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

Clinical, Pathological, and Prognostic Analysis of Urachal Carcinoma

OBJECTIVE

The aim of this study was to improve understanding the clinical, pathologic, and prognostic features of urachal carcinoma (UrC), a retrospectively descriptive study was done in 2 clinical centers.

METHODS

After excluding the 2 missed patients, the clinical and pathological data of 59 patients with UrC, who were diagnosed or treated at 2 clinical centers between 1986 and 2019, was retrospectively analyzed. SPSS 22.0 (IBM) and GraphPad Prism 8.0.1 were used for statistics and data visualization. Survival data were analyzed by the Kaplan-Meier method and Log-rank tests. Cox proportional hazards regression were performed for find risk factors on predicting the prognosis.

RESULTS

Of all 59 patients, 47 were male and 12 were female. The median age at diagnosis was 51.6 years (range: 22-84 years). Gross hematuria was the most common symptom (79.66%). The majority of urachal neoplasms were adenocarcinomas (94.92%). Forty-two patients (72.41%) underwent extended partial cystectomy with en bloc resection of the entire urachus. The mean follow-up was 52 months (3-277 months). Median overall survival was 52.8 months (4-93 months). The 3-year cancer-specific survival (CSS) rate and 5-year CSS rate were 69.1% and 61.2%. There was no significant difference among localized T stage, tumor histologic grade and surgical procedures in determining prognosis by survival analyze. While patients with high-risk TNM stage (local abdominal metastasis, lymph node metastasis, or distant metastasis) (p = 0.003) and positive surgical margin (p < 0.001) had significantly worse prognosis.

CONCLUSIONS

The results indicate that high-risk TNM stage and positive surgical margin are risk predictors of prognosis. Localized T stage, histologic grade, and surgical procedure cause no significant effect on patient prognosis. The extended partial cystectomy is the recommended surgical approach for patients with UrC. Active multimodal treatments may improve the survival of patients with recurrent and metastatic disease.

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.

Urachal Carcinoma with Peritoneal Dissemination Treated with Chemotherapy and Surgical Resection Leading to Prolonged Survival with No Recurrence

A 56-year-old man was admitted to our hospital for urachal carcinoma with peritoneal dissemination. He received first-line chemotherapy with gemcitabine and cisplatin. After the fifth cycle, a computed tomography (CT) scan revealed abdominal fluid, and his serum tumor marker levels were increased. The patient was started on second-line therapy with FOLFIRI. After 11 cycles, his tumor decreased in size and no new metastatic lesions were detected. The patient underwent complete tumor resection with partial cystectomy and pelvic lymph node dissection. The tumor was removed, along with adhering surrounding organs, including the omentum, peritoneum, abdominal rectus muscle, and vermiform appendix. Although pathological examination confirmed peritoneal dissemination, his tumor markers normalized soon after surgery. The patient has survived 62 months after surgery without any adjuvant therapy and with no evidence of recurrence. To our knowledge, this is the longest duration of survival without recurrence of a patient with urachal carcinoma with peritoneal dissemination who received multimodal therapy.

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.

Surgical treatment of recurrent urachal carcinoma with liver metastasis: a case report and literature review

Background

Urachal carcinoma is a rare malignancy with poor prognosis due to late presentation of the disease and its aggressiveness. Surgery remains the mainstay of therapy even in cases of disease recurrence. To the best of our knowledge, this is the first report of salvage surgery in the case of urachal carcinoma with liver metastasis.

Case presentation

The patient was a young woman who suffered from locally advanced urachal carcinoma treated with en-bloc cystectomy, hysterectomy with bilateral adnexectomy, partial resection of the sigmoid colon, and partial resection of the rectus abdominis muscle with the fascia, skin, and umbilicus. Adjuvant chemotherapy with paclitaxel and carboplatin was applied. Two years after the treatment, she was diagnosed with a single liver metastasis and a local pelvic recurrence. In a two-step operation, the patient underwent right hemihepatectomy as well as resection of pelvic recurrence site and adjuvant chemotherapy with gemcitabine. Due to the disease progression, a complete resection of the lesions was not achieved and the response to chemotherapy was poor. The patient died of the disease after a year.

Conclusions

Surgery is the first line of treatment for urachal carcinoma and should be always considered as an option in cases of disease recurrence. Radical initial surgical management, close patient surveillance, and prompt treatment of disease relapse may all contribute to prolonging patient’s survival.

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.

Combined modalities treatment of pulmonary metastasis from an urachal adenocarcinoma

Urachal adenocarcinoma is a rare neoplasm of the bladder. Most of these tumors arise from urachal remnants in the dome of the bladder and extend into the umbilicus. These tumors can recur and most commonly metastasize to lymph nodes, retroperitoneum, lungs, liver and bone. Here we report a case of an urachal adenocarcinoma followed for seven years with lung metastasis for three years.

[Urachal cancers]

Urachal cancer is a rare pathology (less than 1% among all bladder tumors) with a poor prognosis for all stages, because of clinical delay leading to a late diagnosis, difficult differential diagnosis with bladder cancer, and no consensus for the treatment, mostly about the chemotherapy for advanced stages, because there are no data from prospective studies. A surgical treatment can be performed for the localized stages, but there are no real guidelines for local relapses and metastatic progression treatment. Those cancers are not radio- or chemosensitive; nevertheless data from fundamental research are missing. As this pathology is really uncommon, there are no clinical studies with targeted therapies. The purpose of this review is to introduce the most important clinical and paraclinical features of those cancers, and the usual treatment performed.

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.

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.

[Urachal diseases]

Urachal diseases are infrequent. Congenital affections include cysts, fistula, diverticulum, external sinus, and alternating drainage sinus. Ultrasonography and fistulography are useful for the diagnosis. Treatment of malformations is rarely conservative; it consists in urachal resection. Urachal tumours are frequently malignant and adenocarcinomas are the main histological form. CT scanning is useful for staging. Treatment of urachal carcinomas consists in urachal, umbilicus and bladder removal. Prognosis is poor.

Urachal carcinoma: clinicopathologic features and long-term outcomes of an aggressive malignancy

BACKGROUND

Urachal carcinoma (UrC) is a rare malignancy, and patients with this disease have a poor prognosis. In this article, the authors report 50 years of experience with this tumor at the Mayo Clinic.

METHODS

A urachal mass was described in 130 patients, and 66 of those masses were malignant. The authors identified multivariate predictors of malignancy in clinically diagnosed urachal masses and predictors of UrC-specific survival. This report presents a novel 4-category staging system for UrC along with the treatment history of this tumor and the results of salvage therapy.

RESULTS

Twenty women and 46 men were identified with UrC. The strongest predictors of malignancy in a urachal mass were hematuria and age older than 55 years. The 5-year cancer-specific survival rate was 49%. The new Mayo staging system was less complicated than the Sheldon system, although both systems predicted cancer-specific mortality equally well. Positive surgical margins (hazard ratio [HR], 4.7), high tumor grade (HR, 3.6), positive local lymph nodes (HR, 5.1), metastases at diagnosis (HR, 3.3), advanced tumor stage (HR, 4.8), failure to perform umbilectomy (HR, 3.0), and primary radiation therapy (HR, 2.9) were all univariately associated with death (P <.05). Only grade and margins were significant in the multivariate analysis. No survival benefit was noted for lymphadenectomy or adjuvant therapy. Salvage surgery resulted in a long-term cure for 50% of patients who had local recurrences. No effective treatment was identified for patients with metastatic UrC.

CONCLUSIONS

Early and complete extended partial cystectomy, including umbilectomy, is critical to the survival of patients with UrC. The authors recommend using the Mayo staging system in future studies because of its simplicity. The current results indicated that the most important predictors of prognosis were tumor grade and surgical margin status.

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.

Krukenberg Tumor of Renal Pelvic Origin: Report of a Case With Selected Comments on Ovarian Tumors Metastatic From the Urinary Tract

Metastatic tumors to the ovary are infrequently of urinary tract origin. In approximate descending order of frequency, this subset of secondary ovarian neoplasms includes renal cell carcinoma, transitional cell carcinoma of the urinary bladder, and urachal adenocarcinomas. These tumors usually raise a differential in turn of primary ovarian clear cell, transitional cell, or mucinous carcinomas. Only rare metastatic signet-ring adenocarcinomas of the bladder have shown the features of a Krukenberg tumor. We report the case of a 74-year old woman with bilateral Krukenberg tumors metastatic from a primary renal pelvic transitional cell carcinoma with glandular and signet-ring cell differentiation. This unique case reinforces that tumors with signet-ring cell morphology have a propensity to metastasize to the ovary, and indicates that renal pelvic carcinoma rarely may be the source of Krukenberg tumors.

An isolated vertebral metastasis of urachal adenocarcinoma

We describe a case of urachal adenocarcinoma arising in a 30-year-old woman. The patient underwent partial cystectomy. Three years later, she presented with an isolated metastasis to a thoracic vertebra, which was treated by vertebral corporectomy. Histologic findings are described, and the clinical findings, management, and metastatic patterns of this rare tumor, as well as the differential diagnosis on a biopsy specimen, are discussed.

[Cystectomy for indications other than bladder cancer]

A cystectomy for indications other than transitional cell cancer of the bladder or general bladder cancer is frequently performed in cooperation with other surgical specialties such as general surgery or gynecology. In these cases the urological procedure as well as the oncological and surgical concepts of other specialties have to be combined. We studied our cystectomy patients who had undergone such a combined procedure for a non-urothelial indication concerning perioperative and postoperative complications.A total of 204 cystectomies were performed by the Department of Urology at the University of Hamburg, Germany between 1995 and 2003. Bladder cancer was the indication for cystectomy in 162 patients, but 42 patients had a non-urothelial indication for this procedure. These patients included 12 cases of advanced rectal cancer, 9 cases of advanced cervical cancer, 6 cases of advanced sigmoid cancer, 4 cases of advanced prostate cancer, 1 case of prostate sarcoma, 5 cases of complex vesicointestinal fistulae, 2 cases of urachal cancer, 1 leiomyosarcoma, 1 rhabdomyoma, and 1 rhabdomyosarcoma, respectively. Perioperative and postoperative complications of those patients were compared to patients who underwent cystectomy for transitional cell cancer of the bladder.Those 42 patients who underwent cystectomy for non-urothelial indications included 14 male and 28 female patients. The mean age was 58.2 years with a range of 3-78 years. For urinary diversion 30 ileum conduits, 4 sigma conduits, and 8 ileum neobladders were used. The mean operative time was 6.25 h. The mean blood loss was 2200 ml. An average of four red blood cell concentrates (RBC) had to be given. Postoperative hydronephrosis had to be treated in three (7%) patients unilaterally and in two (5%) patients bilaterally with a temporary nephrostomy. Postoperative urinary leakage lasting more than 30 days was found in two (5%) patients. A deep vein thrombosis as well as an ileus was found in five (12%) patients each, respectively. There was no perioperative mortality in this study. When comparing the complications of those patients with the 162 patients who underwent cystectomy for bladder cancer, the only significant difference ( p=0.033, chi-square test) was a higher ileus rate in the patients with cystectomy for a non-urothelial indication. Complications with cystectomy for non-urothelial indications are in large comparable to those for transitional cell carcinoma of the bladder. The higher ileus rate in non-urothelial patients can be explained by the more radical procedures in this group of patients. Even though the group of patients undergoing cystectomy for indications other than bladder cancer was small in this trial, the procedure is standardized in combination with other specialties. Larger patient numbers and a longer follow-up will lead to more data in this special group of patients.

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.

Urachal adenocarcinoma metastatic to the ovaries: case report and literature review

We report a urachal adenocarcinoma metastatic to both ovaries in a 50-year-old Japanese woman. Pelvic examination and imaging studies revealed a large cystic tumor occupying the pelvis and another cystic tumor between the umbilicus and the urinary bladder. A laparotomy was performed. Histopathological examination revealed a urachal tumor that was a well-differentiated invasive mucinous adenocarcinoma; the overlying urothelium was intact. The right and left ovarian tumors were well-differentiated mucinous adenocarcinomas. The urachal and ovarian tumors were immunoreactive for cytokeratin 20 and carcinoembryonic antigen, but negative for cytokeratin 7. The patient is alive with lymph node and bone metastases 6 months postoperatively. This is the eighth reported case of an adenocarcinoma of the bladder with ovarian metastasis.

[Mucinous adenocarcinoma of the urachus]

OBJECTIVE

The Adenocarcinoma of the Urachus is very rare tumor, with an incidence of 1/5,000,000 inhabitants, represents less than 0.001 of all types of bladder cancer.

CASE REPORT

A 51 year old man with a chronic history of suprapubic pain and hematuria. Physical examination and excretory urography were normal. The cystoscopy demonstrated a oedematosa area in cupola of bladder wall. The transuretral biopsy was moderately differentiated adenocarcinoma, with positive antibody to CK7 and CK20, the carcinoembryonic antigen was 6.6 ng/ml. Extended partial cystectomy was done, followed for chemotherapy and radiotherapy.

CONCLUSIONS

The treatment of adenocarcinoma of the urachus with a combination of extended partial cystectomy, chemotherapy and radiation, is a effective treatment.