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.

Fournier’s Gangrene in the Setting of Underlying Carcinoma: A Case Report and Review of the Literature

“…Local procedures and chronic indwelling catheters increase the risk of infection. Chemotherapy as a treatment for a previously diagnosed unrelated cancer was seen in 15% (3/20) of the case reports [3][4][5][6][7].…”

“…It is included in many medical calculator applications and includes the measurement of CRP, hemoglobin, white blood cell count, serum sodium, creatinine, and blood glucose level. Scores of ≥6 raise the suspicion for necrotizing fasciitis/FG and scores of ≥8 are strongly predictive of the disease [5,17]. Initial studies of the LRINEC score showed a 92% positive predictive value in diagnosing FG but subsequent studies have questioned its utility [19].…”

“…CT has been proven to have greater specificity than plain film radiography or ultrasonography for identifying the process and the extent of the disease and can help to identify a local or distant malignancy [13]. Common CT findings of FG include soft-tissue stranding and edema, asymmetric fascial thickening, coexisting fluid collections, subcutaneous or deep soft tissue emphysema, or findings consistent with a mass lesion, invading the surrounding tissues [5,6]. In our review, CT was performed in 70% (14/20) of the patients; all patients showed at least one finding, and 85% (12/14) demonstrated a mass lesion with inflammation extending into soft tissue [7,12].…”

“…Ultrasonography may be helpful as a rapid initial (bedside) imaging modality and can be useful when CT is not immediately available. Sonographic findings of FG may include identification of fluid collections or mass-like lesion, tissue edema, or air shadows indicative of tissue emphysema [3,5].…”

“…In our review, rectal adenocarcinomas were responsible for 70% (14/20) of cases. The remaining cases included two colonic adenocarcinomas and isolated cases of prostatic adenocarcinoma, scrotal pleomorphic sarcoma, urethral squamous cell carcinoma, and scrotal squamous cell carcinoma [3,5,9,10]. In two patients with malignancy-induced FG, the tissue was not sent for histopathologic analysis.…”