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| Journal of the New Zealand Medical Association,
22-September-2006, Vol 119 No 1242
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Managing squamous cell carcinoma of the bulbomembranous male
urethra with genital-preserving surgery and chemoradiotherapy
Alison Finall, Martha Nicholson, John North, Kampta
Samalia
Invasive squamous cell carcinoma (SCC) of the
bulbomembranous urethra is rare. Radical disfiguring surgery is often
recommended to control this aggressive disease, with subsequent 5-year survival
rates of 5–15%.1
Evidence regarding treatment using genital preserving
surgery and coordinated chemoradiotherapy is scarce. We report a case of SCC of
the bulbomembranous urethra managed using this less mutilating method; results
were encouraging.
Case reportA 62-year-old sexually active man presented in December 2004
with a recurrent episode of obstructive urinary symptoms secondary to a benign
stricture of the bulbomembranous urethra. The stricture was related to traumatic
postoperative urinary catheter insertion in July 2000 and was initially
diagnosed by rigid cystoscopy.
Eight subsequent dilatations were required over the next 4
years, each time with a benign cystoscopic examination. Abdominal, perineal, and
per rectal (PR) examination were normal. A buccal patch urethroplasty was
planned as definitive treatment for February 2005.
Figure 1. Descending urethrogram of patient showing
stricturing of the bulbomembraneous urethra
 During surgery, examination of the stricture had become
abnormally hard in texture. Frozen section suggested transitional cell carcinoma
with extension into periurethral tissues. Consequently, the urethra was excised
from the base of the prostate to meatus with adjacent periurethral tissue. A
postoperative staging CT scan of the chest, abdomen, and pelvis showed no
evidence of lymph node or distant metastases.
A definitive diagnosis of poorly differentiated squamous
cell carcinoma was made on haematoxylin and eosin (H&E) histological
section. There was microscopic involvement of the proximal resection margin, in
addition to perineural and lymphovascular invasion. He had significant risk of
occult metastases to pelvic and inguinal lymph nodes and was staged as having T4
N0 M0 disease (Stage C, Ray’s classification).1
The patient subsequently received 40 Gy / 20 fractions to
the lower pelvis and urethra, plus a 10 / 5 boost to the perineum, and 2 cycles
of mitomycin C (10 mg/m2 stat day 1) and 5 fluorouracil (5FU) (1000 mg/m2 daily
x 4 days, days 1–4), 4 weeks apart. He had no evidence of recurrence 13
months from diagnosis.
DiscussionThe aetiology of SCC of the male urethra appears to have an
association with the presence of HPV 16.2 Other chronic inflammatory conditions,
such as urethral condylomas and urethral stricture disease, as in this case,
also have an association.3 Definitive diagnosis is made by biopsy. Voided urine
cytology is not a useful diagnostic tool.4
Patients with locally advanced squamous cell carcinoma of
the bulbomembraneous urethra fare poorly with radical surgery or primary
radiotherapy.1
The use of chemoradiotherapy in the treatment of SCC of the
anus, penis, and oesophagus has a well-established base in evidence.3 There is a
small amount of evidence regarding a variety of chemoradiotherapy regimes in the
treatment of urethral SCC.5–7 For comparison, we describe two using
mitomicin-C and fluorouracil specifically.
Lutz and Huang (1995) treated a 47-year-old man with
gonococcal urethritis and a poorly differentiated SCC (Stage 4, T4N2M0).8.
Mitomycin C, 5-fluorouracil, and radiotherapy caused marked regression of the
tumour. He had no clinical evidence of disease 16 months after diagnosis.
The second publication by Oberfield et al (1996) describes
two similar cases.3 A 42-year-old man with moderately differentiated stage C
disease (T4N0M0) was given 5FU, mitomycin C and radiation of 45Gy to the primary
site and groin regions. The patient went into full remission for 18 months. The
second patient, a 49-year-old man diagnosed with a 6 x 4 cm proximal bulbous
urethral SCC (Stage C, T4N0M0) was treated similarly. This man survived
disease-free for 4 years.
Our findings add to the evidence in favour of using
chemoradiotherapy in conjunction with genital-preserving surgery for the
treatment of this unusual malignancy.
Author information:
Alison Finall, Department of Urology; Martha Nicholson, Department of Pathology;
John North, Department of Oncology; Kampta Samalia, Department of Urology;
Dunedin Public Hospital, Dunedin
Correspondence: Dr
Alison Finall, Dept of Pathology, Aberdeen Royal Infirmary, Foresterhill Road,
Aberdeen AB25 2ZD, UK. Fax: +44 1224 663002;
email:
afinall1@doctors.org.uk
References:
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