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.

Evaluation and management of urethral and periurethral masses in women

PURPOSE OF REVIEW

Female periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.

RECENT FINDINGS

The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.

SUMMARY

Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.

The effect of centralization of care on overall survival in primary urethral cancer

PURPOSE

Centralization of care to high-volume centers improves outcomes across urologic malignancies, but there exists a paucity of data for low-incidence cancers. Given the rarity of primary urethral cancer (UC) and the need for complex multidisciplinary treatment, we sought to evaluate differences in practice patterns and clinical outcomes across types of treating facilities.

MATERIALS AND METHODS

We identified all patients diagnosed with UC from 2004 to 2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival (OS) and multivariable Cox regression analysis was used to investigate independent predictors of OS. The chi-square test was used to analyze differences in practice patterns.

RESULTS

We identified 6,445 patients with UC. Median overall survival was 40.5 months (interquartile range 38.4-42.6). There was a significant difference in OS based upon facility type, and this difference remained significant on subgroup analysis for squamous cell carcinoma and urothelial carcinoma. Academic centers had superior OS on pairwise comparisons (all P< 0.05) and were associated with decreased risk of death, hazard ratio 0.858 (95% confidence interval 0.749-0.983). Academic centers had a significantly greater frequency of neoadjuvant/adjuvant chemotherapy and radiation (P < 0.001). Academic centers performed radical surgery in 34.1% of patients compared to 14.5% in community programs (P < 0.001), and regional lymphadenectomy in 31.6% of patients compared to 13.2% in community programs (P < 0.001).

CONCLUSION

There exist significant differences in survival for patients with UC based upon treating facility. Variations in practice patterns including multimodal treatment, radical surgery, and regional lymphadenectomy may contribute to the observed differences in clinical outcomes.

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.

Primary Urethral Melanoma: A Case Report and Literature Review

Patients with localized urethral melanoma have a high risk of recurrence and poor disease-specific survival. Multi-disciplinary approach including surgery, radiation therapy, and chemotherapy/immunotherapy is needed to maximize survival. Current research efforts include investigation of novel tyrosine kinases as well as the combination of targeted therapies with immunotherapies in this population. Combinations may provide a synergistic effect to overcome various obstacles to disease response.

Conceptual Framework for Therapeutic Development Beyond Anti-PD-1/PD-L1 in Urothelial Cancer

Platinum-based chemotherapy has been the standard of care in advanced urothelial cancer, but long-term outcomes have remained poor. Immune checkpoint inhibitors, with their favorable toxicity profiles and noteworthy efficacy, have steered a new era in advanced urothelial cancer, with five agents targeting the PD-1/PD-L1 pathway approved by the U.S. Food and Drug Administration (FDA). However, most patients do not achieve response, whereas immunotherapy-related adverse events may cause morbidity, increased health care use, and-rarely-mortality. Therefore, there is an urgent need for additional therapeutic modalities across the disease spectrum. A plethora of clinical trials are ongoing in various disease settings, including chemotherapy regimens, radiotherapy, antibody-drug conjugates, agents targeting additional immune checkpoint pathways, vaccine, cytokines, adoptive cell therapies, as well as targeted and anti-angiogenic agents. Two agents, enfortumab vedotin and erdafitinib, have breakthrough designation by the FDA but are not approved yet (at the time of this paper's preparation). Novel combinations with various treatment modalities and optimal sequencing of active therapies are being investigated in prospective clinical trials. Evaluation of new treatments has met with substantial challenges for many reasons, for example, molecular heterogeneity, clonal evolution, and genomic instability. In the era of precision molecular medicine, and because patients do not respond uniformly to current therapies, there is a growing need for identification and validation of biomarkers that can accurately predict treatment response and assist in patient selection. Here, we review current updates and future directions of experimental therapeutics in urothelial cancer, including examples (but not an exhaustive list) of ongoing clinical trials.

Oncological Outcomes of Patients with Concomitant Bladder and Urethral Carcinoma

INTRODUCTION

The study aimed to investigate oncological outcomes of patients with concomitant bladder cancer (BC) and urethral carcinoma.

METHODS

This is a multicenter series of 110 patients (74 men, 36 women) diagnosed with urethral carcinoma at 10 referral centers between 1993 and 2012. Kaplan-Meier analysis was used to investigate the impact of BC on survival, and Cox regression multivariable analysis was performed to identify predictors of recurrence.

RESULTS

Synchronous BC was diagnosed in 13 (12%) patients, and the median follow-up was 21 months (interquartile range 4-48). Urethral cancers were of higher grade in patients with synchronous BC compared to patients with non-synchronous BC (p = 0.020). Patients with synchronous BC exhibited significantly inferior 3-year recurrence-free survival (RFS) compared to patients with non-synchronous BC (63.2 vs. 34.4%; p = 0.026). In multivariable analysis, inferior RFS was associated with clinically advanced nodal stage (p < 0.001), proximal tumor location (p < 0.001) and synchronous BC (p = 0.020).

CONCLUSION

The synchronous presence of BC in patients diagnosed with urethral carcinoma has a significant adverse impact on RFS and should be an impetus for a multimodal approach.

Survival Outcomes and Predictive Factors for Female Urethral Cancer: Long-term Experience with Korean Patients

The aim of this study was to evaluate female urethral cancer (UCa) patients treated and followed-up during a time period spanning more than 20 yr at single institution in Korea. We reviewed medical records of 21 consecutive patients diagnosed with female UCa at our institution between 1991 and 2012. After exclusion of two patients due to undefined histology, we examined clinicopathological variables, as well as survival outcomes of 19 patients with female UCa. A Cox proportional hazards ratio model was used to identify significant predictors of prognosis according to variables. The median age at diagnosis was 59 yr, and the median follow-up duration was 87.0 months. The most common initial symptoms were voiding symptoms and blood spotting. The median tumor size was 3.4 cm, and 55% of patients had lesions involving the entire urethra. The most common histologic type was adenocarcinoma, and the second most common type was urothelial carcinoma. Fourteen patients underwent surgery, and 7 of these patients received adjuvant radiation or systemic chemotherapy. Eleven patients experienced tumor recurrence after primary therapy. Patients with high stage disease, advanced T stage (≥T3), and positive lymph nodes had worse survival outcomes compared to their counterparts. Particularly, lymph node positivity and advanced T stage were significant predictive factors for all survival outcomes. Tumor location was the only significant predictor for recurrence-free survival. Although our study included a small number of patients, it conveys valuable information about this rare female urologic malignancy in a Korean population.

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.

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.

[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.

[Primary male urethral cancer: management and prognosis]

OBJECTIVE

To further investigate the management and prognosis of primary urethral cancer in male.

METHODS

We treated 3 cases of primary urethral cancer from 2001 to 2011 and followed them up for recurrence and survival.

RESULTS

The 3 male patients all received adjuvant radiotherapy and/or chemotherapy, and 2 of them were treated by distal urethrectomy, while the other underwent no surgery. Follow-up visits revealed 2 cases of metastasis and 1 case of death.

CONCLUSION

Primary cancer of the male urethra is a rare malignancy with poor prognosis, for which radical resection is the main treatment method. Those in the relatively advanced stage can be treated by a combined method of surgery, radiotherapy and chemotherapy.

[Benign neoplasms of female urethra]

In clinical practice neoplasms of female urethra are found usually in adult women. They can also be found in adolescent girls and as rare congenital abnormality. Those conditions are most frequently detected during gynecological or urological examination. Symptoms are few. Lesions are situated at the outer orifice of urethra at the broad basis. Authors have diagnosed and treated 331 patients between 26 and 87 years. Electro coagulation has been performed in 185 patients. Surgical excision has been performed in 41 patients. Excision with following electrocoagulation has been performed in 18 patients. Conservative treatment has been performed in 87 patients. Histological sample analysis has provided diagnosis of urethral polyp, caruncle and mucosal prolaps. Second electrocoagulation after surgical excision has been performed in 5 patients. Collaboration between urologists and gynecologists is essential for early diagnosis, prophylaxis and successful treatment of above mentioned diseases.

[Primary adenocarcinoma of the female urethra treated by multimodal therapy]

A 64-year old female presented with urinary retention. Physical examination revealed a firm mass on the anterior vaginal wall. Magnetic resonance imaging showed a tumor surrounding the urethra, which invaded to the vesical triangle and the anterior vaginal wall. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were elevated, but squamous cell carcinoma antigen and prostate specific antigen were within normal limits. Pathological examinations of the transurethral and transvaginal needle biopsy specimen suggested mucinous adenocarcinoma. First, the patient received local chemoradiotherapy and systemic chemotherapy using a fluoropyrimidine drug TS-1 and cisplatin. The tumor markers declined to within normal limits after this preoperative therapy. Then she underwent total cysto-urethrectomy with anterior vaginal wall resection, pelvic lymphadenectomy, and urinary diversion with ureterocutaneous fistula. Histopathological examination of the surgical specimen showed mutinous adenocarcinoma invading to the vesical triangle and the anterior vaginal wall. No metastasis was found in the lymph nodes. The final diagnosis was urethral adenocarcinoma, pT4N0, Stage IV. Five months after surgery, local recurrence and distant metastases appeared, and she died 14 months after surgery.

Benign masses of the female periurethral tissues and anterior vaginal wall

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.

[Primary malignant melanoma of the male urethra: a case report]

A 70-year-old man presented with hematuria and urodynia. A hemorrhagic black tumor and surrounding tan-colored flat lesions were observed at the distal urethra on urethroscopy. Atypical cells consistent with malignant melanoma were noted in urinary cytologic samples. Total penectomy and prostatectomy were performed with negative surgical margin. Because of negative sentinel biopsy of inguinal lymph nodes, further lymph nodes exploration was omitted. However, recurrent tumors at the perineal region and metastases to pelvic lymph nodes appeared four months after surgery, and he died eleven months later.

Management of urethral hemangiomas associated with Klippel-Trenaunay-Weber syndrome by endoscopic sclerotherapy

Klippel-Trenaunay-Weber syndrome (KTS) is an unusual congenital anomaly characterized by cutaneous hemangiomas, varicosities and bony hypertrophy of the extremities. Herein the case is reported of a 24-year-old man with urethral bleeding from hemangiomas associated with KTS that were successfully managed by endoscopic sclerotherapy. A 23-G puncture needle was inserted into the bleeding vein to inject a 5% solution of monoethanolamine oleate (Oldamine), which is typically used for sclerotherapy of esophageal vasix. At a 4-month follow-up, the patient only had slightly bloodstained urethral discharge, and is doing well. This is the first case reporting endoscopic sclerotherapy for a KTS-associated urethral hemangioma.

Primary Rhabdomyosarcoma of Urethra in a 5-Year-Old Girl: Case Report and Literature Review

Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma of childhood, while RMS from the urinary tract has rarely been reported. Aspects of the manifestation, diagnosis, and treatment of these tumors are discussed in the case of a girl with rapidly progressive RMS from the urethral tract. She was treated with a two-stage surgical procedure and chemotherapy. At the latest follow-up visit at 18 months after treatment, the patient had no evidence of disease on clinical examination or imaging studies. The present case underscores that careful history, physical examination, and laboratory tests should be performed, in additional to using adequate tissue for routine pathologic examination, before making the diagnosis. A combined approach to treating RMS using multidrug chemotherapy and surgery has markedly improved survival.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The diagnosis and treatment of urethral recurrence after radical cystectomy

OBJECTIVE

To illustrate the problem of urethral recurrence of transitional cell carcinoma (TCC) after radical cystectomy, and define surveillance and treatment algorithms.

METHODS

There are 6 unique cases of urethral tumor recurrence presented, and current relevant literature is reviewed. Three risk groups are defined based on the likelihood of urethral recurrence. Surveillance and treatment options are delineated.

RESULTS

Although the incidence of recurrent tumor in the urethra is low, the prevalence is increasing because of improvements in bladder cancer survival and the fact that the urethra is retained more often for orthotopic urinary diversion. Patients can be categorized as low, intermediate, and high risk based on the pathologic finding of degree of prostatic involvement by the initial tumor.

CONCLUSION

Based on limited available literature, it appears that surveillance strategies range from observation alone to more invasive monitoring that includes urethral wash cytology and urethroscopy. Treatment options include local resection, intraurethral agents, and complete urethrectomy. A surveillance algorithm based on risk for recurrence and a treatment algorithm based on histopathologic risk factors of the recurrent tumor are proposed. This problem will assume increasing importance in the future.

Evaluation of palliative stenting for management of malignant urethral obstructions in dogs

OBJECTIVE

To evaluate use of balloon-expandable and self-expanding metallic stents in management of malignant urethral obstructions in dogs.

DESIGN

Original study.

ANIMALS

12 dogs with malignant urethral obstructions.

PROCEDURES

The extent and location of urethral obstructions and the diameter of adjacent unaffected luminal segments were determined by use of fluoroscopically guided wires and measuring catheters. Stents were chosen to extend approximately 1 cm proximal and distal to the obstruction. Stent diameters were chosen to be approximately 10% greater than the diameter of healthy portions of the urethra to prevent displacement. Stents were placed in the urethra under fluoroscopic guidance to restore luminal patency.

RESULTS

3 dogs received balloon-expandable metallic stents, and 9 dogs received self-expanding metallic stents. The placement procedures were rapid, safe, and effective at restoring luminal patency and were not associated with major complications. Complications included recurrent urethral obstruction secondary to blood clot formation and urethral edema in 1 dog and stent dislodgement into the urinary bladder in 1 dog. All dogs were able to urinate immediately after the procedure. Nine dogs (3/4 females and 6/8 males) were continent or mildly incontinent after stent placement. Of the remaining 3 dogs, 2 developed severe incontinence and 1 had an atonic bladder. Seven dogs were considered to have good to excellent outcome, 3 had fair outcome, and 2 had poor outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

Transurethral placement of metallic stents was a safe and effective palliative treatment option for dogs with malignant urethral obstructions.

[Adenocarcinoma of the female urethra: report of two cases and bibliography review]

OBJECTIVES

Primary adenocarcinoma of the female urethra is a rare malignancy. We report two cases and a review of the latest articles focused on classification and treatment of this kind of neoplasm.

METHODS

We present two females diagnosed of urethral adenocarcinoma, describing clinic and pathological features, diagnosis and treatment.

CONCLUSIONS

Female urethral adenocarcinoma is an uncommon neoplasm with a heterogeneous histogenesis. The distal urethral carcinoma is more amenable to treatment, and the prognosis is better than that of proximal or entire urethral carcinoma, which is often associated with extensive local invasion and metastasis.

TREATMENT OF URETHRAL RECURRENCE FOLLOWING RADICAL CYSTECTOMY AND ILEAL BLADDER SUBSTITUTION

PURPOSE

With the introduction of orthotopic bladder substitution after radical cystectomy in patients with invasive bladder cancer urethral recurrences have become a therapeutic challenge.

MATERIALS AND METHODS

We retrospectively evaluated our patients with urethral recurrences treated with a urethra sparing approach after orthotopic bladder substitution. Depending on the extension of recurrence and eventual concomitant metastases patients were treated with urethrectomy, no treatment, systemic chemotherapy or intraurethral bacillus Calmette-Guerin (BCG). Three times the common dose of BCG (ImmuCyst, Aventis, Paris, France or OncoTICE, Organon, West Orange, New Jersey) in 150 ml NaCl 0.9% was used for intraurethral BCG perfusion therapy according to an institutional protocol using a modified Foley catheter. This regimen was repeated weekly for 6 weeks and patients were followed prospectively.

RESULTS

Between 1985 and 2001, 15 of 371 patients (4%) who received an orthotopic bladder substitute had urethral recurrence. Two patients were treated with systemic chemotherapy (methotrexate, vinblastine, doxorubicin and cisplatin) alone due to metastatic disease and 10 received intraurethral BCG therapy. Five of 6 patients (83%) with carcinoma in situ remained free of recurrence following treatment with BCG, while in 4 with papillary or invasive disease treatment failed. Three patients underwent urethrectomy, including 2 following failed BCG therapy for papillary disease.

CONCLUSIONS

Carcinoma in situ urethral recurrence following orthotopic bladder substitution can be treated successfully with intraurethral BCG perfusion therapy in approximately 80% of patients. However, papillary and invasive transitional cell urethral recurrence should be treated with urethrectomy.

Small cell carcinoma arising from the proximal urethra

Primary neuroendocrine carcinomas of the lower urinary tract are distinctly rare, locally aggressive neoplasms with a high rate of metastasis. We present a case of primary small cell carcinoma of the urethra occurring in a 64-year-old man. The clinical, histological and immunohistochemical features of urethral small cell carcinoma are highlighted with respect to the differential diagnosis of neuroendocrine and other urethral tumors. The possible histogenesis of urethral small cell carcinoma, reported at this location in only a small number of cases, is briefly discussed. We favor an origin from pluripotent epithelial stem cells as one of the possible histogenic pathways.

Bulbous urethra involved in perineal extraskeletal myxoid chondrosarcoma in a child

Extraskeletal myxoid chondrosarcoma is a rare soft-tissue sarcoma that usually occurs in deep soft tissues, especially those of the proximal extremities and limb girdles, but is rare in children. We present an unusual case of a tumor arising in the perineum and involving the bulbous urethra in a 21-month-old boy. The patient was treated with surgical excision and urethroplasty followed by combination chemotherapy.

[Advanced urethral carcinoma. Which is the best management of a infrequent disease?]

Urethral cancer is an uncommon tumor (<0.1% of all genitourinary neoplasms). Most of them are squamous carcinoma, adenocarcinomas are about 5% of all urethral cancer. Surgery is the only curative treatment. Surgical technics depend of tumoral location and extension. Conservative surgery is elective if survival is not compromised. Extensive surgery is needed in large lesions. Chemotherapy (CT) and radiotherapy (RT) must be used in patients in which surgery is not possible. Due to the low incidence of this neoplasm is not well established the best therapeutic approach. We present the case of a female (35 years old) with a diagnosis of urethral adenocarcinoma. The initial stage was IV due to non-regional lymph nodes metastases. Surgery was impossible and the patient received chemotherapy and radiotherapy. The patient achieved complete response with CT but a progression was observed in course of RT. The patient died due to systemic progression.

Retrospective Study of the Treatment of Urethral Cancer

Urethral cancer is rare, encompassing less than 1% of all malignancies. Optimal management, at present, often relies on the limited experience gained from the study of retrospective cases. Therefore, it is imperative to share all available information regarding urethral cancer treatment via reportage of pertinent cases, thus enabling more complete comprehension and decision-making options by both clinicians and researchers. A retrospective review of 18 consecutive patients with primary urethral cancer was performed. An analysis was performed of clinical stage, treatment modality, and outcome. Overall patient survival rate for this retrospective was 44%, with a mean follow-up of 63.5 months. Seven of 10 patients with low-stage diagnosis remained disease free. Comparatively, only one of eight patients with high-stage cancer had no apparent disease. Patients with advanced cancer treated with surgery alone had a shorter disease-free survival (23.3 months) versus those treated with combination chemo/radiation therapy (45.2 months). The major characteristic with prognostic impact was statistically found to be low (T1-2, N0, M0) versus high (T3-4, N1, M1) stage, as assessed by Mann-Whitney U test (z = 2.83, p = 0.0023). Clinical staging afforded the strongest prognostic indication of survival. Patients with low-stage disease exhibited increased survival with single-modality therapy. However, patients with advanced cancer benefited from combined treatment using chemotherapy and radiation therapy.

Management of urethral recurrence in patients with Studer ileal neobladder

OBJECTIVE

The overall risk of urethral recurrence (UR) of transitional cell carcinoma (TCC) in patients with orthotopic neobladder ranges from 2% to 6%. We are presenting herein our experience in order to evaluate and define the management of these patients, since the cases with urethral recurrence in patients with orthotopic neobladder are very scarce.

MATERIALS AND METHODS

Five hundred and sixteen radical cystectomies due to TCC were performed at our Centre between January 1990 and February 1998. One hundred and thirty-eight of them (26.7%) underwent an orthotopic neobladder procedure with the Studer's technique. We are reviewing five cases of UR in patients with orthotopic neobladder, the cystectomy indications and the differences between the clinical and the pathologic stages. We are also assessing its clinical presentation, diagnosis, treatment and evolution.

RESULTS

Five patients (3.6%) from 50 to 71 years old with Studer's orthotopic neobladder presented with UR. All of those neobladders were initially superficial TCC, mostly multifocal, and all had failed the endovesical treatment. Endoscopic treatment was administered in two cases with superficial UR. One patient with urethral CIS received intraurethral BCG instillations. One case because of multiplicity, and another due to the presence of an infiltrating urethral tumour, underwent urethrectomy and neobladder exeresis. In both cases, the intact 15-20cm isoperistaltic proximal ileal limb of the Studer-type orthotopic neobladder was used as an ileal conduit.

CONCLUSIONS

UR in patients with orthotopic bladder substitution is unusual. A conservative approach is possible when dealing with superficial recurrences. In cases of urethrectomy, the isoperistaltic proximal ileal limb of the Studer neobladder may be used as an ileal conduit.

Adenocarcinoma of the female urethral diverticulum treated by multimodality therapy

A 75-year-old female presented with a 7-month history of intermittent macrohematuria and urinary retention. Physical examination revealed a firm, round mass on the anterior vaginal wall. The diagnosis by urethroscopy and radiological evaluation was localized urethral diverticular tumor. Pathological examination of the biopsy specimen revealed adenocarcinoma. The patient received two courses of intra-arterial and systemic chemotherapy using cisplatin, 5-fluorouracil and leucovorin, followed by radiation to the urethra. The tumor shrunk markedly after chemotherapy. The patient underwent total urethrectomy and vesicostomy. Two years after the operation, she had no evidence of recurrence. Adenocarcinoma of the female urethral diverticulum is rare and has been treated by surgery and/or radiation. The present case is the first case of it being treated by multimodality therapy including chemotherapy.

Clear cell adenocarcinoma in a female urethral diverticulum

Primary urethral carcinoma is an uncommon diagnosis, and carcinomas arising from within a urethral diverticulum are rare. Because of the limited number of diagnosed cases, optimal treatment guidelines are not available. However, patients require an aggressive treatment approach to provide the best chance for cure.

Primary adenocarcinoma arising from a paraurethral cyst in a female patient

A very rare case of primary adenocarcinoma arising from a paraurethral cyst in a 63-year-old woman is reported. Initially she was diagnosed as having a simple paraurethral cyst because of absent communication with the urethra. The resected paraurethral cyst was histologically associated with adenocarcinoma. We also performed chemotherapy composed of methotrexate, vinblastine, Adriamycin and cisplatin because of lymph node metastasis. Our treatment, however, was not effective and the patient died of systemic metastases.

Targeting actin remodeling profiles for the detection and management of urothelial cancers--a perspective for bladder cancer research

The actin cytoskeleton and numerous proteins associated with its regulation and function constitute over 25% of total proteins in the cell. Growing evidence from this laboratory and others shows that alterations of actin polymerization, or actin remodeling, plays a pivotal role in regulating the morphologic and phenotypic events of a malignant cell. The actin remodeling is the result of activation of oncogenic actin signaling pathways (e.g., Ras and Src), or inactivation of several important actin-binding proteins that have tumor suppressive functions (e.g., Gelsolin, E-Cadherin, etc.). Recently distinctive protein expression patterns of some of these genes in bladder cancer carcinogenic and progressive processes have been observed. Specific actin-pathway antagonists that have growth inhibitory effect on transformed cells, but not normal cells, have been developed. Our overall hypothesis is that actin alterations are progressive and that distinctive actin remodeling profiles are associated with different stages of cancer development and progression. These patterns can be used as markers for cancer early detection and prognostic indication. On the other hand, detection of specific types of actin-signaling pathway alterations also enables a targeted preventive or therapeutic intervention with specific actin signaling pathway blockers, thereby providing an actin-based paradigm for individualized monitoring and intervention of human bladder cancer.