Chemotherapy for adenocarcinomas of bladder and urachal origin: 5-fluorouracil, doxorubicin, and mitomycin-C

Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as treatment choice of metastatic Urachal carcinoma

INTRODUCTION

Urachal carcinoma accounts for approximately 0.01 % of all adult malignancies and 1 % of bladder cancers. Its prognosis remains poor, with a 5-year overall survival rate of less than 50 %.

PRESENTATION OF CASE

A 51-years-old black female, affected by peritoneal malignancies from urachal carcinoma, underwent multiple surgical cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with different chemotherapy regimen, alternating with intravenous chemotherapy. Thirty-two months recurrence-free survival was registered, and overall survival was more than 5 years.

DISCUSSION

Our case suggests the importance of rigorous follow-up with both tumor marker testing (CEA) and imaging studies. Optimal debulking surgery plays a pivotal role in controlling primary and recurrent disease. The use of combined intraperitoneal and intravenous chemotherapy may have contributed to her long-term survival.

CONCLUSION

CRS and HIPEC combined with intravenous chemotherapy may be potential candidates for treating patients with urachal carcinoma with peritoneal metastases. Our patient is a challenging case in daily surgical practice.

Urachal carcinoma: The journey so far and the road ahead

Urachal carcinoma, a rare cancer arising from urachus, accounts for about 1% of bladder cancer. The diagnosis at stage I shows about 63% 5-year survival whereas only 8% of the patients at stage IV shows a 5-year survival. Above 90% of urachal carcinomas are adenocarcinomas and most of the urachal carcinoma cases are invasive, showing a high resemblance to adenocarcinoma of various origins, making it hard for a conclusive diagnosis. Even though inconclusive, immunohistochemistry can play a significant role in identifying urachal carcinoma. Most cases show the biomarkers CK20 and CDX2, whereas CK7 and β-catenin are expressed at a lesser frequency. Due to the few cases available, there is a lack of evidence regarding specific markers differentiating urachal carcinoma from colorectal or primary bladder adenocarcinomas. In addition to immunohistochemistry, genomic characterization is emerging to play a role in the classification and treatment of the disease. Urachal carcinoma has been reported to have a molecular level similarity with colorectal malignancies regarding certain gene expressions. The TP53 mutations inactivating the tumor suppressor can probably be explored as a possible target in treating urachal carcinoma. Additionally, certain targets identified in gastric and breast cancer along with anti-HER2 treatment strategies can be explored. Immuno-oncology utilizes immune checkpoint inhibitors for the treatment of MSI-H tumors whereas a combination of tyrosine kinase inhibitors along with immune checkpoint inhibitors are being studied to treat MSI stable tumors. The article is an in-depth overview of urachal carcinoma addressing the current landscape with an emphasis on the future scenario.

Challenges and opportunities in the management of non-urothelial bladder cancers

Urothelial carcinoma accounts for approximately 90% of all bladder cancer diagnoses. Localized, muscle-invasive disease is often managed with a multidisciplinary approach including either neoadjuvant chemotherapy (NAC) followed by radical cystectomy or concurrent chemoradiation, whereas multiple immunotherapies and novel antibody drug conjugates have recently joined platinum-based chemotherapy as standard of care therapy for metastatic disease. However, the clinical trials leading to these standards often require majority if not complete urothelial histology for eligibility. As many as one quarter of patients diagnosed with bladder cancer will have either divergent differentiation of their urothelial carcinoma or an alternate epithelial tumor such as squamous cell carcinoma, adenocarcinoma, or small cell carcinoma; even more rare are non-epithelial tumors such as sarcoma. The rarity of these diseases and their general exclusion from treatment within prospective clinical trials has created a challenging situation where treatment plans are often derived from case series or extrapolated from other disease types and outcomes are poor compared to pure urothelial carcinoma. In this review, we summarize the existing data on the diagnosis and treatment of epithelial, non-urothelial bladder cancers including adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in their localized and advances stages. We will also review the current clinical trial landscape investigating novel approaches to these diseases.

Ovarian metastasis from a urachal adenocarcinoma primary in a young female

Metastasis to the ovary from a bladder primary is extremely rare with limited case reports. The most common primary sites arise from stomach, colon or renal origin and usually occur from 40 years of age onwards. We report a case of an 18-year old woman with a right sided Krukenberg tumour from a bladder primary. This patient is much younger than any other case report of Krukenberg tumour and reiterates the need for early excision of urachal masses in all age groups.

Trends of incidence and prognosis of primary adenocarcinoma of the bladder

Background:

Primary adenocarcinoma of the bladder (ACB) is a rare malignant tumor of the bladder with limited understanding of its incidence and prognosis.

Methods:

Patients diagnosed with ACB between 2004 and 2015 were obtained from the SEER database. The incidence changes of ACB patients between 1975 and 2016 were detected by Joinpoint software. Nomograms were constructed based on the results of multivariate Cox regression analysis to predict overall survival (OS) and cancer-specific survival (CSS) in patients with ACB, and the constructed nomograms were validated.

Results:

The incidence of ACB was trending down from 1991 to 2016. A total of 1039 patients were included in the study and randomly assigned to the training cohort (727) and validation cohort (312). In the training cohort, multivariate Cox regression showed that age, marital status, primary site, histology type, grade, AJCC stage, T stage, SEER stage, surgery, radiotherapy, and chemotherapy were independent prognostic factors for OS, whereas these were age, marital status, primary site, histology type, grade, AJCC stage, T/N stage, SEER stage, surgery, and radiotherapy for CSS. Based on the above Cox regression results, we constructed prognostic nomograms for OS and CSS in ACB patients. The C-index of the nomogram OS was 0.773 and the C-index of CSS was 0.785, which was significantly better than the C-index of the TNM staging prediction model. The area under the curve (AUC) and net benefit of the prediction model were higher than those of the TNM staging system. In addition, the calibration curves were very close to the ideal curve, suggesting appreciable reliability of the nomograms.

Conclusion:

The incidence of ACB patients showed a decreasing trend in the past 25 years. We constructed a clinically useful prognostic nomogram for calculating OS and CSS of ACB patients, which can provide a personalized risk assessment for ACB patient survival.

Management of the Uncommon Bladder Cancers: A Single-Center Experience over 10 Years

Background

Under the name of uncommon bladder cancers are gathered rare histological entities which represent less than 5% of bladder tumors. There is not a clear and consensual therapeutic management for these entities.

Purpose

To review a single-institution 10-year experience with rare form of bladder cancers detailing the diagnosis, treatment, and patient outcome.

Materials and Methods

We performed a retrospective review of 27 medical records of rare bladder cancer form treated at our center between February 2006 and February 2015. The clinicopathologic features are reported with emphasis on treatment and survival.

Results

Mean patient age was 65.5 ± 20 yr and 70% of patients were males. Smoking background was found in 16 cases, chronic bladder irritation factors were found in 12 cases, and past urinary tract infection was found in 11 cases. The main symptom was total hematuria (93%) causing an anemia in 16 cases. The two mean histological forms were epidermoid carcinoma (37%) and adenocarcinoma (22%). 26% of patients were found to have extended invasive tumors (T4) at diagnosis. Metastatic disease was confirmed in 8 cases. Our patients were managed by a wide range of therapeutic modalities as total cystectomy with bilateral lymph node dissection (63%), palliative chemotherapy (30%), or concomitant radiochemotherapy (7%). 55.6% of patients were alive one year after diagnosis. Epidermoid carcinoma has the best prognosis followed by leiomyosarcoma and sarcomatoid carcinoma. Neuroendocrine carcinoma has the worst outcome. The overall 5-year survival rate is 33.3%.

Conclusion

The rarity and small size of these tumors justify the absence of clear and consensual therapeutic management. No role of total cystectomy concerning the conclusions could be drawn but elements suggest this may be the treatment of choice. The highly aggressive nature of those lesions justifies an aggressive and fast therapy when feasible which gives the best outcomes.

[Primitive adenocarcinoma of the bladder: about 6 cases]

L´adénocarcinome primitif de la vessie est une variété rare de tumeurs vésicales qui représente moins de 2% des cancers de la vessie. Il semble atteindre préférentiellement le sexe masculin avec un sexe ratio de 3/1 et un âge moyen de survenu entre 60 ans et 70 ans. Sa présentation clinique est non spécifique et dominée par l´hématurie. La résection endoscopique de la vessie avec un examen anathomopathologique permet de poser le diagnostic. Le traitement de l´adénocarcinome primitif de la vessie reste sujet à de nombreuses controverses du fait de la rareté des cas rapportés dans la littérature. Cependant, le traitement de choix semble être une cystectomie totale avec curage ganglionnaire étendu. Nous rapportons une série de 6 cas d´adénocarcinome qui ont été traités et suivis au sein de notre formation. Notre analyse est basée sur l´évaluation des caractéristiques épidémiologiques, cliniques, anatomo-pathologiques, et thérapeutiques de l´adénocarcinome de la vessie, ainsi que sur l´étude des aspects évolutifs et des facteurs pronostiques.

Current Understanding of Urachal Adenocarcinoma and Management Strategy

PURPOSE OF REVIEW

The aim of this review is to sum up the state of the art of urachal carcinoma (UC) in order to easily guide clinicians.

RECENT FINDINGS

UC is a rare and aggressive disease with consequent few data about diagnosis and treatment. Dates are mainly based on retrospective trial and case reports with limited prospective trial. Clinical presentation is not specific, often with urinary symptoms. Diagnosis is mainly based on CT scan and MRI, useful to evaluate local invasion and nodal status and to detect the presence of distant metastases. Therefore, biopsy is needed to obtain histological confirmation. Surgery is the gold standard for localized disease, while different chemotherapy schemes have been used in metastatic setting. Novel findings based on mutational analysis of the tumor include the use of biological treatment, such as cetuximab, and immunotherapy, such as atezolizumab, with satisfactory responses, suggesting that personalized treatment could be the most suitable option for UC.

Biomarkers in Urachal Cancer and Adenocarcinomas in the Bladder: A Comprehensive Review Supplemented by Own Data

Urachal cancer (UrC) is a rare but aggressive cancer. Due to overlapping histomorphology, discrimination of urachal from primary bladder adenocarcinomas (PBAC) and adenocarcinomas secondarily involving the bladder (particularly colorectal adenocarcinomas, CRC) can be challenging. Therefore, we aimed to give an overview of helpful (immunohistochemical) biomarkers and clinicopathological factors in addition to survival analyses and included institutional data from 12 urachal adenocarcinomas. A PubMed search yielded 319 suitable studies since 1930 in the English literature with 1984 cases of UrC including 1834 adenocarcinomas (92%) and 150 nonadenocarcinomas (8%). UrC was more common in men (63%), showed a median age at diagnosis of 50.8 years and a median tumor size of 6.0 cm. No associations were noted for overall survival and progression-free survival (PFS) and clinicopathological factors beside a favorable PFS in male patients (p = 0.047). The immunohistochemical markers found to be potentially helpful in the differential diagnostic situation are AMACR and CK34βE12 (UrC versus CRC and PBAC), CK7, β-Catenin and CD15 (UrC and PBAC versus CRC), and CEA and GATA3 (UrC and CRC versus PBAC). Serum markers like CEA, CA19-9 and CA125 might additionally be useful in the follow-up and monitoring of UrC.

Next-generation sequencing-based molecular characterization of primary urinary bladder adenocarcinoma

Primary bladder adenocarcinoma is a rare and aggressive tumor with poor clinical outcomes and no standard of care therapy. Molecular biology of this tumor is unknown due to the lack of comprehensive molecular profiling studies. The study aimed to identify genomic alterations of clinical and therapeutic significance using next-generation sequencing and compare genomic profile of primary bladder adenocarcinoma with that of high-grade urothelial carcinoma and colorectal adenocarcinoma. A cohort of 15 well-characterized primary bladder adenocarcinoma was subjected to targeted next-generation sequencing for the identification of mutations and copy-number changes in 51 cancer-related genes. Genomic profiles of 25 HGUCs and 25 colorectal adenocarcinomas using next-generation sequencing of 50 genes were compared with primary bladder adenocarcinoma. Genomic profiles were visualized using JavaScript library D3.js. A striking finding was the distinct lack of genomic alterations across the 51 genes assessed in mucinous subtype of primary bladder adenocarcinoma. Eleven of 15 primary bladder adenocarcinoma harbored at least one genomic alteration in TP53, KRAS, PIK3CA, CTNNB1, APC, TERT, FBXW7, IDH2 and RB1, many of which are novel findings and of potential therapeutic significance. CTNNB1 and APC mutations were restricted to enteric subtype only. While genomic alterations of primary bladder adenocarcinoma showed substantial overlap with colorectal adenocarcinoma, FGFR3 and HRAS mutations and APC, CTNNB1 and IDH2 alterations were mutually exclusive between primary bladder adenocarcinoma and high-grade urothelial carcinoma. These alterations affecting the MAP kinase, PI3K/Akt, Wnt, IDH (metabolic) and Tp53/Rb1 signaling pathways may provide the opportunity for defining targeted therapeutic approaches.

New Developments and Challenges in Rare Genitourinary Tumors: Non-Urothelial Bladder Cancers and Squamous Cell Cancers of the Penis

The diagnosis and treatment of rare genitourinary tumors is inherently challenging. The Rare Diseases Act of 2002 initially defined a rare disorder as one that affects fewer than 200,000 Americans. The lack of widely available clinical guidelines, limited research funding, and inaccessible clinical trials often lead to difficulty with treatment decisions to guide practitioners in rendering effective care for patients with rare genitourinary cancers. This article will discuss basic tenets of diagnosis and treatment as well as recent developments and clinical trials in rare non-urothelial bladder cancers and penile squamous cell cancers.

National Incidence, Management and Survival of Urachal Carcinoma

Urachal carcinoma is an uncommon cancer whose rarity has precluded its study and evidence-based management strategies are lacking. This study assessed all urachal carcinomas in Ireland and clinical parameters in order to improve understanding. Urachal carcinomas diagnosed from 1994 to 2011 were identified from the National Cancer Registry in Ireland. Data obtained included patient age, gender, diagnostic year, pathology, tumor stage, patient treatment strategies and survival. Twenty-six urachal carcinomas were identified, the majority being adenocarcinoma. This comprised 0.3% of all invasive bladder tumors. Patients were predominantly male (62%) and over 50 years of age (58%). Twenty-two patients (85%) underwent surgery, with only six (23%) undergoing chemotherapy. On average, median overall survival was 2.6 years (range 0-15.2 yrs). Survival was longer in women (5 vs. 1.9 yrs), patients under 50 years of age (3.6 vs. 1.9 yrs), those without confirmed metastasis (4.1 vs. 0.7 yrs) and those who received chemotherapy (3.6 vs. 2.6 yrs). The overall survival of urachal carcinoma in Ireland is less than expected from published literature. This study highlights the need for centralization of rare tumors with international collaboration to identify the optimal treatment strategy and improve outcome.

Neoadjuvant chemotherapy for primary adenocarcinomas of the urinary bladder: a single-site experience

Background

Adenocarcinoma of the urinary bladder is a rare malignancy. Radical surgery is suggested as the best available treatment for early-stage disease, but there is currently no consensus on standard chemotherapy regimen for advanced stage. We assessed the feasibility and effect of neoadjuvant chemotherapy with gemcitabine and cisplatin (GC) plus S-1 for patients with locally advanced primary adenocarcinomas of the urinary bladder.

Methods

Six patients with locally advanced urachal or non-urachal (n = 3, each) primary adenocarcinoma of the bladder were treated from October 2010 to October 2013 at a single center. All the patients were treated with 3 cycles (21d, each) of GC plus S-1 (gemcitabine, 1000 mg/m², days 1 and 8; cisplatin, 70 mg/m², day 2; and S-1, 50 mg bid, day 1-14). After neoadjuvant chemotherapy, patients with urachal cancer were treated with en bloc radical cystectomy and umbilectomy; the remaining 3 patients were treated with cystectomy.

Results

All patients successfully completed the neoadjuvant chemotherapy without serious side effects. Two patients were assessed as complete response, 2 as partial response, 1 as stable disease and 1 as progressive disease.

Conclusions

Despite the limitations of a small study population, the GC plus S-1 regimen for locally advanced primary adenocarcinoma of the urinary bladder was effective, and facilitated the success of surgery to a certain extent. Short follow-up time was also a limitation of our study. More studies are needed to evaluate the results.

Treatment Outcome and Relevance of Palliative Chemotherapy in Urachal Cancer

BACKGROUND

Urachal cancer is a rare malignancy that accounts for <1% of bladder cancers. There is currently no consensus on the diagnosis and management of urachal cancer and there are very few reports on palliative chemotherapy for unresectable disease. We delineate the clinical features and treatment outcome of urachal cancer, in particular the relevance of palliative chemotherapy in recurrent, metastatic disease.

METHODS

The clinicopathologic variables and treatment outcome of patients who were treated for urachal cancer were retrospectively reviewed.

RESULTS

Among 28 eligible patients, 25 had localized disease and 3 had metastatic disease at initial diagnosis. All patients with localized disease underwent curative resection and there was disease recurrence in 10. Out of 13 patients with metastatic disease either at initial diagnosis or during follow-up, the lung was the most common metastatic site (n = 5), followed by the liver, bone and peritoneum. Ten patients received palliative chemotherapy. A total of 24 chemotherapeutic regimens were administered; regimens with a base of fluoropyrimidine (5-FU), taxane and gemcitabine were the most common. The overall response rate of all chemotherapeutic regimens was 16.7%. The 5-FU-based regimens showed a good response, with 2 of 4 patients who received these showing a partial response. One tumor with a partial small-cell component showed a partial response to both an etoposide-based regimen and a taxane-based regimen.

CONCLUSIONS

In urachal cancer, curative surgery is still the recommended treatment with respect to overall survival. A 5-FU-based chemotherapy regimen could be considered for metastatic recurrent disease.

Surgical and chemotherapeutic experience regarding a urachal carcinoma with repeated relapse: case report and literature review

Background

Urachal carcinoma is a rare tumor that is usually associated with a poor prognosis, especially the pathological type, urachal mucinous adenocarcinoma. Surgery remains the primary treatment in prolonging the overall survival time of patients.

Case presentation

We report on a 41-year-old woman with urachal mucinous adenocarcinoma who underwent three surgeries and several courses of chemotherapy over a 42-month period. The first surgery, involving en-bloc excision of the urachal mass, partial urinary bladder, urachal ligament, and umbilicus was performed in May 2007. It is well known that the correct surgical scheme plays a key role in preventing recurrence or metastasis. However, a second debulking surgery with only a single salpingo-oophorectomy may have contributed directly to the patient’s subsequent left ovarian metastasis. Therefore, we strongly recommend performing a bilateral salpingo-oophorectomy once ovarian metastasis has been detected, even if the metastasis is only present on one side. Although postoperative adjuvant chemotherapy regimens, first with Taxol, carboplatin, gemcitabine, and cisplatin, and then with IFO, EPI, and mesna were consecutively administered after the first and second surgeries, they seemed less effective, since recurrence and metastasis occurred shortly after each surgical treatment. After a third debulking surgery in June 2009, docetaxel, oxaliplatin, and capecitabine were administered. This chemotherapy regimen was chosen based on an immunohistochemical test that involved the multidrug resistance gene; this test indicated that the urachal mucinous adenocarcinoma was resistant to the two chemotherapy regimens used previously. Surprisingly, the patient exhibited a marker response to the new regimen and the metastatic foci entered into a stable disease stage. However, the patient still died of diffuse metastatic disease 1.5 years later. During the whole period of treatment, we found that serum tumor markers including CA724, CA125, CA19-9, and CEA were elevated in a linear pattern, with parallel increases in line with peritoneal carcinomatosis and parallel reductions in line with response to personalized chemotherapy.

Conclusion

Personalized treatment can be given to those patients who experience a poor response to initial therapy. Moreover, an immunohistochemical test for the multidrug resistance gene and serum tumor markers may supply key information in the choice of reasonable chemotherapeutics.

Metastatic urachal carcinoma of the ovary

A 52-year-old woman had undergone a partial cystectomy for a cystic mass at the dome of the urinary bladder in 1997. The pathological diagnosis was a urachal mucinous cystadenoma with borderline malignancy. Twelve years later, multiple masses were noted on the uterus, ovaries and abdominal wall. She underwent debulking surgery, including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, infracolic omentectomy, appendectomy, colon mass removal and abdominal wall mass removal. Remnants of the tumor were seeded throughout the abdominal cavity. The pathological evaluation confirmed metastatic urachal mucinous adenocarcinoma in both ovaries, the abdominal wall, the colon mass, the uterosacral ligament and the bladder. Adjuvant chemotherapy with paclitaxel and carboplatin was administered, which showed stable disease. She is now undergoing second-line chemotherapy.

Metastatic signet-ring cell cancer of the bladder responding to chemotherapy with capecitabine: case report and review of literature

Signet-ring cell cancers deriving from the bladder are rare entities and usually present with advanced incurable disease and associated poor outlook. No standard effective chemotherapeutic option has been described largely due to the rarity of this malignancy. We report a case of a patient with metastatic bladder cancer, signet-ring cell variant. The patient progressed rapidly on standard first-line bladder cancer chemotherapy with gemcitabine and carboplatin. He responded well to second-line capecitabine with a clinically meaningful progression-free survival.

Clinical characteristics and outcomes of patients with primary signet-ring cell carcinoma of the urinary bladder

OBJECTIVE

The aim of this study was to examine the epidemiology, natural history, treatment pattern and predictors of long-term survival of patients with signet-ring cell carcinoma (SRCC) of the urinary bladder based on the analysis of the national Surveillance, Epidemiology, and End Results (SEER) database.

METHODS AND RESULTS

In total, 230 patients with pathologically confirmed SRCC of the urinary bladder were identified between 1973 and 2004. The mean age was 65 ± 13 years. Overall, 75.7% of the patients had a poorly differentiated or undifferentiated histology grade, 26.5% presented with metastatic disease, 59 (25.7%) underwent transurethral resection for bladder tumor only and 107 (46.5%) had partial or radical cystectomy. The 1-, 3- and 10-year cancer-specific survival rates were 66.8, 40.6 and 25.8%, respectively. Using multivariable Cox proportional hazard model, age (HR 1.024; p = 0.004), stage (distant vs. local, HR 6.2; p < 0.001) and cystectomy (HR 0.53; p = 0.002) were identified as independent predictors for cancer-specific survival.

CONCLUSIONS

Receipt of cystectomy was strongly associated with improved survival in the patients with SRCC of urinary bladder. However, many patients with localized tumors did not receive potentially curative cystectomy. Further studies to address the barriers to the delivery of appropriate care to these patients are warranted.

Sustained response of adenocarcinoma of the urinary bladder to FOLFOX plus bevacizumab

BACKGROUND

A 44-year-old patient presented with intermittent macroscopic hematuria on a background of chronic left-sided hydronephrosis and intestinal metaplasia of the bladder. Cystoscopic examination revealed a mass at the dome of the urinary bladder, which was resected. Histopathologic analysis of the specimen confirmed the presence of muscle-invasive adenocarcinoma. Radical cystectomy with curative intent was planned, but review of systems and subsequent CT demonstrated pleural effusion with positive cytology, confirming metastatic disease. Owing to the histologic similarity between this patient's tumor and colorectal cancer, palliative FOLFOX6 (folinic acid, 5-fluorouracil and oxaliplatin) chemotherapy plus bevacizumab was administered. After 3 months of treatment the patient showed a good response, which was sustained for more than 10 months after diagnosis. However, his disease subsequently relapsed, and the patient died shortly thereafter.

INVESTIGATION

Physical examination, cystoscopy, transurethral resection of bladder tissue, CT, histopathologic, cytopathologic and immunohistochemical analysis.

DIAGNOSIS

Metastatic adenocarcinoma of the urinary bladder.

MANAGEMENT

12 cycles of infused and bolus 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX6) plus bevacizumab.

Recurrent urachal mucinous adenocarcinoma presenting as bilateral ovarian tumors on cesarean delivery

Secondary ovarian cancers, Krukenberg tumors, are a distinctive subset of metastatic tumors arising from the gastrointestinal tract (stomach, colon, and appendix), the biliary system, the breast, or other genital organs. These tumors account for 5% of all ovarian malignancies. Such metastases could mimic primary mucinous ovarian adenocarcinomas. Metastases from the urinary tract are uncommon. Primary adenocarcinoma of the bladder accounts for less than 1% of all bladder malignancies; one third of these tumors are urachal in origin. Urachal cancers are rare and tend to occur in older men (mean age, 50-60 years); however, it was described previously in a 15-year-old girl. Symptoms include hematuria, dysuria, frequency, urgency, and recurrent urinary tract infections. These tumors have a predilection to locally spread to the surrounding organs. Ovarian metastasis is a rare event and is infrequently reported in literature.

Treatment of metastatic urachal adenocarcinoma in a young woman: a case report

A 30-year-old woman with a history of smoking presented with abdominal pain and haematuria. On physical examination, she had a palpable pelvic mass. Imaging revealed a large pelvic mass located on the dome of the bladder, extending from the urachus, with pulmonary metastases. After open biopsy, urachal adenocarcinoma was histologically confirmed. The patient received six cycles of palliative chemotherapy combination 5 fluorouracil and irinotecan with complete response on the pelvic mass and partial response estimated to more than 80% on pulmonary metastasis.

Predictors of survival from urachal cancer: a Mayo Clinic study of 49 cases

BACKGROUND

Outcome results of a long-term analysis of urachal cancer using a new staging system are presented.

METHODS

The authors analyzed clinical outcomes from 49 patients with the diagnosis of urachal cancer who were seen at the Mayo Clinic, Rochester, Minnesota from 1950 to 2003. The TNM staging system was used to predict outcome after surgical resection.

RESULTS

Among 49 study patients, 33 were men, 16 were women, and their median age at presentation was 57.5 years. The vast majority of tumors were adenocarcinomas (89%), 4% were sarcomas and transitional cell carcinomas, and the rest were high-grade mixed neoplasms. Among the adenocarcinomas, 63.6% were mucin-producing tumors. Partial cystectomy with or without pelvic lymph node dissection and removal of the urachus was performed in 41 (83%) cases. Overall survival for all stages was 62 months with 17 (34%) patients still alive more than 5 years after treatment. Applying the TNM staging system, the authors demonstrated a median survival time for stage I/II patients of 10.8 years (95% CI, 6.9 years to 12.0 years) compared with a median survival of 1.3 years (95% CI, 1.1 years to 1.9 years; log-rank P<.0001) for patients with advanced disease (stages III and IV).

CONCLUSIONS

Stage at presentation by the TNM staging system proved to be the main predictor of outcome after surgery for urachal cancer. Better systemic modality treatments are needed for advanced stages of this disease.

Clinical and therapeutic significance of aberrant differentiation patterns in bladder cancer

Pure urothelial carcinoma makes up 90-95% of all bladder cancer. The remaining 5-10% represent urothelial carcinoma with aberrant differentiation patterns and nonurothelial carcinoma. Reviews on this topic often focus on the pathological features of these histologic subtypes. In this review we have summarized the clinical significance of each major histologic pattern and analyzed the response of each to standard treatment modalities. The main limitation to optimizing management is the inability to perform clinical trials owing to the rarity of these tumors. This can be circumvented to some degree by extrapolating knowledge acquired from more common similar tumors in other organ sites. Ultimately, however, multicenter clinical trials will need to be organized to address some key management issues.

Urachal signet ring cell carcinoma

Urachal adenocarcinoma is a rare neoplasm associated with poor prognosis. We report a case of urachal signet ring cell carcinoma in a 65-year-old man. He was admitted with a chief complaint of microscopic hematuria. Cystoscopic examination and transurethral biopsy showed an urachal tumor. After undergoing radical cystectomy and intravenous chemotherapy, the patient developed bilateral hydronephroses as a result of bilateral ureteral metastases and bowel obstraction because of the Para-aortic lymphnode metastasis. He has been alive for 5 years after three courses of chemotherapy and a bypass operation.

Nonurothelial cancer of the bladder

In this article, we review available evidence on the treatment of patients with nonurothelial cancer of the bladder. More than 150 published works were reviewed in preparation for this summary. Squamous cell carcinoma and adenocarcinoma are ideally treated with radical cystectomy. High-risk groups for these diseases are defined. Small cell carcinoma should be treated with multimodality therapy, including chemotherapy. Other rarer tumors of the bladder are also discussed.

Urachal carcinoma: surgical and chemotherapeutic options

The urachal ligament is an embryologic remnant connecting the dome of the bladder to the umbilicus via the ligamentum commune. Autopsy series suggest that in approximately a third of subjects, the urachal remnant may persist with tubular or cystic structures. However, tumors of this site are extremely rare. Patients usually present with hematuria and upon imaging, have evidence of a cystic or solid structure in the bladder dome or in the bladder midline. If a biopsy confirms adenocarcinoma, these tumors should be considered an urachal cancer until proven otherwise. Although there are no prospective clinical trials reported to date, large single-institution reports suggest surgical resection with a partial cystectomy and en bloc resection of the urachal ligament with umbilicus as the treatment of choice in the setting of localized disease. Although there is currently no definitive role for neoadjuvant or adjuvant chemotherapy in this tumor, risk factors predicting progression may allow for the selection of patients at higher relapse risk for prospective studies. Unfortunately, there are many patients who present with metastatic disease that currently is not likely to be curable. There is no standard chemotherapy regimen for these patients; however, there is new-found hope with a currently accruing clinical trial exploring a 5-fluorouracil-based chemotherapy combination in this patient population.

Urachal carcinoma during pregnancy

We report a case of Stage T4aN2M0 urachal carcinoma that was diagnosed early in pregnancy. Because positive pelvic lymph nodes and uterine involvement were present, surgical resection, including hysterectomy with termination of the pregnancy, and postoperative radiotherapy were performed. The treatment options, which largely depend on the duration of the pregnancy, the tumor stage, and the patient's desire to continue the pregnancy, are discussed.

Irinotecan as a New Agent for Urachal Cancer

The urachal carcinoma, in a 64-year-old male with multiple lung metastases, had shown the resistance to several anti-neoplastic agents including cisplatinum, methotrexate, 5-FU, doxorubicin, epirubicin, and mitomycin C. Because the tumor was adenocarcinoma producing mucin and serum carcinoembryonic antigen (CEA) increased, which resembled colorectal carcinoma, we administrated Irinotecan, which was very effective as the CEA decreased from 98.3 to 38.7 ng/ml and the pulmonary metastatic lesions were reduced by 60%. To our knowledge, this is the first case with urachal carcinoma in which Irinotecan was effective.

Multimodality management of urachal carcinoma: the M. D. Anderson Cancer Center experience

PURPOSE

Enteric type adenocarcinomas arising in the dome of the bladder or along the urachal ligament are uncommon. To improve our understanding of urachal carcinoma and define outcome with current management, we performed a retrospective review of cases seen at the M. D. Anderson Cancer Center.

MATERIALS AND METHODS

We reviewed the records of 42 patients with urachal carcinoma evaluated at our institution from 1985 to 2001. Specifically, we sought to evaluate the importance of extent of disease, surgical characteristics and systemic therapy on clinical outcome.

RESULTS

Of the 42 patients 7 had clinically evident metastases at diagnosis and 35 had resectable disease that was managed initially with surgery. Overall survival from diagnosis for all 42 patients was 46 months with 40% surviving at 5 years. Of the resected cases 16 (46%) remain disease-free (median followup 31 months). Covariates associated with long-term survival were negative surgical margins (p = 0.004) and absence of nodal involvement (p = 0.01). Median survival from recognition of metastatic disease was 24 months in 26 patients in whom metastases ultimately developed. Chemotherapy for metastatic disease produced only 4 significant responses, including 3 of 9 patients treated with 5-fluorouracil and cisplatin containing regimens.

CONCLUSIONS

Urachal carcinomas are usually locally advanced at presentation with a high risk of distant metastases. However, long-term survival following radical resection occurs in a significant fraction of patients (16 of 35 in our series), supporting an attempt at margin-negative, en bloc resection if at all possible. Chemotherapy appropriate for enteric type adenocarcinoma can induce objective responses but meaningful improvement in survival is not yet demonstrated.

Successful treatment of metastatic adenocarcinoma of the urachus: report of 2 cases with more than 10-year survival

Metastatic urachal cancer is often considered lethal. We report 2 cases of metastatic urachal carcinoma successfully treated with surgical excision followed by combinations of surgery, radiation, and chemotherapy against local recurrence and/or distant metastases, with a recurrence-free survival period of more than 10 years. These cases provide support for multimodal treatments of metastatic urachal cancer.

Advanced adenocarcinoma of the urinary bladder successfully treated by the combination of cisplatinum, mitomycin-C, etoposide and tegafur-uracil chemotherapy

Primary adenocarcinoma of the urinary bladder has shown an extremely poor response to radiation or chemotherapy. Therefore, radical surgery is the only therapeutic treatment for it. A case report is presented of a primary advanced adenocarcinoma of the urinary bladder invaded into the uterus with distant metastases which responded completely to systemic combination chemotherapy including tegafur-uracil. The patient was a 53-year-old woman with a history of asymptomatic macrohematuria. She was treated with the combination of cisplatinum, mitomycin-C, etoposide and tegafur-uracil chemotherapy. After four courses of the chemotherapy, computed tomography showed marked regression of the primary tumor of the urinary bladder and the complete disappearance of the distant metastases in the liver, lung and para-aortic lymph node. Subsequently, she underwent radical cystectomy and cutaneous ureterostomy. Pathologically, no viable cancer cells were detected. Three years after the operation, she has no evidence of disease recurrence. Treatment of advanced adenocarcinoma of the urinary bladder by this combination chemotherapy is of benefit.

Successful chemotherapy in a patient with recurrent carcinoma of the urachus

Urachal neoplasm generally has a poor prognosis, because of long latency period, extravesical progression and pathological predominant pattern of adenocarcinomas. We report a case of recurrent poorly differentiated carcinoma of urachal remnant, which responded well to combination systemic chemotherapy (methotrexate, vinblastine, doxorubicin and cisplatin: M-VAC). Our case was possibly of transitional cell origin. The patient has been symptom-free even 13 months after the first chemotherapy course.

Primary adenocarcinoma of the urinary bladder: a report of 185 cases

OBJECTIVE

To evaluate the outcome after the treatment of primary non-urachal vesical adenocarcinoma and to determine the significant prognostic factors.

PATIENTS AND METHODS

The records of 185 patients with vesical adenocarcinoma were reviewed. The pathological evaluation included the determination of pathological stage, tumour grade, presence or absence of mucin and its location, evidence of bilharzial infestation and flow-cytometric DNA analysis. The mean follow-up of the treated patients was 3.1 years. Disease-free survival was estimated and the results correlated with patient and tumour characteristics (univariate analysis). Cox's proportional hazards analysis was used to determine prognostic factors.

RESULTS

The overall 5-year disease-free survival was 55%; only three factors had a significant impact on survival, the tumour pathological stage and grade, and lymph node involvement.

CONCLUSIONS

Radical cystectomy remains the only satisfactory treatment option for primary vesical adenocarcinoma. Tumour stage, grade and lymph node involvement are the only significant prognostic factors.

Adenocarcinoma of bladder

Forty-eight patients with adenocarcinoma (21 urachal and 27 non-urachal) of the bladder were treated at the Tata Memorial Hospital between 1976 and 1992. The study group consisted of 32 men and 16 women. The urachal tumours were more common in younger patients (mean age: 49 years) than were non-urachal tumours (mean age: 58 years). The overall 5-year survival in this series was 37%. Stage and grade were powerful predictors of outcome. Patients with non-urachal tumours showed an overall survival rate of 29.9% compared with 45.7% in patients with urachal tumours (P= 0.14). Radical cystectomy was the most common treatment modality in patients with non-urachal tumours and yielded an overall 5-year survival of 35%. Patients with urachal tumours were treated with either partial cystectomy or radical cystectomy. The 5-year survival following partial cystectomy was 56.3% compared with 25.9% following a radical cystectomy and the difference between the two was not statistically significant (P = 0.76).

Urachal cancer: role of conservative surgery

Urachal carcinoma is a rare neoplasm (0.22% of all bladder cancers) associated with a dismal prognosis. The obscure anatomic position of the tumor often minimizes early symptoms and precludes a timely diagnosis. The reported survival for urachal neoplasms has been inauspicious, and radical surgery (en bloc cystoprostatectomy and wide excision of the urachus and umbilicus) has been recommended as the primary treatment. To provide a rationale for the surgical management of this cancer, 38 patients with urachal carcinoma were reviewed, including 28 men and 10 women (2.8:1) (median age at diagnosis, 56 years; range, 28 to 88 years). The majority of the tumors were of high grade and stage at the time of diagnosis; they were exclusively DNA aneuploid in the 10 patients studied. Most patients had partial (segmental) cystectomy/umbilectomy (n = 30) or en bloc radical cystoprostatectomy/umbilectomy (n = 4) as their initial treatment; five-year overall survival of 43 percent and 50 percent revealed essentially comparable outcomes for the two surgical approaches. Thus, in the initial management of urachal carcinoma, umbilectomy with partial cystectomy may be considered in selected cases; this can enhance quality of life without necessarily influencing survival adversely. Rather, disease outcome seems more dependent on the adverse biologic potential of this usually DNA aneuploid tumor, necessitating the development of more innovative systemic treatment modalities.

Carcinoma of the urachus. A case report and review of the literature

A 63-year-old man presented with haematuria and suprapubic pain. After transurethral resection of the prostate a tumour was seen in the bladder dome at cystoscopy. Biopsy revealed an adenocarcinoma. Based on intraoperative and histological examination of the partial cystectomy specimen, the tumour was judged to be an urachus carcinoma. Four years after diagnosis the patient has no evidence of tumour. While partial cystectomy is the most frequent treatment, a radical total cystectomy is advocated in poorly differentiated tumours.

Adenocarcinoma of the bladder: study of 14 cases and review of the literature

Fourteen patients with adenocarcinoma of the bladder have been seen over a 14-year period; 6 tumours were of urachal origin and the remaining 8 were primary. All tumours were muscle-infiltrating. The 6 patients with urachal tumours were subjected to surgery; 3 underwent partial cystectomy and 3 radical total cystectomy. All patients who underwent partial cystectomy are alive and free of disease at 60 months, 12 months and 12 months respectively. The other 3 patients who underwent radical cystectomy suffered recurrence and 2 succumbed to their disease within 1 year. All patients with primary adenocarcinoma of the bladder underwent radical cystectomy, 5 of them after planned pre-operative radiotherapy. There were 3 post-operative deaths. One patient died of an unrelated cause 30 months after surgery and 2 died of disseminated disease 8 and 16 months after surgery. One patient developed inguinal lymph node metastases 4 months after surgery and is controlled at 12 months with radiotherapy. Only 1 of the 8 patients with primary adenocarcinoma of the bladder is alive and free of disease at 6 months.

Adenocarcinoma of urinary bladder: classification and management

Adenocarcinoma of the urinary bladder is an uncommon, often aggressive urologic cancer. In an attempt to classify and define management of this tumor, 28 patients with vesical adenocarcinoma were studied. Excluded were patients with mixed transitional cell carcinoma and adenocarcinoma. Three major classes of tumor were identified: primary vesical adenocarcinoma, urachal adenocarcinoma, and extravesical adenocarcinoma involving the bladder. Signet ring cell tumors appeared to behave more aggressively than other cell types. Radical surgery was the most effective treatment.

Adenocarcinoma of the urinary bladder

We report 40 patients seen over a 15-year period with a histological diagnosis of adenocarcinoma of the bladder; 18 patients had primary adenocarcinoma of the bladder, arising either from the urachus or from glandular metaplasia of the urothelium, and the other 22 had secondary lesions representing invasion from adjacent structures, notably prostate, colon and ovary. In this latter group symptoms related to the primary lesion were variable. The distinction between primary and secondary neoplasm is an important one and was rarely made on the basis of endoscopic or clinical findings alone. Urachal tumours were more common in females, whereas primary and secondary vesical adenocarcinomas were more common in males. The urachal tumours also occurred in a younger age group. Most of the adenocarcinomas, urachal or primary, were already advanced at the time of diagnosis. All tumours were palpable bimanually after resection and were at least T2 or T3. In the urachal carcinomas the results of partial cystectomy were disappointing because of the high rate of local recurrence and death from metastases. Primary non-urachal vesical adenocarcinoma carried an even poorer prognosis if non-radical surgery was carried out. The mean survival was 13 months. Radiotherapy was not effective in urachal and primary adenocarcinomas as these tumours are generally radioresistant. The treatment of secondary adenocarcinoma was governed by the primary site of the tumour. Radical surgery combined with chemotherapy and radiotherapy appeared to give the longest survival in the colonic tumours. Patients with prostatic cancer had a poorer survival rate than those with the same stage tumour but without bladder involvement, with renal failure secondary to obstructive uropathy being the commonest cause of death.

Radiation therapy-associated invasive bladder tumors

Radiotherapy-associated bladder carcinoma was found in 3.7 percent of 244 cases of advanced urothelial carcinoma. Average age at diagnosis of the bladder tumor was 63.1 years, with a mean of 20.5 years between radiation treatment and diagnosis. All 9 patients presented with gross hematuria. Eight patients had transitional cell carcinoma, 7/8 (87.5%) also had vascular or lymphatic invasion, and 1 was adenocarcinoma. Mean survival was 15.4 months (range 1-40 mos.), with a 55.5 percent one-year disease-free survival after diagnosis. Four patients died of bladder tumor, 4 were alive with no evidence of disease, and 1 was alive with metastasis.