Local advanced transitional cell cancer and squamous cell cancer of ... treated with neoadjuvant chemotherapy followed by radical surgery

Abstract transitional cell cancer of the urethra.
Chemotherapy with Gemcitabin and Cisplatinum
Background: Primary urethral cancer is rare, together with local radiation to the pelvis and the
accounting for less than 1% of all malignancies. The perineum was given. There was remarkable
management of the urethral cancer depends on regression of the tumour was identified by clinical
several factors which includes the clinical stage and examination and computed tomography scan after
the location of the lesion. Local surgical excision is the treatment. The patient subsequently underwent
the treatment of choice for the distal and low stage cystoprostatectomy, radical penectomy, excision of
tumor while proximal tumors need more radical the scrotum and ileal conduit. He recovered well
surgery. postoperatively.
Aim: To report a case of a young African man who Conclusion: Multimodal therapy combining
presented with locally advanced squamous cell chemotherapy and surgical resection should be used
cancer of the periurethral tissues and underlying in locally advanced cases to improve the patient's
isolated transitional cell cancer of the urethra. survival chance.
Case report: A 51-year-old man presented with a
locally advanced squamous cell cancer of the Key words: Urethral cancer, Transitional cancer,
periurethral tissues as well as an underlying isolated Squamous cell cancer, Chemotherapy
Local advanced transitional cell cancer and squamous cell cancer of the urethra
treated with neoadjuvant chemotherapy followed by radical surgery
E.H. Abdel Goad, T. De Bastiani and S. Ramksoon
Department of Urology, Nelson R Mandela School of Medicine, Durban, South Africa
Correspondence to: Dr Ehab. H. Abdel Goad,Private Bag 7, Congella 4013 Durban, South Africa
(E-mail:abdelg[email protected])Phone :[phone] Fax : [phone]
Introduction Case report
Carcinoma of the male urethra is an uncommon A case of urethral cancer treated in Nelson R
neoplasm, accounting for less than 1% of all Mandela school of medicine, Durban, South Africa
1is presented. A 51-year-old male presented with
malignancies . Aetiologic factors identified include acute urinary retention and a 1-year history of
chronic inflammation owing to a history of perineal mass and scrotal sinus. His past genito-
frequent sexually transmitted diseases, urethritis, urinary history was insignificant while his past
and urethral stricture, and there is likely a causal role medical history included diabetes mellitus,
for human papillomavirus 16 (HPV 16) in
2hypertension and tobacco abuse. On physical
squamous cell carcinoma of the urethra . Patients examination, the patient had a large tender perineal
with urethral cancer present with different lower mass fixed to the symphysis and the iliac bone and
urinary tract symptoms. The most common displacing the scrotum upward and anteriorly. The
presenting symptom is urethral bleeding and corpora spongiosum and cavernosum were
urethral mass on physical examination. Other involved up to the middle of the shaft of the penis
clinical features include urinary retentions, abscess (Figure 1). On digital rectal examination the mass
and urethrocutaneous fistula. was palpable and fixed to the pelvic structures. In
addition to the mass, there was a scrotal sinus
discharging seropurulent fluid.
Port Harcourt Medical Journal 2007; 1: 208-211 208

Figure 4. The excised penis and scrotum
Figure 1. Scrotal fistula and solid mass pushing
the scrotum anterior and superior.
Figure 2. Voiding cystourethrogram showing complete Figure 5. The urinary bladder with tumor extension
obstruction of the anterior urethra with an irregular to the membranous urethra and two stones.
posterior urethra and multiple filling defects.
Voiding cystourethrogram showed complete
obstruction of the anterior urethra with an irregular
posterior urethra and multiple calculi (Figure 2).
Further evaluation consisted of a Tru-cut biopsy
of the mass which revealed features consistent with
high grade squamous cell carcinoma. A
computerized tomography (CT) of the chest,
abdomen and pelvis revealed a large mass involving
the corpora spongiosum and cavernosum with
attachment to the rectum and the pelvic bone and
generalized pelvic lymphadenopathy.
The patient received broad spectrum antibiotics
Figure 3. CT Scan showing a solid mass replacing and neo-adjuvant chemotherapy in the form of
the corpora spongiosum and cavernosum.three cycles of cisplatinum, mitomycin and 5-
Port Harcourt Medical Journal 2007; 1: 208-211 209
Local advanced transitional cell cancer E.H. Abdel Goad, T. De Bastiani and S. Ramksoon

flurouracil. Clinical examination which was done on carcinomas of the bulbomembranous urethra are
completion of the chemotherapy treatment of squamous cell origin in 80%, of transitional cell
revealed marked decrease in the size of the mass, origin in 10%, and adenocarcinoma or
3
although still palpable, and closure of the scrotal undifferentiated in 10% .
sinus. Staging of the tumour includes clinical
Repeat CT scan confirmed the clinical findings examination, cystoscopy, and bimanual palpation to
and did not detect any abdominal lymphadenopathy evaluate the extent of local involvement of the
(Figure 3). The patient was scheduled for radical tumor. Transurethral or needle biopsy of the lesion,
penectomy, scrotectomy, cystoprostatectomy, pelvic and of the prostate if indicated, is also performed as
lymphadenectomy and urinary diversion ( ileal part of the staging (Table 1).
conduit ). The mass was excised with difficulty, as it
was attached to the iliac bone and to the rectum. Table 1. Clinical-pathologic staging for
Accidental rectal injury was encountered during urethral cancer
excision of the bladder and was primarily repaired
using vicryl and anal dilatation. Figures 4 and 5 show
the external genitalia and the excised bladder . The
testes were inserted into an inguinal pouch
bilaterally. The perineal wound was left open for
future skin graft.
The patient developed rectal fistula to the
perineal wound. This closed in 10 days of low
residue diet. The perineal wound was subsequently
covered with skin graft.
The pathological specimen showed a locally
advanced high grade transitional cell carcinoma of
the urethra with local extension to the corpus
cavernosum. The surgical margin was free of
tumour and the lymph nodes showed reactive
lymphadenopathy. There was no evidence of
squamous cell cancer in the specimen. In addition, a
focal prostatic adenocarcinoma with Gleason score
of 6 (3+3) was demonstrated within the prostate
specimen.
Due to the nature of the tumour, the patient was
administered adjuvant chemo-radiotherapy using
Urethral cancer staging in accordance with the criteria
Gemcitabin and Cisplatinum with local radiation to outlined by the American Joint Committee on Cancer
the pelvis and the perineum. The patient remains Staging System
disease free six months post treatment.
No consensus has been reached regarding the
Discussion optimal therapeutic approach for urethral tumours
due to the small number of patients treated at
The histologic subtype of urethral cancer varies by individual institutions. The overall management
anatomic location. Carcinomas of the prostatic depends on the site and the stage of the tumor.
urethra are of transitional cell origin in 90% and of Distal urethral tumours are usually of low stage
squamous cell origin in 10%, carcinomas of the and are amenable to local excision with good overall
penile urethra are of squamous cell origin in 90% prognosis. On the contrary, proximal urethral
and of transitional cell origin in 10%, and tumours present with higher stage require
Port Harcourt Medical Journal 2007; 1: 208-211 210
Local advanced transitional cell cancer E.H. Abdel Goad, T. De Bastiani and S. Ramksoon
Tx
T0
Ta
Primary tumor cannot be assessed
No evidence of primary tumor
Noninvasive papillary, polypoid, or
verrucous carcinoma
Tis
T1
Carcinoma in situ
Tumor invades subepithelial connective
tissue
T2 Tumor invades any of the following :
corpus spongiosum, prostate, periurethral
muscle
T3 Tumor invades any of the following:
corpus cavernosum, beyond prostate
capsule, anterior vagina, bladder neck
T4 Tumor invades other adjacent organs
Regional
lymph nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph nodes metastasis
N1 Metastasis in a single lymph node, 2 cm
or less in greatest dimension
N2 Metastasis in a single lymph node, more
than 2 cm in greatest dimension, or in
multiple lymph nodes
Distant
metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metatasis
Primary tumor (T) (men and women)

multimodality approach for treatment with overall be considered. Adjuvant chemo-radiotherapy was
poor prognosis. The 5-year disease-free survival rate chosen because the tumuor was locally advanced
of proximal urethral tumours is only 20% to 30% and of high grade.
4
with surgical therapy only .
Radical cystoprostatectomy, pelvic
lymphadenectomy, and total penectomy are usually References
required. Extending the operation to include in-
continuity resection of the pubic rami and the 1Levine RL. Urethral cancer. Cancer 1980;
adjacent urogenital diaphragm may improve the
245 ( 7 Suppl ): 1965-1972.
margin of resection and local control . 2Donat SM, Cozzi PJ, Herr HW. Surgery of
Most of the urethral tumuors are high stage, penile and urethral carcinoma. In: Walsh PC,
making surgical resection inadequate as the sole Retik AB, Vaughan ED Jr, Wein AJ, eds.
modality of treatment. Furthermore, in several Campbell's Urology. 8th ed. Philadelphia: WB
series, patients who received radiation therapy and Saunders, 2002: 2983 -2998.
then salvage surgery seemed to fare worse than if
5, 6 3Grigsby PW, Herr HW. Urethral tumors. In:
surgery was performed first . Vogelzang J, Scardino PT, Shipley WU, Coffey
Disease-free survival rate of 60% to 100% was DS, eds. Comprehensive Textbook of Genitourinary
achieved, in reported cases, with the use of nd
Oncology. 2 edition. Philadelphia: Lippincott,
chemotherapy (5-Fluorouracil, Cisplatin or Williams & Wilkins, 2000: 1133-1140.
Mitomycin C) and radiation therapy as neoadjuvant
7 - 9 4Baskin LS, Turzan C. Carcinoma of male
treatment . urethra: management of locally advanced
Patients with low stage urethral tumours had disease with combined chemotherapy,
good treatment outcomes regardless of treatment radiotherapy, and penile-preserving surgery.
employed (surgery versus multimodal therapy) and Urology 1992; 39: 21-25.
local surgical therapy should be used as the primary 5Zeidman EJ, Desmond P, and Thompson IM.
treatment. Insufficient data are available to Surgical treatment of carcinoma of the male
recommend certain modality of treatment in urethra. Urol Clin North Am 1992; 19: 359-372.
advanced urethral tumours. However, previous 6Dalbagni G, Zhang ZF, Lacombe L, Herr HW.
series have found a high incidence of local Male urethral carcinoma: analysis of treatment
recurrence and metastasis with single modality
1,4-9 outcome. Urology 1999; 53: 1126-1132.
therapy . 7Gheiler EL, Tefilli MV, Tiguert R, de Oliveira
From the literature, it appears that JG, Pontes JE, Wood DP Jr. Management of
multimodality therapy may provide better disease- primary urethral cancer. Urology 1998; 52: 487-
free survival. 493.
In addition to local control, chemotherapy treats 8Johnson DW, Kessler JF, Ferrigni RG, Anderson
micro metastases associated with such aggressive JD . L o w d o s e c o m b i n e d
tumuor with possible benefit to the overall survival. chemothe rapy/ radio therapy i n th e
In our case the patient had clinically and management of locally advanced urethral
radiologically irresectable locally advanced urethral squamous carcinoma. J Urol 1989; 141: 615-616.
tumour. The tumour showed remarkable regression 9Tran LN, Krieg RM, Szabo RJ. Combination
on chemotherapy which encouraged the decision chemotherapy and radiotherapy for a locally
for a radical surgical excision. The surgical margin advanced squamous cell carcinoma of the
was clear and in spite of the development of recto urethra: a case report. J Urol 1995; 153: 422-423.
cutaneous fistula the patient did well. Although the
radiotherapy may increase the morbidity of the
treatment, the risk of the tumour recurrence should
Port Harcourt Medical Journal 2007; 1: 208-211 211
Local advanced transitional cell cancer E.H. Abdel Goad, T. De Bastiani and S. Ramksoon