Carcinoma of the urachus

The Management of a Case With Mucin-Producing Adenocarcinoma Originating From the Urachus

Urachal cancer is a rare and aggressive type of cancer, frequently characterized by a lack of prominent symptoms. We herein report a case of a 50-year-old female with mucin-producing adenocarcinoma originating from the urachus who underwent partial cystectomy and the patient remains disease-free for 30 months after treatment.

Urachal carcinoma: a large retrospective multicentric study from the French Genito-Urinary Tumor Group

Introduction

Urachal cancer (UrC) is a rare, non-urothelial malignancy. Its natural history and management are poorly understood. Although localized to the bladder dome, the most common histological subtype of UrC is adenocarcinoma. UrC develops from an embryonic remnant, and is frequently diagnosed in advanced stage with poor prognosis. The treatment is not standardized, and based only on case reports and small series. This large retrospective multicentric study was conducted by the French Genito-Urinary Tumor Group to gain a better understanding of UrC.

Material and Methods

data has been collected retrospectively on 97 patients treated at 22 French Cancer Centers between 1996 and 2020.

Results

The median follow-up was 59 months (range 44-96). The median age at diagnosis was 53 years (range 20-86), 45% were females and 23% had tobacco exposure. For patients with localized disease (Mayo I-II, n=46) and with lymph-node invasion (Mayo III, n=13) median progression-free-survival (mPFS) was 31 months (95% CI: 20-67) and 7 months (95% CI: 6-not reached (NR)), and median overall survival (mOS) was 73 months (95% CI: 57-NR) and 22 months (95% CI: 21-NR) respectively. For 45 patients with Mayo I-III had secondary metastatic progression, and 20 patients were metastatic at diagnosis. Metastatic localization was peritoneal for 54% of patients. Most patients with localized tumor were treated with partial cystectomy, with mPFS of 20 months (95% CI: 14-49), and only 12 patients received adjuvant therapy. Metastatic patients (Mayo IV) had a mOS of 23 months (95% CI: 19-33) and 69% received a platin-fluorouracil combination treatment.

Conclusion

UrC is a rare tumor of the bladder where patients are younger with a higher number of females, and a lower tobacco exposure than in standard urothelial carcinoma. For localized tumor, partial cystectomy is recommended. The mOS and mPFS were low, notably for patients with lymph node invasion. For metastatic patients the prognosis is poor and standard therapy is not well-defined. Further clinical and biological knowledge are needed.

Topography and Clinical Characteristics of Malignant Tumors of the Urachus

Nine patients with urachal tumors have been reevaluated. There were 5 men and 4 women, whose ages ranged from 6 to 72 years. Surgery was performed in 4 cases, radiotherapy was used in 2 cases, and the remaining 3 cases were judged to be beyond therapeutic help. Three years after treatment, also all cases subjected to therapy were dead. The diagnostic delay, the inadequacy of treatment, and therefore the absolutely unfavorable prognosis of these tumors are discussed.

Abscess of urachal remnants presenting with acute abdomen: a case series

Introduction

Urachal diseases are rare and may develop from a congenital anomaly in which a persistent or partial reopening of the fetal communication between the bladder and the umbilicus persists. The most frequently reported urachal anomalies in adults are infected urachal cyst and urachal carcinoma. The diagnosis of this entity is not always easy because of the rarity of these diseases and the atypical symptoms at presentation. Imaging techniques, such as ultrasonography and computed tomography have a significant role in recognizing the presence of urachus-derived lesions.

Cases presentations

Case presentation 1: A 25-year-old Arab-Berber man presented with a 10-day history of progressive lower abdominal pain accompanied by fever, vomiting, and low urinary tract symptoms to our emergency department. Laboratory data revealed leucocytosis. The diagnosis of an acute peritonitis was made initially. Abdominal ultrasonography revealed a hypoechoic tract from the umbilicus to the abdominal wall, and the diagnosis was rectified (infected urachal remnants). The patient was initially treated with intravenous antibiotics in combination with a percutaneous drainage. Afterwards an extraperitoneal excision of the urachal remnant including a cuff of bladder was performed. The histological analysis did not reveal a tumor of the urachal remnant. Follow-up examinations a few months later showed no abnormality.

Case presentation 2: A 35-year-old Arab-Berber man, without prior medical history with one week of abdominal pain, nausea and vomiting, associated with fever but without lower urinary tract symptoms visited our emergency department. Laboratory data revealed leucocytosis. Abdominal ultrasonography was not conclusive. Computed tomography of the abdomen was the key to the investigation and the diagnosis of an abscess of urachal remnants was made. The patient underwent the same choice of medical-surgical treatment as previously described for case one, with a good follow-up result.

Case presentation 3: A 22-year-old Arab-Berber man, with no relevant past medical history, presented to our emergency department because of suspected acute surgical abdomen. Physical examination revealed umbilical discharge with erythema and a tender umbilical mass. Abdominal ultrasonography and computed tomography scan confirmed the diagnosis of infected urachal sinus. Initial management was intravenous antibiotics associated with a percutaneous drainage with a good post-operative result, but a few days later, he was readmitted with the same complaint and the decision was made for surgical treatment consisting of excision of the infected urachal sinus. The clinical course was uneventful. Histological examination did not reveal any signs of malignancy.

Conclusions

We describe our clinical observations and an analysis of the existing literature to present the various clinical, radiological, pathological and therapeutic aspects of an abscess of urachal remnants. To the best of our knowledge, this manuscript is an original case report because this atypical presentation is rarely reported in the literature and only a few cases have been described.

[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.

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.

The umbilical mass: a rare neonatal anomaly

Umbilical anomalies are a rare presentation in the pediatric patient. The differential diagnosis includes anomalies resulting from urachal and vitelline duct derivatives such as urachal sinus, urachal cyst, urachal diverticulum, patent urachus, herniated Meckel's diverticulum, umbilico-enteric fistula, or umbilical polyp. In this article, a case presentation of an umbilical anomaly along with the differential diagnosis and management options are discussed. Based upon this review of the literature, the authors propose a management algorithm for treating children with umbilical anomalies.

Computed tomographic appearance of urachal carcinoma associated with urachal diverticulum misdiagnosed by cystoscopy

Urachal carcinoma associated with the urachal diverticulum is rare. We present a surgical case of this condition that was initially diagnosed as bladder urothelial carcinoma by cystoscopy, but was then correctly diagnosed by computed tomography (CT). Whereas the CT appearance mimicked that of bladder cancer, accurate localization of the lesion and identification of the median umbilical ligament clarified diagnosis.

Urachal anomalies in children: the vanishing relevance of the preoperative voiding cystourethrogram

PURPOSE

Children with a wet, draining, or infected umbilicus are often referred to pediatric surgeons. Unfortunately, uniform guidelines regarding diagnostic imaging are lacking. Historically, the persistence of the urachus was attributed to intrauterine distal urinary obstruction. Today, many surgeons continue to advocate preoperative voiding cystourethrogram (VCUG).

METHODS

Records of children with urachal abnormalities over the past 10 years were reviewed. Demographics, presentation, imaging, genitourinary anomalies, operations, length of stay, and complications were recorded. Statistical evaluation was by descriptive analysis.

RESULTS

Fifty-six children were diagnosed with urachal anomalies. Age at operation was 2.5 years (1 day-13 years). Fifty percent of patients were less than 1 year. Ultrasound was used in 88% of cases. Voiding cystourethrogram (34%) and computed tomography (14%) were also used. Average hospitalization was 1.9 (0-13) days. Thirty-two percent underwent operations as outpatients. Seven percent developed wound infections. Eight children (14%) had genitourinary anomalies. However, no VCUG examination (n = 19) documented an obstructive process.

CONCLUSIONS

The current study represents the largest reported series of symptomatic urachal anomalies in children. Disorders of the urachus are variable in presentation with the diagnosis reliably made by history and ultrasound alone. Further testing, including VCUG, is not warranted, adding additional cost, an invasive procedure, and inconvenience to the child.

Urachal anomalies: ultrasonography and management

BACKGROUND

Fifty-six children with anomalies of the urachus remnant identified by ultrasound scan have been encountered in the authors' hospital over the last 4 years.

METHODS

Twenty of these 56 cases were symptomatic urachal remnants, whereas the urachus remnants were seen incidentally by ultrasound scanning in the other 36 patients. Symptomatic cases were treated with antibiotics or observation. Then, symptomatic cases were divided into 2 groups. One group, surgical group, was treated with surgical resection of the urachal remnant. The other group, observation group, was followed up without its surgical resection. Forty-four patients, 11 cases of symptomatic urachal remnant and 33 asymptomatic cases, were followed up, excluding patients who had surgical treatment and who were lost to follow-up.

RESULTS

Thirty patients underwent periodical ultrasonographic examination during follow-up. In 9 cases, including 2 symptomatic cases, urachal remnants have disappeared during the follow-up period spontaneously. No symptom had developed during follow-up from asymptomatic cases.

CONCLUSIONS

The patients with asymptomatic urachal remnants do not require follow-up, and urachal remnants, especially those under 1 year of age, do not require surgical resection unless the patient has multiple episodes.

[A case of urachal remnant and review of the literature]

Urachal remnants are not exceptional and are symptomatics if complicated. Ultrasound and CT scan identify most diseases entities originating from urachal remnant. Treatment consists on total exeresis because there is a risk of malignant degeneration. The authors report a case of urachal remnant and analysis the anatomopathologic, diagnosis and therapeutic features of urachal remnants in a review of the literature.

Urachal remnant diseases: spectrum of CT and US findings

Computed tomography (CT) and ultrasonography (US) are ideally suited for demonstrating urachal remnant diseases. A patent urachus is demonstrated at longitudinal US and occasionally at CT as a tubular connection between the anterosuperior aspect of the bladder and the umbilicus. An umbilical-urachal sinus manifests at US as a thickened tubular structure along the midline below the umbilicus. A vesicourachal diverticulum is usually discovered incidentally at axial CT, appearing as a midline cystic lesion just above the anterosuperior aspect of the bladder. At US, it manifests as an extraluminally protruding, fluid-filled sac that does not communicate with the umbilicus. Urachal cysts manifest at both modalities as a noncommunicating, fluid-filled cavity in the midline lower abdominal wall located just beneath the umbilicus or above the bladder. Both infected urachal cysts and urachal carcinomas commonly display increased echogenicity at US and thick-walled cystic or mixed attenuation at CT, making it difficult to differentiate between them. Percutaneous needle biopsy or fluid aspiration is usually needed for diagnosis and therapeutic planning. Nevertheless, CT and US can help identify most disease entities originating from the urachal remnant in the anterior abdominal wall. Understanding the anatomy and the imaging features of urachal remnant diseases is essential for correct diagnosis and proper management.

Urachal anomalies: defining the best diagnostic modality

OBJECTIVES

Urachal abnormalities are uncommon and the literature is primarily comprised of case reports. Conclusions regarding the presentation and diagnosis of these abnormalities may be elucidated by reviewing a large experience.

METHODS

The records of 45 patients with urachal abnormalities in the pediatric age group were reviewed from 1970 to 1997. This included 24 boys and 21 girls with an age range from 1 day to 20 years (average 4.0 years). The presenting complaint was periumbilical discharge in 19 patients (42%), umbilical cyst or mass in 15 (33%), abdominal or periumbilical pain in 10 (22%), and dysuria in 1 (2%). The diagnosis consisted of a urachal sinus in 22 children (49%), a urachal cyst in 16 (36%), and a patent urachus in 7 (15%). Various radiographic studies were used to establish the diagnosis.

RESULTS

Patients with a urachal sinus had 16 voiding cystourethrograms performed (only 1 diagnostic), 9 sinograms (all diagnostic), 8 ultrasounds (4 diagnostic), and 1 excretory urogram (normal). Those with a urachal cyst had 8 voiding cystourethrograms (1 diagnostic), 5 excretory urograms (all normal), 4 ultrasounds (all diagnostic), and 1 computed tomography scan (diagnostic). Children with a patent urachus had 2 excretory urograms (both diagnostic), 1 voiding cystourethrogram (diagnostic), and 2 ultrasounds (normal). One baby with a patent urachus was diagnosed prenatally during ultrasound screening. The diagnosis was made by history and physical examination alone in 5 children and at the time of surgery in 1. Treatment consisted of surgical excision of the urachal abnormality with a cuff of bladder in 22 children, surgical excision without a bladder cuff in 22, incision and drainage of a urachal cyst (1%), and laparoscopic excision of a patent urachus with a bladder cuff in another (1%). There were three wound infections postoperatively. None developed any long-term sequelae.

CONCLUSIONS

The diagnosis of urachal abnormalities can be made with certainty if a good physical examination and the appropriate radiographic test are performed. A patient who presents with periumbilical drainage should have a sinogram performed, which should be diagnostic for both a urachal sinus and a patent urachus. Any child who presents with a periumbilical mass should have an ultrasound performed, which should be diagnostic for a urachal cyst.

Is partial cystectomy the treatment of choice for mucinous adenocarcinoma of the urachus?

OBJECTIVES

To determine if well-differentiated colonic-type adenocarcinoma of the urachus behaves in a benign fashion, and thus might be treated by segmental rather than radical cystectomy.

METHODS

A retrospective review of the literature since 1863 with one added case review is presented here. Only cases with photomicrograph confirmation were accepted.

RESULTS

Sixteen previously reported patients with well differentiated colonic-type adenocarcinoma of the urachus were treated by partial cystectomy. None were treated by radical cystectomy. Most (88%) of these patients were cured, whereas all patients (100%) treated in the last 45 years were cured.

CONCLUSIONS

These data support a more limited approach to the surgical excision of these benign-appearing tumors. The influence of this histologic type on the prognosis of patients with urachal tumors has not been previously reported.

Adenocarcinoma of the urachus

During the past 5 years, three patients with adenocarcinoma of the urachus were treated at our hospital. Abdominal ultrasonography helped clinch the diagnosis in all cases. All patients underwent surgical excision of the neoplasm with partial cystectomy. The clinical, radiological, and histological findings, as well as the pathogenesis of this rare neoplasm are discussed along with the surgical management.

A case of urachal carcinoma

Urachal carcinoma is an uncommon tumor, with a poor prognosis. The most common histological type is adenocarcinoma, which may produce mucus. The symptoms aren't specific, such as hematuria or abdominal mass. Diagnosis can be made endoscopically with a biopsy or by echography and above all by computerized tomography. The treatment of choice is cystectomy with lymphadenectomy or segmental resection of the bladder to. The Authors refer to a patient with urachal carcinoma, stage IIIA involving the bladder.

Alpha-fetoprotein-producing urachal adenocarcinoma

A 45-year-old Japanese male with a history of macroscopic hematuria for more than 6 months presented multiple metastatic lesions in the lungs. Cystoscopic examination demonstrated a large tumor mass protruding from the dome of the urinary bladder. Ultrasonography and CT highlighted a solid and cystic urachal tumor continuous from the vesical dome to the navel. Serum levels of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were elevated to 17,100 ng/ml and 17.7 ng/ml, respectively. He underwent palliative curettage of the vesical dome tumor twice, followed by chemotherapy with little effect. One year after admission, he died of progressive metastases to the lungs, left pleura, liver and brain. Final serum levels of AFP and CEA were 86,200 ng/ml and 60.9 ng/ml, respectively. The tumor was histologically classified as adenocarcinoma with a medullary growth pattern. Both papillotubular and solid (hepatoid) components were observed. The cancer cells were rich in glycogen and were immunoreactive diffusely for AFP and focally for CEA. CA15-3, CA19-9, epithelial membrane antigen and cytokeratin were also positive. In addition, argyrophilic cancer cells with immunoreactivities of neuron-specific enolase, chromagranin A and peptide YY were demonstrated. To our knowledge, this is the first reported case of AFP-producing adenocarcinoma of urachal origin.

Diagnosis of urachal carcinoma by computed tomography and magnetic resonance imaging

Urachal carcinoma is an extremely rare tumor. Computed tomography (CT) and magnetic resonance imaging (MRI) are useful to correctly diagnose and stage such lesions preoperatively. The characteristic location and appearance of such tumors on CT and MRI is discussed and a review of urachal carcinoma is presented.

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.

Urachal carcinoma: evaluation with computed tomography

The computed tomographic (CT) findings in 7 patients with urachal carcinoma were reviewed. Computed tomography was useful in establishing an initial diagnosis, determining the tumor extent, and visualizing tumor recurrence. The embryology, histology, and clinical course of urachal carcinoma are reviewed.

Neoplastic nature of argyrophil cells in urachal adenocarcinoma

The histological, histochemical and electron microscopic features of the metastatic tumors of an urachal adenocarcinoma, were presented. Metastatic tumor nodules in the lungs and brain as well as the primary tumor showed tubular adenocarcinoma containing many argyrophil cells. Immunoperoxidase examination revealed three kind of endocrine cells which contained different endocrine hormones. Electron microscopic examination showed small, round endocrine granules in the endocrine cells and desmosome-like complexes in between these cells and the adjacent glandular neoplastic cells. These findings suggested that the endocrine cells were neoplastic in nature and originated from primitive neoplastic cells as well as glandular neoplastic cells.

Squamous cell carcinoma of the urachus. A case report and review of literature

A rare case of squamous cell carcinoma (SCC) is reported. A cystic tumor, measuring 4 X 4 cm was surgically removed from the supravesical portion in a 77-year-old woman. Macroscopically, it had a communicating canal to the urinary bladder. Microscopically, well differentiated squamous cell carcinoma with pearl formation was noted. An aspiration biopsy was helpful for the histopathological diagnosis at operation. The patient developed purulent peritonitis because of rupture of the tumor which was vulnerable to infection. Six documented cases and the present case were reviewed. The tumors were classified into two types on morphological features: supravesical type and intramural type. Site and local extension of the tumor accounted for clinical features of each type. The authors considered that SCC cells were derived from totipotential epithelial lining of the urachal remnant.

Infected suture granuloma simulating mass of urachal origin: case report

We report a case of an infected suture granuloma. The patient presented with a solid mass located superior to the dome of the bladder. Evaluation showed a normal intestinal tract and absence of a primary bladder abnormality. Based on these findings the mass was considered to be of urachal origin but surgical excision revealed that the mass was an infected suture granuloma. Suture granuloma should be considered in patients who have had previous inguinal surgery, particularly when associated with the use of nonabsorbable suture.

Computed tomographic imaging of microscopic dystrophic calcification in urachal adenocarcinoma

Supravesical calcification noted on conventional radiography when associated with a bladder lesion has been considered nearly pathognomonic of the uncommon lesion, urachal adenocarcinoma. As the case reported here demonstrates, stippled microscopic calcification undetected by conventional means can be demonstrated uniquely by computed tomography with great sensitivity. Because urachal adenocarcinoma may be managed in a distinctly different manner if adequate preoperative preparation is made, it is suggested that in cases of anterior bladder lesions, computed tomographic imaging can detect this typical characteristic of urachal adenocarcinoma and may thereby provide further comfirmatory diagnostic evidence helpful in surgical planning.

Urachal carcinoma

Urachal carcinoma is a rare tumor that often does not manifest clinically until late in its course. Several radiographic features are helpful in suggesting the diagnosis preoperatively. We present a case of urachal carcinoma in which preoperative evaluation included magnetic resonance imaging. This technique was helpful not only in suggesting the diagnosis preoperatively, but also, and more importantly, in the preoperative staging of the neoplasm.

Urachal adenocarcinoma presenting as vesicoenteric fistula

We report a case, which we believe to be the first, of urachal carcinoma presenting as vesicoenteric fistula.

Adenocarcinoma of the urachus with vesicoenteric fistula

A case of mucoid adenocarcinoma of the urachus demonstrated by ultrasonography, cystography, and computerized tomography is presented. The inhomogeneous, echogenic mass was confluent with the anterior--superior aspect of the bladder but was also associated with a fistula between the bladder and small intestine, a finding not previously reported.

Argyrophil cells in the urachal epithelium and urachal adenocarcinoma

Urachal adenocarcinoma, normal urachus, and urinary bladder were studied by histochemical methods and electron microscopy. Many argyrophil cells were found in urachal adenocarcinoma and urachal epithelium. Autofluorescence and immunoperoxidase examinations showed that the argyrophil cells possessed serotonin, glucagon, and secretin. Some of the carcinoma cells and urachal epithelial cells contained fairly large amount of mucosubstances. On the other hand, only a few argyrophil cells and very weakly PAS positive cells were observed in the urinary bladder mucosa. This study showed that there were close similarities in the histochemical and electron microscopical features between the urachal carcinoma and urachal epithelium, and suggested that the undifferentiated stem cells were able to differentiate to both glandular and endocrine cells.

Carcinoma of the urachus

Two cases of carcinoma of the urachus are reported, 1 involving the dome of the bladder and 1 occurring beneath the peritoneum of the anterior abdominal wall below the umbilicus at the apex of an elongated bladder. Both patients died shortly after diagnosis, a fact which emphasizes the poor prognosis of this group of patients. The poor prognosis and need for more than local resection of the tumour may not be widely appreciated. Tumours arising above the bladder have a different mode of presentation from those arising within the bladder wall. Bladder wall tumours are most frequently mucus-secreting adenocarcinomas; tumours arising above the bladder may be more variable in their histological type, and include squamous and undifferentiated cancer. A simple classification into vesicle and supra-vesical tumours is proposed, to replace an early classification into 7 groups.

10-year experience with adenocarcinoma of the bladder

Adenocarcinoma is an uncommon form of bladder carcinoma. We review our 10-year experience with primary adenocarcinoma of the bladder in 28 patients who were managed by a wide range of therapeutic modalities. Our data reaffirm the highly aggressive nature of this lesion. However, aggressive therapy is justified when feasible.

Malignant urachal lesions

Urachal cancers are uncommon malignancies with a location that often permits considerable local extension before they are discovered. The most common histological type is adenocarcinoma, which may produce mucus that is a valuable aid in diagnosis. The presence of stippled calcification in a midline abdominal wall mass is almost pathognomonic for urachal carcinoma. More commonly, however, the symptoms are less specific, such as hematuria and an abdominal mass. Many lesions are visible endoscopically and, thus, the diagnosis can be made preoperatively from a biopsy. Most treatment failures occur because the tumor is not controlled locally by the initial operation and, therefore, we recommend en bloc cystectomy with umbilectomy and pelvic lymphadenectomy unless the tumor is known to be a sarcoma or early stage (I) carcinoma. If these patients are undertreated and there is a local recurrence then the patient usually is not salvageable. Because of the difficulty in identifying the origin of a bladder adenocarcinoma, any tumor on the dome or anterior wall should be approached initially as if it were a urachal tumor.

Clinical features of urachal carcinoma in Japan: review of 157 patients

Carcinoma of the urachus is not as uncommon as previously considered. 157 cases diagnosed to have urachal carcinoma collected from the Japanese literature were reviewed and the findings were compared with those reported in the English literature. The incidence of the disease ranges from 0.55 to 1.2% of bladder tumours in Japan in contrast with 0.07 to 0.70% in the Western countries. Males accounted for 72% of the patients. The highest age incidence occurred between fifth and sixth decades. The commonest presenting symptom was haematuria (71%). Adenocarcinoma accounted for 88% of the tumours most being mucous producing. Various treatment modalities were used, however, and the prognosis remained uniformly poor. An analysis of 66 patients with known outcome revealed an overall 5-year survival rate of 6%. The authors conclude that the disease tends to have a relatively higher incidence in Japan (Far East). When comparing the parameters of sex, age, presenting symptom, histopathology, treatment and prognosis, urachal carcinoma appears to have the same characteristics in the Far East as in Western countries.

Adenocarcinoma of urachus. Report of 7 cases and review of literature

Seven cases of adenocarcinoma of the urachus treated at the National Cancer Center Hospital, Tokyo, over a nineteen-year period are reported. One hundred fifty-five cases reported in English literature and 140 cases in Japanese literature were analyzed with respect to the modalities of treatment, mean remission times, and sites of recurrence or metastases. From this review and experience on the 7 cases reported here, extended radical total cystectomy with well-designed radio- and chemotherapy was proposed for the treatment of this disease.