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Sarcoma of the prostate treated with radiotherapy
Clinical Oncology (1994) 6:269-270 (~) 1994 The Royal College of Radiologists
Clinical Oncology
Case Report Sarcoma of the Prostate Treated with Radiotherapy P. J. Atherton 1, A. D. Stockdale I and C. D. Rennie 2 1 D e p a r t r n e n t of R a d i o t h e r a p y , W a l s g r a v e Hospital, C o v e n t r y a n d 2Alexandra Hospital, R e d d i t e h , U K
Abstract. Sarcoma of the prostate is a rare primary tumour in adults. We report a 73year-old man who presented with urinary outflow obstruction. He had histologically proven prostatic sarcoma and probably derived some benefit from radiotherapy. A brief review of the literature is included. Keywords: Prostate; Radiotherapy; Sarcoma
CASE REPORT A 73-year-old man presented with symptoms of urinary outflow obstruction. He had undergone transurethral resection of the prostate (TURP) 8 years previously for benign prostatic hypertrophy. Examination under anaesthesia showed gross enlargement of the prostate, mainly of the lateral lobes, with an unusual appearance of the prostatic urethra; a TURP was performed. Histology showed approximately half of the chippings to consist of a cellular spindle cell sarcoma with a mitotic activity of 8/high power field. Tumour cells were arranged in broad bands with a vaguely storiform pattern. Immunohistochemical staining for prostatic specific antigen and epithelial markers was negative. Connective tissue and leucocyte markers were negative (vimentin, desmin, actin and leucocyte common antigen). It was concluded that the tumour could not be further classified, although the appearances fell within the range of those included as 'malignant fibrous histiocytoma'. A C T scan showed a massively enlarged prostate of mixed tissue density, but well encapsulated (Fig. 1). There was a rightsided hydronephrosis. The liver was normal. Serum creatinine was 170 ~tmol/1 but prostate specific antigen and bone scan were normal. Following TURP, he began a course of radiotherapy to the prostate, using 6 MV photons. A four-field technique was employed to deliver 45 Gy to the tumour with a small margin, in 20 fractions over 28 days. He remained well with an indwelling Correspondence and offprint requests to: Dr P. J. Atherton, Registrar, Department of Radio-
therapy, Walsgrave Hospital, Coventry CV2 2DX, UK.
Fig. 1. CT scan at presentation, showing a massively enlarged prostate of mixed tissue density.
mas and fibrosarcomas represent the majority of tumours in older patients. In adults, the presenting picture is chiefly one of obstructive uropathy, although there may be a suprapubic or perineal mass. Tenesmus, rectal bleeding, and constipation may also be present due to pressure on the rectum. Deep pelvic pain is said to be characteristic. Rhabdomyosarcomas have the potential for rapid growth, but leiomyosarcomas and fibrosarcomas tend to grow more slowly, with early urethral compression, and invasion of peri-prostatic and peri-vesical tissues. Eventually a large mass forms in the pelvis. Metastatic spread is via the lymphatics to the nodes, and haematogenously to the liver, lungs, and bone [1]. For adult non-rhabdomyosarcomas, the treatment of choice is radical surgery, if complete excision is possible. External beam radiotherapy may be used as the primary modality, or following surgical debulking or incomplete extirpation. Recommended doses are 40-60 Gy in 2 Gy daily fractions (or equivalent) [2,3]. Some have given preoperative irradiation, and brachytherapy has been used with apparent Success.
Fig. 2. CT scan 12 months after radiotherapy.
catheter until 4 months later, when he was admitted with haematuria. This settled rapidly with conservative management, and a repeat CT scan showed possible minimal reduction in the size of the tumour. He continued to be asymptomatic, and a further CT scan 12 months after radiotherapy showed the tumour to be unchanged (Fig. 2), although there were possibly small lymph nodes on the right psoas muscle. He remained well until shortly before admission, 14 months after radiotherapy, with renal failure secondary to bilateral ureteric obstruction. He died 4 days later.
DISCUSSION Sarcoma of the prostate accounts for less than 0.1% of all prostatic malignancies. It may occur at any age, but only 25% of patients are over 40 years old. Whereas rhabdomyosarcomas are the commonest histological type in children, leiomyosarco-
The prognosis of primary prostatic sarcoma (excluding rhabdomyosarcoma) is difficult to determine, given the paucity of cases. It seems that, whilst patients with rhabdomyosarcomas can probably be cured, those with other histological types of sarcoma eventually succumb to their disease. However, possibly because of the slower growth of these tumours, survival following a variety of therapeutic modalities may often be 5-6 years, sometimes longer [3,4]. We would recommend the reporting of further cases of sarcomas of the prostate (excluding rhabdomyosarcomas), in order to further elucidate the natural history, optimal management, and prognosis of these rare turnouts. In our patient, the turnout had grown to a large size prior to presentation. Despite this there was no further documented growth, and possibly slight regression, maintained for 12 months after a modest dose of radiotherapy.
Acknowledgements. We are indebted to Dr J. McCartney, consultant histopathologist, and to Dr C. D. Fletcher, CRC Soft Tissue Tumour Group, London, for kindly reviewing the pathology.
P. J. Atherton et al.
270
References 1. MostofiFK, Price EB. Tumoursof the male genitalsystem.In: FirmingerHI, editor. Atlas of tumourpathology,2nd series. Washington
DC: Armed Forces Institute of Pathology 3. NarayanaAS, LoeningS, WeimarGW, et al. 1973;(8):253-6. Sarcomaof the bladder and prostate. J Urol 2. Scully JM, Uno JM, Mclntyre M, et al. 1978;119:72-6. Radiation-induced prostatic sarcoma:A case 4. SchmidtJD, WelchMJ. Sarcomaof the prostate. Cancer1976;37:1908-12. report. J Uro11990;144:746-8. Received and accepted for publication November 1993
Announcements
United Kingdom December 1-2 1994 CYCLING OUT OF CONTROL: NATURE'S 1994 CONFERENCE FOCUSES ON THE CELL CYCLE Cycle out of control: the cell cycle in growth, differentiation and disease Location: Hotel Lutetia, Paris Cell, developmental, neurological and clinical biologists are set to converge at Nature's second international conference in Europe this December. Cycling out of Control: the cell cycle in growth, differentiation and disease, will explore the ways in which cell division is deranged in oncogenesis, focusing on the checkpoints built into the mammalian cell cycle, and how they can be evaded by cancer cells. The two-day programme consists of four half-day sessions as follows: December 1
Normal Control of the Cell Cycle Chaired by Tony Pawson of the Samuel Lunenfield Research Institute, Mount Sinai Hospital Speakers include: Paul Nurse, ICRF Laboratories "Ordering S-phase and mitosis in fission yeast"; Patrick O'Farrell, UCSF School of Medicine "How development takes control of the cell cycle"; Kim Nasmyth, Institute of Molecular Pathology, Vienna "Regulation of the Cdc28 protein kinase during the yeast cell cycle"; Tim Hunt, ICRF Clare Hall Laboratories "Cyclin/CDKs in Xenopus development".
December 2
Apoptosis Chaired by Paul Nurse, ICRF Laboratories Speakers include: Andrew Wyllie, University Medical School, Edinburgh "Sensitivity to apoptosis in animal tissues and tumours"; Stanley Korsmeyer, Howard Hughes Medical Institute Research Laboratories "Bcl-2 gene family in the regulation of cell death"; Eileen White, Center for Advanced Biotechnology & Medicine, New Jersey "Regulation of apoptosis by DNA virus transforming proteins"; David Housman, Massachusetts Institute of Technology
The Cell Cycle in Cancer Chaired by Andrew Wyllie, University Medical School, Edinburgh Speakers include: Ed Harlow, Massachusetts General Hospital "Losing control in GI"; David Beach, Cold Spring Harbour Laboratory "Negative regulators of the cell cycle"; Thea Tlsty, University of North Carolina. Conference details: Pippa Burnett, Tel: +44 (0)71 836 6633 x2593, Fax: +44 (0)71 379 5417 Media enquiries: Lisa Jackson, Tel: +44 (0)71 872 0104, Fax: +44 (0)71 240 2408.
Mitogenesis Chaired by Ed Harlow, Massachusetts General Hospital Speakers include: Tony Pawson, Samuel Lunenfield Research Institute "Tyrosine kinase targets in normal and transformed cells"; Charles J. Sherr, Howard Hughes Medical Institute Research Laboratories "Growth factorregulated cell cycle progression"; John Cooper, Fred Hutchinson Cancer Research Center "Protein-protein interactions in mitogenic signal transduction"; Paolo Sassone-Corsi, CNRS, "CREM, nuclear pacemaker"; Tom Curran, Roche Institute of Molecular Biology "Fos, a paradigm for stimulus-transcription coupling".
Announcements for these pages should be submitted to: Dr T J Priestman, Editor, Clinical Oncology, The Royal College of Radiologists, 38 Portland Place, London WIN 3DG, UK. Announcements must be typewritten giving clear and concise details of the date, location and point of contact. Submission deadline: A minimum of four months before the event.
Clinical Oncology
Case Report Sarcoma of the Prostate Treated with Radiotherapy P. J. Atherton 1, A. D. Stockdale I and C. D. Rennie 2 1 D e p a r t r n e n t of R a d i o t h e r a p y , W a l s g r a v e Hospital, C o v e n t r y a n d 2Alexandra Hospital, R e d d i t e h , U K
Abstract. Sarcoma of the prostate is a rare primary tumour in adults. We report a 73year-old man who presented with urinary outflow obstruction. He had histologically proven prostatic sarcoma and probably derived some benefit from radiotherapy. A brief review of the literature is included. Keywords: Prostate; Radiotherapy; Sarcoma
CASE REPORT A 73-year-old man presented with symptoms of urinary outflow obstruction. He had undergone transurethral resection of the prostate (TURP) 8 years previously for benign prostatic hypertrophy. Examination under anaesthesia showed gross enlargement of the prostate, mainly of the lateral lobes, with an unusual appearance of the prostatic urethra; a TURP was performed. Histology showed approximately half of the chippings to consist of a cellular spindle cell sarcoma with a mitotic activity of 8/high power field. Tumour cells were arranged in broad bands with a vaguely storiform pattern. Immunohistochemical staining for prostatic specific antigen and epithelial markers was negative. Connective tissue and leucocyte markers were negative (vimentin, desmin, actin and leucocyte common antigen). It was concluded that the tumour could not be further classified, although the appearances fell within the range of those included as 'malignant fibrous histiocytoma'. A C T scan showed a massively enlarged prostate of mixed tissue density, but well encapsulated (Fig. 1). There was a rightsided hydronephrosis. The liver was normal. Serum creatinine was 170 ~tmol/1 but prostate specific antigen and bone scan were normal. Following TURP, he began a course of radiotherapy to the prostate, using 6 MV photons. A four-field technique was employed to deliver 45 Gy to the tumour with a small margin, in 20 fractions over 28 days. He remained well with an indwelling Correspondence and offprint requests to: Dr P. J. Atherton, Registrar, Department of Radio-
therapy, Walsgrave Hospital, Coventry CV2 2DX, UK.
Fig. 1. CT scan at presentation, showing a massively enlarged prostate of mixed tissue density.
mas and fibrosarcomas represent the majority of tumours in older patients. In adults, the presenting picture is chiefly one of obstructive uropathy, although there may be a suprapubic or perineal mass. Tenesmus, rectal bleeding, and constipation may also be present due to pressure on the rectum. Deep pelvic pain is said to be characteristic. Rhabdomyosarcomas have the potential for rapid growth, but leiomyosarcomas and fibrosarcomas tend to grow more slowly, with early urethral compression, and invasion of peri-prostatic and peri-vesical tissues. Eventually a large mass forms in the pelvis. Metastatic spread is via the lymphatics to the nodes, and haematogenously to the liver, lungs, and bone [1]. For adult non-rhabdomyosarcomas, the treatment of choice is radical surgery, if complete excision is possible. External beam radiotherapy may be used as the primary modality, or following surgical debulking or incomplete extirpation. Recommended doses are 40-60 Gy in 2 Gy daily fractions (or equivalent) [2,3]. Some have given preoperative irradiation, and brachytherapy has been used with apparent Success.
Fig. 2. CT scan 12 months after radiotherapy.
catheter until 4 months later, when he was admitted with haematuria. This settled rapidly with conservative management, and a repeat CT scan showed possible minimal reduction in the size of the tumour. He continued to be asymptomatic, and a further CT scan 12 months after radiotherapy showed the tumour to be unchanged (Fig. 2), although there were possibly small lymph nodes on the right psoas muscle. He remained well until shortly before admission, 14 months after radiotherapy, with renal failure secondary to bilateral ureteric obstruction. He died 4 days later.
DISCUSSION Sarcoma of the prostate accounts for less than 0.1% of all prostatic malignancies. It may occur at any age, but only 25% of patients are over 40 years old. Whereas rhabdomyosarcomas are the commonest histological type in children, leiomyosarco-
The prognosis of primary prostatic sarcoma (excluding rhabdomyosarcoma) is difficult to determine, given the paucity of cases. It seems that, whilst patients with rhabdomyosarcomas can probably be cured, those with other histological types of sarcoma eventually succumb to their disease. However, possibly because of the slower growth of these tumours, survival following a variety of therapeutic modalities may often be 5-6 years, sometimes longer [3,4]. We would recommend the reporting of further cases of sarcomas of the prostate (excluding rhabdomyosarcomas), in order to further elucidate the natural history, optimal management, and prognosis of these rare turnouts. In our patient, the turnout had grown to a large size prior to presentation. Despite this there was no further documented growth, and possibly slight regression, maintained for 12 months after a modest dose of radiotherapy.
Acknowledgements. We are indebted to Dr J. McCartney, consultant histopathologist, and to Dr C. D. Fletcher, CRC Soft Tissue Tumour Group, London, for kindly reviewing the pathology.
P. J. Atherton et al.
270
References 1. MostofiFK, Price EB. Tumoursof the male genitalsystem.In: FirmingerHI, editor. Atlas of tumourpathology,2nd series. Washington
DC: Armed Forces Institute of Pathology 3. NarayanaAS, LoeningS, WeimarGW, et al. 1973;(8):253-6. Sarcomaof the bladder and prostate. J Urol 2. Scully JM, Uno JM, Mclntyre M, et al. 1978;119:72-6. Radiation-induced prostatic sarcoma:A case 4. SchmidtJD, WelchMJ. Sarcomaof the prostate. Cancer1976;37:1908-12. report. J Uro11990;144:746-8. Received and accepted for publication November 1993
Announcements
United Kingdom December 1-2 1994 CYCLING OUT OF CONTROL: NATURE'S 1994 CONFERENCE FOCUSES ON THE CELL CYCLE Cycle out of control: the cell cycle in growth, differentiation and disease Location: Hotel Lutetia, Paris Cell, developmental, neurological and clinical biologists are set to converge at Nature's second international conference in Europe this December. Cycling out of Control: the cell cycle in growth, differentiation and disease, will explore the ways in which cell division is deranged in oncogenesis, focusing on the checkpoints built into the mammalian cell cycle, and how they can be evaded by cancer cells. The two-day programme consists of four half-day sessions as follows: December 1
Normal Control of the Cell Cycle Chaired by Tony Pawson of the Samuel Lunenfield Research Institute, Mount Sinai Hospital Speakers include: Paul Nurse, ICRF Laboratories "Ordering S-phase and mitosis in fission yeast"; Patrick O'Farrell, UCSF School of Medicine "How development takes control of the cell cycle"; Kim Nasmyth, Institute of Molecular Pathology, Vienna "Regulation of the Cdc28 protein kinase during the yeast cell cycle"; Tim Hunt, ICRF Clare Hall Laboratories "Cyclin/CDKs in Xenopus development".
December 2
Apoptosis Chaired by Paul Nurse, ICRF Laboratories Speakers include: Andrew Wyllie, University Medical School, Edinburgh "Sensitivity to apoptosis in animal tissues and tumours"; Stanley Korsmeyer, Howard Hughes Medical Institute Research Laboratories "Bcl-2 gene family in the regulation of cell death"; Eileen White, Center for Advanced Biotechnology & Medicine, New Jersey "Regulation of apoptosis by DNA virus transforming proteins"; David Housman, Massachusetts Institute of Technology
The Cell Cycle in Cancer Chaired by Andrew Wyllie, University Medical School, Edinburgh Speakers include: Ed Harlow, Massachusetts General Hospital "Losing control in GI"; David Beach, Cold Spring Harbour Laboratory "Negative regulators of the cell cycle"; Thea Tlsty, University of North Carolina. Conference details: Pippa Burnett, Tel: +44 (0)71 836 6633 x2593, Fax: +44 (0)71 379 5417 Media enquiries: Lisa Jackson, Tel: +44 (0)71 872 0104, Fax: +44 (0)71 240 2408.
Mitogenesis Chaired by Ed Harlow, Massachusetts General Hospital Speakers include: Tony Pawson, Samuel Lunenfield Research Institute "Tyrosine kinase targets in normal and transformed cells"; Charles J. Sherr, Howard Hughes Medical Institute Research Laboratories "Growth factorregulated cell cycle progression"; John Cooper, Fred Hutchinson Cancer Research Center "Protein-protein interactions in mitogenic signal transduction"; Paolo Sassone-Corsi, CNRS, "CREM, nuclear pacemaker"; Tom Curran, Roche Institute of Molecular Biology "Fos, a paradigm for stimulus-transcription coupling".
Announcements for these pages should be submitted to: Dr T J Priestman, Editor, Clinical Oncology, The Royal College of Radiologists, 38 Portland Place, London WIN 3DG, UK. Announcements must be typewritten giving clear and concise details of the date, location and point of contact. Submission deadline: A minimum of four months before the event.