A case report of squamous cell carcinoma in a suprapubic urinary catheter tract: surgical excision and simultaneous colostomy formation

A case report of squamous cell carcinoma in a suprapubic urinary catheter tract: surgical... Squamous cell carcinoma (SCC) arising from a suprapubic cystostomy tract is a rare complication of long-term suprapubic catheterization (SPC). A 53-year-old man with paraplegia secondary to spina bifida presented with a painful granulomatous lesion around his SPC site that was being treated with silver nitrate cauterization in the community. Consequently, he developed a sacral pressure sore due to reduced mobility from the pain. He also had increasing difficulties with defaecation secondary to his spina bifida. His sacral pressure sore was secondary to a cryptoglandular fistula with coccygeal osteomyleli- tis. Post-operative pathology revealed infiltrative SCC involving full thickness of the specimen from skin to the bladder wall with clear surgical margins. We describe the first case requiring a simultaneous suprapubic tract SCC excision and colos- tomy formation. We recommend early investigation of lesions arising from a long-term suprapubic tract especially in patients with spinal cord injuries or congenital defects. INTRODUCTION CASE REPORT Squamous cell carcinoma (SCC) of the bladder represents a A 53-year-old, wheelchair-bound man with a long-term SPC (20 small proportion of bladder cancers in the West, the incidence years) and paraplegia secondary to spina bifida presented to his varying from 2 to 5% [1]. However, the incidence increases with GP with painful catheter changes, recurrent urinary tract infec- concomitant spinal cord injuries particularly in those with tions (Pseudomonas) and a granulomatous lesion around his SPC long-term catheters [1, 2]. site. He had no other co-morbidities and had sensation only to SCCarising from thesiteofasuprapubiccatheter(SPC) the level of L1/2. The lesion was treated with silver nitrate cau- tract, with or without involvement of the bladder urothelium, terization in the community but it continued to grow over the is very poorly represented in literature with minimal studies ensuing 2–3 months period. He was referred urgently to the to date [3–9]. urology outpatient clinic for assessment. Examination revealed Received: January 14, 2018. Accepted: February 7, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Khadhouri et al. a granulomatous growth around his suprapubic site, protruding that an end colostomy should be performed alongside the exci- 2–3 cm (Fig. 1). A biopsy was taken, which revealed an infiltrat- sion of SCC. ing, moderately differentiated SCC. A staging CT scan was The patient’s condition improved following antibiotic ther- negative for metastatic disease. A flexible cystoscopy excluded apy and wound care. Seven days post admission, he underwent any obvious bladder mucosal involvement. The findings were an excision of SCC, abdominoplasty, formation of an end colos- discussed in the uro-oncology multi-disciplinary team (MDT) tomy and debridement of sacral sores. meeting and an elective excision was planned. The SCC was excised en-bloc with a partial cystectomy However, as a result of the pain that the patient was experi- through a modified elliptical incision. Included in the excision encing, regular position changes were not maintained, leading to was skin, fat, rectus sheath, rectus muscle and bladder cuff the development of a Grade 4 (full thickness tissue loss with (Fig. 3). The incision was then extended superiorly as a Fleur-de- exposed bone) sacral pressure sore. This ultimately resulted in Lys to allow for a laparotomy and colostomy formation. The des- an emergency surgical admission ahead of his planned operation cending colon was found to be obstructed with hard stool that date as he had developed signs of sepsis. On examination, the was evacuated through the stoma. A Fleur-de-Lys abdomino- sacral sore measured 3 cm in depth and 15 cm wide, with visible plasty was necessary to ensure appropriate skin closure, and the bone and surrounding cellulitis. Clinically, there were no signs of necrotizing fasciitis. The patient was started on intravenous anti- biotics and his pressure sore managed by the tissue viability nursing team. A repeat CT scan was performed and this demon- strated air within the left ischial rectal fossa with evidence of osteomyelitis in the coccygeal bones (Fig. 2). A joint review was undertaken by the colorectal and urology team as an inpatient. Due to the proximity of the anus to the sacral pressure sore and the patient’s chronic problem with constipation (requiring man- ual evacuation), it was decided after discussion with the patient Figure 3: Elliptical en-bloc excision of SCC. Figure 1: SCC growing from suprapubic tract. Figure 2: CT cross-sectional plane of pelvis. (a) Infiltrating SCC along suprapubic Figure 4: Post-operative image showing Fleur-de-Lys incision, SPC re-siting and tract. (b) Air in left ischiorectal space from sacral sore. colostomy. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 A case report of squamous cell carcinoma in a suprapubic urinary catheter tract 3 Figure 5: Histopathological images of SCC. Microscopy showed widely infiltrative squamous cell carcinoma involving full thickness of the specimen from skin to the bladder wall. No lymphovascular invasion was seen. The margins were clear although the deep detrusor muscle margin was clear by only 1 mm. (a) Photomicrograph showing abdominal wall skin with carcinoma (H&E ×1.25), (b) Photomicrograph showing infiltrating islands of squamous carcinoma in the subcutaneous tissue (H&E ×10), (c) Photomicrograph showing squamous carcinoma involving the bladder (H&E ×4). umbilicus was re-sited. A SPC was re-sited superior–lateral to the Treatment of these cases varied in the literature according midpoint of the Fleur-de-Lys incision, with the bladder and abdo- to the patient’s co-morbidities and staging of the tumour. Most menclosedinlayers(Fig. 4). Apercutaneousdrain wasleftsuper- cases favoured surgical excision for locally advanced disease, ficial to the anterior rectus sheath. Debridement of the sacral or radiotherapy if the patient is not fit for surgery and/or has wound and coccygectomy were then performed, having identified metastatic disease. Outcome of treatment was varied. The mor- acryptoglandular fistula as the source. tality rate seems to be high in general due to recurrence or The patient made a good post-operative recovery. His sacral complications of treatment, and usually occurred within a year wound was managed with negative pressure dressings and a following treatment [4, 5, 9]. seton suture. Pathologically, gross examination revealed an Follow-up is therefore necessary, although the rarity of this ulcerated tumour involving skin, which extended through the disease means there are no set recommendations for frequency subcutaneous fat and appeared to communicate with the blad- and type of surveillance, or indeed prognostic factors. The der cuff. Histology confirmed moderately differentiated SCC authors propose that this is decided in a local MDT setting. throughout the tract involving the bladder wall, with clear sur- The authors recommend early investigation of lesions arising gical margins (Fig. 5). from asuprapubic cystostomytract,especiallyinlong-term SPC The patient was reviewed 8 weeks later in clinic and was over 5 years in patients with spinal cord injury or neurocongenital recovering well with no complications. His case was discussed defects, to assist early detection and treatment of SCC. at the MDT meeting where cystoscopic and cross-sectional sur- veillance was advised. At 8 months follow-up, the patient had CONFLICT OF INTEREST STATEMENT no evidence of recurrence. None declared. DISCUSSION REFERENCES We discuss the first case report of an excision of SPC tract SCC and simultaneous colostomy formation. This required careful 1. Martin JW, Carballido EM, Ahmed A, Farhan B, Dutta R, surgical planning and consideration had to be made to minimize Smith C, et al. Squamous cell carcinoma of the urinary blad- the midline laparotomy incision as the patient relied heavily on der: systematic review of clinical characteristics and thera- his abdominal wall muscles when transferring himself from and peutic approaches. Arab J Urol 2016;14:183–91. to the wheelchair. A Fleur-de-Lys incision was thought to be the 2. Welk B, McIntyre A, Teasell R, Potter P, Loh E. Bladder cancer optimal approach to primarily excise the tumour through a lower in individuals with spinal cord injuries. Spinal Cord 2013;51: elliptical incision, then allow for a colostomy by extending a mid- 516–21. line incision only as was necessary to mobilize the colon and 3. Massaro PA, Moore J, Rahmeh T, Morse M. Squamous cell bring out a colostomy, with the abdominoplasty allowing forma- carcinoma of the suprapubic tract: a rare presentation in tion of the stoma on a flat surface. patients with chronic indwelling urinary catheters. Can Urol Thereare fewcasereports describing SCCarising from the Assoc J 2014;8:7–8. suprapubic tract [3–9], most of them in patients with spinal cord 4. Chung JM, Oh JH, Kang SH, Choi S. Squamous cell carcinoma injuries, with a long-term catheter in situ (ranging from 5 to 37 of the suprapubic cystotomy tract with bladder involvement. years). Bladder involvement amongst these is mixed. Our case Korean J Urol 2013;53:638–40. showed a grossly normal bladder on cystoscopy but there was 5. Schaafsma RJ, Delaere KP, Theunissen PH. Squamous cell evidence of SCC in the bladder on histology. This demonstrates carcinoma of suprapubic cystotomy tract without bladder that a normal cystoscopy cannot rule out bladder involvement. involvement. Spinal Cord 1999;37:373–4. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 S. Khadhouri et al. 6. Patel K, Hori S, Roberts J, Sengutpa A. Need for early imaging 8. Zhang X, Mi Y, Wang D, Yuan X, Zhang B, Bai T. High differ- in symptomatic suprapubic catheter tracts: rare case of cuta- entiated squamous cell carcinoma arising from a suprapubic neous squamous cell carcinoma of tract origin without blad- cystostomy tract in a patient with transplanted kidney. Int J der involvement. J Clin Urol 2017;10:193–6. Clin Exp Med 2015;8:21770–72. 7. Ito H, Arao M, Ishigaki H, et al. A case of squamous cell car- 9. Stokes S, Wheeler JS, Reyes CV. Squamous cell carcinoma cinoma arising from a suprapubic cystostomy tract. BMC Urol arising from a suprapubic cystostomy tract with extension 2011;11:20. into the bladder. J Urol 1995;154:1132–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

A case report of squamous cell carcinoma in a suprapubic urinary catheter tract: surgical excision and simultaneous colostomy formation

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Abstract

Squamous cell carcinoma (SCC) arising from a suprapubic cystostomy tract is a rare complication of long-term suprapubic catheterization (SPC). A 53-year-old man with paraplegia secondary to spina bifida presented with a painful granulomatous lesion around his SPC site that was being treated with silver nitrate cauterization in the community. Consequently, he developed a sacral pressure sore due to reduced mobility from the pain. He also had increasing difficulties with defaecation secondary to his spina bifida. His sacral pressure sore was secondary to a cryptoglandular fistula with coccygeal osteomyleli- tis. Post-operative pathology revealed infiltrative SCC involving full thickness of the specimen from skin to the bladder wall with clear surgical margins. We describe the first case requiring a simultaneous suprapubic tract SCC excision and colos- tomy formation. We recommend early investigation of lesions arising from a long-term suprapubic tract especially in patients with spinal cord injuries or congenital defects. INTRODUCTION CASE REPORT Squamous cell carcinoma (SCC) of the bladder represents a A 53-year-old, wheelchair-bound man with a long-term SPC (20 small proportion of bladder cancers in the West, the incidence years) and paraplegia secondary to spina bifida presented to his varying from 2 to 5% [1]. However, the incidence increases with GP with painful catheter changes, recurrent urinary tract infec- concomitant spinal cord injuries particularly in those with tions (Pseudomonas) and a granulomatous lesion around his SPC long-term catheters [1, 2]. site. He had no other co-morbidities and had sensation only to SCCarising from thesiteofasuprapubiccatheter(SPC) the level of L1/2. The lesion was treated with silver nitrate cau- tract, with or without involvement of the bladder urothelium, terization in the community but it continued to grow over the is very poorly represented in literature with minimal studies ensuing 2–3 months period. He was referred urgently to the to date [3–9]. urology outpatient clinic for assessment. Examination revealed Received: January 14, 2018. Accepted: February 7, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Khadhouri et al. a granulomatous growth around his suprapubic site, protruding that an end colostomy should be performed alongside the exci- 2–3 cm (Fig. 1). A biopsy was taken, which revealed an infiltrat- sion of SCC. ing, moderately differentiated SCC. A staging CT scan was The patient’s condition improved following antibiotic ther- negative for metastatic disease. A flexible cystoscopy excluded apy and wound care. Seven days post admission, he underwent any obvious bladder mucosal involvement. The findings were an excision of SCC, abdominoplasty, formation of an end colos- discussed in the uro-oncology multi-disciplinary team (MDT) tomy and debridement of sacral sores. meeting and an elective excision was planned. The SCC was excised en-bloc with a partial cystectomy However, as a result of the pain that the patient was experi- through a modified elliptical incision. Included in the excision encing, regular position changes were not maintained, leading to was skin, fat, rectus sheath, rectus muscle and bladder cuff the development of a Grade 4 (full thickness tissue loss with (Fig. 3). The incision was then extended superiorly as a Fleur-de- exposed bone) sacral pressure sore. This ultimately resulted in Lys to allow for a laparotomy and colostomy formation. The des- an emergency surgical admission ahead of his planned operation cending colon was found to be obstructed with hard stool that date as he had developed signs of sepsis. On examination, the was evacuated through the stoma. A Fleur-de-Lys abdomino- sacral sore measured 3 cm in depth and 15 cm wide, with visible plasty was necessary to ensure appropriate skin closure, and the bone and surrounding cellulitis. Clinically, there were no signs of necrotizing fasciitis. The patient was started on intravenous anti- biotics and his pressure sore managed by the tissue viability nursing team. A repeat CT scan was performed and this demon- strated air within the left ischial rectal fossa with evidence of osteomyelitis in the coccygeal bones (Fig. 2). A joint review was undertaken by the colorectal and urology team as an inpatient. Due to the proximity of the anus to the sacral pressure sore and the patient’s chronic problem with constipation (requiring man- ual evacuation), it was decided after discussion with the patient Figure 3: Elliptical en-bloc excision of SCC. Figure 1: SCC growing from suprapubic tract. Figure 2: CT cross-sectional plane of pelvis. (a) Infiltrating SCC along suprapubic Figure 4: Post-operative image showing Fleur-de-Lys incision, SPC re-siting and tract. (b) Air in left ischiorectal space from sacral sore. colostomy. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 A case report of squamous cell carcinoma in a suprapubic urinary catheter tract 3 Figure 5: Histopathological images of SCC. Microscopy showed widely infiltrative squamous cell carcinoma involving full thickness of the specimen from skin to the bladder wall. No lymphovascular invasion was seen. The margins were clear although the deep detrusor muscle margin was clear by only 1 mm. (a) Photomicrograph showing abdominal wall skin with carcinoma (H&E ×1.25), (b) Photomicrograph showing infiltrating islands of squamous carcinoma in the subcutaneous tissue (H&E ×10), (c) Photomicrograph showing squamous carcinoma involving the bladder (H&E ×4). umbilicus was re-sited. A SPC was re-sited superior–lateral to the Treatment of these cases varied in the literature according midpoint of the Fleur-de-Lys incision, with the bladder and abdo- to the patient’s co-morbidities and staging of the tumour. Most menclosedinlayers(Fig. 4). Apercutaneousdrain wasleftsuper- cases favoured surgical excision for locally advanced disease, ficial to the anterior rectus sheath. Debridement of the sacral or radiotherapy if the patient is not fit for surgery and/or has wound and coccygectomy were then performed, having identified metastatic disease. Outcome of treatment was varied. The mor- acryptoglandular fistula as the source. tality rate seems to be high in general due to recurrence or The patient made a good post-operative recovery. His sacral complications of treatment, and usually occurred within a year wound was managed with negative pressure dressings and a following treatment [4, 5, 9]. seton suture. Pathologically, gross examination revealed an Follow-up is therefore necessary, although the rarity of this ulcerated tumour involving skin, which extended through the disease means there are no set recommendations for frequency subcutaneous fat and appeared to communicate with the blad- and type of surveillance, or indeed prognostic factors. The der cuff. Histology confirmed moderately differentiated SCC authors propose that this is decided in a local MDT setting. throughout the tract involving the bladder wall, with clear sur- The authors recommend early investigation of lesions arising gical margins (Fig. 5). from asuprapubic cystostomytract,especiallyinlong-term SPC The patient was reviewed 8 weeks later in clinic and was over 5 years in patients with spinal cord injury or neurocongenital recovering well with no complications. His case was discussed defects, to assist early detection and treatment of SCC. at the MDT meeting where cystoscopic and cross-sectional sur- veillance was advised. At 8 months follow-up, the patient had CONFLICT OF INTEREST STATEMENT no evidence of recurrence. None declared. DISCUSSION REFERENCES We discuss the first case report of an excision of SPC tract SCC and simultaneous colostomy formation. This required careful 1. Martin JW, Carballido EM, Ahmed A, Farhan B, Dutta R, surgical planning and consideration had to be made to minimize Smith C, et al. Squamous cell carcinoma of the urinary blad- the midline laparotomy incision as the patient relied heavily on der: systematic review of clinical characteristics and thera- his abdominal wall muscles when transferring himself from and peutic approaches. Arab J Urol 2016;14:183–91. to the wheelchair. A Fleur-de-Lys incision was thought to be the 2. Welk B, McIntyre A, Teasell R, Potter P, Loh E. Bladder cancer optimal approach to primarily excise the tumour through a lower in individuals with spinal cord injuries. Spinal Cord 2013;51: elliptical incision, then allow for a colostomy by extending a mid- 516–21. line incision only as was necessary to mobilize the colon and 3. Massaro PA, Moore J, Rahmeh T, Morse M. Squamous cell bring out a colostomy, with the abdominoplasty allowing forma- carcinoma of the suprapubic tract: a rare presentation in tion of the stoma on a flat surface. patients with chronic indwelling urinary catheters. Can Urol Thereare fewcasereports describing SCCarising from the Assoc J 2014;8:7–8. suprapubic tract [3–9], most of them in patients with spinal cord 4. Chung JM, Oh JH, Kang SH, Choi S. Squamous cell carcinoma injuries, with a long-term catheter in situ (ranging from 5 to 37 of the suprapubic cystotomy tract with bladder involvement. years). Bladder involvement amongst these is mixed. Our case Korean J Urol 2013;53:638–40. showed a grossly normal bladder on cystoscopy but there was 5. Schaafsma RJ, Delaere KP, Theunissen PH. Squamous cell evidence of SCC in the bladder on histology. This demonstrates carcinoma of suprapubic cystotomy tract without bladder that a normal cystoscopy cannot rule out bladder involvement. involvement. Spinal Cord 1999;37:373–4. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 S. Khadhouri et al. 6. Patel K, Hori S, Roberts J, Sengutpa A. Need for early imaging 8. Zhang X, Mi Y, Wang D, Yuan X, Zhang B, Bai T. High differ- in symptomatic suprapubic catheter tracts: rare case of cuta- entiated squamous cell carcinoma arising from a suprapubic neous squamous cell carcinoma of tract origin without blad- cystostomy tract in a patient with transplanted kidney. Int J der involvement. J Clin Urol 2017;10:193–6. Clin Exp Med 2015;8:21770–72. 7. Ito H, Arao M, Ishigaki H, et al. A case of squamous cell car- 9. Stokes S, Wheeler JS, Reyes CV. Squamous cell carcinoma cinoma arising from a suprapubic cystostomy tract. BMC Urol arising from a suprapubic cystostomy tract with extension 2011;11:20. into the bladder. J Urol 1995;154:1132–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy030/4904291 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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