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Sinus Tract Carcinoma1
SINUS TRACT CARCINOMA 1 ERNEST M. WATSON Prem the Urological Service of the New York 8tate Institute for the 8tudy of Malignant Disease, and the Department of Urology, Medical 8chool Univer.sity of Buffalo, Buffalo, New Yark
Any integral organ of the urinary tract may be the site of a primary malignant growth and from the epithelial lined cavities of this somewhat intricate system primary carcinoma is common. However, from the pathological accessory channels of this system, i.e., fistulous tracts and old urinary sinuses, such an extreme hyperplastic change is quite rare. In 1881 Poncet (1) reported 2 cases of carcinoma developing in fistulous tracts which led from the perineum into the deep urethra. In the first case the fistula, forming after the incision of a periurethral abscess, drained for sixteen years before the onset of the carcinoma, and in the second case the perineal fistula similarly following the incision of a periurethral abscess, drained for six months before the onset of carcinoma which was first recognized along the skin border of the sinus. Englisch (2) in 1907, reported a similar case in which a fistula formed in the perineum following the incision of a periurethral abcess. This persisted for three years at the end of which time there developed within this area a carcmoma. In a fairly thorough search of the urologic literature of the past fifty years, the above 3 cases were the only instances encountered where a primary carcinoma of a urinary sinus tract was recorded. In one additional case, however, Guyon (3) recorded the occurrence of a carcinoma at the urethral end of a series of perineal sinuses which had persisted for a period of ten years, this growth he more correctly termed a urethral carcinoma. 1 Read before the American Urological Association at its twenty-seventh annual meeting, New York City, June 10-12, 1930.
469 •rHE JOURNAL OF UROLOGY, VOL. XXV. NO.
5
470
ERNEST M. WATSON
It has long been recognized that a continued irritation of discharging urine through sinus tracts from the kidney, ureter, bladder or urethra tends to stimulate a hyperplasia particularly at the epithelial border, and to a lesser extent along the tract itself. Paget (4), Orth (5), and Guiard (6) have especially described the cell changes that occur in these old sinus tracts, and have called attention to the simularity of these changes to those seen in certain of the less malignant epitheliomas. More recently Scholl and Braasch (7) have stated that in a small number of cases
FIG. 1. CASE 1. CARCINOMA OF A SuPRAPUBic SrNus Cystogram showing a fairly normal bladder with no filling defect and no suggestion of fluid escaping through the sinus. Bladder capacity 300 cc.
the formation of the fistulous tract may be the final determining factor in the later development of certain malignancies. In addition the element of infection, which condition is always present in these cases must be viewed as an added source of irritation not without its telling effect. The cases thus far reported have all involved the perineums and have been secondary to periurethral abscess. The present discussions deal with 2 proved cases of primary carcinoma of a suprapubic sinus, each following a urethral stricture of some years duration, one traumatic, the other of gonorrheal origin. For
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those strictures suprapubic cystotomy had been performed. The suprapubic incision had reopened with recurrence of the urethral obstruction, and with no evidence of any bladder growth on cystoscopic examinations, the tissue curetted from the suprapubic sinus showed the process within to be in each instance a mucous membrane epithelioma.
FIG.
2.
CASE
1.
OPERATIVE EXPOSURE OF A PRIMARY CARCINOMA OF A SUPRAPUBIC FISTULA
Casel State Institute No. 861. Admitted August 20, 1924. Male, aged forty-six. Occupation: Retired. Complaint. (1) Burning during urination, (2) Frequency of urination, (3) Draining urine from old suprapubic incision. Family history. Father died from heart trouble. Mother alive but in poor health. One sister alive and well.
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ERNEST M. WATSON
Marital history. Married twenty years. Wife died one year ago from a gun shot wound. Two daughters alive and well. Habits. Apetite good. Bowels regular. Sleeps fairly well. Smokes a package of cigarettes a day and one to two cigars. Moderate coffee drinker. Uses alcoholic liquors occasionally. Past history. General health has been good. Had the usual diseases of childhood including diphtheria. Had typhoid fever twenty years ago. Had rheumatism at the age of fourteen, which lasted for ten months and went from joint to joint, involving practically all of the extremities. Had pneumonia twice, the last time complicated with a prolonged pleurisy. Recovery from both of these attacks was good. Eyes: Wears glasses for reading and sees well. Ears: No impairment in hearing. Nose: No obstruction to breathing. No chronic infections.
Fm. 3. CASE 1. CARCINOMA OF A SuPRAPUBIC Srnus Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. XlOO.
Mouth: Tonsils not enlarged. Teeth in fair condition, some bridgework. No sore throats. Cardio-respiratory: No shortness of breath. No palpitation. No night sweats. No cough or expectoration. Gastrointestional: No indigestion. No vomiting. Belching of gas only occasionally. No constipation up to onset of present more acute symptoms three months ago, since when bowels have been sluggish. Genito-urinary: Gonorrhea at the age of sixteen. Denies having had syphilis. Operations: Suprapubic operation eight years ago for stricture of the urethra. Present illness. Eight years ago he began to have trouble passing urine. He noticed that the stream was small in size and that it took him longer to urinate than formerly. Soon after this, during a period of severe constipation, he had an attack of acute retention and was operated upon. At this time a suprapubic incision was made, a drainage
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tube was placed in the bladder and he was confined to the hospital for a period of ten weeks. Following this operation for a period of seven years he had attacks of urinary frequency with pain and burning during and after urination at irregular intervals. At these times relief was finally obtained by taking Urotropin. Three months ago the burning on urinating became very annoying and frequency became more marked causing him to void three to five times at night and about every hour during the day. At this time the suprapubic incision opened and drained a small amount of urine. Since then he has gradually been getting worse. He has had sharp shooting pains in the pelvis which can not be definitely localized, and which have not been constant. At no time has there been any hematuria. During the past few months he has been treated by his physician at weekly intervals by the passing of
FIG. 4. CASE 1. CARCINOMA OF A SUPRAPUBIC SINUS Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. X400.
urethral bougies. At the present time his frequency is about every half hour with burning during and after urination, and from the suprapubic sinus there escapes a little pus which moistens one small gauze pad each day. Physical examination. General appearance: Patient is well nourished. Skin is clear. Patient cooperates and gives a clear history. Head: Eyes react to light and accommodation. Pupils regular and equal. Nose and ears negative to external examination. Mouth: Complete upper plate. Lower teeth in fair condition. Neck: No nodes palpable. Thorax: Chest. Tactile fremitus increased in the right anterior and posterior regions. Resonance exaggerated on the left side, many fine moist rales heard during inspirations throughout both chests. Heart:
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Apparently not enlarged. First sound is not of good quality. Second sound accentuated at the apex. No murmurs. Abdomen: Slightly distended, liver and spleen not palpable. No masses felt. A suprapubic scar is present at the upper angle of which is a sinus from which a little pus and debris exude:c,. This sinus area is thickened and slightly indurated. The inquinal nodes are enlarged moderately in both groins. Genitals: Are normal. Extremities. Above the right knee are a few old healed scars. Reflexes: The patella response is very slight on both sides. On the left is a suggestive Babinski and also a slight Oppenheim response. The right is normal.
Fm. 5.
CAsE
2.
CARCINOMA OF A SuPRAPUBIC SINUS
Cystogram showing a moderately contracted somewhat irregular bladder with no outstanding filling defect and no suggestion of a fluid escaping through the sinus. Badder capacity 90 cc.
Rectal examination: Rectal sphincter is in normal tone no hemorrhoids or fissures noted. The prostate is not appreciably enlarged and does not bulge per rectum. The left lobe is firm, smooth, regular in outline. It is moderately indurated especially along the lateral margin where it is moderately adherent. The median furrow is present and the notch above the prostate is not widened or deepened. The right lobe is similar to the left, smooth, firm, regular in outline, moderately indurated along the periphery and toward the apex where it is moderately adherent. Both seminal vesicles are palpable, they are a little larger than normal, not tender, and both are slightly indurated and moderately adherent to the upper margins of the prostate.
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Cystoscopy under gas. Urine: glasses 1, 2, 3, all moderately cloudy. Cystoscope No. 24 French will not pass an obstruction at the bulbomembranous junction. It is necessary to dilate this stricture with filliforms and followers. Stricture dilated to No. 26 French. Cystoscope then passed without much difficulty. Residual urine 20 cc. Bladder capacity 300 cc. A study of the vesical orifice showed it to be quite irregular. There is no cleft anteriorly. In the region of the right lobe there is a definite pedunculated lobule which encroaches considerably upon the vesical orifice. It appears about the size of a large cherry. This joins by a deep cleft formation another irregular lobule in the region of the middle lobe at the apex of the trigone. This portion of the middle lobe is very irregular and markedly elevated about the trigonal floor. There is a shallow cleft in the region of the left lateral segment where the markedly enlarged middle portion joins a rather fluted left lateral lobe which is not appreciably rounded. At the apex of the trigone there is a tunneled-out groove, probably the result of previous operation. The trigone is asymmetrical. The interureteric ligament is considerably hypertrophied and beyond it there is a shallow bas-fond. Both ureteral orifices are situated at the extremities of the hypertrophied ridge, and are larger than normal. The bladder wall is considerably trabeculated with a few deep cellules present which contain adherent pus and mucus. There is considerable edema and hyperemia of the mucosa of the entire lower portion of the bladder. At the vertex is an irregular sloughing, necrotic ball about the size of a cherry just at the sight of the supra pubic sinus. There is no sign of any stone, tumor or diverticulum. No. 6 catheter passes easily to the pelvis of the kidney on either side. No obstructions. Funtion from each kidney was normal in general appearance. After withdrawal of the cystoscope an internal urethrotomy was performed and a No. 26 French catheter placed in the urethra. The suprepubic sinus was curetted thoroughly and closed with adhesive. Ureteral catheterization. Right side: Rare pus cells; no red blood cells; many organisms; bacilli and cocci. Left side: No pus cells; no red blood cells; no organisms. By means of the Young rongeur the cherry like ball of slough was removed from the vertex of the bladder. The microscopic examination of this showed it to be necrotic material with no cells characteristic of tumor growth. The curettings from the suprapubic sinus were then studied mic:oscopically. Report on this tissue removed, mucous membrane epithelioma. Wassermann. Negative. Urine examination, specimen very cloudy.
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Specific gravity 1022. Alkaline in reaction. Albumen: Faint trace. Sugar: Negative. Microscopic: Many pus cells, few red blood cells. No casts, many bacilli and cocci. Operation. Excision of suprapubic sinus and implantation of radium emenations. Under nitrous oxide anesthesia, a probe was introduced into the suprapubic sinus down to the bladder. With about three-quarters of an inch of fairly normal muscle tissue beyond the hard, somewhat irregular, and bulging sinus mass was dissected free. On cutting down to the bladder it was found that the large bowel and omentum were densely adherent to the upper surface of the bladder. The bladder wall was here about three quarters of an inch thick but within the bladder wall itself the mucosa about the opening appeared smooth to the palpating finger. Into the bladder wall about the opening was placed fifteen seeds of radium emenation, a total of 1095.6 m.c. hours. A suprapubic tube was placed in the bladder and the muscles brought together in layers. Recovery from operation was uneventful, and three weeks later the patient was given a deep x-ray treatment with two exposures. (Anterior pelvis, size of area 20 cm. by 20 cm., angle 90, distance 80, time 25.5 minutes, skin dose 85 per cent, tumor dose 50 per cent. Posterior pelvis, size of area 20 cm. by 20 cm., angle 90, distance 80, time 28.5 minutes, skin dose 95 per cent, tumor dose 50 per cent.) One month after the operation the patient left the hospital with the suprapubic tube still draining and able to walk about. Two months later his condition became worse, a general weakness developed and he died three months after operation with the clinical symptoms of toxemia. No autopsy was obtained. Case2 State Institute No. 10336. Admitted July 1, 1927. Male, aged sixty-three. Occupation: Retired. Complaint. (1) Pain over the bladder region and in the perineum, (2) unable to void, (3) suprapubic opening. Family history. Father died at seventy-six from an injury. Mother died at sixty-five of heart trouble. One sister well. One brother died at seventy, cause unknown. One sister died at twenty-two from an injury. There is no history of cancer, tumor or tuberculosis in the family. Marital history. Married forty years, wife well, two sons and three daughters well, no other children.
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Habits. Appetite good. Used to a mixed diet with meat once or twice a day. Eats plenty of fresh vegetables and fruits. Takes plenty of out door exercise. Smokes a pipe daily. Uses alcohol sparingly. Does not sleep well of late due to pain over bladder and perineum. Past history. General health has been fairly good. Had some of the usual children's diseases but does not remember which ones. Had pneumonia in 1918, recovery uneventful. Has had bronchitis in frequent attacks for the past eighteen to twenty years. Eyes: Has worn
FIG.
6.
CASE
2.
EXPOSURE THROUGH A SPECULUM OF A PRIMARY CARCINOMA OF A SUPRAPUBIC FISTULA
glasses for the past eighteen years. He has poor vision and some pain in the left eye, due to an old war injury. Nose: No obstruction to breathing, no discharge. Ears: No impairment to hearing. Mouth: Tonsils not enlarged. Teeth in fair condition. No sore throats. Cardiorespiratory: Has considerable shortness of breath when he has bronchitis. No palpitation. No night sweats. No cough or expectoration except when he has bronchitis. Gastro-intestional: No indigestion. No vomiting. No belching of gas. Appetite good. No constipation. Genito-
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urinary: Denies having had gonorrhea or syphilis. Injuries: At the age of seven, while bending over, he received a severe kick in the perineum which "knocked him out." Following this he passed no urine for one day and then passed blood in the urine for a day. Since this injury he has had more or less difficulty in passing urine. As a young man began to pass a small catheter at times, on advice of his physician, to withdraw his urine when his bladder trouble became very irritating. Present illness. Patient dates his bladder trouble from the kick in the perineum he received as a boy. During his early life and middle adult life the periods of urinary frequency, and pain, and burning on voiding came at quite irregular intervals. Sometimes several years would pass without the necessity of passing a catheter. Of late years,
Fm. 7.
CASE
2.
CARCINOMA OF A SuPRAPUBIC Srnus
Photomicrograph of tissue removed by curetting the sinus. membrane epithelioma. XlOO.
Diagnosis mucous
however, catheterization has become more frequent and during the last two years he has cateterized himself every day or two. During these past two years his frequency has been about once an hour during the day, and three to five times a night. Usually only small amounts of urine would pass, and this was accompanied with considerable smarting and burning. When the discomfort would become too great the passing of the catheter would bring a measure of relief. Four months ago he developed acute retention and was unable to pass the catheter. At this time a suprapubic cystotomy was done and a drainage tube inserted into the bladder by his physician. After two months the tube was removed and the suprapubic sinus has now contracted down to about a pin point in size. At the present time, on voiding, some of the urine comes through the urethra and a portion through the suprapubic opening.
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Physical examinaiion. General appearance: Patient is fairly well nourished and of medium build. No evident recent loss of weight. Head: Right pupil reacts to light and accomodation. Left sluggish, pupil dilated. Nose and ears show no abnormalities on external examination. Mouth: Teeth in fair condition, wears a partial upper plate. No nodes palpable in neck. Thorax: Chest slightly barrel-shaped, ribs prominent. Breath sounds are harsh and exaggerated over both backs and front. Heart: Not enlarged. First sound is clear. No murmurs. Abdomen: Is flat. Liver edge just palpable. Spleen not felt. No masses felt. Over the lower abdomen is a suprapubic scar. From the upper angle of this a little pus and an occasional drop of urine exudes on
Fm. 8. CASE 2. CARCINOMA OF A SuPRAPUBIC SINUS Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. X400.
pressure. The region of the sinus is slightly indurated, and along the scar some tenderness is elicited on pressure. The nodes in both groins are palpable but not grossly enlarged. Reflexes: Are easily elicited and normal in both extremities. Rectal examination: Sphincter in normal tone, no hemorrhoids. Prostate is felt, not enlarged. The left lobe is normal in size, regular in outline, everywhere rather soft and rubbery in consistency. No localized areas of induration. Along the periphery there is a narrow border of induration (inflammatory). It is not adherent. The median furrow is normal as is also the notch above the prostate. The right lobe is similar to the left, only slightly larger than the left, smooth and regular in outline, rubbery in consistency, nowhere indurated except along the periphery (inflammatory), it is not adherent. Both vesicles
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are readily palpated, they are slightly adherent to the upper border of the prostate, not enlarged, indurated or tender. Cystoscopic examination. Ureteral catheterization. Internal urethrotomy. Cautery punch. Urethra very tight, dilated to No. 24 F. Cystoscope passed with difficulty owing to strictured urethra. Residual urine 30 cc. Bladder capacity 90 cc. A study of the vesical orifice shows it to be irregular with some fibrosis and in the middle portion and the posterior lateral portions definite elevation into the vesical cavity, but with no definite lobe formation. The trigone is enlarged, irregular, markedly hyperaemic and its surface here and there ulcerated. The region of the right ureteral orifice is markedly ulcerated and bleeding and raised in the form of a hillock-the size of a bean. The left ureteral orifice is also obscured in oedema and ulceration. The bladder is everywhere edematous and thrown into many folds. Some of these are covered with a diphtheric membrane. About the vertex is a cone-shaped depression continuous with the persisting sinus. This is lined with necrotic slough which somewhat resembles tumor (piece of tissue sent to the laboratory for study). There is no further evidence of tumor. No stone or diverticulum seen. Both ureters catheterized with difficulty. Flow appears normal from each, but the right is bloody. Catheters passed up easily, no ureteral obstruction. Internal urethrotomy done. Several small pieces of tissue removed from the vessical orifice by means of the cautery punch. A No. 28 F. Conde catheter left in the urethra. Suprapubic sinus curettedandconsiderable necrotic tissue (a spoonful) removed. U reteral catheterization. Right side: Many pus .cells; many red blood cells; many motile bacilli. Left side: Many pus cells; no red blood cells; many motile bacilli. Wassermann. Negative. Urine examination, specimen very cloudy. Specific gravity 1018, acid in reaction. Albumen: atrace. Sugar: Negative. Microscopic: Many pus cells, few red blood cells. Many bacilli. With the Young's Rongeur the necrotic ball of slough was removed from the dome of the bladder. The microscopic study of this showed only necrotic material no evidence of new growth. The examination of the tissue removed from the curretting of the suprapubic sinus showed the same to be mucous membrane epithelioma.
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Operation. On July 2, 1927, under nitrous oxide anesthesis the suprapubic sinus was dilated with the finger and a thorough exploration of the bladder cavity made. After palpating the inner surface of the bladder no evidence of tumor was found in it. The bladder was markedly contracted and the walls thickened. Around the sinus tract from the skin surface to the bladder cavity was a thickened friable irregular coating (carcinomatous). Through this sinus tract were then implanted 15 gold seeds. A suprapubic tube was left draining the bladder cavity. Recovery from the implantation of radium was uneventful and one month after operation the patient was given three deep x-ray treatments at two-day intervals as follows: Over anterior pelvis, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Over the posterior pelvis two days later, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Again over the anterior pelvis two days later, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Patient left the hospital two weeks after the deep x-ray treatment with the supra pubic drainage tube in place. When seen one month later a hernia had developed in the suprapubic scar below the drainage tube. His condition was unchanged and suprapubic drainage was continued. Two years later in another hospital the patient was operated upon in an attempt to cure the hernia in the old suprapubic scar and died eight days later of uraemia. At the time of the operation there was no clinical or palpable evidence of carcinoma about the suprapubic tube or in the old incision. SUMMARY
Two cases are reported of a primary carcinoma of a suprapubic sinus each following many years after a stricture of the urethra for which a suprapubic cystotomy had been done. One of these was traumatic, the other of gonorrheal origin. In each instance secondary infection had been present for several years. One of these cases treated by excision, radium, and deep x-ray died of generalized carcinoma in three months. The other, treated by radium implantation and deep x-ray, lived two years and died of uraemia following an operation for hernia without clinical or palpatory evidence of carcinoma. 283 Linwood Avenue, Buffalo, New York
482
DISCUSSION
REFERENCES (1) PoNCET: Du cancer profond de la verge. Gez. hebd. d. sc. med. de Bordeaux, 1881, xviii, 282. (2) ENGLISCH, J.: Das Epitheliom der Mannlichen Harnrohre. Folgia Urol., 1907, i, 38--76. (3) GUYON: Quoted by Guiard. (4) PAGET, J.: Lectures on surgical pathology. Philadelphia, Linsay and Blakiston, 1871, ii, 462 pp. (5) ORTH, J.: Pathologisch-anatomische Diagnostik. Berlin, Hirschwald, 1917, 841 pp. (6) GurARD, F. P.: Transformation en epithelioma a marche rapide de trajets fistuleux consecutifs a un retrecissement de l'urethre. Ann. d. mal. d. org. genito-urin., 1883, i, 513-522; 568--579. (7) ScHOLL AND BRAASCH: Tumors of the urethra. Annals of Surgery, 1922, lxxvi, 246.
DISCUSSION Dr. J. DELLINGER BARNEY (Boston, Mass.): I was very much interested in the paper by Dr. Colby on cancer of the penis. About twenty-five years ago I looked up the subject of cancer of the penis and was able to trace 90 cases to their ultimate end, and while I have forgotten a good many of the details I found at that time, a few things stick in my mind. In the first place, we found that in 85 per cent of those cases there was phimosis of long duration and as a correlary to that we found that no patient who had a circumcision in infancy or childhood had ever been known to develop carcinoma. I think that still holds true. It should be remembered that most of the deaths from carcinoma of the penis are due to internal metastases and that these internal metastases may occur and do occur when there is either no involvement of the inguinal gland at all or even if they are excised. In other words, the deep lymphatics of the penis are quite as efficient in carrying metastatic cells as the more superficial ones which carry to the groin. I think that should be taken into consideration in giving a prognosis in these cases. It is also, of course, well known that penile carcinoma is of comparatively low grade malignancy. There are undoubtedly classifications to be found in the various types of penile cancer, but I saw a case only this morning at the Memorial Hospital that Dr. Barringer showed me, a man of thirty-four, who had had penile·carcinoma for nine years. He was beginning to show the effects of it, there is no doubt about· that. It was an inoperable case.
Any integral organ of the urinary tract may be the site of a primary malignant growth and from the epithelial lined cavities of this somewhat intricate system primary carcinoma is common. However, from the pathological accessory channels of this system, i.e., fistulous tracts and old urinary sinuses, such an extreme hyperplastic change is quite rare. In 1881 Poncet (1) reported 2 cases of carcinoma developing in fistulous tracts which led from the perineum into the deep urethra. In the first case the fistula, forming after the incision of a periurethral abscess, drained for sixteen years before the onset of the carcinoma, and in the second case the perineal fistula similarly following the incision of a periurethral abscess, drained for six months before the onset of carcinoma which was first recognized along the skin border of the sinus. Englisch (2) in 1907, reported a similar case in which a fistula formed in the perineum following the incision of a periurethral abcess. This persisted for three years at the end of which time there developed within this area a carcmoma. In a fairly thorough search of the urologic literature of the past fifty years, the above 3 cases were the only instances encountered where a primary carcinoma of a urinary sinus tract was recorded. In one additional case, however, Guyon (3) recorded the occurrence of a carcinoma at the urethral end of a series of perineal sinuses which had persisted for a period of ten years, this growth he more correctly termed a urethral carcinoma. 1 Read before the American Urological Association at its twenty-seventh annual meeting, New York City, June 10-12, 1930.
469 •rHE JOURNAL OF UROLOGY, VOL. XXV. NO.
5
470
ERNEST M. WATSON
It has long been recognized that a continued irritation of discharging urine through sinus tracts from the kidney, ureter, bladder or urethra tends to stimulate a hyperplasia particularly at the epithelial border, and to a lesser extent along the tract itself. Paget (4), Orth (5), and Guiard (6) have especially described the cell changes that occur in these old sinus tracts, and have called attention to the simularity of these changes to those seen in certain of the less malignant epitheliomas. More recently Scholl and Braasch (7) have stated that in a small number of cases
FIG. 1. CASE 1. CARCINOMA OF A SuPRAPUBic SrNus Cystogram showing a fairly normal bladder with no filling defect and no suggestion of fluid escaping through the sinus. Bladder capacity 300 cc.
the formation of the fistulous tract may be the final determining factor in the later development of certain malignancies. In addition the element of infection, which condition is always present in these cases must be viewed as an added source of irritation not without its telling effect. The cases thus far reported have all involved the perineums and have been secondary to periurethral abscess. The present discussions deal with 2 proved cases of primary carcinoma of a suprapubic sinus, each following a urethral stricture of some years duration, one traumatic, the other of gonorrheal origin. For
SINUS TRACT CARCINOMA
471
those strictures suprapubic cystotomy had been performed. The suprapubic incision had reopened with recurrence of the urethral obstruction, and with no evidence of any bladder growth on cystoscopic examinations, the tissue curetted from the suprapubic sinus showed the process within to be in each instance a mucous membrane epithelioma.
FIG.
2.
CASE
1.
OPERATIVE EXPOSURE OF A PRIMARY CARCINOMA OF A SUPRAPUBIC FISTULA
Casel State Institute No. 861. Admitted August 20, 1924. Male, aged forty-six. Occupation: Retired. Complaint. (1) Burning during urination, (2) Frequency of urination, (3) Draining urine from old suprapubic incision. Family history. Father died from heart trouble. Mother alive but in poor health. One sister alive and well.
472
ERNEST M. WATSON
Marital history. Married twenty years. Wife died one year ago from a gun shot wound. Two daughters alive and well. Habits. Apetite good. Bowels regular. Sleeps fairly well. Smokes a package of cigarettes a day and one to two cigars. Moderate coffee drinker. Uses alcoholic liquors occasionally. Past history. General health has been good. Had the usual diseases of childhood including diphtheria. Had typhoid fever twenty years ago. Had rheumatism at the age of fourteen, which lasted for ten months and went from joint to joint, involving practically all of the extremities. Had pneumonia twice, the last time complicated with a prolonged pleurisy. Recovery from both of these attacks was good. Eyes: Wears glasses for reading and sees well. Ears: No impairment in hearing. Nose: No obstruction to breathing. No chronic infections.
Fm. 3. CASE 1. CARCINOMA OF A SuPRAPUBIC Srnus Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. XlOO.
Mouth: Tonsils not enlarged. Teeth in fair condition, some bridgework. No sore throats. Cardio-respiratory: No shortness of breath. No palpitation. No night sweats. No cough or expectoration. Gastrointestional: No indigestion. No vomiting. Belching of gas only occasionally. No constipation up to onset of present more acute symptoms three months ago, since when bowels have been sluggish. Genito-urinary: Gonorrhea at the age of sixteen. Denies having had syphilis. Operations: Suprapubic operation eight years ago for stricture of the urethra. Present illness. Eight years ago he began to have trouble passing urine. He noticed that the stream was small in size and that it took him longer to urinate than formerly. Soon after this, during a period of severe constipation, he had an attack of acute retention and was operated upon. At this time a suprapubic incision was made, a drainage
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tube was placed in the bladder and he was confined to the hospital for a period of ten weeks. Following this operation for a period of seven years he had attacks of urinary frequency with pain and burning during and after urination at irregular intervals. At these times relief was finally obtained by taking Urotropin. Three months ago the burning on urinating became very annoying and frequency became more marked causing him to void three to five times at night and about every hour during the day. At this time the suprapubic incision opened and drained a small amount of urine. Since then he has gradually been getting worse. He has had sharp shooting pains in the pelvis which can not be definitely localized, and which have not been constant. At no time has there been any hematuria. During the past few months he has been treated by his physician at weekly intervals by the passing of
FIG. 4. CASE 1. CARCINOMA OF A SUPRAPUBIC SINUS Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. X400.
urethral bougies. At the present time his frequency is about every half hour with burning during and after urination, and from the suprapubic sinus there escapes a little pus which moistens one small gauze pad each day. Physical examination. General appearance: Patient is well nourished. Skin is clear. Patient cooperates and gives a clear history. Head: Eyes react to light and accommodation. Pupils regular and equal. Nose and ears negative to external examination. Mouth: Complete upper plate. Lower teeth in fair condition. Neck: No nodes palpable. Thorax: Chest. Tactile fremitus increased in the right anterior and posterior regions. Resonance exaggerated on the left side, many fine moist rales heard during inspirations throughout both chests. Heart:
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ERNEST M. WATSON
Apparently not enlarged. First sound is not of good quality. Second sound accentuated at the apex. No murmurs. Abdomen: Slightly distended, liver and spleen not palpable. No masses felt. A suprapubic scar is present at the upper angle of which is a sinus from which a little pus and debris exude:c,. This sinus area is thickened and slightly indurated. The inquinal nodes are enlarged moderately in both groins. Genitals: Are normal. Extremities. Above the right knee are a few old healed scars. Reflexes: The patella response is very slight on both sides. On the left is a suggestive Babinski and also a slight Oppenheim response. The right is normal.
Fm. 5.
CAsE
2.
CARCINOMA OF A SuPRAPUBIC SINUS
Cystogram showing a moderately contracted somewhat irregular bladder with no outstanding filling defect and no suggestion of a fluid escaping through the sinus. Badder capacity 90 cc.
Rectal examination: Rectal sphincter is in normal tone no hemorrhoids or fissures noted. The prostate is not appreciably enlarged and does not bulge per rectum. The left lobe is firm, smooth, regular in outline. It is moderately indurated especially along the lateral margin where it is moderately adherent. The median furrow is present and the notch above the prostate is not widened or deepened. The right lobe is similar to the left, smooth, firm, regular in outline, moderately indurated along the periphery and toward the apex where it is moderately adherent. Both seminal vesicles are palpable, they are a little larger than normal, not tender, and both are slightly indurated and moderately adherent to the upper margins of the prostate.
SINUS TRACT CARCINOMA
475
Cystoscopy under gas. Urine: glasses 1, 2, 3, all moderately cloudy. Cystoscope No. 24 French will not pass an obstruction at the bulbomembranous junction. It is necessary to dilate this stricture with filliforms and followers. Stricture dilated to No. 26 French. Cystoscope then passed without much difficulty. Residual urine 20 cc. Bladder capacity 300 cc. A study of the vesical orifice showed it to be quite irregular. There is no cleft anteriorly. In the region of the right lobe there is a definite pedunculated lobule which encroaches considerably upon the vesical orifice. It appears about the size of a large cherry. This joins by a deep cleft formation another irregular lobule in the region of the middle lobe at the apex of the trigone. This portion of the middle lobe is very irregular and markedly elevated about the trigonal floor. There is a shallow cleft in the region of the left lateral segment where the markedly enlarged middle portion joins a rather fluted left lateral lobe which is not appreciably rounded. At the apex of the trigone there is a tunneled-out groove, probably the result of previous operation. The trigone is asymmetrical. The interureteric ligament is considerably hypertrophied and beyond it there is a shallow bas-fond. Both ureteral orifices are situated at the extremities of the hypertrophied ridge, and are larger than normal. The bladder wall is considerably trabeculated with a few deep cellules present which contain adherent pus and mucus. There is considerable edema and hyperemia of the mucosa of the entire lower portion of the bladder. At the vertex is an irregular sloughing, necrotic ball about the size of a cherry just at the sight of the supra pubic sinus. There is no sign of any stone, tumor or diverticulum. No. 6 catheter passes easily to the pelvis of the kidney on either side. No obstructions. Funtion from each kidney was normal in general appearance. After withdrawal of the cystoscope an internal urethrotomy was performed and a No. 26 French catheter placed in the urethra. The suprepubic sinus was curetted thoroughly and closed with adhesive. Ureteral catheterization. Right side: Rare pus cells; no red blood cells; many organisms; bacilli and cocci. Left side: No pus cells; no red blood cells; no organisms. By means of the Young rongeur the cherry like ball of slough was removed from the vertex of the bladder. The microscopic examination of this showed it to be necrotic material with no cells characteristic of tumor growth. The curettings from the suprapubic sinus were then studied mic:oscopically. Report on this tissue removed, mucous membrane epithelioma. Wassermann. Negative. Urine examination, specimen very cloudy.
476
ERNEST M. WATSON
Specific gravity 1022. Alkaline in reaction. Albumen: Faint trace. Sugar: Negative. Microscopic: Many pus cells, few red blood cells. No casts, many bacilli and cocci. Operation. Excision of suprapubic sinus and implantation of radium emenations. Under nitrous oxide anesthesia, a probe was introduced into the suprapubic sinus down to the bladder. With about three-quarters of an inch of fairly normal muscle tissue beyond the hard, somewhat irregular, and bulging sinus mass was dissected free. On cutting down to the bladder it was found that the large bowel and omentum were densely adherent to the upper surface of the bladder. The bladder wall was here about three quarters of an inch thick but within the bladder wall itself the mucosa about the opening appeared smooth to the palpating finger. Into the bladder wall about the opening was placed fifteen seeds of radium emenation, a total of 1095.6 m.c. hours. A suprapubic tube was placed in the bladder and the muscles brought together in layers. Recovery from operation was uneventful, and three weeks later the patient was given a deep x-ray treatment with two exposures. (Anterior pelvis, size of area 20 cm. by 20 cm., angle 90, distance 80, time 25.5 minutes, skin dose 85 per cent, tumor dose 50 per cent. Posterior pelvis, size of area 20 cm. by 20 cm., angle 90, distance 80, time 28.5 minutes, skin dose 95 per cent, tumor dose 50 per cent.) One month after the operation the patient left the hospital with the suprapubic tube still draining and able to walk about. Two months later his condition became worse, a general weakness developed and he died three months after operation with the clinical symptoms of toxemia. No autopsy was obtained. Case2 State Institute No. 10336. Admitted July 1, 1927. Male, aged sixty-three. Occupation: Retired. Complaint. (1) Pain over the bladder region and in the perineum, (2) unable to void, (3) suprapubic opening. Family history. Father died at seventy-six from an injury. Mother died at sixty-five of heart trouble. One sister well. One brother died at seventy, cause unknown. One sister died at twenty-two from an injury. There is no history of cancer, tumor or tuberculosis in the family. Marital history. Married forty years, wife well, two sons and three daughters well, no other children.
SINUS TRACT CARCINOMA
477
Habits. Appetite good. Used to a mixed diet with meat once or twice a day. Eats plenty of fresh vegetables and fruits. Takes plenty of out door exercise. Smokes a pipe daily. Uses alcohol sparingly. Does not sleep well of late due to pain over bladder and perineum. Past history. General health has been fairly good. Had some of the usual children's diseases but does not remember which ones. Had pneumonia in 1918, recovery uneventful. Has had bronchitis in frequent attacks for the past eighteen to twenty years. Eyes: Has worn
FIG.
6.
CASE
2.
EXPOSURE THROUGH A SPECULUM OF A PRIMARY CARCINOMA OF A SUPRAPUBIC FISTULA
glasses for the past eighteen years. He has poor vision and some pain in the left eye, due to an old war injury. Nose: No obstruction to breathing, no discharge. Ears: No impairment to hearing. Mouth: Tonsils not enlarged. Teeth in fair condition. No sore throats. Cardiorespiratory: Has considerable shortness of breath when he has bronchitis. No palpitation. No night sweats. No cough or expectoration except when he has bronchitis. Gastro-intestional: No indigestion. No vomiting. No belching of gas. Appetite good. No constipation. Genito-
478
ERNEST M. WATSON
urinary: Denies having had gonorrhea or syphilis. Injuries: At the age of seven, while bending over, he received a severe kick in the perineum which "knocked him out." Following this he passed no urine for one day and then passed blood in the urine for a day. Since this injury he has had more or less difficulty in passing urine. As a young man began to pass a small catheter at times, on advice of his physician, to withdraw his urine when his bladder trouble became very irritating. Present illness. Patient dates his bladder trouble from the kick in the perineum he received as a boy. During his early life and middle adult life the periods of urinary frequency, and pain, and burning on voiding came at quite irregular intervals. Sometimes several years would pass without the necessity of passing a catheter. Of late years,
Fm. 7.
CASE
2.
CARCINOMA OF A SuPRAPUBIC Srnus
Photomicrograph of tissue removed by curetting the sinus. membrane epithelioma. XlOO.
Diagnosis mucous
however, catheterization has become more frequent and during the last two years he has cateterized himself every day or two. During these past two years his frequency has been about once an hour during the day, and three to five times a night. Usually only small amounts of urine would pass, and this was accompanied with considerable smarting and burning. When the discomfort would become too great the passing of the catheter would bring a measure of relief. Four months ago he developed acute retention and was unable to pass the catheter. At this time a suprapubic cystotomy was done and a drainage tube inserted into the bladder by his physician. After two months the tube was removed and the suprapubic sinus has now contracted down to about a pin point in size. At the present time, on voiding, some of the urine comes through the urethra and a portion through the suprapubic opening.
SINUS TRACT CARCINOMA
479
Physical examinaiion. General appearance: Patient is fairly well nourished and of medium build. No evident recent loss of weight. Head: Right pupil reacts to light and accomodation. Left sluggish, pupil dilated. Nose and ears show no abnormalities on external examination. Mouth: Teeth in fair condition, wears a partial upper plate. No nodes palpable in neck. Thorax: Chest slightly barrel-shaped, ribs prominent. Breath sounds are harsh and exaggerated over both backs and front. Heart: Not enlarged. First sound is clear. No murmurs. Abdomen: Is flat. Liver edge just palpable. Spleen not felt. No masses felt. Over the lower abdomen is a suprapubic scar. From the upper angle of this a little pus and an occasional drop of urine exudes on
Fm. 8. CASE 2. CARCINOMA OF A SuPRAPUBIC SINUS Photomicrograph of tissue removed by curetting the sinus. Diagnosis mucous membrane epithelioma. X400.
pressure. The region of the sinus is slightly indurated, and along the scar some tenderness is elicited on pressure. The nodes in both groins are palpable but not grossly enlarged. Reflexes: Are easily elicited and normal in both extremities. Rectal examination: Sphincter in normal tone, no hemorrhoids. Prostate is felt, not enlarged. The left lobe is normal in size, regular in outline, everywhere rather soft and rubbery in consistency. No localized areas of induration. Along the periphery there is a narrow border of induration (inflammatory). It is not adherent. The median furrow is normal as is also the notch above the prostate. The right lobe is similar to the left, only slightly larger than the left, smooth and regular in outline, rubbery in consistency, nowhere indurated except along the periphery (inflammatory), it is not adherent. Both vesicles
480
ERNEST M. WATSON
are readily palpated, they are slightly adherent to the upper border of the prostate, not enlarged, indurated or tender. Cystoscopic examination. Ureteral catheterization. Internal urethrotomy. Cautery punch. Urethra very tight, dilated to No. 24 F. Cystoscope passed with difficulty owing to strictured urethra. Residual urine 30 cc. Bladder capacity 90 cc. A study of the vesical orifice shows it to be irregular with some fibrosis and in the middle portion and the posterior lateral portions definite elevation into the vesical cavity, but with no definite lobe formation. The trigone is enlarged, irregular, markedly hyperaemic and its surface here and there ulcerated. The region of the right ureteral orifice is markedly ulcerated and bleeding and raised in the form of a hillock-the size of a bean. The left ureteral orifice is also obscured in oedema and ulceration. The bladder is everywhere edematous and thrown into many folds. Some of these are covered with a diphtheric membrane. About the vertex is a cone-shaped depression continuous with the persisting sinus. This is lined with necrotic slough which somewhat resembles tumor (piece of tissue sent to the laboratory for study). There is no further evidence of tumor. No stone or diverticulum seen. Both ureters catheterized with difficulty. Flow appears normal from each, but the right is bloody. Catheters passed up easily, no ureteral obstruction. Internal urethrotomy done. Several small pieces of tissue removed from the vessical orifice by means of the cautery punch. A No. 28 F. Conde catheter left in the urethra. Suprapubic sinus curettedandconsiderable necrotic tissue (a spoonful) removed. U reteral catheterization. Right side: Many pus .cells; many red blood cells; many motile bacilli. Left side: Many pus cells; no red blood cells; many motile bacilli. Wassermann. Negative. Urine examination, specimen very cloudy. Specific gravity 1018, acid in reaction. Albumen: atrace. Sugar: Negative. Microscopic: Many pus cells, few red blood cells. Many bacilli. With the Young's Rongeur the necrotic ball of slough was removed from the dome of the bladder. The microscopic study of this showed only necrotic material no evidence of new growth. The examination of the tissue removed from the curretting of the suprapubic sinus showed the same to be mucous membrane epithelioma.
SINUS TRACT CARCINOMA
481
Operation. On July 2, 1927, under nitrous oxide anesthesis the suprapubic sinus was dilated with the finger and a thorough exploration of the bladder cavity made. After palpating the inner surface of the bladder no evidence of tumor was found in it. The bladder was markedly contracted and the walls thickened. Around the sinus tract from the skin surface to the bladder cavity was a thickened friable irregular coating (carcinomatous). Through this sinus tract were then implanted 15 gold seeds. A suprapubic tube was left draining the bladder cavity. Recovery from the implantation of radium was uneventful and one month after operation the patient was given three deep x-ray treatments at two-day intervals as follows: Over anterior pelvis, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Over the posterior pelvis two days later, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Again over the anterior pelvis two days later, skin area 20 cm. by 24 cm., angle 90, distance 80, time 12 minutes, skin dose 40 per cent. Patient left the hospital two weeks after the deep x-ray treatment with the supra pubic drainage tube in place. When seen one month later a hernia had developed in the suprapubic scar below the drainage tube. His condition was unchanged and suprapubic drainage was continued. Two years later in another hospital the patient was operated upon in an attempt to cure the hernia in the old suprapubic scar and died eight days later of uraemia. At the time of the operation there was no clinical or palpable evidence of carcinoma about the suprapubic tube or in the old incision. SUMMARY
Two cases are reported of a primary carcinoma of a suprapubic sinus each following many years after a stricture of the urethra for which a suprapubic cystotomy had been done. One of these was traumatic, the other of gonorrheal origin. In each instance secondary infection had been present for several years. One of these cases treated by excision, radium, and deep x-ray died of generalized carcinoma in three months. The other, treated by radium implantation and deep x-ray, lived two years and died of uraemia following an operation for hernia without clinical or palpatory evidence of carcinoma. 283 Linwood Avenue, Buffalo, New York
482
DISCUSSION
REFERENCES (1) PoNCET: Du cancer profond de la verge. Gez. hebd. d. sc. med. de Bordeaux, 1881, xviii, 282. (2) ENGLISCH, J.: Das Epitheliom der Mannlichen Harnrohre. Folgia Urol., 1907, i, 38--76. (3) GUYON: Quoted by Guiard. (4) PAGET, J.: Lectures on surgical pathology. Philadelphia, Linsay and Blakiston, 1871, ii, 462 pp. (5) ORTH, J.: Pathologisch-anatomische Diagnostik. Berlin, Hirschwald, 1917, 841 pp. (6) GurARD, F. P.: Transformation en epithelioma a marche rapide de trajets fistuleux consecutifs a un retrecissement de l'urethre. Ann. d. mal. d. org. genito-urin., 1883, i, 513-522; 568--579. (7) ScHOLL AND BRAASCH: Tumors of the urethra. Annals of Surgery, 1922, lxxvi, 246.
DISCUSSION Dr. J. DELLINGER BARNEY (Boston, Mass.): I was very much interested in the paper by Dr. Colby on cancer of the penis. About twenty-five years ago I looked up the subject of cancer of the penis and was able to trace 90 cases to their ultimate end, and while I have forgotten a good many of the details I found at that time, a few things stick in my mind. In the first place, we found that in 85 per cent of those cases there was phimosis of long duration and as a correlary to that we found that no patient who had a circumcision in infancy or childhood had ever been known to develop carcinoma. I think that still holds true. It should be remembered that most of the deaths from carcinoma of the penis are due to internal metastases and that these internal metastases may occur and do occur when there is either no involvement of the inguinal gland at all or even if they are excised. In other words, the deep lymphatics of the penis are quite as efficient in carrying metastatic cells as the more superficial ones which carry to the groin. I think that should be taken into consideration in giving a prognosis in these cases. It is also, of course, well known that penile carcinoma is of comparatively low grade malignancy. There are undoubtedly classifications to be found in the various types of penile cancer, but I saw a case only this morning at the Memorial Hospital that Dr. Barringer showed me, a man of thirty-four, who had had penile·carcinoma for nine years. He was beginning to show the effects of it, there is no doubt about· that. It was an inoperable case.