The most common bladder tumors in patients with spinal cord injury are SCC (33-46.9%), urothelial carcinoma (31.3-55%), and adenocarcinoma (9.4-10%) [4
]. In the literature SCC is more common in patients with indwelling urethral and suprapubic catheters than other forms of bladder management. The incidence of SCC of the bladder in patients with indwelling catheters for more than 10 years is 10% [7
]. In a study of 48 patients, the mean time between spinal cord injury and the first bladder malignancy diagnosis was 22.6 years [8
In the present case, we were unable to perform a cystoscopy and assess the bladder mucosa for a possible origin of the tumor. However, we concluded that the SCC developed not from the bladder but from the epidermis around the suprapubic catheter. This conclusion was based on the absence of gross hematuria during follow-up, and a class II urine cytologic evaluation. In addition, front formation [9
] was observed subcutaneously at an obvious border between normal epithelial cells and carcinoma cells (Figure arrow). These findings indicated the origin of SCC was squamous epithelial cells. To our knowledge, the present case is only the fourth report of SCC arising from the suprapubic cystostomy tract in the literatures [7
We believe that this case of SCC was caused by chronic exposure of the cystostomy site to the mechanical stimuli from the indwelling suprapubic catheter. However, the risk of SCC would not have been eliminated by intermittent catheterization, as demonstrated by reported cases bladder malignancies in patients who perform intermittent catheterization [4
The only acceptable treatment for deeply invasive but localized SCC arising from a suprapubic cystostomy tract is radical cystectomy and urinary diversion [11
]. In this case, the patient's tumor was not localized and had metastasized to the inguinal and para-aortic lymph nodes. In such cases, chemotherapy is considered, but was contraindicated in this patient due to his poor performance status. Thus, the patient underwent external radiation therapy as a palliative treatment. This treatment led to partial disease remission and good palliation of symptoms and it would appear that palliative radiation therapy (a total of 56 Gy) has a role to play in the palliation of metastatic SCC, with good relief of symptoms.
We have presented here a rare case of epidermal SCC in a patient with a suprapubic cystostomy. Physicians and patients should pay close attention to any suspicious signs associated with such long-term cystostomy sites, including skin changes. In this case, other urologists who were changing the catheter once a month had noticed the abdominal mass for 6 months before referring the patient to our clinic admission, but they had considered the cause to be hyperplasia due to benign granulation. The slow growth of the mass may have made early diagnosis difficult. This case clearly demonstrates that chronic indwelling catheters may cause malignancy of not only the bladder but also the epidermis. Thus, early detection and treatment of SCC arising from a suprapubic cystostomy tract are crucial.