URACHAL CARCINOMA DURING PREGNANCY KRISTEL VAN CALSTEREN, KRISTIN VAN MENSEL, STEVEN JONIAU, RAYMOND OYEN, MYRIAM HANSSENS, FREDERIC AMANT, AND HENDRIK VAN POPPEL ABSTRACT We report a case of Stage T4aN2M0 urachal carcinoma that was diagnosed early in pregnancy. Because positive pelvic lymph nodes and uterine involvement were present, surgical resection, including hysterec- tomy with termination of the pregnancy, and postoperative radiotherapy were performed. The treatment options, which largely depend on the duration of the pregnancy, the tumor stage, and the patient’s desire to continue the pregnancy, are discussed. UROLOGY 67: 1290.e19–1290.e21, 2006. © 2006 Elsevier Inc. T he urachus, the intraembryonic part of the al- lantois, is a midline tubular structure extend- ing from the anterior dome of the bladder to the region of the umbilicus between the fascia trans- versalis and the peritoneum of the space of Retzius. This structure closes or involutes at the 32nd week of intrauterine life and persists as the median um- bilical ligament. However, in 70% of adults, a small lumen lined by transitional epithelium can still be found. Carcinomas of the urachus are believed to origi- nate either from malignant transformation of co- lumnar metaplasia out of the lining of transitional epithelium or from enteric remnants during em- bryologic development. 1 Most of these tumors are located at the junction of the urachal ligament and the bladder dome and typically have histo- logic characteristics of adenocarcinomas of in- testinal origin. Urachal carcinoma accounts for only 0.1% to 0.7% of all bladder tumors. However, it usually presents with locally advanced disease that cannot be cured with extensive surgery. 1 The peak inci- dence of urachal carcinoma is between the fifth and sixth decade of age, and the male/female ratio is 4:1. 2 Although fertile women rarely present with ura- chal carcinoma, we report a case of urachal adeno- carcinoma during pregnancy. Because this entity has not been previously described, we discuss the treatment options further. CASE REPORT A 31-year-old woman, P2G3, presented at the gestational age of 14 weeks, with intermittent gross hematuria of 2 weeks’ duration. Microscopic uri- nalysis showed no malignancy. An ultrasound ex- amination showed a polypoid mass in the dome of the bladder next to a normally developing single- ton pregnancy (Fig. 1). Magnetic resonance imag- ing confirmed the presence of the solid, well-vas- cularized mass in the wall of the bladder dome that was connected to the lower end of the umbilical ligament (Fig. 2). No clear demarcation was visible between the mass and the lower border of the uterus. Moreover, some nodules were present in the adjacent fat, and a single slightly enlarged lymph node was recognized in the right obturator region. The patient was informed of the therapeutic op- tions, including extensive surgery with the poten- tial need for hysterectomy and termination of the pregnancy. The surgery started with exploration of the pelvis through a midline laparotomy, which revealed a 3-mm peritoneal implant at the level of the anterior wall of the bladder and tumor invasion on the an- terior wall of the uterus that was greater than 2.2 cm (Fig. 3). In the right obturator region, a cluster of lymph nodes was found, of which the largest lymph node measured 2.5 cm in diameter. Further- more, three implants measuring 2.0, 1.5, and 0.7 cm From the Departments of Obstetrics and Gynecology, Urology, and Radiology, UZ Gasthuisberg, Katholieke Universiteit Leu- ven, Leuven, Belgium Address for correspondence: Frederic Amant, M.D., Ph.D., Di- vision of Gynecological Oncology, Department of Obstetrics and Gynecology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Herestraat 49, Leuven 3000, Belgium. E-mail: Frederic.amant@ uz.kuleuven.ac.be Submitted: September 7, 2005, accepted (with revisions): De- cember 19, 2005 CASE REPORT © 2006 ELSEVIER INC. 0090-4295/06/$32.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.12.041 1290.e19