Primary Metastatic Squamous Cell Carcinoma of the Male Urethra Presenting with Scrotal Abscess and Subsequent Development of Fournier's Gangrene

Abstract

This male patient presented with a scrotal abscess and urinary obstruction. The patient's history included a perineal abscess and the development of urethrocutaneous fistulae (watering-can perineum). He underwent multiple debridement procedures without resolution. During the fifth debridement for Fournier's gangrene, a biopsy revealed invasive squamous cell carcinoma. The patient was bedridden because of the large mass, a wide en bloc resection with lymphadenectomy and reconstruction was performed revealing a large (22 cm) squamous cell carcinoma originating from the urethra. He also received palliative chemoradiotherapy and hip hemiarthroplasty. Unfortunately, he succumbed to the disease. Given the recognized relationship between inflammation and the development of cancer, it is important to entertain a differential diagnosis of cancer, especially with erosive infections. This case report highlights the all too common late presentation of urethral cancer. Interestingly, despite correction of the bedridden state with palliative surgery, the patient did not perceive an improvement in quality of life based on the FACT-G questionnaire.

Keywords: Fournier’s gangrene; inflammation; primary urethral carcinoma; scrotal abscess; squamous cell carcinoma.

Figure 1

Preoperative. This photo illustrates the extent of the scrotal abscess and cancer upon presentation. The urethra was obliterated. In addition to multiple areas of infection, there were nodular areas with squamous keratinization.

Figure 2

Preoperative FDG-PET scans. The scans reveal enlarged PET avid bilateral groin LNs, in addition the PET avid scrotal and perineal tissue. (A) Coronal image at level of the positive iliac LNs. (B) Coronal image at level of greater trochanter.

Figure 3

Intraoperative. The photo shows the completed en bloc resection defect prior to flap closure.

Figure 4

Histology specimen. This slide demonstrates the SCC with keratin and both (1) lymphatic invasion and (2) vascular invasion.

Figure 5

Metastasis to the pubic rami. This histopathology slide demonstrates the multifocal distant metastasis of the primary urethral tumor to the bone, in particular, to the right pubic inferior rami.

Figure 6

Postoperative FDG-PET scan. Restaging revealed progression with multiple lung metastasis and recurrent pelvic disease, with left ischial and femoral bone metastases. (A) Coronal image at level of the iliac LNs, corresponding to Figure 2A. (B) Coronal image at level of greater trochanter, corresponding to Figure 2B.

Figure 6

Postoperative FDG-PET scan. Restaging revealed progression with multiple lung metastasis and recurrent pelvic disease, with left ischial and femoral bone metastases. (A) Coronal image at level of the iliac LNs, corresponding to Figure 2A. (B) Coronal image at level of greater trochanter, corresponding to Figure 2B.