Female+Urethra


 * Epidemiology: || Incidence is rare with only 1,600 cases (approximately) reported in the literature. 1 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. 4 ||
 * Etiology: || The risks and causes of urethral cancer in females 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 giving birth, sexual intercourse, or infection can also be etiologic. 4 ||
 * Signs & Symptoms: || Symptoms can include: diminished stream or straining to void; increased frequency; nocturia; itching; dysuria; incontinence; hematuria; hard nodule area in perineum or labia; watery and foul-smelling discharge; perineal, suprapubic or urethral pain; dyspareunia (painful sexual intercourse); swelling; priapism (erect clitoris). 4

Signs upon examination can include: urethrocutaneous fistula; urethrovaginal fistula; urethral diverticula; periurethral abscess or tissue necrosis; recurrent urinary tract infections; vaginal lesions; lymphadenopathy; palpable mass along urethra. 4 || Radiography evaluations should also be done which would include chest x-rays, an intravenous urogram and a CT of the abdomen and pelvis. 1 ||
 * Diagnostic Procedures: || Routine history and physical examination as well as a detailed pelvic exam. Anesthesia should be used during the pelvic exam to fully evaluate the extent of disease which can be done during a urethroscopy and cystoscopy.
 * Histology: || Transitional cell carcinoma is most common in the proximal urethra and squamous cell carcinoma predominates in the distal urethra. 2 ||
 * Lymph Node Drainage: || The lymphatic drainage of the urethral meatus parallels that of the vulva to the superficial and deep inguinal and external iliac lymph nodes. The primary drainage of the entire urethra is mainly to the obturator and internal and external iliac nodes. 1 ||
 * 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 and labia 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. 5 ||
 * 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. 5 ||
 * 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

||||  || Incontinence, cystitis, and vaginal stenosis may also develope. Severe complications are fistula formation, bowel obstrction, and occasional operative mortality Fistula formation may be unavoidable because of tumor erosion of the organ and subsequent tumor necrosis. 1 || •open excision, electroexcision, fulguration or laser coagulation can be used to treat tumors at the meatus or in-situ involvement of the distal urethra (stage 0). •for larger and more invasive lesions (stage I), interstitial irradiation or combined interstitial and external beam irradiation are alternatives to surgical resection of the distal third of the urethra. •anterior urethral lesions that recur after treatment by local excision or radiation therapy may require anterior exenteration and urinary diversion. •if no inguinal adenopathy exists, node dissection is not recommended but prophylactic groin irradiation is recommended for patients with invasive lesions. __Posterior Urethral Cancer__ •cancers of the posterior or entire urethra (stages II, III, and IV) are usually associated with invasion of the bladder and a high incidence of inguinal and pelvic lymph node metastases. __Radiation Therapy Techniques__ •interstitial implant is the usual method for treating meatal carcinomas. Radioactive needles forming a double-plane or a volume implant have been used. After radiographs are used to verify needle placement, a dose of 60-70 Gy can be given in 6-7 days (0.4 Gy per hour to the target volume) when an implant alone is used. •large tumors extending into the labia, vagina, entire urethra or base of the bladder cannot be treated with an implant alone. A combination of external beam irradiation and implant is recommended. The external beam portal should flash the perineum to cover the entire urethra. The portal should be wide enough to cover the inguinal nodes and extend cephalad to the L5-S1 interspace to include the pelvic nodes. Bolus should be added to the groins when inguinal nodes are positive. The whole pelvis is treated to a dose of 50 Gy. A boost of 10-15 Gy is delivered to positive nodes through reduced anterior photon or en face electron fields. •for advanced disease, the primary tumor is treated with a vaginal cylinder to bring the dose to the entire urethra to ~60 Gy. An interstitial implant is used to raise the total tumor dose to 70-80 Gy. 1 ||
 * Radiation Side Effects: || Urthrral strictures develop in some patients, necessitating dilation or urinary diversion.
 * Prognosis: || The tumor size is the most important part in determining prognosis and survival. 81% of patients with lesions less than 2 cmhad a 5 year progression-free survival. This is compared with 37% of those lesions 2cm to 4 cm and 7% of patients with lesions greater than 4cm . Bladder neck involvement, parametrail extension, and inquinal lymph node involvement are poor prognostic factors. 1 ||
 * Treatments: || __Anterior Urethral Cancer__
 * TD5/5: || Bladder Contracture 6000 cGy, Rectum, Ulcer, stricture 6000 cGy, Skin Acute and chronic dermatitis 5500 cGy, Uterus stricture 7500 cGy, Bone marrow Alplasia, pancytopenia 250 cGy, Spinal cord Infarction, necrosis 4500 cGy, Uterus necrosis, perforation > 10,00 cGy, Vagina Ulcer, fistula 9000 cGy, Small Bowel 4500 cGy Ulcer, perforation and hemorrhage. 6 ||
 * Planning Photos || Digitally Reconstructed Radiographs (DRR) of portals encompassing pelvis and inguinal nodes in the female pelvis. 3



|| 1. Chao KS, Perez CA, Brady LW. //Radiation Oncology - Management Decisions.// 2nd ed: 441-445. Philadelphia, PA//:// Lippincott, Williams & Wilkins; 2002. 2. National Cancer Institute. []. Accessed January 22, 2010. 3. Digitally Reconstructed Radiographs courtesy of Ginnie Dea, RT(T), Alta Bates Summit Comprehensive Cancer Center. 4. eMedicine. //Urethral Cancer//. []. Accessed January 28, 2010. 5. []. Accessed January 29, 2010. 6. 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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