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Unusual presentation of advanced prostate cancer masquerading as metastatic and obstructing rectosigmoid cancer An 80-year-old man presented with a 1 week history of constipation, abdominal pain and distension and overflow faecal incontinence on a background of 4 weeks of anorexia. His past history included a total hip replacement, pharyngoesophageal diverticulum and an incarcerated right femoral hernia requiring resection of 5 cm of ileum (necrotic bowel). He had no past or family history of malignancy. On examination, he appeared cachectic with a distended and tender abdomen. Digital rectal examination (DRE) revealed a rectal stricture 2 cm from the anal verge, which was too tight to pass. Computed tomography (CT) scan of his abdomen and pelvis demonstrated extensive ascites, a 9 cm segment of mural thickening affecting the rectosigmoid colon (Fig. 1) with proximal dilatation of distal small intestine and large bowel consistent with developing large intestine obstruction (LBO). There was no evidence of perforation, ischaemia or metastatic disease. Gastrografin enema confirmed a high grade fixed stenosis involving the proximal rectum and rectosigmoid junction (Fig. 2). A presumptive diagnosis of rectosigmoid carcinoma was made. The patient underwent emergency laparotomy with biopsies taken via flexible sigmoidoscopy at the same time. The caecum was noted to be 15–16 cm in diameter, with areas of ischaemia and perforation. There was extensive ascites, peritoneal metastases and omental caking present. He underwent caecal decompression followed by a caecotomy and caecostomy. Histopathological examination of the caecotomy specimen showed ulceration, inflammation and multiple small foci of poorly
Fig. 1. Axial portal venous computed tomography through the pelvis shows circumferential thickening of the rectum (long arrow) with replaced anterior mesorectal fat (arrowhead) in continuity with the prostate (short arrow).
© 2014 Royal Australasian College of Surgeons
differentiated adenocarcinoma in the serosa and subserosa (Fig. 3). Similar histology was seen in the biopsy specimen obtained from the rectum. The tumour cells were stained strongly for cytokeratin (CK) AE1/AE3 and moderately for prostate specific antigen (PSA). This immunohistochemical staining profile is most consistent with prostatic adenocarcinoma with a Gleason pattern 5 + 5 = 10. The tumour was negative with CK20, CK7, S100 and transcription factor 1. CK20 negativity suggests that it is not colorectal adenocarcinoma. Post-operatively, the patient’s PSA was 154 ng/mL. There was no preoperative measurement to compare. Bone scan post-operatively showed no definite evidence to suggest osteoblastic metastatic disease. Bicalutamide was commenced. The patient’s post-operative course was complicated by myocardial infarction, atrial fibrillation, feeding issues and aspiration pneumonia. The patient died 22 days post-operatively from cardiac and malignancy-related causes. This case represents a very rare presentation of prostate cancer masquerading as both obstructing and metastatic rectal cancer. Locally advanced prostate cancer with rectal infiltration is uncommon. Historical series have reported between 1 and 9% rectal involve-
Fig. 2. Frontal view of a gastrografin enema demonstrating a tight apple core stricture (arrow) at the anorectal junction. Note the small volume contrast within the otherwise decompressed bladder (arrow heads) as the enema was performed after a contrast enhanced computed tomography scan.
ANZ J Surg •• (2014) ••–••
2
Fig. 3. Biopsy of rectal stricture. Prostate specific antigen (PSA) stain ×200. Biopsy of rectal stricture displaying moderate staining with PSA, consistent with poorly differentiated adenocarcinoma, most likely of prostatic origin (Gleason pattern 5 + 5 = 10).
ment, but these were from the pre-PSA era (1935–1978).1 Similarly, an autopsy series (1967–1995) suggesting peritoneal metastasis occurring in 7% of men with prostate cancer likely overestimates contemporary occurrence. Our patient presented acutely with LBO requiring emergent laparotomy and was subsequently diagnosed with both locally invasive prostate cancer and extensive peritoneal carcinomatosis. Due to delayed presentation, the need for emergency laparotomy and pre-existing co-morbidities, our patient died 22 days after surgery from cardiorespiratory and cancer-related causes. Diagnosis of prostate cancer in this man was not considered because of the unusual clinical presentation. The abnormal DRE may have prompted PSA testing; however, the clinical picture was more in keeping with LBO secondary to a stenosing colorectal lesion. Prostate cancer metastasizes distantly via the lymphatic and haematogenous routes, most commonly seeding to lymph nodes and bone.1 Peritoneal carcinomatosis rarely occurs in the absence of bone metastasis.2 In men with metastatic prostate cancer, visceral metastasis, poor performance status and PSA ≥ 65 are poor prognostic factors.3 There are no series describing outcomes of men with both locally obstructing prostate cancer and peritoneal carcinomatosis. In a review of men with rectal infiltration by prostate cancer, it was found that 51% presented with gastrointestinal symptoms without prior established diagnosis of prostate cancer. Patients with acute large bowel obstruction were usually managed by defunctioning colostomy and androgen deprivation.4 The median survival for the 86 patients reviewed was 15 months. Metastatic peritoneal carcinomatosis is usually reported in the context of castrate-resistant prostate cancer and response to docetaxel chemotherapy has been reported (six patients, five responded, median survival from starting docetaxel was 24.5 months).5 Proponents of PSA screening would argue cases such as this, with advanced symptomatic disease at presentation, could be prevented. PSA
Images for surgeons
screening remains contentious with a large number needed to screen and treat to prevent one death from prostate cancer.6 The Melbourne Consensus Statement is an example of a balanced approach to this controversial subject.7 Elderly men often have an elevated PSA, but a level >100 ng/mL as in this patient is diagnostic of widespread prostate cancer. As screening over the age of 75 is not recommended, rapid development of an aggressive cancer above this age, while uncommon, is possible. Watchful waiting, a management strategy to monitor patients not able to tolerate or accept the side effects of radical curative treatment, is often offered to more elderly patients, particularly those with shorter life expectancy. In this group of men, the decision to commence noncurative treatment is based on symptoms and disease progression. In this case, rising PSAmay have prompted imaging to diagnose progression of disease, with initiation of palliative androgen deprivation to prevent presentation in extremus. This unusual case of prostate cancer with both local invasion and rare peritoneal carcinomatosis highlights the need for consideration of unusual presentations of prostate cancer in elderly men.
References 1. Bowrey DJ, Otter MI, Billings PJ. Rectal infiltration by prostatic adenocarcinoma: report on six patients and review of the literature. Ann. R. Coll. Surg. Engl. 2003; 85: 382–5. 2. Kehinde EO, Aberdeen SM, Al-Hunayan A, Ali Y. Prostate cancer metastatic to the omentum. Scand. J. Urol. Nephrol. 2002; 36: 225–7. 3. Glass TR, Tangen CM, Crawford ED, Thompson IM. Metastatic carcinoma of the prostate: identifying prognostic groups using recursive partitioning. J. Urol. 2003; 169: 164–9. 4. Benedict SP, Ahuja M, Mammen KJ. Hormone refractory carcinoma prostate with peritoneal metastases and malignant ascites without skeletal involvement: a case report and review of literature. Indian J. Urol. 2010; 26: 287–8. 5. Rita R, Danse E, Aydin S, Tombal B, Machiels JP. Castrate-resistant prostate cancer with peritoneal metastases treated with docetaxel-based chemotherapy. Urol. Int. 2014; 93: 49–54. 6. Schröder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N. Engl. J. Med. 2012; 366: 981–90. 7. Murphy DG, Ahlering T, Catalona WJ et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int. 2014; 113: 186–8.
Melanie Danielle Chang,* MBBS (Hons), BMedSci Adee Jonathan Davidson,* MBBS, FRACS Tom Sutherland,† MBBS, FACR Dayan De Fontgalland,‡ MBBS, FRACS Daryl Johnson,§ MBBS, FRCPA Lih-Ming Wong,* MBBS, FRACS *Department of Urology, St Vincent’s Hospital, Melbourne, Victoria, Australia, †Department of Radiology, St Vincent’s Hospital, Melbourne, Victoria, Australia, ‡Department of Colorectal Surgery, St Vincent’s Hospital, Melbourne, Victoria, Australia and §Department of Anatomical Pathology, St Vincent’s Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12917
© 2014 Royal Australasian College of Surgeons
Unusual presentation of advanced prostate cancer masquerading as metastatic and obstructing rectosigmoid cancer An 80-year-old man presented with a 1 week history of constipation, abdominal pain and distension and overflow faecal incontinence on a background of 4 weeks of anorexia. His past history included a total hip replacement, pharyngoesophageal diverticulum and an incarcerated right femoral hernia requiring resection of 5 cm of ileum (necrotic bowel). He had no past or family history of malignancy. On examination, he appeared cachectic with a distended and tender abdomen. Digital rectal examination (DRE) revealed a rectal stricture 2 cm from the anal verge, which was too tight to pass. Computed tomography (CT) scan of his abdomen and pelvis demonstrated extensive ascites, a 9 cm segment of mural thickening affecting the rectosigmoid colon (Fig. 1) with proximal dilatation of distal small intestine and large bowel consistent with developing large intestine obstruction (LBO). There was no evidence of perforation, ischaemia or metastatic disease. Gastrografin enema confirmed a high grade fixed stenosis involving the proximal rectum and rectosigmoid junction (Fig. 2). A presumptive diagnosis of rectosigmoid carcinoma was made. The patient underwent emergency laparotomy with biopsies taken via flexible sigmoidoscopy at the same time. The caecum was noted to be 15–16 cm in diameter, with areas of ischaemia and perforation. There was extensive ascites, peritoneal metastases and omental caking present. He underwent caecal decompression followed by a caecotomy and caecostomy. Histopathological examination of the caecotomy specimen showed ulceration, inflammation and multiple small foci of poorly
Fig. 1. Axial portal venous computed tomography through the pelvis shows circumferential thickening of the rectum (long arrow) with replaced anterior mesorectal fat (arrowhead) in continuity with the prostate (short arrow).
© 2014 Royal Australasian College of Surgeons
differentiated adenocarcinoma in the serosa and subserosa (Fig. 3). Similar histology was seen in the biopsy specimen obtained from the rectum. The tumour cells were stained strongly for cytokeratin (CK) AE1/AE3 and moderately for prostate specific antigen (PSA). This immunohistochemical staining profile is most consistent with prostatic adenocarcinoma with a Gleason pattern 5 + 5 = 10. The tumour was negative with CK20, CK7, S100 and transcription factor 1. CK20 negativity suggests that it is not colorectal adenocarcinoma. Post-operatively, the patient’s PSA was 154 ng/mL. There was no preoperative measurement to compare. Bone scan post-operatively showed no definite evidence to suggest osteoblastic metastatic disease. Bicalutamide was commenced. The patient’s post-operative course was complicated by myocardial infarction, atrial fibrillation, feeding issues and aspiration pneumonia. The patient died 22 days post-operatively from cardiac and malignancy-related causes. This case represents a very rare presentation of prostate cancer masquerading as both obstructing and metastatic rectal cancer. Locally advanced prostate cancer with rectal infiltration is uncommon. Historical series have reported between 1 and 9% rectal involve-
Fig. 2. Frontal view of a gastrografin enema demonstrating a tight apple core stricture (arrow) at the anorectal junction. Note the small volume contrast within the otherwise decompressed bladder (arrow heads) as the enema was performed after a contrast enhanced computed tomography scan.
ANZ J Surg •• (2014) ••–••
2
Fig. 3. Biopsy of rectal stricture. Prostate specific antigen (PSA) stain ×200. Biopsy of rectal stricture displaying moderate staining with PSA, consistent with poorly differentiated adenocarcinoma, most likely of prostatic origin (Gleason pattern 5 + 5 = 10).
ment, but these were from the pre-PSA era (1935–1978).1 Similarly, an autopsy series (1967–1995) suggesting peritoneal metastasis occurring in 7% of men with prostate cancer likely overestimates contemporary occurrence. Our patient presented acutely with LBO requiring emergent laparotomy and was subsequently diagnosed with both locally invasive prostate cancer and extensive peritoneal carcinomatosis. Due to delayed presentation, the need for emergency laparotomy and pre-existing co-morbidities, our patient died 22 days after surgery from cardiorespiratory and cancer-related causes. Diagnosis of prostate cancer in this man was not considered because of the unusual clinical presentation. The abnormal DRE may have prompted PSA testing; however, the clinical picture was more in keeping with LBO secondary to a stenosing colorectal lesion. Prostate cancer metastasizes distantly via the lymphatic and haematogenous routes, most commonly seeding to lymph nodes and bone.1 Peritoneal carcinomatosis rarely occurs in the absence of bone metastasis.2 In men with metastatic prostate cancer, visceral metastasis, poor performance status and PSA ≥ 65 are poor prognostic factors.3 There are no series describing outcomes of men with both locally obstructing prostate cancer and peritoneal carcinomatosis. In a review of men with rectal infiltration by prostate cancer, it was found that 51% presented with gastrointestinal symptoms without prior established diagnosis of prostate cancer. Patients with acute large bowel obstruction were usually managed by defunctioning colostomy and androgen deprivation.4 The median survival for the 86 patients reviewed was 15 months. Metastatic peritoneal carcinomatosis is usually reported in the context of castrate-resistant prostate cancer and response to docetaxel chemotherapy has been reported (six patients, five responded, median survival from starting docetaxel was 24.5 months).5 Proponents of PSA screening would argue cases such as this, with advanced symptomatic disease at presentation, could be prevented. PSA
Images for surgeons
screening remains contentious with a large number needed to screen and treat to prevent one death from prostate cancer.6 The Melbourne Consensus Statement is an example of a balanced approach to this controversial subject.7 Elderly men often have an elevated PSA, but a level >100 ng/mL as in this patient is diagnostic of widespread prostate cancer. As screening over the age of 75 is not recommended, rapid development of an aggressive cancer above this age, while uncommon, is possible. Watchful waiting, a management strategy to monitor patients not able to tolerate or accept the side effects of radical curative treatment, is often offered to more elderly patients, particularly those with shorter life expectancy. In this group of men, the decision to commence noncurative treatment is based on symptoms and disease progression. In this case, rising PSAmay have prompted imaging to diagnose progression of disease, with initiation of palliative androgen deprivation to prevent presentation in extremus. This unusual case of prostate cancer with both local invasion and rare peritoneal carcinomatosis highlights the need for consideration of unusual presentations of prostate cancer in elderly men.
References 1. Bowrey DJ, Otter MI, Billings PJ. Rectal infiltration by prostatic adenocarcinoma: report on six patients and review of the literature. Ann. R. Coll. Surg. Engl. 2003; 85: 382–5. 2. Kehinde EO, Aberdeen SM, Al-Hunayan A, Ali Y. Prostate cancer metastatic to the omentum. Scand. J. Urol. Nephrol. 2002; 36: 225–7. 3. Glass TR, Tangen CM, Crawford ED, Thompson IM. Metastatic carcinoma of the prostate: identifying prognostic groups using recursive partitioning. J. Urol. 2003; 169: 164–9. 4. Benedict SP, Ahuja M, Mammen KJ. Hormone refractory carcinoma prostate with peritoneal metastases and malignant ascites without skeletal involvement: a case report and review of literature. Indian J. Urol. 2010; 26: 287–8. 5. Rita R, Danse E, Aydin S, Tombal B, Machiels JP. Castrate-resistant prostate cancer with peritoneal metastases treated with docetaxel-based chemotherapy. Urol. Int. 2014; 93: 49–54. 6. Schröder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N. Engl. J. Med. 2012; 366: 981–90. 7. Murphy DG, Ahlering T, Catalona WJ et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int. 2014; 113: 186–8.
Melanie Danielle Chang,* MBBS (Hons), BMedSci Adee Jonathan Davidson,* MBBS, FRACS Tom Sutherland,† MBBS, FACR Dayan De Fontgalland,‡ MBBS, FRACS Daryl Johnson,§ MBBS, FRCPA Lih-Ming Wong,* MBBS, FRACS *Department of Urology, St Vincent’s Hospital, Melbourne, Victoria, Australia, †Department of Radiology, St Vincent’s Hospital, Melbourne, Victoria, Australia, ‡Department of Colorectal Surgery, St Vincent’s Hospital, Melbourne, Victoria, Australia and §Department of Anatomical Pathology, St Vincent’s Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12917
© 2014 Royal Australasian College of Surgeons
