Open Access

Metastatic prostate cancer masquerading clinically and radiologically as a primary caecal carcinoma

  • Muhammad A Kabeer1,
  • Edward Lloyd-Davies2,
  • Giles Maskell3,
  • Rolf Hohle1 and
  • Joseph Mathew1Email author
World Journal of Surgical Oncology20075:2

DOI: 10.1186/1477-7819-5-2

Received: 11 August 2006

Accepted: 07 January 2007

Published: 07 January 2007

Abstract

Background

Prostatic carcinoma is the second most common cause of cancer-related deaths in males in the West. Approximately 20% of patients present with metastatic disease. We describe the case of a patient with metastatic prostate cancer to the bowel presenting clinically and radiologically as a primary caecal cancer.

Case presentation

A 72 year-old man presented with abdominal discomfort and a clinically palpable caecal mass and a firm nodule on his thigh, the latter behaving clinically and radiologically as a lipoma. Computed tomographic (CT) scan showed a luminally protuberant caecal mass with regional nodal involvement. The patient was being treated (Zoladex®) for prostatic cancer diagnosed 6 years previously and was known to have bony metastases. On admission his PSA was 245.4 nmol/ml. The patient underwent a right hemicolectomy. Histology showed a poorly differentiated adenocarcinoma which was PSA positive, confirming metastatic prostatic adenocarcinoma to the caecum. The patient underwent adjuvant chemotherapy and is free from recurrence a year later.

Conclusion

Metastasis of prostatic carcinoma to the bowel is a very rare occurrence and presents a challenging diagnosis. The diagnosis is supported by immunohistochemistry for PSA. The treatment for metastatic prostate cancer is mainly palliative.

Background

Prostatic carcinoma is the second most common cause of cancer related deaths in males in the West [1]. Approximately 20% of patients present with metastatic disease but colo-rectal involvement is rare[2]. We describe the case of a patient with metastatic prostate cancer to the bowel presenting as primary caecal cancer.

Case presentation

A 72-year-old man presented with abdominal discomfort with small amount of bleeding per rectum and a clinically palpable lump in the right iliac fossa. He also had a large, firm, mobile lump on his left thigh.

He had been treated six years previously for prostatic carcinoma which was Gleason's grade 3+3= 6. Bony metastases had been diagnosed recently. He was on Zoladex® injections.

Clinical examination showed a 6 cm hard, mobile, non-tender mass in his right iliac fossa. Digital rectal examination was unremarkable. Rigid sigmoidoscopy revealed radiation proctitis, which would explain his bleeding per rectum. CT scan of abdomen showed a caecal tumour with regional lymphadenopathy and vertebral metastasis (Figure 1). A non-palpable left iliac mass was identified: this was defined as internal iliac nodes lymphadenopathy, associated with partial obstruction of the left ureter (the possibility of prostatic metastasis to these nodes was considered). A fatty mass lesion was identified in the left thigh, the CT appearances of which were that of a simple lipoma; this has remained unchanged on subsequent CT scans. Bone scan confirmed bony metastasis in the 12th thoracic and 1st lumbar vertebrae and rib cage. In 2003, there was a gradual rise in his PSA levels which had gone upto 233 nmol/ml. Zoladex® injections were then started and his PSA levels fell to 6.3 nmol/ml by January 2004. This however had gradually risen again to 254.4 nmol/ml on admission, inspite of being on Zoladex®.
Figure 1

a) Imaging shows a well defined caecal tumour (arrow) with evidence of vertebral metastasis (arrowhead). b) The tumour is irregular in outline (arrow) and is closely approximated to the anterior abdominal wall.

The patient underwent a right hemicolectomy for what appeared to be an obvious locally advanced luminally protuberant caecal carcinoma with mesenteric lymph nodal involvement. Histopathological examination of the specimen showed a poorly differentiated adenocarcinoma of the caecum extending throughout the whole bowel wall and breaching the serosa with metastatic involvement of 5 of 15 paracolic lymph nodes (Figure 2). The possibility of prostatic metastasis was considered and confirmed on immunohistochemical staining for PSA (Figure 2) and, given this, stains for CK7, CK20 and CDX2 immunoprofile were considered unnecessary. The final histological diagnosis was of a metastatic prostatic adenocarcinoma to the caecum. The patient underwent adjuvant chemotherapy with Docetaxel and Paclitaxel and is free from recurrence a year later.
Figure 2

a) Histology shows a well defined intraluminal, protuberant tumour invading the submucosa. This invasive tumour extends to pericolonic fibroadipose tissue. b) This tumour is positive with PSA, confirming its metastatic origin from a primary prostatic carcinoma.

Discussion

Progression of prostate cancer occurs either by direct extension or metastasis through haematogenous or lymphatic routes. The most commonly involved organs are the seminal vesicles, base of the bladder, bones (mainly axial skeleton) and lymph nodes[1]. Widespread visceral involvement is quite rare. Some unusual sites of spread have been described in literature as the parotid gland[3], oesophagus[4], vocal cords[5], larynx[6], lung &bronchus[7], stomach[8], liver[9], skin[10], umbilicus [11], sphenoid sinus[12], cranium[13], meninges[14], testes[15], penis[16], breast[17], mediastinum[18], thymus [19], orbit[20], uveal tract[21], brain[22], cerebellum[23] and bones[24]. Rectal seeding on needle biopsy[25] and direct involvement occasionally occurs [26], but distant metastasis to the bowel is quite rare (prevalence 1–4% in autopsy series)[27]. So far only three accounts of metastasis to the distant bowel have been recorded, one involving the small bowel[27] and the other two involving the rectosigmoid[28, 29].

It is important to distinguish primary from metastatic colorectal lesions, especially in the presence of a previous history of cancer at another site, in order to facilitate appropriate management. This is best achieved by defining the tumour type on histopathologic grounds and, in this instance, by immunohistochemical staining for PSA[17, 30]. The treatment of primary colonic adenocarcinomas is potentially curative with a combination of surgery and chemo-irradiation; treatment of colonic metastasis depends on the primary site and might not be 'curative'. The treatment of metastatic disease from the prostate is purely palliative; hormonal treatment represents the standard[31], although this can be combined with debulking surgery to reduce the tumour load where feasible. However, the impact of debulking surgery on patient survival is not known. Metastatic prostate cancer has poor prognosis and survival rates range from 1 to 3 years[8].

The response of prostatic carcinoma to oestrogen therapy has been well established[32] but patients often become refractory after prolonged treatment. Options for hormone-refractory prostate cancer include secondary hormonal treatment (anti-androgens), radiotherapy and cytotoxic chemotherapy. The metastatic component, as described in our case, can be managed with debulking surgery and may well need adjuvant chemotherapy or secondary hormonal treatment to achieve reasonable regression of disease.

Conclusion

Metastasis of prostatic carcinoma to the bowel is a very rare occurrence and presents a challenging diagnosis. The mainstay of diagnosis is histopathology supported by immunohistochemistry for PSA.

Palliative treatment remains the mainstay of therapy for metastatic prostate cancer and hormonal therapy represents the standard with debulking surgery where feasible.

Declarations

Acknowledgements

Written consent was obtained from the patient for publication of this case report.

Authors’ Affiliations

(1)
Department of Histopathology, Royal Cornwall Hospital
(2)
Department of Surgery, Royal Cornwall Hospital
(3)
Department of Clinical Imaging, Royal Cornwall Hospital

References

  1. Epstein JI: The Lower Urinary Tract and Male Genital System, Pathologic Basis Of Disease. 2004, London: Elsevier-Saunders, 7Google Scholar
  2. Siddiqui E, Mumtaz FH, Gelister J: Understanding prostate cancer. J R Soc Health. 2004, 124: 219-221.View ArticleGoogle Scholar
  3. Kirkali Z, Koyuncuoglu M, Pabuccuoglu U, Guneri A, Mungan U: Prostatic carcinoma presenting with painless parotid mass. Urology. 1995, 46: 406-407. 10.1016/S0090-4295(99)80231-3.View ArticlePubMedGoogle Scholar
  4. Nakamura T, Mohri H, Shimazaki M, Ito Y, Ohnishi T, Nishino Y, Fujihiro S, Shima H, Matsushita T, Yasuda M, Moriwaki H, Muto Y, Deguchi T: Esophageal metastasis from prostate cancer: diagnostic use of reverse transcriptase-polymerase chain reaction for prostate-specific antigen. J Gastroenterol. 1997, 32: 236-240.View ArticlePubMedGoogle Scholar
  5. Park YW, Park MH: Vocal cord paralysis from prostatic carcinoma metastasizing to the larynx. Head Neck. 1993, 15: 455-458.View ArticlePubMedGoogle Scholar
  6. Coakley JF, Ranson DL: Metastasis to the larynx from a prostatic carcinoma. A case report. J Laryngol Otol. 1984, 98: 839-842.View ArticlePubMedGoogle Scholar
  7. Hofland CA, Bagg MD: An isolated pulmonary metastasis in prostate cancer. Mil Med. 2000, 165: 973-974.PubMedGoogle Scholar
  8. Christoph F, Grunbaum M, Wolkers F, Muller M, Miller K: Prostate cancer metastatic to the stomach. Urology. 2004, 63: 778-779. 10.1016/j.urology.2003.12.009.View ArticlePubMedGoogle Scholar
  9. Taylor J, Lindor K: Metastatic prostate cancer simulating sclerosing cholangitis. J Clin Gastroenterol. 1993, 16: 143-145.View ArticlePubMedGoogle Scholar
  10. Spiller JC, Hall JC, Watson KR: Cancer of prostate metastatic to the skin diagnosed by immunoperoxidase staining. Mo Med. 1991, 88: 642-644.PubMedGoogle Scholar
  11. Fukuda H, Saito R: A case of Sister Mary Joseph's nodule from prostatic cancer. J Dermatol. 2006, 33: 46-51. 10.1111/j.1346-8138.2006.00009.x.View ArticlePubMedGoogle Scholar
  12. McClatchey KD, Lloyd RV, Schaldenbrand JD: Metastatic carcinoma to the sphenoid sinus. Case report and review of the literature. Arch Otorhinolaryngol. 1985, 241: 219-224. 10.1007/BF00453691.View ArticlePubMedGoogle Scholar
  13. Lippman SM, Buzaid AC, Iacono RP, Steinbronn DV, Stanisic TH, Rennels MA, Yang PJ, Garewal HS, Ahmann FR: Cranial metastases from prostate cancer simulating meningioma: report of two cases and review of the literature. Neurosurgery. 1986, 19: 820-823.View ArticlePubMedGoogle Scholar
  14. Scarrow AM, Rajendran PR, Marion D: Metastatic prostate adenocarcinoma of the dura mater. Br J Neurosurg. 2000, 14: 473-474. 10.1080/02688690050175328.View ArticlePubMedGoogle Scholar
  15. Bashein HJ, Ginsberg P, Zond JR, Finkelstein LH: Testicular metastasis from adenocarcinoma of the prostate. J Am Osteopath Assoc. 1991, 91: 895-897.PubMedGoogle Scholar
  16. Nakayama F, Sheth S, Caskey CI, Hamper UM: Penile metastasis from prostate cancer: diagnosis with sonography. J Ultrasound Med. 1997, 16: 751-753.PubMedGoogle Scholar
  17. Sahoo S, Smith RE, Potz JL, Rosen PP: Metastatic Prostate Adenocarcinoma Within a Primary Solid Papillary Carcinoma of NMale Breast- Application of Immunhohistochemistry to a Unique Collision Tumour. Archives of Pathology & Laboratory Medicine. 2001, 125: 1101-1103.Google Scholar
  18. Park Y, Oster MW, Olarte MR: Prostatic cancer with an unusual presentation: polymyositis and mediastinal adenopathy. Cancer. 1981, 48: 1262-1264. 10.1002/1097-0142(19810901)48:5<1262::AID-CNCR2820480535>3.0.CO;2-C.View ArticlePubMedGoogle Scholar
  19. Hayashi S, Hamanaka Y, Sueda T, Yonehara S, Matsuura Y: Thymic metastasis from prostatic carcinoma: report of a case. Surg Today. 1993, 23: 632-634. 10.1007/BF00311913.View ArticlePubMedGoogle Scholar
  20. Autorino R, Zito A, Di Giacomo F, Cosentino L, Quarto G, Di Lorenzo G, Mordente S, Pane U, Giordano A, D'Armiento M: Orbital metastasis as a first indication of prostate cancer: a case report. Arch Ital Urol Androl. 2005, 77: 109-110.PubMedGoogle Scholar
  21. Obek C, Kural AR, Yaycioglu O, Kendiroglu G, Solok V: Metastatic adenocarcinoma of the prostate to the uvea as the initial presenting symptom in a 49-year-old man. Urology. 2001, 58: 106-10.1016/S0090-4295(01)00981-5.View ArticlePubMedGoogle Scholar
  22. Tsai V, Kim S, Clatterbuck RE, Ewend MG, Olivi A: Cystic prostate metastases to the brain parenchyma: report of two cases and review of the literature. J Neurooncol. 2001, 51: 167-173. 10.1023/A:1010606427945.View ArticlePubMedGoogle Scholar
  23. Papatsoris AG, Mpadra FA, Karamouzis MV: Prostate cancer presenting as a solitary cerebellar metastasis. A case report and review of the literature. Tumori. 2002, 88: 61-64.PubMedGoogle Scholar
  24. Cheville JC, Tindall D, Boelter C, Jenkins R, Lohse CM, Pankratz VS, Sebo TJ, Davis B, Blute ML: Metastatic prostate carcinoma to bone: clinical and pathologic features associated with cancer-specific survival. Cancer. 2002, 95: 1028-1036. 10.1002/cncr.10788.View ArticlePubMedGoogle Scholar
  25. Vaghefi H, Magi-Galluzzi C, Klein EA: Local recurrence of prostate cancer in rectal submucosa after transrectal needle biopsy and radical prostatectomy. Urology. 2005, 66: 881-10.1016/j.urology.2005.04.005.View ArticlePubMedGoogle Scholar
  26. 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: 382-385. 10.1308/003588403322520726.PubMed CentralView ArticlePubMedGoogle Scholar
  27. Malhi-Chowla N, Wolfsen HC, Menke D, Woodward TA: Prostate cancer metastasizing to the small bowel. J Clin Gastroenterol. 2001, 32: 439-440. 10.1097/00004836-200105000-00017.View ArticlePubMedGoogle Scholar
  28. Culkin DJ, Demos TC, Wheeler JS, Castelli M, Canning JR: Separate annular strictures of the rectosigmoid colon secondary to unsuspected prostate cancer. J Surg Oncol. 1990, 43: 189-192.View ArticlePubMedGoogle Scholar
  29. Gengler L, Baer J, Finby N: Rectal and sigmoid involvement secondary to carcinoma of the prostate. Am J Roentgenol Radium Ther Nucl Med. 1975, 125: 910-917.View ArticlePubMedGoogle Scholar
  30. Ars c, Duck L, Baurain JF, Moulin P, Duprez T, Machiels JP: Unusual metastatic features in a patient with concomitant malignant orbital melanoma and prostate carcinoma. Journal of Neuro-Oncology. 2004, 66: 361-363. 10.1023/B:NEON.0000014540.05737.1a.View ArticlePubMedGoogle Scholar
  31. Fusi A, Procopio G, Delia Torre S, Ricotta R, Bianchini G, Salvioni R, Ferrari L, Martinetti A, Savelli G, Villa S, Bajetta E: Treatment options in hormone-refractory metastatic prostate carcinoma. Tumori. 2004, 90: 535-546.PubMedGoogle Scholar
  32. de la Monte SM, Moore GW, Hutchins GM: Metastatic behavior of prostate cancer. Cluster analysis of patterns with respect to estrogen treatment. Cancer. 1986, 58: 985-993. 10.1002/1097-0142(19860815)58:4<985::AID-CNCR2820580432>3.0.CO;2-I.View ArticlePubMedGoogle Scholar

Copyright

© Kabeer et al; licensee BioMed Central Ltd. 2007

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement