Urethral Cancer: Staging and Treatment

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. Tests like blood work, CT scan, MRI, biopsy, and cystoscopy may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Cancer staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for urethral cancer is called the “TNM system.” It has three parts:

• T-describes the size/location/extent of the "primary" tumor in the urethra.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (called metastases).

How is urethral cancer staged?

Urethral cancer staging depends on where the tumor is along the urethra. Staging is split into two types of urethral cancer:

• Male Penile Urethra/Female Urethra: Cancer of the male penile urethra involves only the part of the urethra inside the penis. This type is closer to the outside of the body.
• Prostatic Urethra: Cancer of the female urethra and of the prostatic urethra in men is closer to the inside organs of the body, like the pelvic bones, bladder, and the prostate and penis (in men).

Staging for both types of urethral cancer is based on:

• The size of your tumor seen on imaging tests.
• Surgery to test if your lymph nodes have cancer cells.
• Any evidence of spread to other organs (metastasis).

The staging system is very complex. Below is a summary of the staging. Talk to your provider about the stage of your cancer.

Male Penile Urethra/Female Urethra

Stage 0is (Tis, N0, M0): Primary tumor cannot be assessed (Tis). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage0a (Ta, N0, M0): Non-invasive papillary carcinoma (Ta). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage I (T1, N0, M0): Tumor invades subepithelial connective tissue (T1). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage II (T2, N0, M0): Tumor invades any of the following: corpus spongiosum, periurethral muscle (T2). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage III (T1/T2/T3, N0/N1, M0): Tumor invades subepithelial connective tissue (T1), OR Tumor invades any of the following: corpus spongiosum, periurethral muscle (T2), OR Tumor invades any of the following: corpus cavernosum, anterior vagina (T3). There is either no regional lymph node metastasis (N0) OR there is single regional lymph node metastasis in the inguinal region or true pelvis, or presacral lymph node (N1). No distant metastasis (M0).

Stage IV (T4/Any T, N0/N1/N2/Any N, M0/M1): Tumor invades other adjacent organs (e.g., invasion of the bladder wall) (T4) OR any other T (Any T). There is no regional lymph node metastasis (N0) OR there is single regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node (N1), OR there are multiple regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node (N2). There may (M0) or may not be distant metastasis (M1).

Prostatic Urethra

Stage 0is (Tis, N0, M0): Carcinoma in situ involving the prostatic urethra or periurethral or prostatic ducts without stromal invasion (Tis). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage0a (Ta, N0, M0): Non-invasive papillary carcinoma (Ta). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage I (T1, N0, M0): Tumor invades urethral subepithelial connective tissue right under the urothelium (T1). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage II (T2, N0, M0): Tumor invades the prostatic stroma surrounding ducts either by direct extension from the urothelial surface or by invasion from prostatic ducts (T2). No regional lymph node metastasis (N0). No distant metastasis (M0).

Stage III (T1/T2/T3, N0/N1, M0): Tumor invades urethral subepithelial connective tissue right under the urothelium (T1), OR tumor invades the prostatic stroma surrounding ducts either by direct extension from the urothelial surface or by invasion from prostatic ducts (T2), OR tumor invades the periprostatic fat (T3). No regional lymph node metastasis (N0), OR single regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node (N1). No distant metastasis (M0).

Stage IV (T4/Any T, N0/N1/N2/Any N, M0/M1): Tumor invades other adjacent organs (e.g.,

extraprostatic invasion of the bladder wall, rectal wall) (T4), OR any other T (Any T). No regional lymph node metastasis (N0), OR single regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node (N1), OR Multiple regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node (N2). There may (M0) or may not be distant metastasis (M1).

How is urethral cancer treated?

Treatment for urethral cancer depends on many things, like your cancer stage, age, overall health, and testing results. Your treatment may include some or all the following:

• Surgery.
• Radiation therapy.
• Chemotherapy.
• Clinical trials.

Surgery

Surgery is the main treatment for urethral cancer. The goal of surgery is to remove all of or as much of the cancer as possible while trying to keep other tissue and organs safe. There are a few surgical options to treat cancer of the urethra:

• Open excision: As much of the cancer as possible is removed.
• Transurethral resection (TUR): A special tool is inserted into the urethra to remove the cancer.
• Electroresection with fulguration: Electric current is used to remove the cancer. A lighted tool with a small wire loop on the end removes the cancer or burns the tumor away with high-energy electricity.
• Laser surgery: A laser beam is used as a knife to make cuts in tissue or to remove or kill tissue.
• Cystourethrectomy: The bladder and the urethra are removed.
• Cystoprostatectomy: The bladder and the prostate are removed.
• Anterior exenteration: The urethra, the bladder, and the vagina are removed. You may need surgical reconstruction after to rebuild the vagina.
• Partial penectomy: The part of the penis around the urethra where cancer has spread is removed. You may need surgical reconstruction after to rebuild the penis.
• Radical penectomy: The whole penis is removed. You may need surgical reconstruction after to rebuild the penis.
• Lymph node dissection: Lymph nodes in the pelvis and groin may be removed.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells. There are two main types of radiation used to treat urethral cancer:

• External radiation therapy: A beam of radiation from outside of the body is directed into the body. It may also be called x-ray therapy, 3D conformal radiation, intensity-modulated radiation therapy (IMRT), cobalt, photon, or proton therapy.
• Internal radiation therapy: A radioactive source is placed inside the body, in or near the tumor. This is called brachytherapy or implant therapy.

The type of radiation therapy you get will depend on where the cancer is along your urethra. Ask your provider if radiation will be a part of your treatment and, if so, which kind will be used.

Chemotherapy

Chemotherapy is the use of anti-cancer medications to kill cancer cells. Chemotherapy may be used for metastatic urethral cancer (cancer that has spread to other parts of your body), or in combination with radiation and/or surgery. There are no standard chemotherapy treatment plans, but there are some medications that may be used:

• Cisplatin.
• Fluorouracil.
• Bleomycin.
• Methotrexate.
• Irinotecan.
• Gemcitabine.
• Paclitaxel.
• Docetaxel.
• Mitomycin.
• Vinblastine.
• Doxorubicin.
• Carboplatin.
• Ifosfamide.

Talk with your provider about whether chemotherapy will be used to treat your urethral cancer.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Services.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about urethral cancer at OncoLink.org.