Male+Urethra


 * Epidemiology: || A SEER study reported an incidence of urethral cancer of 4.3 per million in males. There is a higher incidence in African Americans, and it can occur at any age but is most often seen during the 7th decade of life. 3 ||
 * Etiology: || The risks and causes of urethral cancer in males is not definitive. People with a history of bladder cancer are at an increased risk of developing urethral cancer. Some sexually transmitted diseases, such as HPV, have been associated with some cases of urethral cancer. Chronic irritations from sexual intercourse or infection can also be etiologic. 3 ||
 * Signs & Symptoms: || Symptoms can include: diminished stream or straining to void; increased frequency; nocturia; itching; dysuria; incontinence; hematuria; hard nodule area in perineum or penis; hematospermia; watery and foul-smelling discharge; perineal, suprapubic or urethral pain; dyspareunia (painful sexual intercourse); swelling; priapism (erect penis). 3

Signs upon examination can include: urethrocutaneous fistula; urethral diverticula; periurethral abscess or tissue necrosis; recurrent urinary tract infections; penile lesions; lymphadenopathy; palpable mass along urethra. 3 || •15% transitional cell carcinoma •5% adenocarcinomas •1% undifferentiated or mixed carcinomas 1 ||
 * Diagnostic Procedures: || A transurethral biopsy is essential is diagnosing urethral cancer. Intravenous urography is helpful if hematuria is present. Chest x-rays, MRI and CT of abdomen, pelvis, and perineum aid in staging. 4 ||
 * Histology: || •approximately 80% of urethral carcinomas in men can be classified as squamous cell carcinomas, usually well or moderately differentiated
 * Lymph Node Drainage: || Lymphatic drainage of the distal male urethra is similar to that of penile tumors. Tumors of the fossa and pendulous urethra drain to the superficial inguinal lymph nodes, while tumors of the bulbar, membranous, and prostatic urethral segments drain to the iliac, obturator, and presacral node groups. There may be crossover at the prepubic lymphatic plexus. 7 ||
 * Metastatic Spread: || Urethral cancers spread first by local extension and later metastasize via lymphatic channels and bloodborne routes. The lymphatic drainage of the distal urethra is to the superficial and deep inguinal nodes. The proximal urethra drains to the nodes of the iliac, obturator, presacral, and para-aortic lymphatic chains. Palpably abnormal lymph nodes are present in 20% to 50% of patients at presentation, and almost always represent metastatic cancer. Metastases to distant sites—liver, lung, brain and bone—occur late and are more common with adenocarcinomas. 7 ||
 * Grading: || Long-term survival is related to the stage of the tumor at the time of diagnosis and appears to be independent of tumor histology or grade. 7 ||
 * Staging: || Urethral tumors can be classified as those involving the distal half of the urethra and those located in the proximal or entire urethra. Most authors have found that this classification correctly depicts the feasibility of treatment and thre prognosis. 1

The AJCC staging system may also be used as shown in the table below. 1

|| Tumor-free regional nodes imply excellent long-term survival 85% to 90% some of which are cured. 50% survive long term. Pelvic lymph node involement is the worst with less than 20% of patients living. 1 ||
 * Radiation Side Effects: || Erythema, dry or moist desquamation, and swelling of the subcutaneous tissue. Telangiectasia and fibrosis are asymptomatic and are late consequences of radiation. Sterilization 100 cGy. 8 ||
 * Prognosis: || Extent of the primary lesion and status of the lymph nodes are the major prognostic factors.
 * Treatments: || Surgical excision remains the standard as a primary mode of treatment for urethral cancer. The extent of surgery depends on the location to the tumor within the urethra an the clinical stage. 3

__Anterior Urethral Cancer__ Stage 0/Tis, Ta - open excision or electroresection and fulguration, or laser vaporization-coagulation. Stage T1, T2, T3 lesions - amputation of penis; radiation if amputation is refused. __Posterior Urethral Cancer__ (associated with advanced stages) Preoperative radiation followed by cystoprostatectomy, urinary diversion, and penectomy with bilateral pelvic node dissection with or without inguinal node dissection. 5 

__Radiation Therapy Techniques__ •Anterior urethra - same as carcinoma of the penis. •Bulbomembranous urethra - treat the groins and pelvis using parallel-opposed fields, followed by perineal and inguinal boost. •Prostatic urethra - similar to treatment of the prostate. 6 

Chemotherapy does not have a well defined role in the treatment of penis and male urethra carcinomas. 6 ||
 * TD5/5: || Bladder Contracture 6000 cGy, Rectum, Ulcer, stricture 6000 cGy, Skin Acute and chronic dermatitis 5500 cGy, Bone marrow Alplasia, pancytopenia 250 cGy, Spinal cord Infarction, necrosis 4500 cGy, Small Bowel 4500 cGy Ulcer, perforation and hemorrhage. 8 ||
 * Planning Photos || Digitally Reconstructed Radiographs (DRR) of portals encompassing inguinal nodes in the male pelvis. 2



|| 1. Chao KS, Perez CA, Brady LW. //Radiation Oncology - Management Decisions.// 2nd ed: 481-488. Philadelphia, PA//:// Lippincott, Williams & Wilkins; 2002. 2. Digitally Reconstructed Radiographs courtesy of Ginnie Dea, RT(T), Alta Bates Summit Comprehensive Cancer Center. 3. eMedicine. //Urethral Cancer//. []. Accessed January 28, 2010. 4. eMedicine. //Urethral Cancer//. [] Accessed January 28, 2010. 5. National Cancer Institue. Urethral Cancer Treatment. []. Accessed January 22, 2010. 6. Lenards, N. //Clinical Oncology for Medical Dosimetrists: Penis and Male Urethra. //  Course content - Slide 11. December 2009. 7. []. Accessed January 29, 2010. 8. Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy, 2 // nd ed: 80. Philadelphia, PA: Mosby Inc, 2004.
 * References**

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