Primary cancer of the urethra and penis is rare. Cancer of the male urethra is extremely uncommon, there are only about 700 cases reported worldwide. Carcinoma of the urethra in women is also unusual, when it does occur, it is usually in post–menopausal and older women. In both males and females the causal factors in this disease are not known, inflammation, however, is felt plays a role. Penile cancer represents 2 per cent of urogenital cancers. It is felt that bacterial production of smegma in uncircumcised men is a risk factor.
Diagnosis of Urethral/Penile Cancer
In male urethral cancer, diagnosis is established by transurethral biopsy. In women, the diagnosis is established in much the same way. Pathologically, most tumors are squamous cell carcinomas, although transitional cell carcinomas, adenocarcinomas and melanomas may also be seen. In penile cancer, incisional or excisional biopsy is performed to obtain the diagnosis. Histologically, squamous cell is the predominant cell type, although melanomas, basal cell carcinomas, lymphomas and metastatic lesions from other primaries have been seen.
Staging
In men, CT scan and/or MRI of the abdomen and pelvis and bimanual examination under anesthesia are performed. In women, the above are done along with a careful pelvic examination under anesthesia. Barium enema and bone scan may also be performed in those patients with worrisome signs or symptoms. For penile cancers, CT or MRI of the abdomen and pelvis are indicated for staging. Currently, there is no agreed upon classification system for female urethral cancer. In men, the Tumor Node Metastasis (TNM) staging is used.
Treatment of Urethral/Penile Cancer
The treatment of male urethral cancer is surgery. The extent of the surgery depends upon the location and stage of the tumor. Radiation is usually reserved for those patients with early stage lesions of the anterior urethra who refuse surgery. Chemotherapy has shown promise in those with metastatic urethral cancer and is being integrated into therapy for those with locally advanced disease. In females, urethral cancer surgery is the primary modality of therapy. However, radiation therapy plays a larger role in treatment of this disease than in male cancer. Unfortunately, neither of these modalities alone produces an acceptable morbidity rate and low tumor recurrence rate. Due to the inadequacy of these procedures, chemotherapy in conjunction with radiation and/or surgery (a combined modality approach) is being investigated. Long term results of studies are being awaited.
For either male or female urethral cancer, if the patient is willing, and an investigative study is available, participation should be encouraged. In penile cancer, surgery is used for control of the primary tumor and also to control the inguinal lymph node bearing regions. Radiation therapy to the penis may work best in patients with low stage disease. In these patients, if prophylactic or therapeutic lymph node dissection cannot be performed, external beam radiation to the inguinal and pelvic lymph nodes should be considered.
Chemotherapy used in penile cancer is dependent upon the histology of the lesion. For those lesions which appear as transitional cell cancers, bladder cancer chemotherapy agents should be considered. For squamous cell cancer of the penis, there is some suggestion that cytotoxic therapy is beneficial. In those patients with locally advanced disease, combined modality therapy with neoadjuvant chemotherapy should be considered.
