CARCINOMA OF THE FEMALE URETHRA RESPONSIVE TO MODERATE DOSE CHEMORADIOTHERAPY

Abstract

A 68-year-old white woman with a long history of urinary retention and multiple episodes of urinary tract infection was admitted to the hospital in urinary retention. Cystoscopic examination revealed a periurethral mass. Well differentiated keratinizing squamous cell carcinoma was demonstrated on biopsy. Staging evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) of the pelvis, chest x-ray and bone scan did not show any metastases. CT was suggestive of but MRI did not confirm pelvic lymphadenopathy. Instead, MRI showed an increased T2-weighted signal compatible with bladder neck as well as distal vaginal involvement by a well-defined 8 3 6 cm. mass extending from the bladder neck to the introitus where it abutted the symphysis. It was easily palpable as a submucosal mass along the entire length of the vagina anteriorly. Therefore, disease was classified as T3N0M0, American Joint Committee on Cancer stage III or Grabstald stage C. Partially precipitated by reaction to antibiotic treatment given for the urinary tract infection, the patient had a massive myocardial infarction and had to be resuscitated. Because she was not able to tolerate aggressive surgery and life expectancy was limited, palliative treatment was recommended. She received limited volume radiation using opposing anterior-posterior fields measuring 8 3 10 cm. with 4 mv. photons to a dose of only 4,000 cGy. in 4 weeks. The intent was to perform either limited excision with the patient under local anesthesia or apply intracavitary irradiation via a catheter to address the residual central disease following external beam irradiation. To maximize this relatively low radiation dose 45 to 60 mg./m. cisplatin and 1.5 gm. 5-fluorouracil intravenously daily for a total of 6 gm. for 4 days were given. Chemotherapy began concurrently with irradiation. After radiotherapy was completed, 2 more cycles of cisplatin and 5-fluorouracil therapy were administered 4 weeks apart. Then 5-fluorouracil alone was given for 3 more doses 4 weeks apart. Probably because of the exclusion of pelvic and inguinal lymphatics, no bowel, bladder, skin or any other side effects of irradiation occurred despite concurrent chemotherapy. At the completion of radiotherapy the mass had been reduced to 4 3 4 cm. and was no longer tender. The Foley catheter was removed at the initiation of the second cycle of chemotherapy with relatively normal urinary function. At 1 month after radiotherapy only minimal smooth induration was palpated along the anterior vaginal wall, which had resolved completely at 2-month followup. At 5-month followup the entire length of the urethra was normal on palpation. Cystoscopy and urethroscopy performed at 3 years 9 months were negative. No biopsy was indicated. The patient died of heart failure with no evidence of disease 5 years 10 months after treatment. DISCUSSION