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Primary Squamous Cell Carcinoma of the Male Proximal Urethra

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Primary Squamous Cell Carcinoma of the Male Proximal Urethra EUF-685; No. of Pages 7 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X ava ilable at www.sciencedirect.com journa l homepage: www.europeanurology.com/eufocus Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre a,d,e a a a Fabio Castiglione , Hussain M. Alnajjar , Michelle Christodoulidou , Maarten Albersen , a b b c a a Arie Parnham , Alex Freeman , Charles Jameson , Anita Mitra , Raj Nigam , Peter Malone , a,d,e, Asif Muneer *, on behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists a b Department of Urology, University College London Hospital, London, UK; Department of Pathology, University College London Hospital, London, UK; c d Department of Oncology, University College London Hospital, London, UK; NIHR Biomedical Research Centre, University College London Hospital, London, e UK; Division of Surgery and Interventional Science, University College London, London, UK Article info Abstract Article history: Background: Primary squamous cell carcinoma (SCC) of the male proximal urethra is an aggressive and rare urogenital malignancy. Accepted February 25, 2019 Objective: To review the surgical management and outcomes for male proximal urethral SCCs within a single centre and to suggest an algorithm for the surgical management of Associate Editor: Malte Rieken these rare tumours. Design, setting, and participants: This was a retrospective study of patients undergoing Keywords: surgery for male proximal urethral SCC within a single tertiary academic centre Primary urethral cancer managing rare genital tumours. Ten patients with a histological diagnosis of proximal urethral SCC were identified from an institutional database over a period of 10 yr with a Urethral tumour median follow-up of 22.5 mo (standard deviation Æ 25.77 mo). Proximal urethral cancer Outcome measurements and statistical analysis: Pathological staging, surgical treat- Urethra ment, and neoadjuvant and adjuvant treatment were recorded. Complications according Squamous cell carcinoma to the Clavien-Dindo classification and overall survival rates were recorded. Kaplan- Meier curves were used for overall survival. Results and limitations: A total of 10 patients were identified of whom eight underwent panurethrectomy and radical prostatectomy. Radical inguinal lymphadenectomy was performed in five patients, which confirmed bilateral metastatic disease. Perioperative complicationswere reportedin six patients (Clavien I and II). Within6 moof surgery, 90% of patients developed distant metastatic disease. Nine patients died of urethra cancer during the follow-up. One patient is still on follow-up. The median overall follow-up was 13.92 mo (range: 5–91 mo).At 5 yr, cancer-specific/overall survivalwas10%. A limitationof thisstudy is the retrospective design, which is unavoidable for such a rare disease. Conclusions: Radical surgery allows local disease control, but despite neo/adjuvant treatment, proximal urethral SCC is associated with poor survival outcomes and progression to distant metastatic disease within 6 mo. Patient summary: Proximal urethral squamous cell carcinoma is a rare cancer in men which is often detected late. Patients often present with problems such as voiding, urethral bleeding, or a palpable mass. Aggressive surgery allows local control, but despite this the overall survival is poor. Adjuvant and neoadjuvant radiochemotherapy can improve survival. Multicentric randomised trials are needed to identify the correct treatment modality. © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. University College London Hospital, London, UK. Tel. +44(0)7779652389. E-mail address: [email protected] (A. Muneer). https://doi.org/10.1016/j.euf.2019.02.016 2405-4569/© 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved. Please cite this article in press as: Castiglione F, et al. Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre.DownloadedEur forUrol AnonymousFocus User(2019), (n/a) athttps://doi.org/10.1016/j.euf.2019.02.016 University of Wisconsin Madison from ClinicalKey.com by Elsevier on June 12, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. EUF-685; No. of Pages 7 2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X included in the study. Patients with a diagnosis of non-SCC (eg, mela- 1. Introduction noma, lymphoma of the urethra), prostatic adenocarcinoma, and pri- mary bladder TCC with urethral involvement (at presentation or later) Primary male urethral cancer (PUC) is a rare and aggres- were excluded from the cohort. Patients with missing clinical informa- sive tumour accounting for <1% of all genitourinary malig- tion were also excluded. OS was calculated from the date of diagnosis to nancies [1] and 0.02% of all cancers [2,3]. Risk factors the date of death or last follow-up. Kaplan-Meier curves were used to include a history of urethral strictures, chronic irritation show the OS. following intermittent self-catheterisation, previous ure- All statistical tests were performed using the R Studio graphical throplasty, external-beam radiation therapy (EBRT), radio- interface v.0.98 for R software environment v.3.0.2. active seed implantation, and chronic urethral inflamma- tion/urethritis following sexually transmitted diseases [4– 3. Results 11]. Patients can present with urinary obstruction, irrita- tive voiding symptoms, haematuria, or a penile discharge A total of 10 cases with histologically proven proximal that is often associated with a palpable lump in the penis urethral SCC were treated within a single centre. Fifteen or perineum [10,11]. patients were excluded from the study because they did not PUCs present as variable histological subtypes. The most meet the inclusion criteria. Patient characteristics are common histological subtypes reported in the Surveillance, shown in Table 1. The median follow-up was 21.8 mo (stan- Epidemiology, and End Results (SEER) review of dard deviation Æ 25.5 mo). 1615 patients were transitional cell carcinoma (TCC) repre- senting 55%, squamous cell carcinoma (SCC) representing 3.1. Clinical presentation 21.5%, and adenocarcinoma accounting for 16.4% [12]. Of all the urethral tumours, anterior urethral tumours have a The mean age at presentation was 55 yr (range: 46–64 yr). higher incidence than posterior urethral tumours Two patients had distant metastasis (pulmonary) at the time [10,11]. SCC is the predominant subtype in the fossa navi- of diagnosis. Three patients presented with proximal urethral cularis and the anterior urethra. TCCs account for 80–90% of posterior urethral tumours [10–12]. – Clinical management and prognosis are related to the Table 1 Patient characteristics. clinical stage and location of the tumour at presentation Variable Overall (n = 10) [10–14]. Conventionally, the anterior urethra includes the Age at surgery (yr) penile and the bulbar urethra, and the posterior urethra Median 55 includes the prostatic and the membranous urethra. Range 43–64 Proximal PUCs refer to tumours in the prostatic, mem- Follow-up (mo) branous, and bulbar urethra, whereas distal tumours Median 22 Range 6–90 involve the penile urethra and fossa navicularis. Although Race (n) this is a nonspecific nomenclature, it is now increasingly White 8 used within the literature [10,11]. Black 2 In men, proximal PUCs are usually more aggressive than Other 0 Pathological grade (n) distal PUCs. Distal urethral tumours tend to be of low stage, G1 0 with reported cure rates of 70–90% following local surgical G2 2 – excision and radiotherapy [10 14]. Most cases (66%) of G3 8 proximal PUC are at an advanced stage at presentation. Pathological tumour stage (n) T1–2 3 The optimal multidisciplinary treatment strategy for proxi- T3–4 7 mal urethral cancer is still unclear. Owing to the small Inguinal lymph node status (n) number of patients who develop these proximal urethral pNx 5 pN0 0 SCC, standardised treatment options are lacking with cases pN1 2 often treated along local protocols on a case-by-case basis pN2 3 [10–14]. Pelvic lymph node status (n) The aim of this study was to analyse the data regarding pNx 9 pN0 0 treatment responses and survival outcomes for patients pN1 1 with advanced proximal urethral SCC managed within a PNI (n) single institution. Yes 7 No 3 LNI, n (%) 2. Patients and methods Yes 8 No 2 We retrospectively collected data of patients diagnosed with proximal ECE, n (%) urethral SCC from an institutional database. Yes 3 No 2 Data were recorded on a standardised pro forma and included patient age, histological subtypes, surgical management, postoperative compli- ECE = extracapsular extension; LNI = lymph node involvement; cations, use of chemoradiotherapy, and overall survival (OS) rates. Only PNI = perineural invasion. patients >18 yr old with SCC located in the proximal urethra were Please cite this article in press as: Castiglione F, et al. Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre.DownloadedEur forUrol AnonymousFocus (2019), User (n/a)https://doi.org/10.1016/j.euf.2019.02.016 at University of Wisconsin Madison from ClinicalKey.com by Elsevier on June 12, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. EUF-685; No. of Pages 7 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X 3 Fig. 1 – (A) Sagittal MRI showing extensive posterior urethral tumour with bilateral testicular involvement and infiltration of the corpora. (B) Descending urethrogram demonstrating fistula between the scrotum and the urethra. MRI = magnetic resonance imaging.
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