partially differentiated nephroblastoma and cystic Wilms tumor in childhood, and multilocular cystic renal cell carcinoma, clear cell papillary renal cell carcinoma, and tubulocystic carcinoma in adults. The association of this tumor with pleuropulmonary blastoma in children exhibits genetic inheritance. US control is particularly recommended in siblings of these children. Albeit rare, the disease can occur as a bilateral synchronous or metachronous lesion. There are four reports of cases with recurrence in the literature. The laparoscopic partial nephrectomy is the recommended treatment method in patients with sufficient renal reserve that are found to be free of malignancy in the frozen section examination. The symptoms of hematuria and flank pain can be associated with invagination of the cysts into the pelvis and intrarenal rupture of the cysts. The invagination of cysts into the pelvis has been previously described. The authors consider that this was the first case of MLCN in the literature exhibiting invagination into the ureter.

The role of preoperative prostatic urethral biopsy in clinical decision-making at the time of radical cystectomy

INTRODUCTION

Involvement of the prostatic urethra by bladder cancer directly impacts prognosis, risk of urethral recurrence, and timing of radical cystectomy (RC); it also affects the type of urinary diversion chosen. Both cold cup biopsies and transurethral (TUR) loop biopsies have been used to evaluate the status of the prostatic urethra. We report our 20 year experience with preoperative and intro-operative prostatic urethral biopsies in order to determine relative efficacy and associated treatment implications.

MATERIALS AND METHODS

The Columbia University urologic oncology database was reviewed and yielded 234 men who underwent preoperative endoscopic biopsies of the prostatic urethra before RC between 1990 and 2010. Two techniques were described: 1) cold cup biopsy, and 2) TUR loop biopsy. We evaluated the sensitivity, specificity, and predictive values for these respective techniques relative to the final pathological status of the prostatic urethra (PU) in the RC specimen.

RESULTS

Of the 234 urethral biopsies 115 (49.1%) were cold cup and 96 (41.1%) were TUR loop biopsies. In the remaining 9.8% of patients, the technique could not be determined. Eighty-one preoperative biopsies (34.6%) revealed involvement of the urethra. No differences were observed in predictive values, sensitivity, and specificity between the two preoperative techniques. The negative predictive value (NPV) was higher than positive predictive value (PPV) for both preoperative approaches. Thirty-eight patients (16.2%) had a urethral frozen section analysis done intra-operatively. Only 1 patient (3%) had an abnormality on frozen section, being the negative predictive value (NPV) higher than the positive predictive value (PPV) for the test's ability to predict the status of the final urethral margin. Urethrectomy was performed at cystectomy in 52 patients with a positive biopsy; 15 (28.8%) of these patients ultimately had a negative PU on final pathology. Only 2/182 (1%) of the patients with an intact urethra presented with a urethral recurrence with a median follow up of 30.5 months.

CONCLUSIONS

Preoperative prostatic urethral biopsy does not adequately predict final prostatic urethral status at radical cystectomy. No differences in predictive capacity could be detected with either cold cup biopsy or TUR biopsy. Intra-operative biopsy of the prostatic urethra is predictive of a negative urethral margin. Simultaneous radical urethrectomy should not be performed based up on preoperative prostatic urethral biopsy results alone.

[Condylomatous carcinoma of the urethra that detected human papillomavirus type 16 genome: a case report]

This is a report on a rare case of male urethral condylomatous carcinoma that detected human papillomavirus type 16 genome (HPV16). He had been administered immunosuppressant, since he had a kidney transplant in 1977. Papillary tumors spread from the external urethral opening to the membranous urethra. Histologically, the tumors presented papillary growth and koilocytotic atypia on the surface part. Moreover, we observed corpus spongiosum penis invasion and vein invasion, and detected HPV16 by immunostaining. We diagnosed condylomatous carcinoma. We treated with anterior urethrectomy and cystostomy.

Primary urethral clear-cell adenocarcinoma: comprehensive analysis by surgical pathology, cytopathology, and next-generation sequencing

Primary clear-cell adenocarcinoma of the urethra, a rare tumor that histomorphologically resembles clear-cell carcinoma of the female genital tract, occurs predominantly in women and is associated with a relatively poor prognosis. The histogenesis of this rare urethral neoplasm has not been completely resolved, but it is thought to arise from either müllerian rests or metaplastic urothelium. Herein, we present comprehensive surgical pathological and cytopathological findings from a patient with primary urethral clear-cell adenocarcinoma and describe next-generation sequencing results for this patient's unique tumor-the first such reported characterization of molecular aberrations in urethral clear-cell adenocarcinoma at the transcriptomic and genomic levels. Transcriptome analysis revealed novel gene fusion candidates, including ANKRD28-FNDC3B. Whole-exome analysis demonstrated focal copy number loss at the SMAD4 and ARID2 loci and 38 somatic mutations, including a truncating mutation in ATM and a novel nonsynonymous mutation in ALK.

[Urethral cancer is rare and difficult to diagnose]

Primary cancer of the urethra is a rare condition with symptoms ranging from haematuria, urethral obstruction and pelvic pain to urethrocutaneous fistula and abscess. Magnetic resonance imaging (MRI) is considered first choice of diagnostic imaging, but experience with treatment is scarce. We present a case of a 69-year-old woman with a one-year history of urinary obstruction. MRI revealed a tumour surrounding the urethra, and biopsies showed adenocarcinoma in situ. Surgery with removal of the bladder, urethra, internal genitals and lymph nodes revealed a periurethral cyst with both adenocarcinoma in situ and focal adenocarcinoma.

Urethral adenocarcinoma associated with intestinal-type metaplasia, case report and literature review

The presence of glandular epithelium in urinary tract biopsies poses a diagnostic challenge. Intestinal metaplasia of the urethra may be seen in many congenital, iatrogenic, and reactive conditions, as well as in association with malignant conditions such as urethral adenocarcinoma. We present a case of a 61 year-old woman presenting with microscopic hematuria. Successive biopsies showed glandular epithelium with focal atypia in close association with inflammation, but no overt malignancy. Only on surgical resection was the associated high grade adenocarcinoma revealed. When intestinal-type mucosa is present within a urinary tract biopsy, associated malignancy may be present only focally. Thorough sampling and consideration of the differential diagnosis is imperative.

[A case of alpha-fetoprotein-producing female urethral adenocarcinoma]

We report a rare case of alpha-fetoprotein (AFP)-producing female urethral adenocarcinoma. A 52- year-old woman had urinary frequency. Ultrasonography showed a mass near the bladder. Therefore, she was referred to our hospital. Magnetic resonance imaging showed an approximately 4 cm mass at the urethra. Computed tomography did not show any lymphnode metastasis or distant metastasis. High serum levels of AFP were revealed. Carcinoembryonic antigen (CEA) and prostate specific antigen (PSA) were within the normal range. A transvaginal needle biopsy suggested adenocarcinoma. Radical cystourethrectomy and ileal conduit formation were performed. Histopathological diagnosis was adenocarcinoma. Immunohistochemical staining was positive for AFP and CEA, and negative for PSA. Serum AFP normalized immediately postoperatively. Adjuvant chemotherapy or radiotherapy was not performed. Eleven years postoperatively, the patient showed no evidence of tumor recurrence. To our knowledge, this is the first reported case of AFP producing female urethral adenocarcinoma.

TRPV2 mediates adrenomedullin stimulation of prostate and urothelial cancer cell adhesion, migration and invasion

Adrenomedullin (AM) is a 52-amino acid peptide initially isolated from human pheochromocytoma. AM is expressed in a variety of malignant tissues and cancer cell lines and was shown to be a mitogenic factor capable of stimulating growth of several cancer cell types. In addition, AM is a survival factor for certain cancer cells. Some data suggest that AM might be involved in the progression cancer metastasis via angiogenesis and cell migration and invasion control. The Transient Receptor Potential channel TRPV2 is known to promote in prostate cancer cell migration and invasive phenotype and is correlated with the stage and grade of bladder cancer. In this work we show that AM induces prostate and urothelial cancer cell migration and invasion through TRPV2 translocation to plasma membrane and the subsequent increase in resting calcium level.

[Long-term survival of metastatic clear cell adenocarcinoma of the female urethra by multidisciplinary treatment: a case report]

We report a case of clear cell adenocarcinoma of the female urethra. A 57-year-old woman presented with complaint of gross hematuria. Abdominal ultrasonography, cystourethroscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed the urethral tumor was invasive to bladder neck. Clinical stage was determined as cT3N1M0, then anterior pelvic exenteration and ileal conduit formation were performed. The pathological diagnosis was clear cell adenocarcinoma of urethra and the stage was pT3N1. The patient received TS-1 and cisplatin for postoperative recurrence, but she died from multiple lung metastasis 54 months after the operation. Clear cell adenocarcinoma of the female urethra is rare case in the Japanese literatures. Pathogenesis and management of this rare condition are discussed.

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

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