Squamous Cell Carcinoma Arising From Suprapubic Cystotomy Site Without Bladder Involvement

Nicholas Stroumbakis, M.D., Mohammad S. Choudhury, M.D.
From the Department of Urology, New York Medical College, Valhalla, New York, and Lincoln Hospital, Bronx, New York


ABSTRACT — We report on an eighty-year-old Haitian man with a suprapubic mass of seven months duration after five years of urinary diversion for urethral stricture. Histologically the mass was a squamous cell carcinoma confined to the suprapubic tract without bladder involvement. We believe this is the first such case reported in the literature, and it stresses the need for close monitoring of patients with any type of long-term indwelling catheter.


Squamous cell carcinoma of the bladder occurs infrequently in the United States, accounting for 5 percent of all bladder cancers. (1) It has been associated with chronic inflammatory states such as those accompanying parasitic infections, particularly bilharziasis (e.g., long-term indwelling Foley catheters), and chronic bladder obstruction. (2) This case report is of a squamous cell cancer that developed along a suprapubic cystotomy tract after five years of urinary diversion.

Case Report
An eighty-year-old Haitian black man was referred for evaluation of a fungating suprapubic mass of seven months duration. His medical history included pulmonary tuberculosis requiring a left thoracotomy in 1985. That same year the patient had undergone suprapubic catheter placement because of urethral stricture. The catheter had remained in place for five years, during which time the patient reported experiencing recurring bouts of urinary tract infections.

The physical examination revealed an 8 x 6 cm exophytic fungating suprapubic mass enveloping the catheter. On routine rectal examination a small prostate with left lobe in duration was noted. There was no abdominal organomegaly, and the penis and scrotum were free of any significant lesions. There was no groin adenopathy. Blood analysis indicated the following abnormal values: prostatic acid phosphatase 24.2 U/L and prostate-specific antigen 22.9 ng/dL (Hybritech monoclonal radioimmunoassay, San Diego, CA). A transrectal ultrasound-guided biopsy was positive for adenocarcinoma of prostate. The patient was given Leuprolide acetate depot suspension. A bone scan was negative. Urinalysis revealed leukocytes (25-50/HPF), hematuria (5-10/HPF), and bacteria. The urine was negative for acidfast bacteria, and cytologic evaluation was negative. A computerized tomography (CT) scan of the abdomen and pelvis demonstrated a mass surrounding the suprapubic cystotomy tube extending into the dome of the bladder. The patient underwent flexible cystoscopy revealing small calculi in the bladder and mucosa consistent with inflammatory changes. Subsequently, a biopsy specimen of the urethral stricture was negative for carcinoma. Biopsy of the suprapubic mass was performed. Histologic examination of the mass demonstrated a squamous cell carcinoma.

The patient was given preoperative radiation (2,000 red) and underwent a wide excision of the mass and partial removal of the bladder dome. During the operation, the tumor was found to be arising adjacent to the suprapubic cystostomy site and extending anteriorly to the anterior abdominal wall. There was no extension of the tumor into the bladder. The anterior abdominal wall defect was closed primarily with mobilization of skin flaps. However, a superficial wound dehiscence developed, necessitating a split-thickness skin graft.

Pathologic examination of the excised specimen revealed a 12-cm conical lesion of firm consistency. Microscopic analysis of the excised mass, stained with hematoxylin and eosin, revealed a squamous cell carcinoma of the cystotomy tract. The carcinoma did not show any invasion into the wall of the bladder (Fig. 3).

Comment
Mostofi (3) has classified the possible responses of the bladder epithelium to chronic irritation into categories: (1) non-neoplastic proliferation, (2) metaplasia, and (3) neoplasia. In a majority of people with indwelling Foley catheters squamous metaplasia develops, which may give rise to neoplasia. For example, Kaufman and associates (4) reported squamous cell carcinoma in 6 of 62 patients with spinal cord injuries, five of whom had indwelling urethral Foley catheters for more than ten years. Others have reported a similar correlation between squamous cell carcinoma and long-term use of catheters.(2) Collectively, these reports demonstrate a 10-percent incidence of squamous cell carcinoma in patients with Foley catheters indwelling for ten years or more. A handful of less frequent associations with this cancer have been reported, for instance, in patients using intermittent selfcatheterization or who have foreign bodies in the pelvis.(5-6)

The presence of a squamous cell carcinoma in a suprapubic tract without distal bladder involvement has not previously been reported in the literature. Nevertheless, the occurrence of such a cancer should have been expected on the basis of other findings. Squamous metaplasia following tracheostomy has been documented. In these cases, squamous metaplasia and squamous papilloma were observed at or near the cuff site. (7) Thus the presence of a catheter, whether in the trachea or in the bladder, may lead to the development of abnormal epithelium or squamous changes around the foreign body.

In the patient described herein, it is highly likely that the carcinoma originated in the suprapubic tract. The primary indication of this was the gross and histologic morphology of the tumor which enveloped the Foley catheter. The abdominal growth ceased at the margin of the bladder wall. This view of the tract origin of the cancer must be confirmed by experimental and clinical studies of premalignant changes along a cystotomy tract. However, the case reports to date of squamous cell carcinoma associated with suprapubic catheters warrant closer management of patients with such catheters to detect any cancerous growth early.

Department of Urology New York Medical College Valhalla, New York 10595 (DR. HERNANDEZ-GRAULAU)

References
1. Rous NS: Squamous cell carcinoma of the bladder, J Urol 120:561 (1978).

2. Locke RJ, Hill ED, and Walzer Y: Incidence of squamous cell carcinoma in patients with long-term catheter drainage, J Urol 133: 1034 (1985).

3. Mostofi FK: Potentialities of bladder epithelium, J Urol 71: 705 (1954)

4. Kautman JM, et al: Bladder cancer and squamous metaplasia in spinal cord injury patient, J Urol 118: 967 (1977).

5. Sene AP, Massey JA, McMahan RJF, and Carrol RNP: Squamous cell carcinoma in a patient on clean intermittent self-eatheterization, Br J Urol 65: 213 (1990).

6. Wyman A, and Kinder RB: Squamous cell carcinoma of the bladder associated with intrapelvic foreign bodies, Br J Urol 61: 460 (1988)

7. Papay F, Wood B, and Coulson M: Squamous cell papilloma at the tracheoesophageal puncture site, Arch Otolaryngol Head Neek Surg 114: 564 (1988)

The Leading Urological Group of Central Illinois Since 1945