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Transitional Cell Carcinoma of the Fossa Navicularis of the Male Urethra
0022-534 7/83/1295-1055$02.00/0
Vol. 129, May Printed in U.S. A.
THE JOURNAL OF UROLOGY
Copyright © 1983 hy The Williams & Wilkins Co.
TRANSITIONAL CELL CARCINOMA OF THE FOSSA NAVICULARIS OF THE MALE URETHRA LARRY L_ BANS, JOHN N. EBLE, JAMES E. LINGEMAN AND BARNEY R. MAYNARD From the Urology Section and Laboratory Service, Richard L. Roudebush Veterans Administration Medical Center and Indiana University School of Medicine, Indianapolis, Indiana
ABSTRACT
We report a case of transitional cell carcinoma arising in the fossa navicularis, a portion of the male urethra ordinarily lined by squamous epithelium. This is the third reported case of transitional cell carcinoma of the distal urethra. The neoplasm metastasized to superficial inguinal lymph nodes. In 1939 Kreutzmann and Colloff reviewed 148 cases of carcinoma of the male urethra, which had been reported in the literature to that date. 1 The majority of those lesions arose in the posterior urethra and consisted of squamous carcinoma. Only 3 cases of transitional cell carcinoma had been recorded, of which 1 was located in the anterior urethra. This is not surprising since urothelial lining is found only in the most proximal portion of the normal urethra. Since that extensive review a number of additional cases and reviews of carcinoma of the male urethra have been published. 2- 8 However, only 2 more cases of transitional cell carcinoma of the distal urethra have been reported9 and those did not distinguish between carcinoma of the pendulous urethra and carcinoma of the fossa navicularis. CASE REPORT
H. L., a 61-year-old man, presented with a split urinary stream. A year previously he had been evaluated elsewhere for painless gross hematuria and diagnosis was meatal stenosis. The patient was treated with urethral dilation. The rest of the medical, urologic and general history was unremarkable. Initial physical examination revealed a firm, gristly lesion that was largest in the fossa navicularis but extended to the base of the glans penis and to the urethral meatus. There were also several firm 10 to 15 mm. lymph nodes in each inguinal region. In May 1980 biopsy of the mucosa of the fossa navicularis revealed invasive transitional cell carcinoma. Partial penectomy was performed to remove the primary lesion. Grossly, the neoplasm consisted of white tissue compressing the urethra and involving a periurethral zone 3 to 4 mm. in diameter (fig. 1). The neoplasm extended from the urethral meatus 20 mm. proximally in the glans. The 50 mm. of urethra proximal to this were normal. Microscopically, transitional cell carcinoma covered nearly the entire circumference of the urethra in the region of the neoplasm. Flat (fig. 2, A) and papillary (fig. 2, B) components were present. The appearance was typical of a moderately differentiated transitional cell carcinoma, showing some nuclear pleomorphism, disorganization and thickening. Mitotic activity was scant and there was an infiltrate of mononuclear inflammatory cells in the underlying stroma. Neither keratinization nor intercellular bridges were present. The corpus spongiosum was invaded by sheets of neoplastic cells. The patient was evaluated for metastases and other primary tumors with excretory urography, cystoscopy with random bladder biopsies, bone scan aJ:J._d-whole lung tomography. All of these studies failed to diseluse any abnormality. After 6 weeks of antibiotic therapy only 1 of the inguinal lymph nodes remained palpable. This lymph node was then excised revealing Accepted for publication October 1, 1982.
metastatic transitional cell carcinoma. Three months after partial penectomy computerized axial tomography of the pelvis, bone scan and whole lung tomography demonstrated no abnormality. A formal lymph node dissection was not performed because of the transitional cell nature of the neoplasm. The patient was treated with 5,000 rad to the whole pelvis and an additional 3,750 rad to the left and right inguinal areas 4 months after penectomy. The only complication of this therapy was transitory mild rectal bleeding. It has been 2 years since the initial diagnosis and the patient is well without evidence of residual or recurrent carcinoma. DISCUSSION
The male urethra is customarily divided into 2 unequal parts: the posterior urethra, consisting of the membranous and prostatic portions and the anterior urethra, consisting of the bulbous, penile and glandular segments. In the normal urethra the prostatic and membranous portions are lined by transitional epithelium, the bulbous and penile portions by pseudostratified or stratified columnar epithelium and the glandular portion by stratified squamous epithelium. According to Levine, 78 per cent of carcinomas of the male urethra are of squamous cell morphology and these most commonly arise in the bulbous, membranous and penile segments. 10 He stated that transitional cell carcinomas make up about 15 per cent of all carcinomas of the male urethra and that they usually arise in the prostatic urethra. Our case of transitional cell carcinoma of the glandular urethra poses a problem in explaining its origin. The most likely explanations would invoke either ectopic urothelium or urothe-
Fm. 1. Coronal section of fossa navicularis shows papillary and flat growth. H & E, reduced from X4. 1055
1056
BANS AND ASSOCIATES
lial metaplasia of the normal squamous epithelium found in that location. The causes of urethral carcinoma are unknown. Urethral strictures have been reported in association with carcinoma of the urethra in 16 to 88 per cent of the patients. However, in our case it seems likely that the stenotic lesion observed in 1979 was probably-the carcinoma. Since this is only the third reported case of transitional cell carcinoma of the distal urethra generalizations regarding the natural history of the disease cannot be made with great confidence. However, the association of lymph node metastases with a high grade seems to parallel the natural history of transitional cell carcinomas found elsewhere in the urinary tract. The rich vascularity of the penis can be expected to have a part in the spread of transitional cell carcinoma of the urethra, analogous to that of squamous carcinoma of the urethra.
REFERENCES 1. Kreutzmann, H. and Colloff, B.: Primary carcinoma of the male
Fm. 2. A, area of flat growth shows increased epithelial thickness and architectural disorganization. B, papillary structure displays moderate nuclear pleomorphism and loss of nuclear polarity. H & E, reduced from X400.
urethra. Arch. Surg., 39: 513, 1939. 2. Ray, B., Canto, A. R. and Whitmore, W. F., Jr.: Experience with primary carcinoma of the male urethra. J. Urol., 117: 591, 1977. 3. Kaplan, G. W., Bulkley, G. J. and Grayhack, J. T.: Carcinoma of the male urethra. J. Urol., 98: 365, 1967. 4. Mullin, E. M., Anderson, E. E. and Paulson, D. F.: Carcinoma of the male urethra. J. Urol., 112: 610, 1974. 5. Guinn, G. A. and Ayala, A. G.: Male urethral cancer: report of 15 cases including a primary melanoma. J. Urol., 103: 176, 1970. 6. Baker, W. J., Graf, E. C. and Vandenberg, J.: Primary carcinoma of the male urethra. J. Urol., 71: 327, 1954. 7. Hotchkiss, R. S. and Amelar, R. D.: Primary carcinoma of the male urethra. J. Urol., 72: 1181, 1954. 8. Lee, D. A. and Bonney, W.: Carcinoma of the fossa navicularis of the male urethra. Amer. Surg., 33: 835, 1967. 9. Mandler, J. I. and Pool, T. L.: Primary carcinoma of the male urethra. J. Urol., 96: 67, 1966. 10. Levine, R. L.: Urethral cancer. Cancer, suppl. 7, 45: 1965, 1980.
Vol. 129, May Printed in U.S. A.
THE JOURNAL OF UROLOGY
Copyright © 1983 hy The Williams & Wilkins Co.
TRANSITIONAL CELL CARCINOMA OF THE FOSSA NAVICULARIS OF THE MALE URETHRA LARRY L_ BANS, JOHN N. EBLE, JAMES E. LINGEMAN AND BARNEY R. MAYNARD From the Urology Section and Laboratory Service, Richard L. Roudebush Veterans Administration Medical Center and Indiana University School of Medicine, Indianapolis, Indiana
ABSTRACT
We report a case of transitional cell carcinoma arising in the fossa navicularis, a portion of the male urethra ordinarily lined by squamous epithelium. This is the third reported case of transitional cell carcinoma of the distal urethra. The neoplasm metastasized to superficial inguinal lymph nodes. In 1939 Kreutzmann and Colloff reviewed 148 cases of carcinoma of the male urethra, which had been reported in the literature to that date. 1 The majority of those lesions arose in the posterior urethra and consisted of squamous carcinoma. Only 3 cases of transitional cell carcinoma had been recorded, of which 1 was located in the anterior urethra. This is not surprising since urothelial lining is found only in the most proximal portion of the normal urethra. Since that extensive review a number of additional cases and reviews of carcinoma of the male urethra have been published. 2- 8 However, only 2 more cases of transitional cell carcinoma of the distal urethra have been reported9 and those did not distinguish between carcinoma of the pendulous urethra and carcinoma of the fossa navicularis. CASE REPORT
H. L., a 61-year-old man, presented with a split urinary stream. A year previously he had been evaluated elsewhere for painless gross hematuria and diagnosis was meatal stenosis. The patient was treated with urethral dilation. The rest of the medical, urologic and general history was unremarkable. Initial physical examination revealed a firm, gristly lesion that was largest in the fossa navicularis but extended to the base of the glans penis and to the urethral meatus. There were also several firm 10 to 15 mm. lymph nodes in each inguinal region. In May 1980 biopsy of the mucosa of the fossa navicularis revealed invasive transitional cell carcinoma. Partial penectomy was performed to remove the primary lesion. Grossly, the neoplasm consisted of white tissue compressing the urethra and involving a periurethral zone 3 to 4 mm. in diameter (fig. 1). The neoplasm extended from the urethral meatus 20 mm. proximally in the glans. The 50 mm. of urethra proximal to this were normal. Microscopically, transitional cell carcinoma covered nearly the entire circumference of the urethra in the region of the neoplasm. Flat (fig. 2, A) and papillary (fig. 2, B) components were present. The appearance was typical of a moderately differentiated transitional cell carcinoma, showing some nuclear pleomorphism, disorganization and thickening. Mitotic activity was scant and there was an infiltrate of mononuclear inflammatory cells in the underlying stroma. Neither keratinization nor intercellular bridges were present. The corpus spongiosum was invaded by sheets of neoplastic cells. The patient was evaluated for metastases and other primary tumors with excretory urography, cystoscopy with random bladder biopsies, bone scan aJ:J._d-whole lung tomography. All of these studies failed to diseluse any abnormality. After 6 weeks of antibiotic therapy only 1 of the inguinal lymph nodes remained palpable. This lymph node was then excised revealing Accepted for publication October 1, 1982.
metastatic transitional cell carcinoma. Three months after partial penectomy computerized axial tomography of the pelvis, bone scan and whole lung tomography demonstrated no abnormality. A formal lymph node dissection was not performed because of the transitional cell nature of the neoplasm. The patient was treated with 5,000 rad to the whole pelvis and an additional 3,750 rad to the left and right inguinal areas 4 months after penectomy. The only complication of this therapy was transitory mild rectal bleeding. It has been 2 years since the initial diagnosis and the patient is well without evidence of residual or recurrent carcinoma. DISCUSSION
The male urethra is customarily divided into 2 unequal parts: the posterior urethra, consisting of the membranous and prostatic portions and the anterior urethra, consisting of the bulbous, penile and glandular segments. In the normal urethra the prostatic and membranous portions are lined by transitional epithelium, the bulbous and penile portions by pseudostratified or stratified columnar epithelium and the glandular portion by stratified squamous epithelium. According to Levine, 78 per cent of carcinomas of the male urethra are of squamous cell morphology and these most commonly arise in the bulbous, membranous and penile segments. 10 He stated that transitional cell carcinomas make up about 15 per cent of all carcinomas of the male urethra and that they usually arise in the prostatic urethra. Our case of transitional cell carcinoma of the glandular urethra poses a problem in explaining its origin. The most likely explanations would invoke either ectopic urothelium or urothe-
Fm. 1. Coronal section of fossa navicularis shows papillary and flat growth. H & E, reduced from X4. 1055
1056
BANS AND ASSOCIATES
lial metaplasia of the normal squamous epithelium found in that location. The causes of urethral carcinoma are unknown. Urethral strictures have been reported in association with carcinoma of the urethra in 16 to 88 per cent of the patients. However, in our case it seems likely that the stenotic lesion observed in 1979 was probably-the carcinoma. Since this is only the third reported case of transitional cell carcinoma of the distal urethra generalizations regarding the natural history of the disease cannot be made with great confidence. However, the association of lymph node metastases with a high grade seems to parallel the natural history of transitional cell carcinomas found elsewhere in the urinary tract. The rich vascularity of the penis can be expected to have a part in the spread of transitional cell carcinoma of the urethra, analogous to that of squamous carcinoma of the urethra.
REFERENCES 1. Kreutzmann, H. and Colloff, B.: Primary carcinoma of the male
Fm. 2. A, area of flat growth shows increased epithelial thickness and architectural disorganization. B, papillary structure displays moderate nuclear pleomorphism and loss of nuclear polarity. H & E, reduced from X400.
urethra. Arch. Surg., 39: 513, 1939. 2. Ray, B., Canto, A. R. and Whitmore, W. F., Jr.: Experience with primary carcinoma of the male urethra. J. Urol., 117: 591, 1977. 3. Kaplan, G. W., Bulkley, G. J. and Grayhack, J. T.: Carcinoma of the male urethra. J. Urol., 98: 365, 1967. 4. Mullin, E. M., Anderson, E. E. and Paulson, D. F.: Carcinoma of the male urethra. J. Urol., 112: 610, 1974. 5. Guinn, G. A. and Ayala, A. G.: Male urethral cancer: report of 15 cases including a primary melanoma. J. Urol., 103: 176, 1970. 6. Baker, W. J., Graf, E. C. and Vandenberg, J.: Primary carcinoma of the male urethra. J. Urol., 71: 327, 1954. 7. Hotchkiss, R. S. and Amelar, R. D.: Primary carcinoma of the male urethra. J. Urol., 72: 1181, 1954. 8. Lee, D. A. and Bonney, W.: Carcinoma of the fossa navicularis of the male urethra. Amer. Surg., 33: 835, 1967. 9. Mandler, J. I. and Pool, T. L.: Primary carcinoma of the male urethra. J. Urol., 96: 67, 1966. 10. Levine, R. L.: Urethral cancer. Cancer, suppl. 7, 45: 1965, 1980.