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Urethral Carcinoma After Radiation Therapy for Mixed Prostatic Carcinoma
Vol. 116, July
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1976 by The Williams & Wilkins Co.
URETHRAL CARCINOMA AFTER RADIATION THERAPY FOR MIXED PROSTATIC CARCINOMA DONALD E. NOVICKI
AND
G. GRANT GEHRING
From the Urology Service, Department of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas
ABSTRACT
The first case of transitional cell carcinoma of the bulbous urethra occurring 8 months after radiation therapy for mixed ductal and adenocarcinoma of the prostate is presented. The significance of the sequential appearance of these tumors is discussed. Periodic endoscopic evaluation appears warranted following the diagnosis of transitional cell carcinoma of the prostate to ensure early recognition of secondary urethral lesions or bladder extension of the tumor. CASE REPORT
A 70-year-old white man was seen initially in September 1974 with symptoms of prostatism. Rectal examination revealed a fixed, firm left prostatic lobe and 2 discrete nodules in the right lobe. The serum acid phosphatase was slightly elevated to 2.2 international units (LU.) (normal, less than 2 I_.U.). Panendoscopy revealed a rigid prostatic fossa with trilobar hypertrophy and asymmetric enlargement of the left lateral lobe. The excretory urogram was normal and cystoscopy showed only mild trabeculation. Transrectal prostatic needle biopsies revealed well differentiated adenocarcinoma of the left lobe and transitional cell carcinoma of the right lobe (part A of figure). External beam cobalt 60 radiotherapy was given,
inguinal nodes were normal on palpation. Transurethral resection of the lesion was accomplished and pathological examination revealed grade II transitional cell carcinoma of the urethra (part B of figure). Needle biopsies of the prostate revealed persistent transitional cell carcinoma of the right lobe and well differentiated adenocarcinoma of the left lobe. A retrograde urethrogram and the voiding habits are normal 2 months postoperatively. DISCUSSION
Primary carcinoma of the male urethra, unassociated with more proximal urothelial tumors, is rare with about 300 such cases reported in the literature. 1 Transitional cell tumors
A, biopsy of right lobe of prostate demonstrates transitional cell carcinoma arising in prostatic duct. B, urethral lesion demonstrates grade II/III transitional cell carcinoma.
delivering 4,000 rads to the whole pelvis and 2,400 rads rotational beam to the prostate. The patient experienced total relief of voiding symptoms and mild radiation proctitis, which has persisted to the present. He was seen in July 1975 complaining of passive urethral bleeding. Endoscopy revealed a 2 by 1 cm., fungating lesion of the mid bulbous urethra from the 3 to 5 o'clock position. A normal portion of urethra, approximately 1 ½ cm. long, was clearly visualized proximal to the tumor and the bladder remained uninvolved. The perineum and Accepted for publication December 23, 1975. The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force. 122
comprise about 20 per cent of urethral carcinomas and occur predominantly in the prostatic urethra. 2 Urethral transitional cell carcinoma has never been associated previously with ductal carcinoma of the prostate, although Ende and associates have emphasized the propensity for trigonal bladder invasion and early ureteral obstruction with transitional cell carcinoma of the prostate. 3 In our case chance occurrence of rare tumors of the same cell type in anatomically separate areas would be extremely unlikely. This leads to the speculation that tumor implantation from the prostate to the bulbous urethra took place in a fashion similar to the bladder seeding that has been postulated to occur in association with upper
URETHRAL CARCINOMA AFTER RADIATION THERAPY FOR PROSTATIC CARCINOMA
urinary tract transitional carcinoma. If the original prostatic biopsies had been transperineal rather than transrectal, tumor implantation along the needle tract might also be implicated provided the bulbous urethra had been inadvertently transpierced. With the increased recognition of transitional cell carcinoma arising in the ductal prostatic epithelium, periodic endoscopic examination of the urethra and bladder for secondary tumors should be made. ADDENDUM
This patient was seen in routine followup in February 1976. Multiple metastatic pulmonary lesions were noted. It is pre-
. I
123
sumed that these represent metastatic transitional cell carcinoma in light of a normal serum acid phosphatase and negative skeletal survey. Appropriate chemotherapy has been instituted. REFERENCES
1. Grabstald, H.: Tumors of the urethra in men and women. Cancer, 32: 1236, 1973.
2. Kaplan, G. W., Bulkley, G. J. and Grayhack, J. T.: Carcinoma of the male urethra. J. Urol., 98: 365, 1967. 3. Ende, N., Woods, L. P. and Shelley, H. S.: Carcinoma originating in ducts surrounding the prostatic urethra. Amer. J. Clin. Path., 40: 183, 1963 .
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1976 by The Williams & Wilkins Co.
URETHRAL CARCINOMA AFTER RADIATION THERAPY FOR MIXED PROSTATIC CARCINOMA DONALD E. NOVICKI
AND
G. GRANT GEHRING
From the Urology Service, Department of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas
ABSTRACT
The first case of transitional cell carcinoma of the bulbous urethra occurring 8 months after radiation therapy for mixed ductal and adenocarcinoma of the prostate is presented. The significance of the sequential appearance of these tumors is discussed. Periodic endoscopic evaluation appears warranted following the diagnosis of transitional cell carcinoma of the prostate to ensure early recognition of secondary urethral lesions or bladder extension of the tumor. CASE REPORT
A 70-year-old white man was seen initially in September 1974 with symptoms of prostatism. Rectal examination revealed a fixed, firm left prostatic lobe and 2 discrete nodules in the right lobe. The serum acid phosphatase was slightly elevated to 2.2 international units (LU.) (normal, less than 2 I_.U.). Panendoscopy revealed a rigid prostatic fossa with trilobar hypertrophy and asymmetric enlargement of the left lateral lobe. The excretory urogram was normal and cystoscopy showed only mild trabeculation. Transrectal prostatic needle biopsies revealed well differentiated adenocarcinoma of the left lobe and transitional cell carcinoma of the right lobe (part A of figure). External beam cobalt 60 radiotherapy was given,
inguinal nodes were normal on palpation. Transurethral resection of the lesion was accomplished and pathological examination revealed grade II transitional cell carcinoma of the urethra (part B of figure). Needle biopsies of the prostate revealed persistent transitional cell carcinoma of the right lobe and well differentiated adenocarcinoma of the left lobe. A retrograde urethrogram and the voiding habits are normal 2 months postoperatively. DISCUSSION
Primary carcinoma of the male urethra, unassociated with more proximal urothelial tumors, is rare with about 300 such cases reported in the literature. 1 Transitional cell tumors
A, biopsy of right lobe of prostate demonstrates transitional cell carcinoma arising in prostatic duct. B, urethral lesion demonstrates grade II/III transitional cell carcinoma.
delivering 4,000 rads to the whole pelvis and 2,400 rads rotational beam to the prostate. The patient experienced total relief of voiding symptoms and mild radiation proctitis, which has persisted to the present. He was seen in July 1975 complaining of passive urethral bleeding. Endoscopy revealed a 2 by 1 cm., fungating lesion of the mid bulbous urethra from the 3 to 5 o'clock position. A normal portion of urethra, approximately 1 ½ cm. long, was clearly visualized proximal to the tumor and the bladder remained uninvolved. The perineum and Accepted for publication December 23, 1975. The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force. 122
comprise about 20 per cent of urethral carcinomas and occur predominantly in the prostatic urethra. 2 Urethral transitional cell carcinoma has never been associated previously with ductal carcinoma of the prostate, although Ende and associates have emphasized the propensity for trigonal bladder invasion and early ureteral obstruction with transitional cell carcinoma of the prostate. 3 In our case chance occurrence of rare tumors of the same cell type in anatomically separate areas would be extremely unlikely. This leads to the speculation that tumor implantation from the prostate to the bulbous urethra took place in a fashion similar to the bladder seeding that has been postulated to occur in association with upper
URETHRAL CARCINOMA AFTER RADIATION THERAPY FOR PROSTATIC CARCINOMA
urinary tract transitional carcinoma. If the original prostatic biopsies had been transperineal rather than transrectal, tumor implantation along the needle tract might also be implicated provided the bulbous urethra had been inadvertently transpierced. With the increased recognition of transitional cell carcinoma arising in the ductal prostatic epithelium, periodic endoscopic examination of the urethra and bladder for secondary tumors should be made. ADDENDUM
This patient was seen in routine followup in February 1976. Multiple metastatic pulmonary lesions were noted. It is pre-
. I
123
sumed that these represent metastatic transitional cell carcinoma in light of a normal serum acid phosphatase and negative skeletal survey. Appropriate chemotherapy has been instituted. REFERENCES
1. Grabstald, H.: Tumors of the urethra in men and women. Cancer, 32: 1236, 1973.
2. Kaplan, G. W., Bulkley, G. J. and Grayhack, J. T.: Carcinoma of the male urethra. J. Urol., 98: 365, 1967. 3. Ende, N., Woods, L. P. and Shelley, H. S.: Carcinoma originating in ducts surrounding the prostatic urethra. Amer. J. Clin. Path., 40: 183, 1963 .