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Primary invasive squamous cell carcinoma of male bulbar urethra completely responded to concurrent chemoradiation therapy

A 64-year-old man complained of urethral bleeding. Urethroscopy showed an irregular tumor of the bulbar urethra (Fig. 1a). Both urine cytology and tumor biopsy showed squamous cell carcinoma (Fig. 1c) without serum SCC elevation (1.5 ng/mL). Magnetic resonance imaging (MRI) showed a 2-cm tumor invaded to the corpus spongiosum penis. Bilateral inguinal lymph nodes swelled (maximum 14 mm in diameter), which were suspicious of lymph node metastases. Bone scintigraphy was negative. The patient underwent a coordinated chemoradiation protocol regimen. The protocol consisted of chemotherapy of an intravenous infusion of 5-FU (1000 mg/m/day) for 96 h and a single intravenous dose of mitomycin (10 mg/m) on the first day and repeated every 28 days, and concurrent external beam radiation therapy of a total of 45 Gy in 25 fractions during 5 weeks delivered to the genitalia, perineum, and inguinal and external iliac lymph nodes. After three cycles of chemotherapy and radiation therapy, the urethral tumor shrunk markedly and could not be detected by both MRI and urethroscopy (Fig. 1b). The size of inguinal lymph nodes decreased slightly (maximum 10 mm in diameter). Adverse events had not been seen during chemoradiation, except grade 2 diarrhea for a few days. Because the patient desired complete surgical resection, a surgical procedure including en bloc cystourethrectomy, bilateral pelvic and inguinal lymphadenectomy, and urinary diversion by ileal conduit was carried out 1 month after the chemoradiation based on adequate informed consent. Histopathological examination showed no viable carcinoma cells in the resected specimens (Fig. 1d). With regard to lymph node, only one of the left inguinal lymph nodes showed an assemblage of foamy cells which means lymph node metastasis would have existed before treatment. Disease recurrence has not been seen at 1.5 years after surgical resection. In 2008, Cohen et al. reported on 18 patients between 1991 and 2006 with invasive or metastatic squamous cell carcinoma of the male urethra. They achieved 83% complete response by 5-FU and mytomycin chemotherapy concurrent with radiation therapy without surgical resection. The 5-year overall and disease specific survival were 60% and 83%. This chemoradiation protocol was based on the treatment of anal canal squamous cell carcinoma reported by Nigro in 1974, and later Sischy et al. reported that anal sphincter preservation was achieved in more than 70–95% cases. Cohen concluded that this chemoradiation protocol for invasive urethral squamous cell carcinoma was as effective as that for anal canal squamous cell carcinoma, and it could enable genital organ preservation. In the present case, we carried out vesicouretherectomy as requested by the patient. However, if complete response was confirmed by transurethral biopsy or inguinal lymphadenectomy, organ preservation would be more acceptable with careful observation of disease recurrence.