Pathology and natural history of urethral tumors in males. Review of 142 cases

Primary mucinous adenocarcinoma of the urethra: A clinicopathological analysis of 35 cases

AIM

Primary mucinous adenocarcinoma of the urethra represents an extremely rare entity. We sought to characterise further these tumours' clinicopathological, immunohistochemical and molecular features.

METHODS AND RESULTS

Thirty-five cases were identified, occurring in 18 males and 17 females. The mean age at diagnosis was 65 years (28-89 years). The main presentation symptoms were haematuria and urinary outlet obstruction. Microscopic analysis revealed that all 35 tumours have stromal dissection by mucin. Ten tumours showed villoglandular dysplasia, nine showed mucinous metaplasia, two showed adenocarcinoma in situ and four showed signet ring cell features. All tumours were immunopositive for CEA, while immunonegative for nuclear β-catenin; 19 of 23 (83%) expressed high molecular weight cytokeratin; 19 of 33 (58%) CK7; 28 of 34 (82%) CK20; 32 of 35 (91%) CDX2; 22 of 27 (81%) cadherin-17 (CDH-17); 26 of 29 (90%) SATB2; and one of 31 (3%) GATA3. Mismatch repair gene products, including MLH1, PMS2, MSH2 and MSH6, were immunopositive, suggesting the MSI-low genotype of mucinous adenocarcinoma of the urethra. BRAF V600E and ALK rearrangements were not detected. During the mean follow-up of 20 months, nine patients either developed distant metastasis or succumbed to the illness.

CONCLUSION

Our study, encompassing the most extensive series of 35 cases of primary mucinous adenocarcinoma of the urethra, provides crucial insights into its precise diagnosis, management and potential targeted treatments. We found a greater CDX2, SATB2 and CDH17 sensitivity in these urethral tumours for the first time, to our knowledge. We identified characteristics such as an MSI-low profile, non-V600E BRAF mutations and an absence of ALK rearrangements.

Clear cell adenocarcinoma of the male urethra: a case report

Background

Primary urethral cancer in males is rare. Clear cell adenocarcinoma is more rare. We report a case in an African male suspected to have a urethral stricture.

Case presentation

A 66-year-old man presented in with preceding intermittent haematuria and acute urinary retention. Failed attempts at catheterisation necessitating a suprapubic catheter insertion raised the suspicion of a urethral stricture. Multiple irregular urethral filling defects were seen on a retrograde urethrogram. Urethroscopy revealed obstructing urethral masses. Histology reported clear cell adenocarcinoma.

Conclusion

Primary urethral cancer should be entertained as a differential diagnosis of a urethral stricture in a patient with haematuria, difficult urethral catheterisation and ambiguous urethrogram findings. Cystoscopy and biopsy are essential in the investigative work-up to make the distinction.

Nomograms for predicting long-term overall survival and cancer-specific survival in patients with primary urethral carcinoma: a population-based study

BACKGROUND

Our aim was to identify the independent prognostic factors in patients with primary urethral carcinoma (PUC) and to predict their overall survival (OS) and cancer-specific survival (CSS) at 3, 5, and 8 years.

METHODS

Patients with PUC identified in the Surveillance, Epidemiology, and End Results (SEER) database were divided into training and validation cohorts. Nomograms were constructed based on the results of Cox regression analysis. The predictive performance of each nomogram was evaluated using the consistency index (C-index), the area under the receiver operating characteristics curve (AUC), and calibration plots. Decision-curve analysis (DCA) was used to test the clinical value of the predictive models.

RESULTS

Our study screened 822 patients with PUC. Multivariate analysis showed that the age at diagnosis, race, histology, American Joint Committee on Cancer (AJCC) stage, and surgery status were independent prognostic factors for CSS and age at diagnosis, race, histology, AJCC stage, surgery status, and chemotherapy for OS (all P < 0.05). We used these prognostic factors to construct nomograms. The C-indexes for OS and CSS were 0.713 and 0.741 in training cohorts and 0.714 and 0.738 in validation cohorts, respectively. The AUC and calibration plots demonstrated the good performance of both nomograms. The DCA indicated the presence of clinical net benefits in both the training and validation cohorts.

CONCLUSION

We developed and validated nomograms for predicting OS and CSS in patients with PUC, which can help clinicians make treatment decisions.

Carcinoma of the urethra

Primary carcinomas of the urethra are rare and poorly understood lesions; hence, their clinical and pathologic spectrum is not completely defined. We analyzed a series of 130 primary urethral tumors and classified 106 of them as primary urethral carcinomas. The age at diagnosis of patients with primary urethral carcinomas ranged from 42 to 97 years (mean, 69.4 years; median, 70 years). There were 73 male and 33 female patients with a ratio of 2.2:1. In male patients, the tumors most frequently developed in the bulbous-membranous segment of the urethra. In female patients, the entire length of the urethra was typically involved. Microscopically, they were poorly differentiated carcinomas with hybrid squamous and urothelial features and developed from precursor intraepithelial conditions such as dysplasia and carcinoma in situ, which were frequently present in the adjacent urethral mucosa. High-risk human papilloma virus infection could be documented in 31.6% of these tumors. Follow-up information was available for 95 patients. Twenty-three patients died of the disease with a mean and median survival of 39 and 21 months, respectively. Urethral carcinomas are aggressive tumors with a high propensity for regional and distant metastases with mean and median survival of 39 and 21 months, respectively. Our observations have important implications for the management of patients with primary carcinoma of the urethra by defining them as a unique entity linked to human papilloma virus infection.

Imaging of the Male Urethra

For imaging of the male urethra, conventional radiographic contrast studies including retrograde urethrography are most commonly utilized. They are best suited for delineating luminal abnormalities of the urethra and thus are commonly used as the primary imaging modality for patients with various urethral abnormalities such as trauma, inflammation, and stricture. More recently, the cross-sectional imaging techniques of ultrasound, computed tomography and magnetic resonance imaging have been utilized increasingly for urethral and periurethral abnormalities. These studies are most valuable as an adjunctive tool in patients with the complex anatomical derangements such as congenital anomalies, posterior (or bulbomembranous) urethral injuries, and with urethral or periurethral tumors. These cross-sectional techniques can be performed during micturition or with retrograde injection of saline or jelly through the urethral meatus to improve visualization of the urethral luminal abnormalities. This article describes imaging techniques, anatomy, and findings of various urethral and periurethral pathology in the male including congenital anomalies, infection/inflammation, stricture, traumatic injury, fistula, tumors, and calculi.

Mucin-producing urothelial-type adenocarcinoma of prostate: report of two cases of a rare and diagnostically challenging entity

The differential diagnosis of mucin-producing adenocarcinoma of the prostate includes conventional prostatic adenocarcinoma with mucin production, secondary adenocarcinoma usually of colorectal origin and, very rarely, urothelial-type adenocarcinoma arising from either the prostatic urethra or proximal ducts. Conventional prostatic adenocarcinoma with mucin production is readily identified by routine microscopy and immunohistochemistry. The distinction between secondary adenocarcinoma and urothelial-type adenocarcinoma, however, can present a significant diagnostic challenge. In addition, documented examples of the latter in the prostate are exceptionally rare. A transurethral resection of prostate specimen and prostatic needle biopsies from two patients showing urothelial-type adenocarcinoma of the prostate were identified in our consultation files. One of the patients subsequently underwent a radical prostatectomy. Both patients had negative gastrointestinal endoscopic workups. Transurethral resection of prostate material from two patients with clinically confirmed secondary adenocarcinoma of colonic origin involving the prostate and a prostatectomy specimen with mucinous conventional prostatic adenocarcinoma were also identified for comparison purposes. Formalin-fixed, paraffin-embedded sections were stained for prostate-specific antigen (PSA), prostatic acid phosphatase, carcinoembryonic antigen, cytokeratin 7, cytokeratin 20 and high molecular weight cytokeratin 34betaE12. The urothelial-type adenocarcinoma cases were diffusely positive for cytokeratin 7 and focally positive for 34betaE12 and cytokeratin 20, consistent with an origin from the urothelium of the prostatic urethra or proximal prostatic ducts. In contrast, the secondary adenocarcinoma of colonic origin cases were diffusely cytokeratin 20 positive and either negative or focally positive for cytokeratin 7 and negative for 34betaE12. The mucinous conventional prostatic adenocarcinoma was positive for PSA and prostatic acid phosphatase and negative for cytokeratin 7, cytokeratin 20 and 34betaE12. All tumors were positive for carcinoembryonic antigen.

Abdominoperineal excision of male lower urinary tract for synchronous adenocarcinoma of urethra and urinary bladder

Urethral adenocarcinoma is the least common histologic subtype of a rare primary carcinoma of the male urethra. Its site of origin remains speculative. The scarcity of reported cases in the literature makes it difficult to define the optimal management. This report is of a 40-year-old morbidly obese man with synchronous adenocarcinoma of the bulbar urethra and bladder, treated surgically by en bloc abdominoperineal penoprostatocystectomy. The pleural recurrence, after a disease-free period of 2 years, responded well to platinum-docetaxel-based systemic chemotherapy. Synchronous occurrence of adenocarcinoma of the urethra and bladder has not been previously reported. This case also highlights the possible role of upcoming adjuvant chemotherapeutic agents.

MR imaging of the male and female urethra

Conventional radiographic contrast material-enhanced studies (eg, retrograde urethrography [RUG], voiding cystourethrography [VCUG], double-balloon catheter urethrography) and ultrasonography are useful in evaluating the anatomy of the urethra but are limited in demonstrating anatomic derangement of adjacent structures. Since the anatomic details of both the urethra and periurethral tissues can be evaluated noninvasively with magnetic resonance (MR) imaging, this modality can be used as an adjunctive tool for evaluation of urethral abnormalities. In patients with congenital anomalies, MR imaging is reserved for cases of intersex anomalies or complex genitourinary anomalies, in which evaluation of internal organs is essential. MR imaging may demonstrate diverticula that are not seen on radiographic contrast-enhanced studies, including VCUG, RUG, or double-balloon catheter study. In cases of inflammation, MR imaging can demonstrate not only inflammatory infiltration around the urethra but also the presence of a periurethral abscess or sinus tract. In cases of trauma, MR imaging is helpful in assessing the presence and extent of anterior or posterior urethral injury and predicting the occurrence of complications. At MR imaging, a fistula can be seen as a direct communicating channel with an adjacent organ. In patients with urethral tumors, the major role of MR imaging is in local staging.

Carcinoma of male urethra: management of locally advanced disease with combined chemotherapy, radiotherapy, and penile-preserving surgery

Squamous cell carcinoma of the urethra is a rare urologic malignancy. In spite of aggressive management with radical and often times disfiguring surgery and/or radiation therapy, prognosis remains poor. Initial success in treating squamous cell carcinoma of the esophagus and anal canal has been reported with a combined radiation and chemotherapy protocol. In hopes for improving the treatment outcome for patients with squamous cell carcinoma of the urethra, we have applied the new combination chemotherapy/radiation therapy protocol. Herein, we report the successful downstaging (clinical Stage C to pathologic Stage TO) and treatment of squamous cell carcinoma of the anterior urethra with combination chemotherapy/radiation therapy. This was followed with penile-preserving surgery to document local control of disease and to avoid the morbidity of a radical disfiguring operation.

Colonic-type adenocarcinoma of male urethra

A case of a rare primary urethral carcinoma is presented. The histochemical characteristics of this tumor are identical to those of colon tumors. The patient was treated with segmental urethrectomy.

Detection of human papillomavirus-6 in primary carcinoma of the urethra in men

The authors report a case of primary urethral carcinoma which seems to be linked to human papillomavirus (HPV) infection. Southern blot hybridization of phosphorus 32 (32P)-labeled DNA extracted from the cancer tissue gave a positive reaction with HPV-6. Specimens of the tumor material subjected to in situ hybridization with 3H-labeled HPV-6 DNA showed numerous tumor cell clusters with clearly labeled nuclei. Using immunoperoxidase staining the authors found papillomavirus structural antigen within cell nuclei of the tumor tissue.

Benign prostatic epithelial polyp of urethra

A case report of polypoid tumor of the prostatic urethra is presented. The tumor was resected transurethrally, and histologic examination revealed a papillary tumor containing prostatic glandular structure.

Papillary adenocarcinoma of the male urethra. Case report and review of the literature

Mucinous papillary adenocarcinoma of the bulbous urethra developed in a 40-year-old man with congenital stricture. The tumor appeared as a localized polypoid exophytic mass without evidence of submucosal invasion (Stage 0). The tumor was determined not to be of prostatic origin clinically and by absence of immunoperoxidase staining for prostatic acid phosphatase, prostate specific antigen, and carcinoembryonic antigen. Surgical resection of the urethra revealed extensive squamous and glandular metaplasia (urethritis glandularis) in association with the neoplasm. The mucosa displayed a spectrum of epithelial changes varying from dysplasia to carcinoma in situ, in confirmation of the urethral origin of the tumor. These observations emphasize the close association of metaplastic proliferative lesions and malignancy in the lower urinary tract.

Primary carcinoma of male urethra

Carcinoma of the male urethra is infrequent. To date approximately 600 cases have been reported. We reviewed 16 cases of carcinoma of the male urethra seen at the University of Tennessee and the Memphis Veterans Administration Hospital. The mean patient age was sixty-three years (range 38 to 84). The most common presentation was a palpable mass followed by symptoms of urinary obstruction. Five urethral carcinomas arose distal to the suspensory ligament of the penis while 11 were of bulbar or bulbomembranous origin. The histology was squamous cell carcinoma in 8 patients (50%), mixed squamous and transitional cell carcinoma in 5 (31%), transitional cell carcinoma in 2 (13%), and adenocarcinoma in 1 (6%). The mean patient survival was fifteen months following diagnosis of a proximal urethral tumor and seventy-seven months for tumors arising distally. Neoplasms of the distal urethra can be surgically managed successfully even if regional lymph nodes are involved. The prognosis for proximal urethra tumors remains poor and is best treated by a combination of surgery and radiotherapy.

Benign prostatic epithelial polyp of the urethra

Acquired polyps of the male urethra often present with hematuria and sometimes hemospermia. The histogenesis of these tumors has been debated. We report a case of a prostatic urethral polyp that proved to be of prostatic epithelial differentiation, as demonstrated by immunohistochemical identification of prostatic acid phosphatase and prostatic specific antigen within the tumor cells.

Papillomavirus structural antigens in condyloma acuminatum of the male urethra

Current developments in the technology of viral identification have rekindled interest in the relationship of human papillomaviruses, condylomata acuminata and neoplasia. Although important observations are being reported in the female genital system the association of human papillomavirus and mucosal condylomata in male patients has not been well documented. Using the horseradish peroxidase technique and antisera to papillomaviruses, viral antigens were identified in 62 per cent of male patients with urethral condylomata acuminata. The implications of this relationship are discussed briefly.

Transitional cell carcinoma of the urethra in a young male with neurogenic bladder. A case report

We are reporting on a 23 year old white male with neurogenic bladder disease secondary to spinal cord injury, who recently was discovered as having a primary transitional cell carcinoma of the posterior urethra. He is the youngest patient with neurologic involvement of the lower urinary tract presenting a malignant urethral tumor.

Mixed mucinous and papillary adenocarcinoma involving male urethra, probably originating in periurethral glands

The case of a patient with primary adenocarcinoma involving the urethra is described. Morphologic evidence supporting an origin in the periurethral glands is presented. The urologist and pathologist must maintain a high index of suspicion in evaluating patients with urethral structure or urethrocutaneous fistulae because superficial transurethral biopsy may fail to obtain adequate depth to demonstrate malignancy.

Primary urethral neoplasms: review of 30 cases

The recent literature shows our findings on primary urethral neoplasms to be consistent with others, although we did not show an increased incidence of these neoplasms in female over male subjects. Similarly, we recommend an operation with or without irradiation, depending on the stage and location of the lesion. The over-all prognosis of urethral neoplasms remains poor. However, the distal urethral lesions in male and female subjects are easier to approach surgically and seem to be diagnosed earlier in the progression of this disease than the more proximally advanced tumors. These early staged and distal neoplasms greatly improve the changes of long survival. The delay in diagnosis gives this neoplasm its poor prognosis. In men the prognosis probably could be improved by more aggressive evaluation of stricture disease, especially when the need for dilation becomes frequent. In women we believe that the caruncle should be biopsied if it shows signs of progression or remains symptomatic (pain, bleeding and so forth). If a 1 to 2-month course of antimicrobials does not resolve this lesion we recommend biopsy. A relationship between tumor and a diverticulum has been noted in the literature, as in 1 of our cases of adenocarcinoma in a female patient. Whether this relationship could be explained on the basis of recurrent infection and stasis remains theoretical. In conclusion, early diagnosis, accurate staging and aggressive treatments are the means for cure of this disease.