Urethral Cancer

Question 1

Incidence

Answer 1

Very Rare, <1% of GU malignancy
.
.
50% of patients die of the disease.
M>F

Question 2

Risk Factors

Answer 2

Chronic inflammation
H/O STD, HPV
Urethritis
Urethral strictres
Urethral Diverticuli
Urinary stasis
Prior XRT
Prior Ca

Question 3

Anatomy

Answer 3

Men: bladder neck to meatus, 20 cms, mostly transitional epithelium, meatus is sq. epithelium
.
.
Females: Shorter, 3-4 cms, 1/3 transitional epithelium 2/3 Sq. epithelium

Question 4

Pathology

Answer 4

Urothelial Carcinoma 55-65%
SCCa - 15-20%
AdenoCa - rare 10-15% - Skene’s gland

Question 5

Clinical Presentation

Answer 5

symptoms of urethral stricture
hematuria
Urethral Discharge
pain
swelling
dyspareunia - females, often mistaken for UTI

Question 6

Palpable nodal mets

Answer 6

if present will be in inguinal LN

Question 7

Distant Mets

Answer 7

10% @ diagnosis
Lung, liver, bone

Question 8

work up

Answer 8

H&P
GU Exam
EUA
to evaluate the extent of disease:
Cystourethroscopy
retrograde urethrogram

Question 9

Labs & Imaging

Answer 9

CBC
CMP
Urine Cytology
CT/MRI Pelvis
CT Chest +/- Bone scan
no need PET CT

Question 10

Biopsy

Answer 10

Transurethral biopsy

Question 11

Poor Prognostic Factors

Answer 11

Advanced age
Proximal > Distal tumors
Size >2cms
nodes +ve
grade- high
presence of mets obv!

Question 12

Staging

Answer 12

Question 13

N Staging

Answer 13

Question 14

Treatment Paradigm

Answer 14

Localized disease: SX, RT-Organ preservation
.
.

Locally Advanced Disease: Neoadjuvant CHT +/- RT followed by Sx
.
.

Metastatic Disease: CHT +/- IO +/- Palliative Rx

Question 15

Prostatic Urethra

Answer 15

Question 16

Surgery

Answer 16

Sx resections + Inguinal LND, no data for SLNB

Question 17

Chemotherapy

Answer 17

Urothelial Ca: Gem + Cisplatin or ddMVAC
.
.
SCCa: 5FU + Cisplatin or 5FU + MMC

Question 18

What needs to be done prior to RT

Answer 18

Circumcision to prevent Phimosis/Balanitis

Question 19

What settings can RT be done

Answer 19

Neoadjuvant, definitive, adjuvant or palliative

Question 20

When is Definitive radiation done

Answer 20

Organ preservation
T1-T2

Question 21

When is adjuvant RT done

Answer 21

T3-T4 disease
+ve margins

Question 22

RT

Answer 22

4500-5040 cGy EBRT to primary site, inguinal LN , Ext/int iliac nodes
.
.

Brachytherapy: 20-25Gy after EBRT for larger tumors

Question 23

CT Sim

Answer 23

Question 24

Dose Constrains

Answer 24

Question 25

Prognosis

Answer 25

OS:
3yrs - 55%
5yrs - 40-55%
10 yrs - 25-30%