Int Urogynecol J (2005) 17: 96–98 DOI 10.1007/s00192-005-1312-7
CASE REPORT
Ersin C¸imentepe Æ O¨mer Bayrak Æ Ali U¨nsal Akif Koc¸ Æ O¨mu¨r Ataog˘lu Æ M. Derya. Balbay
Urethral adenocarcinoma mimicking urethral caruncle
Received: 29 September 2004 / Accepted: 7 March 2005 / Published online: 15 April 2005 International Urogynecology Journal 2005
Abstract Urethral caruncles are considered as benign tumors. They need to be treated surgically; specimens should carefully be evaluated for the presence of any malignancy. We are presenting a 57-year-old female patient with a urethral lesion that looks like caruncle, but histopathologic examination of the excised lesion was reported as urethral adenocarcinoma. Keywords Adenocarcinoma Æ Urethra Æ Caruncle
Introduction Urethral caruncles usually arise from the posterior lip of the urethral meatus. Although the etiology of urethral caruncles is still uncertain, they are the most common benign tumors in the female urethra [1]. They are frequently asymptomatic, but occasionally patients feel a lump at the urethral meatus. Urethral adenocarcinomas are rare genitourinary cancers most commonly seen in women together with urethral diverticula [2]. It has been reported that caruncles are uniformly benign and not considered as a risk factor for subsequent neoplasia [3]. We were presenting a case of urethral adenocarcinoma mimicking urethral caruncle.
E. C¸imentepe (&) Æ O¨. Bayrak Æ A. U¨nsal Æ A. Koc¸ M. D. Balbay School of Medicine, Departments of Urology, Fatih University, C¸iftlik Cd. No: 57, 06510 Emek-Ankara, Turkey E-mail:
[email protected] Tel.: +90-31-22126262 Fax: +90-31-22213276 O¨. Ataog˘lu School of Medicine, Department of Pathology, Gazi University, Ankara, Turkey
Case report A 57-year-old woman presented herself with hematuria and urinary incontinence. Her medical history was significant for a vaginal hysterectomy performed in another hospital and a biopsy from the histopathologic examination of a urethral polipoid lesion which revealed urethral caruncle, 7 months ago. Medical records of the hospital where our patient underwent her previous surgery revealed that an incisional biopsy with a cold knife was done on a urethral polyp, approximately 3·3 cm in diameter. Microscopic examination of the specimen revealed considerable epithelial hyperplasia with significant inflammation including lymphocytes and plasmocytes in the lamina propria, with a final diagnosis of papillomatous type of urethral caruncle. Review of the medical records also revealed that hysterectomy was done for vaginal bleeding after menopause and that there was no malignancy but only hyperkeratosis, inflammation, mucous retention cysts and endometrial proliferation on final pathologic examination. After the operation, she developed stress incontinence. She denied any other urinary symptoms, weight loss, fever or other systemic manifestations. Her family history was unremarkable. There was a Grade III cystocele secondary to a central defect on the anterior vaginal wall on pelvic examination. Additionally, a polypoid lesion, 3·3 cm in diameter, suggesting urethral caruncle macroscopically, was detected at the external urethral meatus (Fig. 1). The vulvar skin, vaginal mucosa, and cervix were normal in appearance. Rectal examination was nonrevealing. Lymph nodes were not enlarged. Laboratory studies were all within normal limits. The patient underwent cystocele repair, bladder neck suspension and excision of urethral lesion at the same session. Histopathologic examination of the urethral lesion was reported as adenocarcinoma within the wall of the urethra invading the lamina propria only, without any further invasion (Fig. 2). There was no other
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Fig. 1 Macroscopic appearance of urethral lesion
Fig. 2 Histopathologic appearance of the adenocarcinoma
tumoral formation in the ovaries and in the gastrointestinal system as per abdominopelvic computerized tomography and upper and lower endoscopic examination, respectively.
Discussion Caruncles are the most common lesions of the female urethra. They are inflammatory nodules occuring at the posterior lip of the external meatus, commonly seen after menopause. Grossly, caruncles are nodular or pedunculated erythematous lesions that may bleed easily. Microscopically, a dense polymorphous infiltrate rich in lymphocytes is common to all types, but other reactive patterns may predominate. These include fibrocapillary proliferation (granulomatous), hypervascularity (angiomatous), epithelial hyperplasia (papillomatous), and even intestinal metaplasia (mucinous). Accurate histologic interpretation is not a problem except when epithelial hyperplasia is the predominant reaction pattern or atypical stromal cells occur. In such
cases, finger-like projections of transitional or squamous epithelium may seem to be isolated deep in the inflammatory lamina propria. Cellular anaplasia is not prominent, although isolated cells may be atypical [3]. Carcinoma of the female urethra is an uncommon neoplasm that represents only 0.02% of all types of cancer in women [3]. It constitutes 5% of all urologic malignancies. Most of them typically occur in the postmenopausal women. Eighty percent of urethral tumors are squamous cell carcinoma. Although most urethral carcinomas are squamous cell in origin, up to 70% of them are adenocarcinomas when associated with a diverticulum [4]. This supports the theory of a glandular origin of the diverticulum. When an adenocarcinoma is seen in any part of the urinary tract, other systems should be detected regarding primary tumor. Some types of neoplasm such as Non-Hodgkin’s lymphoma, malignant melanoma and ovarian tumor presented as a urethral caruncle have been reported in the literature [5–7]. In a series of 376 cases reported by Marshall et al. [8] 2.4% of the clinically diagnosed caruncles were found to be either carcinoma (1.6%) or Bowen’s disease (0.8%). The rarity of urethral carcinomas has made it difficult to establish a common definitive treatment modality. On the basis of treatment data of urethral carcinomas in the literature, pelvic exenteration appears to offer the highest likelihood of a prolonged disease-free interval, especially in patients with long-life expectancy. When tumor is located distally and superficially, patients can safely be treated with local excision only [3]. Cryotherapy is an option in the management of urethral caruncle. But it needs to be biopsied since no accurate histopathological examination can be done on the removed specimen after cryotherapy. In addition to this fact, the location of the lesion may also play in the decision making of how to manage such lesions. Since the caruncle in our patient was located just outside of the external urethral meatus, we elected to proceed with the surgical removal of the lesion. We believe that, despite the fact that caruncles are considered as benign tumors, they need to be treated surgically; specimens should carefully be evaluated for the presence of any malignancy and treatment plans adjusted accordingly.
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7. Hammadeh MY, Thomas K, Philip T (1996) Urethral caruncle: an unusual presentation of ovarian tumour. Gynecol Obstet Invest 42:279–280 8. Marshall FC, Uson AC, Melicow MM (1960) Neoplasms and caruncles of the female urethra. Surg Gynecol Obstet 110: 723–733
