Female+Urethra

Anterior urethra lymphatics drain into: Posterior urethra lymphatics drain into:
 * **Epidemiolgy:** || Female urethral cancer is very rare. There are only 1600 reported cases. [2] Urethral cancer is the only urologic cancer that has higher incidence in women than men. Diagnosed mostly between 55 to 60 years of age and has no correlation to race. The female urethra is short, (2-4 cm) in length and is split in to two sections, anterior (distal) urethra and posterior (proximal) urethra.[1] ||
 * **Etiology:** || Common links to urethral cancer include chronic inflammation and HPV.[1] ||
 * **Signs & Symptoms:** || Some of the signs and symptoms of female urethral cancer are: [1]
 * Urethral bleeding
 * Vaginal bleeding
 * Mass
 * Ulceration ||
 * **Diagnostic Procedures:** || Some of the diagnostic procedures to evaluate staging and extent of cancer (spread) are: [1]
 * CT
 * MRI
 * Urethoscopy and biopsy
 * Manual exam
 * Chest roentgenography
 * Serum chemistries
 * Fine needle aspiration ||
 * **Histology:** || The distal two thirds are composed of stratified squamous epithelium, while the proximal one third is composed of transitional cells. [2] ||
 * **Lymph node drainage:** || The lymphatics include: obturator, internal iliac and external iliac nodes. Lymph node metastasis play a role in distant dissemination and are associated with lower survival. [2] Usually, metastases occur by lymphatic embolization to regional lymph nodes. Hematogenous spread is rare.
 * The superficial and deep inguinal lymph nodes
 * Occasionally, they will drain to the external iliac lymph nodes
 * Pelvis lymph nodes
 * 30% metastasize to inguinal lymph nodes [1] ||
 * **Metastatic spread:** || Distant mets are rare. Spread is predominantly by local extension into adjacent organs, then by lymphatic, then hematogenous metastases. Lungs, liver, bone and brain are the most common sites for metastasis. [1] ||
 * **Grading:** || Due to the rarity of this cancer early diagnosis is challenging which makes early staging difficult, the stage of the tumor at the time of diagnosis appears to be independent of tumor histology or grade.[2] ||  ||   ||
 * GX || Grade cannot be assessed ||
 * G1 || Well differentiated ||
 * G2 || Moderately well differentiated ||
 * G3-4 || Poorly differentiated ||  ||
 * **Staging:** || Urethral tumors can be classified as those involving the distal half of the urethra and those located in the proximal or entire urethra. The female urethra is approximately 4.0cm from bladder to the urogenital diaphragm to the vestibule.[2]

 The AJCC staging system may also be used as shown in the table below. ||  ||   ||
 * Primary tumor || Male and female. ||
 * TX || Primary tumor cannot be assessed. ||
 * T0 || No evidence of primary tumor. ||
 * Ta || Noninvasive papillary, polyoid or verrucous carcinoma. ||
 * Tis || Carcinoma in situ. ||
 * T1 || Tumor invades subeptihelial connective tissue. ||
 * T2 || Tumor invades any part of (corpus spongiosum, prostate, periurethral muscle). ||
 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">T3 || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">Tumor invades T2 and (corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neck). ||
 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">T4 || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">Tumor invades other adjacent organs. ||


 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">NX || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">Nodes cannot be assessed. ||
 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">N0 || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">No regional lymph node metastasis. ||
 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">N1 || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">Metastasis in a single node more than 2cm or less in dimension. ||
 * <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">N2 || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif;">Metastasis in a single node more than 2cn in dimension, or in multiple nodes ||  ||
 * **Radiation side effects:** || <span style="color: #808000; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Erythema, dry or moist desquamation, and swelling of the subcutaneous tissue. Telangiectasia and fibrosis are asymptomatic and are late consequences of radiation. There is a rare complication of necrosis or ulceration of the skin but this is rare. [2] ||
 * **Prognosis:** || Prognosis is dependent on tumor size and location[3]. Urethral carcinoma presents certain anatomic and histologic considerations, particularly concerning the differences between the male and female urethra and the respective adjacent structures[3]. In general, however, in both males and females, urethral cancer tends to invade locally and to metastasize to adjacent soft tissues[3]. Therefore, most of these tumors are locally advanced at the time of diagnosis, reflecting the generally poor prognosis despite aggressive treatment[3]. Urethral cancer rarely metastasizes to distant loci[3]. Only 14% of female patients with urethral cancer have evidence of metastatic spread[3].

In females, the most common sites of tumor invasion are the labia, vagina, and bladder neck[3]. In males, the most common sites of extension are the vascular spaces of the corpora and periurethral tissues, deep tissues of the perineum, urogenital diaphragm, prostate, and the penile and scrotal skin, where it causes abscesses and fistulae[3]. ||
 * **Treatments:** || Tumors at the meatus or in situ involvement of the distal urethra can either have Open excision, Electroexcision, Fulguration, and Laser coagulation[3].

Larger and more invasive lesions invovle Interstitial irradiation, combined interstitial and external-beam radiation therapy, and Prophylactic groin irradiation is recommended Recurrent tumors after local excision or radiation therapy[3]:

More advanced stage lesions is usually associated with invasion of the bladder and high incidence of inguinal and pelvic lymph node mets the treatment involves pre-op radiation therapy followed by exenterative surgery and urinary diversion[3]. || Femoral head 5200 cGy TD5/5– – 6500cGy – – Spinal cord (20 cm) 4700 TD5/5 (10 cm) 5000 (5 cm) 5000 – (10 cm) 7000 (5 cm) 7000 Small intestine (obstruction,perforation) 4000 TD5/5– 5000 5500 – 6000 Stomach (ulceration,perforation) 5000 TD5/5 5500 6000 6500 6700 7000 Colon (obstruction,perforation,ulceration) 4500 TD5/5– 5500 5500 – 6500 || 2. Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 3. Powell, C. Urethral Cancer. Urethral Cancer. June 1, 2011. Available at: [|http://emedicine.medscape.com/article/451496-overview - aw2aab6b2b1aa]. Accessed on: June 12, 2012. 4. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys. 1991. || Back to Week 4
 * **TD 5/5:** || Rectum (severe proctitis,necrosis,fistula,stenosis)[4] 6000 cGy TD5/5 – – 8000 cGy – –
 * **References:** || 1. Lenhard RE, Osteen R, Gansler T. The American Cancer Society’s Clinical Oncology. Williston, VT: Blackwell Publishing, Inc; 2001.