Diagnostic difficulties in the case of prostate cancer with massive nodal metastases
without correlation with PSA
Article published in Urologia Polska 2008/61/Supl. 1.
Teresa Gawlik-Jakubczak, Robert Hałasa, Jan Iwanicki
- Szpital Marynarki Wojennej w Gdańsku
Introduction. Prostate cancer is third cancer recognized in male population in Poland. Usually we begin diagnostic procedure in case of alarmed clinical symptoms , abnormalities in DRE, elevated PSA. Very seldom the first and only symptom of prostate cancer is significant enlargement of lymph nodes in the pelvis discovered in ultrasound examination of abdomen due to abdominal pain.
Objectives. Aim of this work is to present the rare case of patient with massive enlargement of lymph nodes in pelvis till 4 cm discovered in US as the first symptom of prostate cancer
Materials and methods. Patient 69y old was diagnosed at surgery department due to enlargement of lymph nodes in several packets in the pelvis, mainly on the left side. In CT of abdomen there was no other suspected, neoplasm lesions. Explorative laparotomy was performed. In HP: molten metastasis cancer, origin- unknown. Patient had no symptoms from urinary tract, was consulted by urologist. DRE-prostate slightly enlarged, more coherent, without palpable tumour, PSA 0.04 ng/ml. Ultrasound guided core biopsy was performed. Pathology-BPH. Patient was admitted to urology department for further investigation 09.2007, when in control CT progression of nodal lesions on both sides, left ureterohydronephrosis and thicken, infiltrated urinary bladder wall on left side were described. 09.2007 TURT was performed. Bladder was pressed and
- displaced to right side. It was impossible to recognise ureteral orifice. HP –“one chip could be suspected” as neoplasm. Than left nephrostomy was done. Next TURT was done, tissue was sent for additional staining. HP: dispersed cells of adenocarcinoma in the mucosa and muscle of the bladder. Changes suggested external invasion, rather from prostate than from bowel-in specific staining. New value of PSA – 11.6 ng/ml. We performed next biopsy of the prostate.
Results. After additional staining -CK7,CK20 adenocarcinoma of prostate Gleason 10(5+5) was recognized. The patient received hormonotherapy (antyandrogen + agonist LHRH). He waits for radiotherapy. In CT of abdomen 04.08 was recognized partial remission-left kidney without hydronephrosis, well secretioning urine, significant regression of nodal metastases and infiltration of bladder wall. PSA <0.001.
Conclusions. Massive nodal metastases could be the first symptom of prostate cancer. Elevation of PSA may be very small or even absent, incommensurable to nodal changes. This can suggest a rare type of non differentiated prostate cancer. Additional staining is very helpful at diagnostic process of rare type of neoplasm.