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Carcinoma of the Female Urethra
THE JOURNAL OF UROLOGY
Vol. 64, No. 5, November 1950
Printea in U.S.A.
CARCINOMA OF THE FEMALE URETHRA C. BERNARD BRACK
AND
GEORGE J. FARBER
From the Departments of Gynecology and Radiology, The Johns Hop kins University and Hospital, Baltimore
Carcinoma of the female urethra is a relatively rare disease. The first case in the literature was reported by Boivin and Duges in 1833. 1 The first case in the English literature is said to have been reported by McGill in 1890 ;2 however, the lesion he described was so extensive that its origin is uncertain. The first large series of cases was reported by V enot and Parcelier in 1921, 3 their series consisting of 87 cases. In 1933 Counseller and Paterson collected 124 cases from the literature and added 12 of their own. 4 Walther in 1942 was able to collect 278 cases from the literature. 5 Our perusal of the recent literature reveals 50 additional cases not included in the previous collections. Included in this group is 1 case reported by Nichol 6 but not included in Walther's series, 14 cases reported by Cuscaden, 7 3 cases of Clayton's,8 13 reported by Hess,9 8 cases of Jackman and Bacon's, 10 6 cases reported by Seng and Siminovitch, 11 and 5 cases from this clinic mentioned by Everett12 in his textbook, but not included in previous series. This brings the total number of cases in the literature at the present time up to 328. When the 10 cases reported for the first time in the present communication are added, the total is 338. Most carcinomas of the female urethra arise at the urethral meatus from the junction between the transitional epithelium of the urethra and the stratified squamous epithelium of the vulva. Halban states that this type of carcinoma is more common than the second type, which arises from the mucosa of the upper urethra. 13 Ehrendorfer named the first type vulvo-urethral carcinoma and the second urethral carcinoma.14 This latter type he believed was the only true carcinoma of the urethra; however, most writers have considered that both types are carcinomas of the urethra. The vulvo-urethral type of caryinoma begins as an ulcer at the urethral meatus, and may sometimes originate in a urethral caruncle. The early lesion often resembles a caruncle in appearance. Extension occurs along the mucous membrane of the vestibule, so that in the late stages 1 Boivin, M.A. V. G. and Duges, A.: Traite pratique des maladies de !'uterus et de ses annexes., Paris: J.B. Balliere, 1833, vol. v, p. 648. 2 McGill, A. F.: Lancet, 2: 966, 1890. 3 Venot, A. and Parcelier, A.: Rev. de Chir., 59: 565, 1921. 4 Counseller, V. S. and Paterson, S. J.: J. Urol., 29: 587, 1933. 5 Walther, H. W. E.: J. Urol., 50: 38, 1943. 6 Nichol, J.E.: Canad. Med. Assoc. J., 45: 155, 1941. 7 Cuscaden, W. G.: Med. J. Australia, 1: 487, 1944. 8 Clayton, S. G.: J. Obst. & Gynec. Brit. Emp., 52: 508, 1945. 9 Hess, E.: Penn. Med. Jour., 48: 1150, 1945. 10 Jackman, J. and Bacon, R. D.: Penn. Med. J., 49: 518, 1946. 11 Seng, M. and Siminovitch, M., Canad. Med. Assoc. J., 58: 29, 1948. 12 Everett, H. S.: Gynecology and Obstetrical Urology., Baltimore: Williams & Wilkins Co., 1947, chapt. 6. 13 Halban, J. and Seitz, L.: Biologie und Pathologic des Weibes., Berlin-Wien: Urban & Schwarzenberg, 1928, vol. V/4, p. 1065. 14 Ehrendorfer, E.: Arch. f. Gynec., 58: 463, 1899. 710
CARCINOMA OF FEMALE URETHRA
711
this lesion may be indistinguishable from carcinoma of the clitoris or vulva. Halban states that extension also takes place along the urethral mucosa toward the sphincter, so that the entire urethra may eventually become thickened and indurated. The rarer urethral type of carcinoma arises from the urethral mucosa somewhere above the meatus. Grossly these lesions are sometimes papillary in appearance, and in rare cases polypoid structures may protrude from the meatus and may be mistaken for benign polyps. Halban states that some of the latter tumors are adenocarcinomas. Two of Everett's 5 tumors were adenocarcinomas although there are none of this type in the 10 cases which we are reporting in this communication. Most writers agree that the urethral type of carcinoma infiltrates the deeper tissues more rapidly than the vulva-urethral type, and
FIG. 1. A, case 10. Epidermoid carcinoma of urethra. X 100. B, case 9. Epidermoid carcinoma of urethra. X 400.
in our experience the former tumor metastasizes more rapidly to the inguinal lymph nodes. Grossly the urethral type of carcinoma is characterized by diffuse enlargement of the urethra, which is transformed into a hard, rigid tube. It may attain the thickness of the human finger or become even larger. Microscopically, most carcinomas of the urethra are of the squamous cell variety. A rare mucoid type characterized microscopically by mucus-containing signet-ring cells has been described by Menville and Counseller, 15 and indeed 1 case in our series showed a few such cells in some areas. Another rare malignant tumor of the urethra is sarcoma. A giant cell sarcoma is among the early cases mentioned by Everett in his textbook. Of the 10 cases in our series, 7 are of the vulvo-urethral type and 3 of the urethral type. Although all were diagnosed microscopically as epidermoid car1•
Menville, J. G. and Counseller, V. S.: J. Urol., 33: 76, 1935.
712
C. BERNARD BRACK AND GEORGE J. FARBER
cinomas (fig. 1), one tumor which arose from the posterior urethra had the gross appearance of a papillary tumor on cystoscopic examination. One of the carcinomas which arose at the meatus was thought by the pathologist to represent malignant degeneration in a caruncle. The vulvo-urethral type of carcinoma metastasizes primarily to the inguinal lymph nodes. Venot and Parcelier report 15 such metastases in 55 cases and Shaw16 found that about one third of his 100 cases metastasized to this group of lymph nodes. In our series of 10 cases, 2 had inguinal metastases. TABLE CASE NO.
AGE
VAGINAL BLEEDING
--
1.
Carcinoma of urethra-Analysis of symptoms
REMATURI.A
FREQUENCY
URGENCY
DYSURI.A
DIFFICULTY
INCONT.
OTHER
---
1
62
l mth.
2 3
52 63
5 yrs.
4 5
50 61
2 mos. 3 mos.
6 7
52 76
8
59
9 10
63 48
Indefinite
One occasion
flank pain 5 days
5 days
5 days
5 days 6 mos.
1 yr.
1 yr.
2 mos. 4 mos.
2 wks.
6 mths.
Partial 6 mths.
Tumor 6 mos. "Growth" All Life
2 mths.
4 mos.
4 mths.
4 mos.
3 mos.
3 mos.
3 mos.
Tumor 1 mth Flank pain 4 mos. 3 mths. 16 days retention 9 days
Shaw states that carcinoma of the female urethra is more common in women over 40. In Counseller and Paterson's series the average age was 52 years, in Venot and Parcelier's 53.4 years, while in our series it is 58.6 years. Forty-five of Venot and Parcelier's 47 patients were married. Among the predisposing factors mentioned by most authors are multiparity, previous infection of the urethra, previous leukoplakia, previous caruncle, and trauma. Scholl and Braasch17 and Counseller and Paterson believe that chronic infection and irritation are important factors in the production of urethral carcinoma. We have been unable to demonstrate such a connection in the majority of our cases. Of the 10 cases, one complained of a "weak bladder all her life," 16
17
Shaw, W. F.: J. Obst. & Gynec. Brit. Emp., 30: 215, 1923. Scholl, A. J. Jr. and Braasch, W. F.: Ann. Surg., 76: 2~6, 1922.
CARCINOMA OF FEMALE URETHRA
713
and another of a "growth" at the meatus since childhood. The others had no previous urinary complaints. Among the symptoms mentioned in the literature are burning and itching at the meatus, serous or bloody discharge, dysuria, urinary retention, incontinence, and tenesmus. After ulceration of the lesion occurs it becomes painful to pressure and to other stimuli such as contact with urine. For the symptoms and their duration in our series, see table L It will be noted that frequency of urination and. dysuria were the commonest symptoms, both occurring in 6 of the 10 cases. The average duration of the symptoms was 9.4 months. However, if case 2, in which genital bleeding was present for 5 years is excluded, the average duration was 3.2 months, probably a more nearly correct figure. This is much shorter than Counseller and Paterson's figure of 7½ months. Diagnosis in symptomatic cases of the vulvo-urethral type of carcinoma is not difficult, since a definite ulcerative lesion may usually be seen at the meatus on inspection. Since the lesion may be mistaken for a urethral caruncle or for prolapse of the urethral mucosa, all suspicious-looking lesions at the meatus should be biopsied as a matter of routine. In late lesions of the urethral type the diagnosis may be suspected from the characteristic diffuse enlargement and induration of the urethra and, of course, confirmed by biopsy. In early lesions of the latter type the diagnosis may be more difficult, and sometimes can only be made by biopsying supposedly benign urethral polyps. The necessity for taking such biopsies is obvious and need hardly be stressed. Indeed, in one of our cases a definite diagnosis could not be made in spite of several biopsies until tissue from the region of the internal sphincter had been removed with a resectoscope and examined microscopically. We believe that such a diagnostic problem is one of the rare indication for using the resectoscope in the female. The methods of treating carcinoma of the female urethra described in the literature may be summarized as follows: 1) radical excision of the urethra including a portion of the vesical neck; 2) less radical excision leaving intact the vesical neck and sphincter; 3) knife or electrosurgical excision followed by radiation; 4) radiation alone. The results have in general been poor, no matter what type of therapy has been used. However, most of the reports are unsatisfactory in that most of the cases have not been followed for as long as 5 years. One of the best series from the standpoint of successful therapy is that of Counseller and Paterson. In their group of 12 cases, 4 were treated with surgery alone, 3 with radfation alone, and 5 with a combination of surgery and radium therapy. Four of their 12 cases were living after 5 years or more, and 3 after shorter periods. One case was lost, and 4 were dead. Of those who died, the average duration of life was 25½ months. These authors concluded that the highest percentage of 5-year cures was obtained in cases treated both with radium and roentgen rays. An interesting recent paper is that of Jackman and Bacon10 who reported 8 urethral carcinomas treated with radium and roentgen ray therapy during the 5 years ending in 1946. In addition to the roentgen ray therapy, radium therapy was administered interstitially by means of needles inserted around the urethra.
714
C. BERNARD BRACK AND GEORGE J. FARBER
Five and possibly 6 of their patients were living and well from a few months to 5 years after therapy. Treatment and results in our series of 10 cases are summarized in table 2. All of our patients received radium therapy, and in addition 8 received roentgen ray therapy as well. Excision of the urethra and vesical neck was done in 2 cases, and local excision of the carcinoma in 1. The ureters were transplanted to the colon in 2 cases. In 6 cases, including the 3 carcinomas of the urethral type, radium was applied intra-urethrally by means of two 25 mg. radium tubes in tandem in a rubber mushroom catheter. The filtration was 1 mm. of platinum and 3 mm. of rubber. The radium was applied in relatively small divided doses averaging 300 mg. hours each at 4 to 7 day intervals. The total intra-urethral dosage varied between 600 mg. hours and 2400 mg. hours. TABLE CASE
NO,
RADIUM THERAPY
X-RAY
THERAPY
Carcinoma of urethra OPERATION
1 2 3
2708 mg. hrs. 3600 mg. hrs. 3200 mg. hrs.
2000 r
4
1950 mg. hrs.
4200 r
-
5
6 7 8
1100 600 160 1200
hrs. hrs. hrs. hrs.
4000 r 1000 r 1600 r
-
9
1200 mg. hrs.
10,000 r
10
4790 mg. hrs.
13,500 r
mg. mg. mg. mg.
5400 r
2.
-
-
Excision urethra
Therapeutic vesicovag. fistula
Local excision of carcinoma Excision of urethra and transplantion of ureters to colon Transplantion of ureters to colon. Local excision of inguinal nodes
RESULT
Well Well Died 4 yrs.
YEARS L. &W.
6¾ 5¾
Living with recurrence 2½ yrs. Died 2 yrs. Well Died 4 mos. Well
1
Well
1
4
Died 14 mos.
In addition, 8 patients were given radium therapy to the surface of the urethra by means of a linen plaque containing radium tubes placed directly over the meatus. Usually two 25 mg. radium tubes placed side by side were used. The contra-urethral dosage varied between 80 and 2400 mg. hours. Usually two divided doses were administered. Of the patients who received intra-urethral radium therapy, 4 also received contra-urethral therapy. The remaining 4 patients received all their radium therapy in the form of contra-urethral applications only. The type of radium therapy used depended on the location and extent of the lesion. Usually lesions at the meatus were treated with both types of radium applicators so as to obtain more uniform distribution of the radiation. Radium therapy was supplemented with divided dose roentgen ray therapy in 8 of the 10 cases. The rays were directed perpendicular to the surface of the body over fields covering the entire pelvis both anteriorly and posteriorly.
CARCINOMA OF FEMALE URETHRA
715
Usually 2 anterior and 2 posterior portals were used. In 3 cases the pelvis was radiated obliquely through a perineal portal. The technical factors were 200 or 400kVP (depending upon the type of x-ray apparatus available); a Thoraeus filter equivalent to 2 mm. of copper plus 1 mm. of aluminum in the first case, and 3 mm. of copper plus 1 mm. of aluminum in the second; a skin-target distance of 50 cm. with the 200kVP machine, and 70 cm. with the 400kVP machine. The total dosages are outlined in table 2. The rather wide variation in both radium and roentgen ray dosage is partly due to the variation in the extent of the lesions, and partly to the fact that in at least one very feeble patient with advanced carcinoma the therapy was considered purely palliative. Of our 10 cases, 5 are living and well after periods varying from 6¾ to 1 year after therapy. The other living patient has metastases to the inguinal lymph nodes 2½ years after therapy. Four patients are dead. Of these latter, 1 lived 4 years after treatment and apparently died from ca,rdiovascular renal disease, although no autopsy was obtained. Of the 3 patients treated more than 5 years ago, 2 are living and well after 6¾ and 5¾ years respectively, and 1 died 4 years after treatment. All 3 of these patients received relatively large doses of radium therapy (2708 to 3600 mg. hours) and 2 of them roentgen ray therapy as welL All 3, however, have had persistent difficulty with micturition in the form of partial or complete incontinence, or of difficulty in emptying the bladder with a large residual urine. These symptoms are thought to be the result of radiation scarring of the urethra. The persistence of such symptoms may necessitate either some plastic procedure upon the urethral sphincter, which is usually difficult because of the scar tissue, or transplantation of the ureters to the colon. following irradiation in order to restore urinary continence. CONCLUSION
The literature on carcinoma of the female urethra is reviewed, the number of recorded cases brought up to 338, and the pathology, symptoms, diagnosis, and therapy discussed, Ten cases treated with radiation or a combination of radiation and surgery are reported. Of this group 6 are living and 4 are dead. Two of the 3 patients treated more than 5 years ago are living and well. Carcinoma of the female urethra may be successfully treated with relatively heavy radium and roentgen ray therapy, In some cases, particularly the urethral type of carcinoma, excision of the urethra following radiation is advisable.
Vol. 64, No. 5, November 1950
Printea in U.S.A.
CARCINOMA OF THE FEMALE URETHRA C. BERNARD BRACK
AND
GEORGE J. FARBER
From the Departments of Gynecology and Radiology, The Johns Hop kins University and Hospital, Baltimore
Carcinoma of the female urethra is a relatively rare disease. The first case in the literature was reported by Boivin and Duges in 1833. 1 The first case in the English literature is said to have been reported by McGill in 1890 ;2 however, the lesion he described was so extensive that its origin is uncertain. The first large series of cases was reported by V enot and Parcelier in 1921, 3 their series consisting of 87 cases. In 1933 Counseller and Paterson collected 124 cases from the literature and added 12 of their own. 4 Walther in 1942 was able to collect 278 cases from the literature. 5 Our perusal of the recent literature reveals 50 additional cases not included in the previous collections. Included in this group is 1 case reported by Nichol 6 but not included in Walther's series, 14 cases reported by Cuscaden, 7 3 cases of Clayton's,8 13 reported by Hess,9 8 cases of Jackman and Bacon's, 10 6 cases reported by Seng and Siminovitch, 11 and 5 cases from this clinic mentioned by Everett12 in his textbook, but not included in previous series. This brings the total number of cases in the literature at the present time up to 328. When the 10 cases reported for the first time in the present communication are added, the total is 338. Most carcinomas of the female urethra arise at the urethral meatus from the junction between the transitional epithelium of the urethra and the stratified squamous epithelium of the vulva. Halban states that this type of carcinoma is more common than the second type, which arises from the mucosa of the upper urethra. 13 Ehrendorfer named the first type vulvo-urethral carcinoma and the second urethral carcinoma.14 This latter type he believed was the only true carcinoma of the urethra; however, most writers have considered that both types are carcinomas of the urethra. The vulvo-urethral type of caryinoma begins as an ulcer at the urethral meatus, and may sometimes originate in a urethral caruncle. The early lesion often resembles a caruncle in appearance. Extension occurs along the mucous membrane of the vestibule, so that in the late stages 1 Boivin, M.A. V. G. and Duges, A.: Traite pratique des maladies de !'uterus et de ses annexes., Paris: J.B. Balliere, 1833, vol. v, p. 648. 2 McGill, A. F.: Lancet, 2: 966, 1890. 3 Venot, A. and Parcelier, A.: Rev. de Chir., 59: 565, 1921. 4 Counseller, V. S. and Paterson, S. J.: J. Urol., 29: 587, 1933. 5 Walther, H. W. E.: J. Urol., 50: 38, 1943. 6 Nichol, J.E.: Canad. Med. Assoc. J., 45: 155, 1941. 7 Cuscaden, W. G.: Med. J. Australia, 1: 487, 1944. 8 Clayton, S. G.: J. Obst. & Gynec. Brit. Emp., 52: 508, 1945. 9 Hess, E.: Penn. Med. Jour., 48: 1150, 1945. 10 Jackman, J. and Bacon, R. D.: Penn. Med. J., 49: 518, 1946. 11 Seng, M. and Siminovitch, M., Canad. Med. Assoc. J., 58: 29, 1948. 12 Everett, H. S.: Gynecology and Obstetrical Urology., Baltimore: Williams & Wilkins Co., 1947, chapt. 6. 13 Halban, J. and Seitz, L.: Biologie und Pathologic des Weibes., Berlin-Wien: Urban & Schwarzenberg, 1928, vol. V/4, p. 1065. 14 Ehrendorfer, E.: Arch. f. Gynec., 58: 463, 1899. 710
CARCINOMA OF FEMALE URETHRA
711
this lesion may be indistinguishable from carcinoma of the clitoris or vulva. Halban states that extension also takes place along the urethral mucosa toward the sphincter, so that the entire urethra may eventually become thickened and indurated. The rarer urethral type of carcinoma arises from the urethral mucosa somewhere above the meatus. Grossly these lesions are sometimes papillary in appearance, and in rare cases polypoid structures may protrude from the meatus and may be mistaken for benign polyps. Halban states that some of the latter tumors are adenocarcinomas. Two of Everett's 5 tumors were adenocarcinomas although there are none of this type in the 10 cases which we are reporting in this communication. Most writers agree that the urethral type of carcinoma infiltrates the deeper tissues more rapidly than the vulva-urethral type, and
FIG. 1. A, case 10. Epidermoid carcinoma of urethra. X 100. B, case 9. Epidermoid carcinoma of urethra. X 400.
in our experience the former tumor metastasizes more rapidly to the inguinal lymph nodes. Grossly the urethral type of carcinoma is characterized by diffuse enlargement of the urethra, which is transformed into a hard, rigid tube. It may attain the thickness of the human finger or become even larger. Microscopically, most carcinomas of the urethra are of the squamous cell variety. A rare mucoid type characterized microscopically by mucus-containing signet-ring cells has been described by Menville and Counseller, 15 and indeed 1 case in our series showed a few such cells in some areas. Another rare malignant tumor of the urethra is sarcoma. A giant cell sarcoma is among the early cases mentioned by Everett in his textbook. Of the 10 cases in our series, 7 are of the vulvo-urethral type and 3 of the urethral type. Although all were diagnosed microscopically as epidermoid car1•
Menville, J. G. and Counseller, V. S.: J. Urol., 33: 76, 1935.
712
C. BERNARD BRACK AND GEORGE J. FARBER
cinomas (fig. 1), one tumor which arose from the posterior urethra had the gross appearance of a papillary tumor on cystoscopic examination. One of the carcinomas which arose at the meatus was thought by the pathologist to represent malignant degeneration in a caruncle. The vulvo-urethral type of carcinoma metastasizes primarily to the inguinal lymph nodes. Venot and Parcelier report 15 such metastases in 55 cases and Shaw16 found that about one third of his 100 cases metastasized to this group of lymph nodes. In our series of 10 cases, 2 had inguinal metastases. TABLE CASE NO.
AGE
VAGINAL BLEEDING
--
1.
Carcinoma of urethra-Analysis of symptoms
REMATURI.A
FREQUENCY
URGENCY
DYSURI.A
DIFFICULTY
INCONT.
OTHER
---
1
62
l mth.
2 3
52 63
5 yrs.
4 5
50 61
2 mos. 3 mos.
6 7
52 76
8
59
9 10
63 48
Indefinite
One occasion
flank pain 5 days
5 days
5 days
5 days 6 mos.
1 yr.
1 yr.
2 mos. 4 mos.
2 wks.
6 mths.
Partial 6 mths.
Tumor 6 mos. "Growth" All Life
2 mths.
4 mos.
4 mths.
4 mos.
3 mos.
3 mos.
3 mos.
Tumor 1 mth Flank pain 4 mos. 3 mths. 16 days retention 9 days
Shaw states that carcinoma of the female urethra is more common in women over 40. In Counseller and Paterson's series the average age was 52 years, in Venot and Parcelier's 53.4 years, while in our series it is 58.6 years. Forty-five of Venot and Parcelier's 47 patients were married. Among the predisposing factors mentioned by most authors are multiparity, previous infection of the urethra, previous leukoplakia, previous caruncle, and trauma. Scholl and Braasch17 and Counseller and Paterson believe that chronic infection and irritation are important factors in the production of urethral carcinoma. We have been unable to demonstrate such a connection in the majority of our cases. Of the 10 cases, one complained of a "weak bladder all her life," 16
17
Shaw, W. F.: J. Obst. & Gynec. Brit. Emp., 30: 215, 1923. Scholl, A. J. Jr. and Braasch, W. F.: Ann. Surg., 76: 2~6, 1922.
CARCINOMA OF FEMALE URETHRA
713
and another of a "growth" at the meatus since childhood. The others had no previous urinary complaints. Among the symptoms mentioned in the literature are burning and itching at the meatus, serous or bloody discharge, dysuria, urinary retention, incontinence, and tenesmus. After ulceration of the lesion occurs it becomes painful to pressure and to other stimuli such as contact with urine. For the symptoms and their duration in our series, see table L It will be noted that frequency of urination and. dysuria were the commonest symptoms, both occurring in 6 of the 10 cases. The average duration of the symptoms was 9.4 months. However, if case 2, in which genital bleeding was present for 5 years is excluded, the average duration was 3.2 months, probably a more nearly correct figure. This is much shorter than Counseller and Paterson's figure of 7½ months. Diagnosis in symptomatic cases of the vulvo-urethral type of carcinoma is not difficult, since a definite ulcerative lesion may usually be seen at the meatus on inspection. Since the lesion may be mistaken for a urethral caruncle or for prolapse of the urethral mucosa, all suspicious-looking lesions at the meatus should be biopsied as a matter of routine. In late lesions of the urethral type the diagnosis may be suspected from the characteristic diffuse enlargement and induration of the urethra and, of course, confirmed by biopsy. In early lesions of the latter type the diagnosis may be more difficult, and sometimes can only be made by biopsying supposedly benign urethral polyps. The necessity for taking such biopsies is obvious and need hardly be stressed. Indeed, in one of our cases a definite diagnosis could not be made in spite of several biopsies until tissue from the region of the internal sphincter had been removed with a resectoscope and examined microscopically. We believe that such a diagnostic problem is one of the rare indication for using the resectoscope in the female. The methods of treating carcinoma of the female urethra described in the literature may be summarized as follows: 1) radical excision of the urethra including a portion of the vesical neck; 2) less radical excision leaving intact the vesical neck and sphincter; 3) knife or electrosurgical excision followed by radiation; 4) radiation alone. The results have in general been poor, no matter what type of therapy has been used. However, most of the reports are unsatisfactory in that most of the cases have not been followed for as long as 5 years. One of the best series from the standpoint of successful therapy is that of Counseller and Paterson. In their group of 12 cases, 4 were treated with surgery alone, 3 with radfation alone, and 5 with a combination of surgery and radium therapy. Four of their 12 cases were living after 5 years or more, and 3 after shorter periods. One case was lost, and 4 were dead. Of those who died, the average duration of life was 25½ months. These authors concluded that the highest percentage of 5-year cures was obtained in cases treated both with radium and roentgen rays. An interesting recent paper is that of Jackman and Bacon10 who reported 8 urethral carcinomas treated with radium and roentgen ray therapy during the 5 years ending in 1946. In addition to the roentgen ray therapy, radium therapy was administered interstitially by means of needles inserted around the urethra.
714
C. BERNARD BRACK AND GEORGE J. FARBER
Five and possibly 6 of their patients were living and well from a few months to 5 years after therapy. Treatment and results in our series of 10 cases are summarized in table 2. All of our patients received radium therapy, and in addition 8 received roentgen ray therapy as well. Excision of the urethra and vesical neck was done in 2 cases, and local excision of the carcinoma in 1. The ureters were transplanted to the colon in 2 cases. In 6 cases, including the 3 carcinomas of the urethral type, radium was applied intra-urethrally by means of two 25 mg. radium tubes in tandem in a rubber mushroom catheter. The filtration was 1 mm. of platinum and 3 mm. of rubber. The radium was applied in relatively small divided doses averaging 300 mg. hours each at 4 to 7 day intervals. The total intra-urethral dosage varied between 600 mg. hours and 2400 mg. hours. TABLE CASE
NO,
RADIUM THERAPY
X-RAY
THERAPY
Carcinoma of urethra OPERATION
1 2 3
2708 mg. hrs. 3600 mg. hrs. 3200 mg. hrs.
2000 r
4
1950 mg. hrs.
4200 r
-
5
6 7 8
1100 600 160 1200
hrs. hrs. hrs. hrs.
4000 r 1000 r 1600 r
-
9
1200 mg. hrs.
10,000 r
10
4790 mg. hrs.
13,500 r
mg. mg. mg. mg.
5400 r
2.
-
-
Excision urethra
Therapeutic vesicovag. fistula
Local excision of carcinoma Excision of urethra and transplantion of ureters to colon Transplantion of ureters to colon. Local excision of inguinal nodes
RESULT
Well Well Died 4 yrs.
YEARS L. &W.
6¾ 5¾
Living with recurrence 2½ yrs. Died 2 yrs. Well Died 4 mos. Well
1
Well
1
4
Died 14 mos.
In addition, 8 patients were given radium therapy to the surface of the urethra by means of a linen plaque containing radium tubes placed directly over the meatus. Usually two 25 mg. radium tubes placed side by side were used. The contra-urethral dosage varied between 80 and 2400 mg. hours. Usually two divided doses were administered. Of the patients who received intra-urethral radium therapy, 4 also received contra-urethral therapy. The remaining 4 patients received all their radium therapy in the form of contra-urethral applications only. The type of radium therapy used depended on the location and extent of the lesion. Usually lesions at the meatus were treated with both types of radium applicators so as to obtain more uniform distribution of the radiation. Radium therapy was supplemented with divided dose roentgen ray therapy in 8 of the 10 cases. The rays were directed perpendicular to the surface of the body over fields covering the entire pelvis both anteriorly and posteriorly.
CARCINOMA OF FEMALE URETHRA
715
Usually 2 anterior and 2 posterior portals were used. In 3 cases the pelvis was radiated obliquely through a perineal portal. The technical factors were 200 or 400kVP (depending upon the type of x-ray apparatus available); a Thoraeus filter equivalent to 2 mm. of copper plus 1 mm. of aluminum in the first case, and 3 mm. of copper plus 1 mm. of aluminum in the second; a skin-target distance of 50 cm. with the 200kVP machine, and 70 cm. with the 400kVP machine. The total dosages are outlined in table 2. The rather wide variation in both radium and roentgen ray dosage is partly due to the variation in the extent of the lesions, and partly to the fact that in at least one very feeble patient with advanced carcinoma the therapy was considered purely palliative. Of our 10 cases, 5 are living and well after periods varying from 6¾ to 1 year after therapy. The other living patient has metastases to the inguinal lymph nodes 2½ years after therapy. Four patients are dead. Of these latter, 1 lived 4 years after treatment and apparently died from ca,rdiovascular renal disease, although no autopsy was obtained. Of the 3 patients treated more than 5 years ago, 2 are living and well after 6¾ and 5¾ years respectively, and 1 died 4 years after treatment. All 3 of these patients received relatively large doses of radium therapy (2708 to 3600 mg. hours) and 2 of them roentgen ray therapy as welL All 3, however, have had persistent difficulty with micturition in the form of partial or complete incontinence, or of difficulty in emptying the bladder with a large residual urine. These symptoms are thought to be the result of radiation scarring of the urethra. The persistence of such symptoms may necessitate either some plastic procedure upon the urethral sphincter, which is usually difficult because of the scar tissue, or transplantation of the ureters to the colon. following irradiation in order to restore urinary continence. CONCLUSION
The literature on carcinoma of the female urethra is reviewed, the number of recorded cases brought up to 338, and the pathology, symptoms, diagnosis, and therapy discussed, Ten cases treated with radiation or a combination of radiation and surgery are reported. Of this group 6 are living and 4 are dead. Two of the 3 patients treated more than 5 years ago are living and well. Carcinoma of the female urethra may be successfully treated with relatively heavy radium and roentgen ray therapy, In some cases, particularly the urethral type of carcinoma, excision of the urethra following radiation is advisable.