|Year : 2018 | Volume
| Issue : 1 | Page : 41-46
Unusual presentation of patients with prostate cancer in Zaria: A report of four cases
Ahmad Bello1, Musliu Adetola Tolani1, Muhammed Ahmed1, Ahmed Tijjani Lawal1, Dauda Eneyamire Suleiman2, Balarabe Kabir2, Abdullahi Sudi1, Babatunde Kolapo Hamza1, Oyelowo Nasir1, Abdulsalam Ibrahim Khalifa1, Hussaini Yusuf Maitama1
1 Division of Urology, Departments of Surgery, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Division of Urology, Department of Pathology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||14-Mar-2019|
Dr. Ahmad Bello
Department of Surgery, Division of Urology, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Advanced prostate cancer usually presents with lower urinary tract symptoms (LUTS) or metastatic bone disease. Detection of an associated jaundice, suprapubic, or flank mass is unusual in advanced disease just as associated visceral or cutaneous metastasis is quite an uncommon presentation in prostate cancer. We report four cases in this series to highlight the unusual presentations of this cancer with a huge suprapubic mass (case 1); jaundice with associated multiple, nodal, and soft tissue metastasis (case 2); associated retroperitoneal mass (case 3); and synchronous primary renal cancer with background HIV infection (case 4). In conclusion, patients with unusual presentation of prostate cancer may constitute diagnostic dilemma, especially in the setting of retroperitoneal or suprapubic mass. Despite the fact that the findings highlighted in this series were unusual, their response to hormonal ablation was good.
Keywords: Presentation, prostate cancer, unusual
|How to cite this article:|
Bello A, Tolani MA, Ahmed M, Lawal AT, Suleiman DE, Kabir B, Sudi A, Hamza BK, Nasir O, Khalifa AI, Maitama HY. Unusual presentation of patients with prostate cancer in Zaria: A report of four cases. Arch Int Surg 2018;8:41-6
|How to cite this URL:|
Bello A, Tolani MA, Ahmed M, Lawal AT, Suleiman DE, Kabir B, Sudi A, Hamza BK, Nasir O, Khalifa AI, Maitama HY. Unusual presentation of patients with prostate cancer in Zaria: A report of four cases. Arch Int Surg [serial online] 2018 [cited 2019 May 23];8:41-6. Available from: http://www.archintsurg.org/text.asp?2018/8/1/41/254144
| Introduction|| |
Prostate cancer is one of the most common malignancies among men. It is estimated that there will be 1.3 million new cases worldwide in 2018. The cancer has an age standardized incidence rate of 31.9 per 100,000 in Western Africa and accounts for 29.1% of all cancers in Nigeria.
Its natural history is associated with unique characteristics of the disease. Early disease is usually asymptomatic and screen detected. In our environment, most cases of prostate cancer present to the caregiver when the malignancy is advanced due to the lack of cancer screening programmes, ignorance of patients about the disease, and/or poverty which affects their ability to seek care. The most common presentation in advanced disease is lower urinary tract symptoms (LUTS) whereas other symptoms include low back pain and paraplegia/papararesis. In some cases, presentation could be uncommon. In a 10-year retrospective study, Vinjamoori et al. reported that uncommon presentation of prostate cancer occurred in 13.2% of patients with metastatic disease. Lung, liver, and renal metastases accounted for 5.3%, 4.8%, and 0.2% of these patients, respectively. Although regional nodal metastasis is common in prostate cancer, it is not often associated with jaundice. Detection with a suprapubic mass or association with a flank mass in this setting of cancer of the prostate is also unusual. We present four cases of atypical presentation and the challenges in management in our environment.
| Case Report 1|| |
A 65-year-old man presented to our emergency unit with LUTS and suprapubic mass. He also had associated anorexia, generalized body weakness, and bilateral limb swelling. He had no low back pain, lower limb weakness, hematuria, or necroturia. Genitourinary examination revealed palpable hard mobile nodular suprapubic mass of about 20 cm from the pubic symphysis that one gets above but not below, and an enlarged hard nodular prostate with fixed overlying rectal mucosa and continuous with the suprapubic mass. Initial PSA was >100 ng/ml. Transrectal ultrasound showed prominent hypoechoic nodules whereas abdominopelvic ultrasound revealed a prostate with a volume of 1030.74 g as an irregular pelvic mass, predominantly solid with mixed parenchymal echoes [Figure 1]. Patient had bilateral hydroureteronephrosis and normal paraaortic areas. Tru-cut prostate biopsy revealed adenocarcinoma (Gleason's 5 + 5 = 10) [Figure 2]. There was uremia of 15.9 mmol/L at presentation.
|Figure 2: Adenocarcinoma of the prostate; Gleason's Score 5 + 5 (HE Stain, ×200) (case 1)|
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Patient was diagnosed with advanced prostate cancer, with obstructive nephropathy and subsequently had bilateral total orchidectomy and open suprapubic cystostomy with intraoperative findings of cranial displacement of bladder to the umbilicus level and normal bladder mucosa.
Two-month postorchidectomy PSA was 42.8 ng/ml and patient's last prostate volume was 82.8 g. He is still on follow-up.
| Case Report 2|| |
A 63-year-old known hypertensive and diabetic man was referred to our emergency unit with a histological diagnosis of prostate adenocarcinoma (Gleason's 4 + 3 = 7) [Figure 3]. He presented with difficulty in passing urine since 2 years and progressive suprapubic swelling of 5 months with failed attempt at urethral catheterization, despite multiple successful urethral catheterization in the preceding year. He also had weight loss, jaundice, and inability to walk. Abdominal examination revealed an umbilical nodule, and a suprapubic mass 18 cm above the pubic symphysis, which was hard and nodular with irregular edges, mobile, one gets above but not below the mass. No hepatomegaly was observed. Prostate was asymmetrically enlarged, hard and nodular, and continuous with the suprapubic mass. Abdominopelvic ultrasound revealed an irregular prostate of 938 g characterized by multiple hypoechoic nodules and cystic areas, superiorly displacing and infiltrating the bladder with associated hydroureteronephrosis. Patient also had multiple paraaortic and abdominal wall masses and right pleural effusion. No hepatic mass was seen. Liver function test showed conjugated hyperbilirubinaemia with raised alkaline phosphatase level. There was also azotemia of 9.1 mmol/L.
|Figure 3: Adenocarcinoma of the prostate; Gleason's Score 4 + 3 (HE Stain, ×200) (case 2)|
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A diagnosis of metastatic prostate cancer with high-pressure chronic urinary retention was made. Patient was resuscitated and subsequently had bilateral subcapsular orchidectomy and open suprapubic cystostomy with findings as previously highlighted.
Presently, jaundice has resolved clinically and biochemically and muscle power has improved. Last posthormonal ablation PSA was 39 ng/ml. He is on regular follow-up and physiotherapy.
| Case Report 3|| |
A 60-year-old man was referred from a peripheral centre 2 months after open channelization for prostate adenocarcinoma on account of low back pain and paraparesis. He earlier had bothersome LUTS complicated by a single episode of acute urinary retention and hematuria of 5 months duration. On examination, there was a flank mass and right inguinal hernia. Serum PSA was >100 ng/ml. Transrectal ultrasound showed a prostate of 43.1 g with distorted parenchyma and hypoechoic nodules and breached capsule. Histology of prostatectomy specimen showed sections of prostate tissue with infiltrating cords and nests of malignant cells with round to oval nuclei having prominent nucleoli and moderate cytoplasm disposed within a fibromuscular stroma (Adenocarcinoma, Gleason's 5 + 5 = 10). Abdominopelvic ultrasound showed a retroperitoneal thick-walled multiseptate oval mass 12 × 7 cm displacing the right kidney anteriorly with moderate pelvicalyceal differentiation. Left femoral X-ray showed cortical irregularity and loss of corticomedullary differentiation in the femoral neck up to the proximal diaphysis. Lumbosacral X-ray was not remarkable.
Patient was diagnosed as metastatic cancer of the prostate. He had external beam radiation therapy and the first dose of depot goserelin was 10.8 mg. He subsequently had bilateral subcapsular orchidectomy and right inguinal herniorraphy. He responded well to therapy with PSA of 7.8 ng/ml and residual prostate of 18 g, 1 and 2 months after orchidectomy, respectively. Five months after orchidectomy, patient's PSA rose to 94.5 ng/ml and CT scan further revealed multiple hepatic metastasis, retroperitoneal mass about the same size as the prehormonal ablation dimension (11.5 × 6.6 cm) [Figure 4] and a prostate volume of 57 g. He has good performance status and is presently on second-line chemotherapy (Cabazitaxel) and Zoledronic acid 4 mg weekly for six courses.
|Figure 4: Abdominal Contrast CT-Scan showing the huge retroperitoneal mass (white arrow) (case 3): A round to oval hypodense non- enhancing mass medial to the right kidney (case 3)|
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| Case Report 4|| |
A 65-year-old man with background retroviral disease presented with recurrent hematuria of 10 years duration and LUTS of 2 years duration. Physical examination revealed a right flank mass and a hard nodular prostate. Prostate specific antigen was >100 ng/ml. Transrectal ultrasound revealed a prostate volume of 61.3 g whereas prostate biopsy diagnosed ductal adenocarcinoma. Abdominopelvic ultrasound revealed irregular right kidney with a heterogenous mass projecting from its lower pole cranially distorting the sinoparenchymal differentiation [Figure 5].
|Figure 5: Abdominal Ultrasound Scan showing the primary synchronous renal mass (white arrow) (case 4)|
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A diagnosis of carcinoma of the prostate with renal metastasis was made. He subsequently had open radical nephrectomy with histology of clear cell renal cell carcinoma grade 3. He was counseled and placed on bicalutamide.
Two months after surgery, patient was admitted with features of septicaemia. CD-4 count was 8 cells/mm3. He later succumbed to the effect of sepsis during the admission.
| Discussion|| |
Patients with prostate cancer have varying clinical presentation depending on the disease stage. Some of these presentations could be at variance with common features. Suprapubic mass in the setting of prostate cancer is unusual. Eke and Sapira reported abdominal mass in 8.5% of the patients retrospectively reviewed over a 14-year-period with prostate cancer. Similarly, Badmus et al. noted it in 5.3% patients diagnosed with prostate cancer over a 16-year period. The volume of the prostate in the previously reported cases are usually above 1,000 g. Brahmbhatt and Liou reported a 1,560 g pelvic mass. The huge prostate adenocarcinoma in this series had a volume of 1,030 and 938 g, similar to the volume of giant prostate cancer reported by the earlier author. In some cases of this presentation, there could be giant prostate locally with no evidence of distant metastasis. In others, there could be local infiltration of the bladder retrotrigonally. This could result in a suprapubic mass. Although the patient had suprapubic mass in our case, there was no clinical evidence of metastasis in the first case whereas the second case had widespread metastasis.
Soft tissue and visceral metastasis are uncommon occurring in about 20% and <10% of cases, respectively. The risk of nodal metastasis increases with the clinical T stage and biopsy grade of prostate cancer. The index patient in case two had a T4 poorly differentiated tumor in agreement with the above statement. Moura et al. similarly described patients with multiple nodal metastasis with a Gleason's score of 7. These metastasis appears to have increasing incidence in prostate tumors with large volume or penetration of the capsule as elucidated in our study.
Multiple primary neoplasm appears to occur in old age in 2–11% of cases. Although prostate carcinoma is the most frequent single cancer in this setting, only about 9.3% of them have associated renal cancer. On the other hand, prostate cancer is the most common cancer associated with a primary renal malignancy., Ozsoy et al. revealed that incidental discovery of another malignancy occurs in 1.2% of prostate cancer with renal cancer constituting the most common. This dual primary cancer can be diagnosed synchronously as Beisland et al. noted it in 18.7% of cases. One of our patients had synchronous diagnosis of two primary tumors. Although patient with papillary renal cell carcinoma (RCC) have increased risk of prostate cancer, our patient had clear cell RCC.
Pathologically, giant prostate cancer could represent an aggressive tumor only or a benign prostatic enlargement coexisting with the cancer. It is likely that the entire prostate of the first two cases are aggressive malignant growth as elucidated by the suspicious rectal examination findings and their Gleason's score. Metastatic lesions in prostate cancer usually take the form of diffuse lymphatic spread and multiple small nodules but can also present with large metastatic deposit. Oster et al., however, noted a large anterior mediastinal and paraaortic mass in their case series. Our second and third cases presented with multiple paraaortic and abdominal wall nodules and a huge retroperitoneal mass, respectively.
Symptoms of prostate cancer could be related directly to the primary cancer or an external compression of surrounding structures. Prostate cancer with a huge volume can cause external bilateral ureteric, external iliac, and rectal compression. Akamatsu et al. also noted dislocation of the bladder and rectum by a huge mass in the lower abdomen continuous with the prostate. Two of our patients had a huge suprapubic mass with either of bladder displacement, bilateral hydroureteronephrosis, or leg swelling consistent with this explanation. Soft tissue and nodal metastasis could present as the initial sign of prostate cancer mimicking lymphoma or could occur in more advanced stage in association with bone metastasis. Saeter et al. found three in five patients who had soft tissue or nodal metastasis with features of bone involvement. Our report revealed suspicious signs of cord compression from vertebral metastasis in the second and third cases. The earlier case also had an umbilical nodule. Skin and subcutaneous metastasis from prostate cancer is rare (about 1% incidence), manifesting with various lesions including Sister Joseph's nodule. It is possible that the abdominal wall lymphatics were obstructed by the multiple tumor nodules causing thrombus reflux and its subsequent retention on the umbilical skin. Jaundice is a rare sign in patients with abdominal lymph node metastasis. The compression of the paraaortic lymph nodes on the biliary duct could account for this presentation in our series. This is because the second case had significantly raised alkaline phosphatase level suggesting extrahepatic biliary obstruction.
Differentiation of the primary origin of the tumor could be confusing, especially if prostate examination and PSA levels are unremarkable. The elevated tumor marker in our report facilitated the conclusion on a nodal metastasis. CT scan can also be helpful. The cystic retroperitoneal mass in the third case was diagnosed as a metastatic nodal involvement with this imaging modality. However, percutaneous needle biopsy can be used to diagnose metastatic lesions. Ibinaye et al. reported a 10.5 × 6.8 cm complex upper pole left renal cyst that had the distinct cytological appearance of prostate adenocarcinoma on this biopsy. Although this is true, our fourth case had a huge renal mass that was confirmed to be clear cell carcinoma following open nephrectomy.
AIDS defining malignancies are well known., Few reports on HIV-associated prostate cancer exists. Crum et al. reported an annual rate of 50–100 cases per 100,000 cases. This increased incidence might be related to the abnormal cell-mediated immunity and inadequate surveillance of tumors. When the viral load is high, there is a release of macrophage inflammatory protein, which causes p53 suppression and subsequently inhibits apoptosis. This could produce the setting for cancer cells to flourish. The cancer may thus be more aggressive presenting either in younger age groups or with extensive metastasis. Our patient (case 4) presented at the age of 65 years. This is similar to the age reported by Quatan et al. (64 years) and Crum et al.(66 years)., Others have reported age of presentation between the 5th and 6th decade.,,, Although PSA could be as high as >100 ng/ml as documented in this report, other case reports revealed values less than this. However, most of these patients had nonmetastatic disease.,, Because of the aggressiveness of this cancer, HIV patients may be considered as a high-risk group for PSA screening.
In contrast to the belief that atypical soft tissue (including pelvic) masses and visceral metastasis commonly have poorly differentiated or small cell histological subtype of prostate cancer that is very aggressive and resistant to endocrine therapy, the converse was the case. Dean et al. noted the disappearance of a 10 cm suprapubic mass in a prostate cancer patient 2 weeks after orchidectomy. Kosugi et al. also noted good response to androgen deprivation therapy in a patient with bulky abdominal nodal metastasis. This report showed a reduction in prostate volume by about 90% within 2 months of therapy. The primary cause of jaundice in metastatic prostate cancer also correlates with survival outcome. Those resulting from hepatic metastasis have a poorer prognosis compared to those associated with features of extrahepatic obstruction. The above patient had extrahepatic obstruction and appeared to have responded within weeks of orchidectomy. However, it appears from this series that acquired immunodeficiency disease worsens the cancer-induced immunosupression and confers a poor prognosis in the final case.
| Conclusion|| |
Some presentations with prostate cancer are uncommon and in some cases may constitute diagnostic dilemma, especially in association with a retroperitoneal or suprapubic mass. Notwithstanding, these and other unusual findings in this series, it does not portend poor response to endocrine therapy or a lower rate of survival.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]