LETTERS
TO THE EDITOR
PERINEAL VERSUS ANAL SUBMUCOSAL INJECTION FOR DRUG ADMINISTRATION IN TREATMENT OF CHRONIC PROSTATITIS To the Editor: Submucosal anal injection of chemotherapeutic agents has been used in the treatment of pelvic malignancies such as cancer of the bladder,’ prostate,2 uterine cervix,3 as well as in chronic prostatitis.4 The technique comprised the introduction of a proctoscope into the anal canal and the injection of the material into the anal submucosa above the pectinate line. In the last 16 patients with chronic prostatitis, I have performed this injection via the perineal route: the needle was inserted into the perineal skin, 1 to 1.5 cm in front of the anal orifice, guided by a finger in the anal canal, until its tip came to lie in the anal submucosa above the pectinate line for the material to be injected. The results were absolutely comparable to those of the previous technique, but the performance by the perineal route-this is why I am communicating it to the readership-was found to be easier than by the anal route.
Department
Ahmed Shafik, M.D. Professor and Chairman of Surgery and Research Cairo University, Egypt
References I. Shafik .4. of a/: Anal submucosal injection: a new route for drug administration in pelvic malignancies. II. Methotrexate anal injection in the treatment of advanced bladder cancer, preliminary study, ] Ural 140: 501 (1988). 2. Shafik .4: Anal submucosal injection: a new route for drug administration in pelvic malignancies. V. Advanced prostatic cancer: results of methotrexate treatment using the anal route, preliminary study, Em Ural 18: 132 (1990). 3. Shafik .4: Anal submucosal injection: a new route for drug administration in pelvic malignancies. IV. Submucosal anal injection in treatment of cancer of uterine cervix. preliminary study, Am J Obstet Gynecol 161: 69 (1989). .1. Shafik .4: Anal submucosal injection: a new route for drug administration. VI. Chronic prostatitis: a new modality of treatment with report of 11 cases, Urology 37: 61 (1991).
SEEDING OF PROSTATE ADENOCARCINOMA FOLLOWING TRANSRECTAL NEEDLE BIOPSY
needle has been reported with transperineal biopsies 2.3 but I can find no reports of tumor implantation following transrectal biopsies. I report herein the first such case. Case Report I saw a sixty-year-old white man in May 1983 for intermittent symptoms of dysuria, urgency, and frequency. He said that one year previously he had had a needle biopsy of the prostate, which had been reported to be negative for malignancy. I found on rectal examination a sharp, firm ridge overlying the left lobe of the prostate. It measured less than 1 cm in largest diameter and seemed clearly to be in the rectal mucosa outside the prostate gland. It was moveable with respect to the prostate. We sent for the original biopsy slides and agreed that there was no malignancy in the specimen. I saw the patient one year later and noted a similar, but considerably larger, firm mass in the rectal mucosa, overlying, but again not attached to, the left lobe of the prostate. A biopsy of the mass was done transrectally, and the specimen showed poorly differentiated adenocarcinoma, histologically compatible with a prostatic origin (Fig. 1). Prostate-specific antigen (PSA) staining was positive, thereby proving the prostatic origin of the adenocarcinoma. Metastatic workup included an elevated prostatic acid phosphatase (PAP) of 7.4 IU (normial, O-O.8 IU), a computerized tomographic (CT) scan positive for lymphadenopathy in the para-aortic and iliac lymph nodes, and a radionuclide bone scan with normal findings. We treated him with bilateral orchiectomy and radiotherapy to the abnormal node-bearing areas and prostate (6,020 cGy total dose). The treatment was complicated by venous thrombosis of his legs, but repeat acid phosphatase four months l.ater was normal, and a CT scan showed a decrease in size of lymph node mass. A year after therapy the CT scan was normal and the bone scan remained normal. Thereafter, his PAP began to rise, and he also began to show sihms and symptoms of widespread metastasis. He died twenty-nine months after the ‘diagnosis and initial therapy for prostate adenocarcinoma. Comment
Needle biopsy of a prostate, suspiTo the Editor: cious for cancer, is a technique that has been available to the urologist for more than fifty years.’ One can do the biopsy transperineally or transrectally, and there are advocates of both approaches. Implantation of carcinoma in the tract of the biopsy
UI1OI~OGk
h4ARCII
1992
VOLUME
NXXIX.
NUMBER
My conclusion is that this patient’s carcinoma of the prostate implanted in the rectal mucosa along the needle tract from the original prostate biopsy. This would be the first reported case of needle tract seeding following a transrectal prostate biopsy.
3
-‘!Yi
TO THE EDITOR
PERINEAL VERSUS ANAL SUBMUCOSAL INJECTION FOR DRUG ADMINISTRATION IN TREATMENT OF CHRONIC PROSTATITIS To the Editor: Submucosal anal injection of chemotherapeutic agents has been used in the treatment of pelvic malignancies such as cancer of the bladder,’ prostate,2 uterine cervix,3 as well as in chronic prostatitis.4 The technique comprised the introduction of a proctoscope into the anal canal and the injection of the material into the anal submucosa above the pectinate line. In the last 16 patients with chronic prostatitis, I have performed this injection via the perineal route: the needle was inserted into the perineal skin, 1 to 1.5 cm in front of the anal orifice, guided by a finger in the anal canal, until its tip came to lie in the anal submucosa above the pectinate line for the material to be injected. The results were absolutely comparable to those of the previous technique, but the performance by the perineal route-this is why I am communicating it to the readership-was found to be easier than by the anal route.
Department
Ahmed Shafik, M.D. Professor and Chairman of Surgery and Research Cairo University, Egypt
References I. Shafik .4. of a/: Anal submucosal injection: a new route for drug administration in pelvic malignancies. II. Methotrexate anal injection in the treatment of advanced bladder cancer, preliminary study, ] Ural 140: 501 (1988). 2. Shafik .4: Anal submucosal injection: a new route for drug administration in pelvic malignancies. V. Advanced prostatic cancer: results of methotrexate treatment using the anal route, preliminary study, Em Ural 18: 132 (1990). 3. Shafik .4: Anal submucosal injection: a new route for drug administration in pelvic malignancies. IV. Submucosal anal injection in treatment of cancer of uterine cervix. preliminary study, Am J Obstet Gynecol 161: 69 (1989). .1. Shafik .4: Anal submucosal injection: a new route for drug administration. VI. Chronic prostatitis: a new modality of treatment with report of 11 cases, Urology 37: 61 (1991).
SEEDING OF PROSTATE ADENOCARCINOMA FOLLOWING TRANSRECTAL NEEDLE BIOPSY
needle has been reported with transperineal biopsies 2.3 but I can find no reports of tumor implantation following transrectal biopsies. I report herein the first such case. Case Report I saw a sixty-year-old white man in May 1983 for intermittent symptoms of dysuria, urgency, and frequency. He said that one year previously he had had a needle biopsy of the prostate, which had been reported to be negative for malignancy. I found on rectal examination a sharp, firm ridge overlying the left lobe of the prostate. It measured less than 1 cm in largest diameter and seemed clearly to be in the rectal mucosa outside the prostate gland. It was moveable with respect to the prostate. We sent for the original biopsy slides and agreed that there was no malignancy in the specimen. I saw the patient one year later and noted a similar, but considerably larger, firm mass in the rectal mucosa, overlying, but again not attached to, the left lobe of the prostate. A biopsy of the mass was done transrectally, and the specimen showed poorly differentiated adenocarcinoma, histologically compatible with a prostatic origin (Fig. 1). Prostate-specific antigen (PSA) staining was positive, thereby proving the prostatic origin of the adenocarcinoma. Metastatic workup included an elevated prostatic acid phosphatase (PAP) of 7.4 IU (normial, O-O.8 IU), a computerized tomographic (CT) scan positive for lymphadenopathy in the para-aortic and iliac lymph nodes, and a radionuclide bone scan with normal findings. We treated him with bilateral orchiectomy and radiotherapy to the abnormal node-bearing areas and prostate (6,020 cGy total dose). The treatment was complicated by venous thrombosis of his legs, but repeat acid phosphatase four months l.ater was normal, and a CT scan showed a decrease in size of lymph node mass. A year after therapy the CT scan was normal and the bone scan remained normal. Thereafter, his PAP began to rise, and he also began to show sihms and symptoms of widespread metastasis. He died twenty-nine months after the ‘diagnosis and initial therapy for prostate adenocarcinoma. Comment
Needle biopsy of a prostate, suspiTo the Editor: cious for cancer, is a technique that has been available to the urologist for more than fifty years.’ One can do the biopsy transperineally or transrectally, and there are advocates of both approaches. Implantation of carcinoma in the tract of the biopsy
UI1OI~OGk
h4ARCII
1992
VOLUME
NXXIX.
NUMBER
My conclusion is that this patient’s carcinoma of the prostate implanted in the rectal mucosa along the needle tract from the original prostate biopsy. This would be the first reported case of needle tract seeding following a transrectal prostate biopsy.
3
-‘!Yi
