Malignancies arising from a suprapubic tract site are rare; the most common reported being Squamous cell carcinomas. We present a case series of three SPC tract malignancies: a mucinous adenocarcinoma, sarcoma and a squamous cell carcinoma (SCC). All three patients were spinal cord injured (SCI).

We performed a systemic literature search on EMBASE, MEDLINE and google scholar, from inception to October 2017 for all English language articles, using the search terms  ‘suprapubic catheter’, ‘malignancies’, ‘cystotomy’, ‘neoplams’, using the boolan operators (and, or) to refine the search.

Our first patient is a 67-year-old man who presented with a short history of bleeding from his SPC site unrelated to catheter changes. He previously sustained a SCI 42 years ago; his level of neurology being C4/5 complete.  A SPC was inserted 8 years ago as part of the management of his neuropathic bladder. The patient presented with bleeding from the SPC tract, subsequent endoscopic evaluation of the SPC tract, in October 2017, revealed a small mass, which was biopsied. Histopathological report confirmed adenocarcinoma of bladder origin. An en-bloc resection including a cystoprostatectomy, anterior abdominal wall removal and removal of part of the sigmoid colon were performed, as at the time of surgery the cancer appeared to have spread to the sigmoid colon. He was reconstructed with a colostomy, ileal conduit and closure of the wound was with mesh and abdominoplasty. Histology demonstrated pT3bN0 adenocarcinoma, with negative margins. At six months follow up he is disease free.

Our second patient was a 69-year-old man at diagnosis in January 2015. He sustained a SCI secondary to a disc prolapse in 1994; his level of neurology being T4 incomplete. His SPC was inserted over a decade ago.  He presented with a rapidly growing lump around his SPC tract, this was investigated with an USS and a CT C/A/P, which demonstrated a thickened SPC tract, and some enlarged inguinal lymph nodes but no metastatic disease.  An urgent cystoscopy and wedge biopsy of the SPC tract was performed within 2 weeks of the CT. This demonstrated malignant sarcoma, probably leiomysarcoma.  He was referred urgently to the regional sarcoma unit, but due to the aggressive nature of his disease he died within three months of diagnosis.

Our third patient in our series was 43 years old at diagnosis, a C7 complete tetraplegic man due to a road traffic accident in 1996. His SPC was placed thirteen years prior to diagnosis.
He attended for his routine cystoscopy and botox injection for his bladder over-activity; at the time of surgery a mass was biopsied from the SPC site. This demonstrated a SCC of the supra-pubic tract. Two weeks later he under went a wide local excision and removal of the SPC tract. The histology from this confirmed a SCC arising from the SPC tract with negative margins. He had his SPC re-inserted six months later and is disease free and well eleven years later.

There are 17 published case reports of malignancy occurring in an SPC tract. Mean age 64 years (37-85), male: female ratio 15:2, and 8/17 of the cases had a SCI. Squamous cell carcinoma (11/17) was the most common type, followed by mucinous adenocarcinoma (3/17). 
Management of carcinoma to the SPC tract was reported in 14 cases, with predominance towards surgical intervention when the patient was suitable for an operation. A combination of wide local excision, partial or full cystectomy, abdominal wall excision and reconstruction with ileal conduit formation appeared to be the treatments of choice.  Four patients were treated with radiotherapy, all having been diagnosed with SCC, one being palliative radiotherapy. Finally one patient with myeloid sarcoma received chemotherapy as they declined surgery. One subject refused conventional intervention and underwent herbal bladder instillation.

The long-term outcome data of these patients are limited due to the lack of long-term follow up. Of the eight patients who underwent surgical intervention, five patients were recurrence free at follow up, the longest reported recurrence free duration was 5 years (range 3 months – 5 years). Two patients were palliated due to recurrence and progression of disease, and one incidentally died of pneumonia but was recurrence free at the time. Of the three patients who underwent radiotherapy only one demonstrated no recurrence, follow up time unspecified, the remaining patients both died at 4 months due to disease progression. Finally, two patients were palliated at the time of diagnosis.

Malignancies of the SPC tract are rare, however they tend to be aggressive leading to poor outcomes even after radical treatment. Increased suspicion and level of investigation may be warranted for patients presenting with discharge or bleeding to the SPC tract or urethra to pre-empt progression to severe disease. Prompt diagnosis and management is likely to afford better outcomes, although the evidence for this is limited.