Primary Epidermoid Carcinoma of the Male Posterior Urethra

Primary Epidermoid Carcinoma of the Male Posterior Urethra

PRIMARY EPIDERMOID CARCINOMA OF THE MALE POSTERIOR URETHRA WALTER D. BIEBERBACH 1¥orcester, M assachusctts AND CLINTON N. PETERS Portland, Maine Ca...

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PRIMARY EPIDERMOID CARCINOMA OF THE MALE

POSTERIOR URETHRA WALTER D. BIEBERBACH 1¥orcester, M assachusctts AND

CLINTON N. PETERS Portland, Maine

Carcinoma of the urethra is a rare condition and very little is encountered on the subject in medical literature. It is for this reason the authors are reporting 2 cases seen simultaneously in different sections of New England and reported at a meeting of the New England Branch of the American Urological Society. Both patients were males, one aged forty-two, the other aged sixtytwo. While carcinoma attacks all sections of the urethra our reremarks in this article will deal with the posterior urethra of the male. Text-books and works on pathology are notably deficient in case descriptions and authentic case histories with no error of diagnosis are comparatively few in number, in fact some less than one hundred. Growths included in this list are squamous cell, columnar cell, papillary and adeno-carcinoma. In the order of their frequency the squamous cell type will account for about 60 per cent. The etiology of the condition is clouded by a series of suggestions adding nothing of value and it seems that age is the only constant factor running through the series. In the majority of cases the lesion arises from the bulbous portion of the urethra. The disease rarely occurs before fifty years of age. However, 2 cases have been reported, one at the age of twenty-two and the other at forty. Like all malignancy many theories are advanced, the most commonly mentioned being trauma and leucoplakia, probably resulting from chronic urethral infections. Stricture has been found in at least 50 per cent of the cases of carcinoma of the urethra. Whether this is an etiological 105 THE JOURNAL OF UROLOGY, VOL, XXII, NO,

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factor is a question, for many cases of stricture with serious complications are seen and how rarely is carcinoma encountered. On the other hand, many of the reported cases give no venereal history. As the growth spreads it invades the corpus spongiosum entering the peri-urethral tissue and produces abscesses and fistulae which open into the perineum or other surrounding tissue. The early symptoms very of ten are not characteristic of malignancy but resemble more those of ordinary urethral stricture. Malignant neoplasms of the urethra are mostly epithelial in origin and are found either in the pendulous or deep urethra. Papillomata that are found anywhere in the urethra may undergo a malignant change and coalesce. The cells lose their larger formation and become uniform and strands of neoplastic cells invade the subjacent tissue. Such changes are mostly seen in the pendulous urethra where papillomata are more commonly found. If the squamous cell type arises at any distant point from the meatus it is believed to be preceded by leukoplakia. This condition is commonest in areas of chronic inflammation associated with stricture. Case 1. (Dr. Clinton N. Peters.) Male, aged forty-two, white, single, laborer, complained of inability to urinate. His family and past history were negative. Present history. Three months ago, patient fell from an elevator striking in perineum on the corner of a packing case. The condition was not thought to be serious. At the time, there was a slight hematuria. This history was obtained from the patient who considered his condition to come under the Industrial Accident Insurance, so I cannot vouch for the truth. There seems to be no question of a fall and injury which was reported by the foreman, and the man received some compensation. Two months later he noticed some difficulty in passing urine and the condition has progressed until at the time of examination there is complete retention. Physical examination. Well developed, 5 feet 8 inches, weight 145 pounds. Heart and lungs negative. Blood pressure 140/90. Blood hemoglobin 70, 145, reds 4,000,000, whites 10,000. Blood Wassermann negative. Blood urea 25 mgm.

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There is nothing of note in the physical examination except a distended bladder and a hard, indurated, much inflamed swelling in the perinea! region extending to the scrotal margin. Attempted catheterization produced some bleeding and no results. I believed the condition to be stricture of the urethra with extravasation and abscess formation and sent the patient to the operating room for perinea! section. Incision into the mass encountered some pus ari:d urine but very little necrotic tissue. The inflammatory portion seemed to be on the edges of a distinct mass of hard tissue which had not broken down. I recognized I was dealing with something out of the ordinary so took sections for the pathologist. Following his report I sent sections to three different pathologists and their reports are as follows: Dr. Mallory, Boston City Hospital: "Epidermoid carcinoma complicated with considerable inflammation." Dr. Hewatt, Maine State Laboratory: "Sections show a dense fibrous stroma which is hemorrhagic and contains leucocytes and lymphocytes. In addition, the fibrous tissue is being infiltrated with dense masses and solid cords and independent clumps of cells which are epithelial in type showing a wide variation in shape, size and staining reaction. Also, under the oil emersion numerous cells can be seen in mitotic division. It is an infiltrative growth, epitheliomatous in type and malignant in character." Dr. Warren, Maine General Hospital: "The bulk of the tissue is granulation or inflammatory tissue. In areas of this tissue, numerous spaces filled with epithelial islands, and small collections with epithelial pearl formation occur in the stroma. Diagnosis is chronic inflammation and epithelioma. I cannot account for this except as an epithelial growth pushing up from the urethra." There was no break in the skin before operation. No fistula existed. Further examination showed inguinal metastasis to exist. I felt local treatment useless. Perinea! drainage was instituted and the patient succumbed to his carcinoma five months later.

Case 2. (Dr. Walter D. Bieberbach.) March 28, 1928, a male, sixtytwo years of age· entered Worcester City Hospital, complaining of urinary fistula and ability to urinate only by straining. Most of his urine passed through a perinea! fistula and only a few drops through the urethra. These symptoms reached their maximum intensity in December, 1927, and gradually became worse until it was a real hardship to empty the bladder. Thirty-five years ago the patient had gonorrhea.

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His treatment consisted of hand injections and internal medication. Such treatment was continued until noticeable discharge disappeared and the patient believed he was cured. Two years following the infection he met with a severe perinea! trauma falling astride a stake. There was severe hemorrhage and he could void only in drops. This condition gave him trouble for eight months when finally he was able to pass a free stream. Five years ago he again noticed a very small stream. He sought medical advice and received urethral dilatation followed by relief. For the past four years he has had no symptom of stricture. December, 1927, he noticed what he called a "boil" in the deep, perineum. This ruptured and discharged a purulent material until March, 1928. Following the rupture of the "boil" no urine was passed through the urethra. Ten days before admission into the hospital he passed a large amount of blood and a quantity of pus at different intervals. Following this there were urinary symptoms of frequency and a desire to void every few minutes. There was no dribbling, the patient being able to control his stream. His family history was negative to any disease of importance. Physical examination. Essentially negative except for local examination. Scrotum negative, both testes and epididymi negative. Both corporae cavernosae could be traced the entire distance and were hard, fibrous and indurated. No pain on palpation. At the bulbo-membranous junction of the urethra there was a filiform stricture through which no instrument could be passed. The perineum was infiltrated and a discharging sinus which pointed left to the middle line admitted a probe down to the deep posterior urethra. Through this sinus the patient was voiding. Prostate flat, smooth, and hard and pushed well up into the rectum. Both vesicles could be outlined and were considerably infiltrated, the left larger and thicker than the right. Smears made from the sinus, urethra and vesicles and prostate showed many pus cells, Gram-positive organisms, but no gonococci were found. Blood pressure 130/80. Laboratory findings. Blood chemistry: Alkaline reserve 60.5 per cent CO2 by volume. Sugar 0.10 per cent. Non-protein nitrogen 40.3 mgm. per 100 cc. Urea nitrogen 8.8 mgm. per 100 cc. Creatinine 2.1 mgm. per 100 cc. Blood work: White blood cells 16,700. Red blood cells 3,400,000. Hemoglobin 80 per cent. Smear-reds normal in size and shape.

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White blood cells, polymorphonuclears 72 per cent, large lymphocytes 8 per cent, small lymphocytes 20 per cent. Urine examination showed nothing of importance except pus, amorphous material persistantly alkaline except when changed by medication. Specific gravity ranged from 1.010 to .015, slight trace of albumin with no casts or sugar. Serological tests. Wassermann and Kahn tests negative. Provisional diagnosis: l. Stricture of the deep posterior urethra wth urethro-perineal fistula and urinary infiltration into the perinea! tissue. 2. Carcinoma of the deep posterior urethra infiltrating the deep perineum with involvement of both corporae cavernosae and probable metastasis. Just a few small inguinal glands could be palpated. Operation. Operation under spinal anesthesia. Perinea! incision exposing membranous and deep urethra. Tissues indurated, hard and reistant to cutting. There was a large fistula extending from membranous urethra to the left of the midline. This was incised and laid open on a grooved director. Being suspicious of malignancy nothing else was done except opening the deep posterior urethra and inserting a large perinea! drainage tube into the bladder. Before insertion of tube, the prostatic urethra, prostate and neck of internal bladder sphincter were explored by digital examination. The prostate was somewhat smaller than normal and fibrous, but otherwise there was no apparent pathology. The internal sphincter felt normal. The whole urethra extending from the membranous junction to the prostatic section was very hard and infiltrated, Section of the membranous urethra was removed with perinea! tissue and sent to the laboratory for examination. The tube was fastened to the skin and the incision was allowed to remain open for radium implantation later. The photograph shows the mass of indurated tissue following operation with the perinea! drainage tube in place. The sections reported by Dr. F ..H. Baker, Pathologist at Worcester City Hospital, were epidermoid carcinoma with fibrous, acute and chronic inflammatory tissue. Following the operation there was relief of pain and urinary symptoms. At the end of two weeks the inflammatory tissue subsided and the wound was well drained and clear in appearance. The tissue of the exposed perinea! section was hard, nodular and stone-like in feeling. On the fourteenth day following operation twelve gold seeds of radium, each 1 millicurie, were implanted into the exposed perineal tissue at a distance of 2 cm. and 4 to 6 cm. deep. Following the implantation

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pelvic x-ray was made and reported as follows: Twelve small radium seeds shown in perineal region. The ascending ramus of right ischium shows a loss of substance nearly complete for a distance of 2.5 cm. and external to this point the bone is rarified for a further distance of 1.5 cm. There is well marked sclerosis in the arteries of the pelvis. The external

Fm. 1

border of the right ilium shows irregularity of outline with some tendency to proliferation at the lower border of the affected area. The area in the ischium represents metastatic carcinoma. At the time of admission the patient had a urinary output of 400 cc. Following the first day after operation it rose to 800 cc. Then there was a gradual drop for the next four days to the starting pont of 400 cc. At this time his output began to climb steadily. His temperature on

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admission was 100.2° and following operation with drainage it fell to normal and remained so. After radium treatment the patient complained of considerable pain in the perineum. On the fifth day the wound around where the seeds were placed began to slough and the temperature rose to 102° with a gradual decrease in the urinary output to 400 cc., this being the low level before operation. Following operation the patient was out of bed, had a good appetite and strong until the fifth day following the radium implantation when the above described reaction took place. He became toxic and was unable to get out of bed, having a temperature elevation with a low urinary output. While abdominal metastasis was considered previous to radiation he now showed marked symptoms of this condition which were not present before operation. On May 17, twenty-four days after the first x-ray another picture was taken and reported substantially the same as the previous one except the bone defect was a little more intensive and one seed had migrated toward the pelvis. The patient gradually failed and died of malignant toxemia on June 8, 1928, seventy days from date of admission. Post-mortem. The autopsy was performed and the organs submitted to the pathologist for examination. The report showed that metastases were positive in the lung, liver, and right kidney. SUMMARY

Carcinoma of the urethra is a rare condition and most generally appears after fifty years of life. Most cases are of the squamous cell type. In reviewing the history of reported cases, it would lead one to believe that trauma and intra-urethral irritation either from infection or stricture are contributing factors. Long standing infections followed by stricture of the membranous urethra at or past the age of fifty years or, as we may say, the cancerous age, are symptoms which may be regarded with suspicion. The diagnosis of such a urethral neoplasm is difficult. They cause partial obstruction, the symptoms of which are easily confused with stricture of the deep urethra and may be overlooked until far advanced. The outstanding symptoms such as hematuria, marked pain following urination and fistula with induration in the deep perineum are questionable symptoms. These cases warrant tissue resection for biopsy. Even these cases

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are very misleading for while the cardinal symptoms point to carcinoma the laboratory :findings are those of chronic inflammatory tissue. The prognosis is very poor under all conditions and many of the advanced operative cases die following operation. A large per cent show recurrences with metastases and die within six to ten months. However, Kretschmer reports a case in which there were no recurrences two years after radical operation. If any favorable results are to be obtained, an early diagnosis must be made for radical operation offers the only chance for cure. From my experience (W. D. B.) in late cases of this type of cancer, radium and x-ray are of little value. I ha:ve found that radium hastens necrosis of the malignant tissue, producing a fatal toxemia and terminating life.