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Papillary intracystic adenocarcinoma of prostate & massive benign prostatic cyst
PAPILLARY INTRACYSTIC ADENOCARCINOMA OF PROSTATE W MASSIVE BENIGN PROSTATIC CYST* BENJAMIN S. BARRINGER, M.D., F.A.C.S. NEW YORK CITY
T
I FIG.
tiveIy by means of a specimen through an aspirating needIe through the perineum.
HESE 2 cases are reported together because from the history, symptoms and physica examination they were
I. PapiIIary intracystica denocarcinoma tate. Cyst is shown behind bIadder.
FIG. 2. Operation in Case II. Cyst was made part of btadder cavity. Prostate subsequentIy became site of adenocarcinoma.
I of pros-
Both cases are very rare, the Iatter possibIy unique. In both of these cases there is no question as to their prostatic origin. Both of the cysts were in the median Iine, neither had any reIation to the semina1 vesicIes. In one of them (Case I) the symptom of hematuria undoubtedIy was caused by bIood from the tumor exuding through a patent prostatic duct emptying into the prostatic urethra. It is interesting to specuIate upon the formation of these cysts. They must have had origin in the obIiteration of a prostatic duct or a series of ducts and a sIow deveIopment of a singIe Iarge prostatic cyst. Just why one shouId deveIop a maIignant growth and
very simiIar. Both were primariIy cysts originating in and eventuaIIy repIacing the prostate; then evidentIy hindered by the fascia of the bIadder base on the one hand and the fascia of DenonveIIiers on the other pushed upwards between the two fasciae and extended behind the bIadder. One deveIoped as a simpIe benign cyst containing 130 C.C. of straw-coiored fluid. The prostate which remained after the erradication of the cyst became maIignant, a rapidIy growing adenocarcinoma. The other deveIoped as a papiIIary intracystic adenocarcinoma of the prostate. Both were accurateIy diagnosed preopera* From the UroIogicaI
Service,
obtained inserted
Memorial HospitaI, New York City. Read before the Section Surgery, N. Y. Academy of Medicine, May 18, 1932. 51
on Genito-Urinary
52
American Journal of Surgery
the other possibIe CASE
cinema
a totaIIy benign to determine.*
Barringer-Adenocarcinoma growth
is im-
I. PapiIIary intracystic adenocarof the prostate. MemoriaI HospitaI
41433.
A. L., aged fifty-nine, admitted to the hospital May 13, 1930, with the folIowing history: His occupation was that of a stationary engineer. He has had the usua1 disease of chiIdhood. Typhoid fever at nineteen years of age. He has been treated by a chiropractor for double inguina1 hernia. His present iIIness began two years ago with hematuria. This has continued with periods of remission. It has been more intense during the Iast two months. There has been neither dysuria or poIIakiuria. He has Iost no weight. The physica examination reveaIed that the patient’s urine was microscopicaIIy bIoody; that he had 60 C.C. of residua1 urine. The recta1 examination reveaIed a prostate the size of a Iarge orange, cystic in feeIing, with a Iump, quite hard at the top of the mass and a hard ridge on the right side. Cystoscopy showed a trabecuIated bIadder with some smaI1 papiIIomatous masses in the internal urethra. His eyes, nose, mouth, throat, heart, Iungs and abdomen were negative with the exception of a doubIe inguinal hernia, the right reducibIe, no adenopathy. BIood pressure 120/78. A fiIm of his Iumbar spine and peIvis reveaIed some increase in density in the peIvis, but they were not characteristic of metastasis from prostatic carcinoma. His bIood urea was not estimated prior to operation. An aspirating needIe was passed through the perineum into the cystic mass, guided by a finger inserted into the rectum. About 40 C.C. of pure bIood was aspirated and then some pIugs of soft, ceIIuIar tissue. After the withdrawa of the bIood, many smaI1 noduIes couId be feIt in the cyst waI1. The pathoIogica1 diagnosis of the aspirated materia1 showed “adenocarcinoma. ” Under spina anesthesia the bIadder was opened and the bIadder found to be entireIy normaI. The median Iobe of the prostate was Iarge, merging into the IateraI Iobes. These three Iobes were removed and a Iarge cystic cavity 8 x 6 X 4 cm. was opened up. This extended up behind the bIadder and was fiIIed *The remaining portions of the prostate of this patient became matignant. This has been controIIedby interstitia1 irradiation.
with a papiIIary growth. There was a distinct cyst waI1 Iimiting the growth. Much of the papiIIomatous materia1 was removed. Three tubes of radium screened by g mm. of siIver were placed in the cyst. These totaIed 164.7 miIIicuries and were Ieft in the cyst for nine hours, giving a tota radium dose of 1482 mc. hours. The bIadder was cIosed and a suprapubic drainage tube left in pIace. We beIieved it would have been futiIe to mobiIize the bIadder and try to remove the cyst as metastatic growths were feIt beyond the cyst. The patient had profuse emesis postoperativeIy. This continued with some intervaIs of remission. SaIine and gIucose soIutions in Iarge quantities were given subcutaneousIy and intravenousIy. Persistent hiccoughing foILowed the vomiting. The patient died on the tenth day after operation, uremic. The pathoIogica1 report was as follows: “Adenocarcinoma and diffuse carcinoma. BuIky intracystic adenocarcinoma. The materiaIs selected for examination were some of the papiIIary contents of the cyst and a portion of the indurated mass in the bIadder base.” This very rare tumor of the prostate has not as far as I can ascertain been described. The prostate in its duct system and anatomy is anaIogous to the femaIe breast. A simiIar condition “papiIIary intracystic adenocarcinoma of the breast” is a reIativeIy common disease. The Ioose connective tissue of the breast and the extensive duct systems aIIow, somewhat unhindered, the deveIopment of breast cysts in which papiIIary adenocarcinoma may deveIop. The prostate ducts are comparatively short. The prostate itseIf is somewhat restricted in growth by various surrounding fascias. The prostate sheath, the fascia at the bIadder base and the fascia of DenonveIIiers a11 inhibit extensive cyst formation. These two factors, the shortness of the prostatic ducts and the firm fascia around the prostate probabIy hinder the development of Iarge prostatic cysts. The cyst in the second case, described beIow, also pushed up behind the bIadder between the fascia of the bIadder base and the fascia of DenonveIIiers.
NEW
SERIES Var. XX.
No.
1
Barringer-Adenocarcinoma
CASE II. Massive benign cyst of the prostate. Memorial HospitaI 43543. J. J. O’C., aged fifty-seven years, admitted to the hospitaI on August I I, 193 I, with the foIIowing history: His symptoms began eight months ago (May, 1931) with dribbling at the end of urination. After that he had pain in his prostatic region and frequent and painfu1 urination. His night urination was three to four times and his day urination every one and onehaIf hours. There had never been hematuria. He compIained of a sIight Ioss of weight and strength. The physical examination reveaIed the foIIowing: He had at various examinations from 20 to 60 C.C. of residua1 urine. The urine was cIear. A cystoscopy showed a norma bIadder and prostate with the exception of a sIight buIging of his median Iobe. The recta1 examination showed a mass at the site of his prostate, the top of which couId not be reached. The mass was regular, smooth, tense and felt cystic. His bIood urea nitrogen was I 1.3 mg. Under spina anesthesia 130 C.C. of bIoody tIuid was aspirated from the cyst. FoIIowing the perinea1 aspiration the cyst entireIy disappeared as did his residua1 urine. Examination of the aspirated fluid reveaIed no tumor ceIIs. Within a week the cyst had refiIIed. At a Iater date m viii of pure carboIic acid was injected into the cyst after aspiration of its contents; this did nothing. The cyst refiIIed and it was decided to operate upon the patient. Under spina anesthesia the bIadder was opened, the median Iobe of the prostate broken into, the cyst opened and its contents evacuated. It was found to be a simpIe cyst with a smooth cyst waI1. A portion of the waI1 was removed for pathoIogica1 examination. The cyst was found to be adherent to the bIadder waI1 and extended about 5 cm. behind the bIadder waI1. In the median Iine through the trigone an incision was made into the cyst cavity, so making it continuous, with the bladder cavity. The edges of this incision were sutured. A drainage tube was Ieft in the bIadder and the wound cIosed. Before the operation mobiIization of the bIadder and dissection of the cyst was considered. Because of its attachment to the prostate and the depth of the cyst this was beIieved to be the poorer and more diflicuIt procedure.
American Journal of Surgery
53
The patient’s recovery was uneventful. Four weeks after the operation and the heaIing of the suprapubic wound, the patient had 20 C.C. of residua1 urine. A pathoIogica1 examination of the piece excised from the cyst waI1 reveaIed no tumor. About two months Iater because of the residual urine and stone formation the stone was crushed and washed out and the Iower part of the bIadder neck resected through the cystoscope. The removed materia1 showed adenocarcinoma. This is to be treated with radium.
Wesson,‘in a very extensive and exceIIent resume of the literature, reviews 29 cases of prostatic cysts, in&ding 4 of his own. In but 3 of the cases reported were the prostatic cysts of Iarge size and these were found at autopsy. In the Iarge majority of cases retention of urine, partia1 or comsymptom. In pIete, was an important most of the cases operated upon, the operation of choice was the opening or puncturing of the cyst by means of the cautery or by fuIguration through the cystoscope. In 18 of the 29 cases the prostatic cysts were found at autopsy. In apparentIy none of them was as extensive an operation done as was performed in our case. There is just one point that I shouId Iike to emphasize in considering these Iesions, that is that they may be maIignant and that the patient shouId be carefuIIy watched for a considerable time to determine whether or not the cysts are part of a maIignant degeneration. If the cyst fluid is bIoody there is a greater chance that the condition may be maIignant. I have seen one case in which a distinct cyst showed in the position of the median Iobe of the prostate. This cyst was punctured by means of the cystoscope, bIoody fluid escaping. I beIieved the condition benign. Further observation however proved that he had a myosarcoma of the prostate which was treated and cured by radium, the patient remaining we11 six years and dying of an intercurrent disease. ’ Wesson: Cyst of the prostate and urethra. J. of Ural.. 13: No. 6, rgq.
T
I FIG.
tiveIy by means of a specimen through an aspirating needIe through the perineum.
HESE 2 cases are reported together because from the history, symptoms and physica examination they were
I. PapiIIary intracystica denocarcinoma tate. Cyst is shown behind bIadder.
FIG. 2. Operation in Case II. Cyst was made part of btadder cavity. Prostate subsequentIy became site of adenocarcinoma.
I of pros-
Both cases are very rare, the Iatter possibIy unique. In both of these cases there is no question as to their prostatic origin. Both of the cysts were in the median Iine, neither had any reIation to the semina1 vesicIes. In one of them (Case I) the symptom of hematuria undoubtedIy was caused by bIood from the tumor exuding through a patent prostatic duct emptying into the prostatic urethra. It is interesting to specuIate upon the formation of these cysts. They must have had origin in the obIiteration of a prostatic duct or a series of ducts and a sIow deveIopment of a singIe Iarge prostatic cyst. Just why one shouId deveIop a maIignant growth and
very simiIar. Both were primariIy cysts originating in and eventuaIIy repIacing the prostate; then evidentIy hindered by the fascia of the bIadder base on the one hand and the fascia of DenonveIIiers on the other pushed upwards between the two fasciae and extended behind the bIadder. One deveIoped as a simpIe benign cyst containing 130 C.C. of straw-coiored fluid. The prostate which remained after the erradication of the cyst became maIignant, a rapidIy growing adenocarcinoma. The other deveIoped as a papiIIary intracystic adenocarcinoma of the prostate. Both were accurateIy diagnosed preopera* From the UroIogicaI
Service,
obtained inserted
Memorial HospitaI, New York City. Read before the Section Surgery, N. Y. Academy of Medicine, May 18, 1932. 51
on Genito-Urinary
52
American Journal of Surgery
the other possibIe CASE
cinema
a totaIIy benign to determine.*
Barringer-Adenocarcinoma growth
is im-
I. PapiIIary intracystic adenocarof the prostate. MemoriaI HospitaI
41433.
A. L., aged fifty-nine, admitted to the hospital May 13, 1930, with the folIowing history: His occupation was that of a stationary engineer. He has had the usua1 disease of chiIdhood. Typhoid fever at nineteen years of age. He has been treated by a chiropractor for double inguina1 hernia. His present iIIness began two years ago with hematuria. This has continued with periods of remission. It has been more intense during the Iast two months. There has been neither dysuria or poIIakiuria. He has Iost no weight. The physica examination reveaIed that the patient’s urine was microscopicaIIy bIoody; that he had 60 C.C. of residua1 urine. The recta1 examination reveaIed a prostate the size of a Iarge orange, cystic in feeIing, with a Iump, quite hard at the top of the mass and a hard ridge on the right side. Cystoscopy showed a trabecuIated bIadder with some smaI1 papiIIomatous masses in the internal urethra. His eyes, nose, mouth, throat, heart, Iungs and abdomen were negative with the exception of a doubIe inguinal hernia, the right reducibIe, no adenopathy. BIood pressure 120/78. A fiIm of his Iumbar spine and peIvis reveaIed some increase in density in the peIvis, but they were not characteristic of metastasis from prostatic carcinoma. His bIood urea was not estimated prior to operation. An aspirating needIe was passed through the perineum into the cystic mass, guided by a finger inserted into the rectum. About 40 C.C. of pure bIood was aspirated and then some pIugs of soft, ceIIuIar tissue. After the withdrawa of the bIood, many smaI1 noduIes couId be feIt in the cyst waI1. The pathoIogica1 diagnosis of the aspirated materia1 showed “adenocarcinoma. ” Under spina anesthesia the bIadder was opened and the bIadder found to be entireIy normaI. The median Iobe of the prostate was Iarge, merging into the IateraI Iobes. These three Iobes were removed and a Iarge cystic cavity 8 x 6 X 4 cm. was opened up. This extended up behind the bIadder and was fiIIed *The remaining portions of the prostate of this patient became matignant. This has been controIIedby interstitia1 irradiation.
with a papiIIary growth. There was a distinct cyst waI1 Iimiting the growth. Much of the papiIIomatous materia1 was removed. Three tubes of radium screened by g mm. of siIver were placed in the cyst. These totaIed 164.7 miIIicuries and were Ieft in the cyst for nine hours, giving a tota radium dose of 1482 mc. hours. The bIadder was cIosed and a suprapubic drainage tube left in pIace. We beIieved it would have been futiIe to mobiIize the bIadder and try to remove the cyst as metastatic growths were feIt beyond the cyst. The patient had profuse emesis postoperativeIy. This continued with some intervaIs of remission. SaIine and gIucose soIutions in Iarge quantities were given subcutaneousIy and intravenousIy. Persistent hiccoughing foILowed the vomiting. The patient died on the tenth day after operation, uremic. The pathoIogica1 report was as follows: “Adenocarcinoma and diffuse carcinoma. BuIky intracystic adenocarcinoma. The materiaIs selected for examination were some of the papiIIary contents of the cyst and a portion of the indurated mass in the bIadder base.” This very rare tumor of the prostate has not as far as I can ascertain been described. The prostate in its duct system and anatomy is anaIogous to the femaIe breast. A simiIar condition “papiIIary intracystic adenocarcinoma of the breast” is a reIativeIy common disease. The Ioose connective tissue of the breast and the extensive duct systems aIIow, somewhat unhindered, the deveIopment of breast cysts in which papiIIary adenocarcinoma may deveIop. The prostate ducts are comparatively short. The prostate itseIf is somewhat restricted in growth by various surrounding fascias. The prostate sheath, the fascia at the bIadder base and the fascia of DenonveIIiers a11 inhibit extensive cyst formation. These two factors, the shortness of the prostatic ducts and the firm fascia around the prostate probabIy hinder the development of Iarge prostatic cysts. The cyst in the second case, described beIow, also pushed up behind the bIadder between the fascia of the bIadder base and the fascia of DenonveIIiers.
NEW
SERIES Var. XX.
No.
1
Barringer-Adenocarcinoma
CASE II. Massive benign cyst of the prostate. Memorial HospitaI 43543. J. J. O’C., aged fifty-seven years, admitted to the hospitaI on August I I, 193 I, with the foIIowing history: His symptoms began eight months ago (May, 1931) with dribbling at the end of urination. After that he had pain in his prostatic region and frequent and painfu1 urination. His night urination was three to four times and his day urination every one and onehaIf hours. There had never been hematuria. He compIained of a sIight Ioss of weight and strength. The physical examination reveaIed the foIIowing: He had at various examinations from 20 to 60 C.C. of residua1 urine. The urine was cIear. A cystoscopy showed a norma bIadder and prostate with the exception of a sIight buIging of his median Iobe. The recta1 examination showed a mass at the site of his prostate, the top of which couId not be reached. The mass was regular, smooth, tense and felt cystic. His bIood urea nitrogen was I 1.3 mg. Under spina anesthesia 130 C.C. of bIoody tIuid was aspirated from the cyst. FoIIowing the perinea1 aspiration the cyst entireIy disappeared as did his residua1 urine. Examination of the aspirated fluid reveaIed no tumor ceIIs. Within a week the cyst had refiIIed. At a Iater date m viii of pure carboIic acid was injected into the cyst after aspiration of its contents; this did nothing. The cyst refiIIed and it was decided to operate upon the patient. Under spina anesthesia the bIadder was opened, the median Iobe of the prostate broken into, the cyst opened and its contents evacuated. It was found to be a simpIe cyst with a smooth cyst waI1. A portion of the waI1 was removed for pathoIogica1 examination. The cyst was found to be adherent to the bIadder waI1 and extended about 5 cm. behind the bIadder waI1. In the median Iine through the trigone an incision was made into the cyst cavity, so making it continuous, with the bladder cavity. The edges of this incision were sutured. A drainage tube was Ieft in the bIadder and the wound cIosed. Before the operation mobiIization of the bIadder and dissection of the cyst was considered. Because of its attachment to the prostate and the depth of the cyst this was beIieved to be the poorer and more diflicuIt procedure.
American Journal of Surgery
53
The patient’s recovery was uneventful. Four weeks after the operation and the heaIing of the suprapubic wound, the patient had 20 C.C. of residua1 urine. A pathoIogica1 examination of the piece excised from the cyst waI1 reveaIed no tumor. About two months Iater because of the residual urine and stone formation the stone was crushed and washed out and the Iower part of the bIadder neck resected through the cystoscope. The removed materia1 showed adenocarcinoma. This is to be treated with radium.
Wesson,‘in a very extensive and exceIIent resume of the literature, reviews 29 cases of prostatic cysts, in&ding 4 of his own. In but 3 of the cases reported were the prostatic cysts of Iarge size and these were found at autopsy. In the Iarge majority of cases retention of urine, partia1 or comsymptom. In pIete, was an important most of the cases operated upon, the operation of choice was the opening or puncturing of the cyst by means of the cautery or by fuIguration through the cystoscope. In 18 of the 29 cases the prostatic cysts were found at autopsy. In apparentIy none of them was as extensive an operation done as was performed in our case. There is just one point that I shouId Iike to emphasize in considering these Iesions, that is that they may be maIignant and that the patient shouId be carefuIIy watched for a considerable time to determine whether or not the cysts are part of a maIignant degeneration. If the cyst fluid is bIoody there is a greater chance that the condition may be maIignant. I have seen one case in which a distinct cyst showed in the position of the median Iobe of the prostate. This cyst was punctured by means of the cystoscope, bIoody fluid escaping. I beIieved the condition benign. Further observation however proved that he had a myosarcoma of the prostate which was treated and cured by radium, the patient remaining we11 six years and dying of an intercurrent disease. ’ Wesson: Cyst of the prostate and urethra. J. of Ural.. 13: No. 6, rgq.