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Isolated Prostate Cancer Recurrence Presenting as Pelvic Mass Nine Years After Radical Retropubic Prostatectomy
Case Report Isolated Prostate Cancer Recurrence Presenting as Pelvic Mass Nine Years After Radical Retropubic Prostatectomy Monica M. Metzdorf and Joseph D. Schmidt Pelvic seeding from radical retropubic prostatectomy for adenocarcinoma of the prostate is uncommon. We describe a patient who presented with a prostate-specific antigen recurrence and was found to have a solitary metastasis adjacent to his pubic bone 9 years after radical prostatectomy. Computed tomography scanning followed by surgery documented the pelvic recurrence. UROLOGY 70: 1007.e17–1007.e18, 2007. © 2007 Elsevier Inc.
P
elvic seeding is an unusual complication of radical retropubic prostatectomy (RRP). Adenocarcinoma of the prostate generally metastasizes to bone, lung, liver, and lymph nodes. Local recurrence typically appears in the area of the prostate bed. We describe a patient who presented with a prostate-specific antigen (PSA) recurrence and was found to have a solitary metastasis adjacent to his pubic bone 9 years after RRP.
density just medial and anterior to the left superior pubic ramus (Fig. 1). The patient underwent open excision of the mass, which was densely adherent to the pubic bone but did not involve the bladder. Pathologic examination revealed adenocarcinoma, which stained positive for PSA (Fig. 2). Postoperatively, the patient’s PSA level decreased to 0.35 ng/mL, and he underwent adjuvant external beam radiotherapy. Eighteen months later, his PSA level was undetectable.
CASE REPORT A 67-year-old man had initially presented in 1994 with a rising PSA level and a left prostate nodule found on digital rectal examination. He had an initial negative biopsy for a PSA level of 6 ng/mL. One year later, with a PSA level of 9 ng/mL, he underwent a repeat biopsy that showed Gleason score 3 ⫹ 4 adenocarcinoma on the left side. He underwent RRP with bilateral pelvic lymph node dissection in August 1995. The pathologic examination again showed Gleason score 3 ⫹ 4 adenocarcinoma on the left (pT2N0M0). Bone scans and ProstaScint scans were negative for metastatic disease. The patient began high-dose bicalutamide (Casodex) in a clinical trial. From December 1997 to March 2004, his PSA level increased from an initial value of 0.5 ng/mL to an eventual level of 12.95 ng/mL. During that period he was given flutamide, which resulted in only a modest decrease in the PSA level. He was also given goserelin acetate, but his PSA level increased from 5 to 12.95 ng/mL with that regimen. The bone scan and ProstaScint scan findings were negative. The physical examination revealed an empty prostatic fossa. Computed tomography of the abdomen and pelvis demonstrated an enhancing 3-cm soft-tissue From the Department of Surgery, Division of Urology, University of California, San Diego, Medical Center, San Diego, California Address for correspondence: Joseph D. Schmidt, M.D., F.A.C.S., c/o Trisha Lane, Division of Urology, University of California, San Diego, Medical Center, 200 West Arbor Drive (8897), San Diego, CA 92103-8897. E-mail: [email protected] Submitted: January 10, 2007; accepted (with revisions): August 10, 2007
© 2007 Elsevier Inc. All Rights Reserved
COMMENT Pelvic seeding is a rare complication of RRP. Our patient had an early PSA increase after RRP but had no evidence of metastatic disease (negative bone and ProstaScint scan findings) and no evidence of local recurrence on digital rectal examination. The patient did not have a preoperative computed tomography scan to look for metastatic lesions. At RRP, no abnormal soft-tissue masses were noted, and his lymph nodes were negative. Nine years later, after multiple courses of hormonal therapy had failed, he was found to have a solitary metastasis near the left pubic ramus. A suggestion has been made in published reports that prostatic secretions shed at RRP con-
Figure 1. Computed tomography scan showing mass at left superior pubic ramus. 0090-4295/07/$32.00 1007.e17 doi:10.1016/j.urology.2007.08.026
Figure 2. Pathologic examination of excised mass revealed adenocarcinoma with positive PSA stain. Hematoxylin-eosin stain, original magnification ⫻10.
reaction assay evaluation of operative site cells to assess for evidence of tumor spillage with operative manipulation during RRP. They identified tumor cells in 20 of 22 samples, again suggesting that this might represent one mechanism for failure after RRP.2 Published reports have also documented several instances of rare perineal seeding after needle biopsy.3 No gross violation of the prostate was noted at RRP in our patient. His case is a rare example of prostate cancer recurrence in the pelvis documented by surgical resection. Our patient represents the unusual case of a surgically documented recurrence of prostate adenocarcinoma in the pelvis 9 years after RRP. Patients presenting with PSA recurrence after RRP, even after an interval of many years, should be examined using computed tomography for the possible presence of a pelvic recurrence. References
tain malignant cells and might account for some instances of surgical failure. In an analysis of fresh prostatic secretions from RRP specimens, Kassabian et al.1 found positive malignant cytology findings in 55% of specimens containing Gleason score 8 to 10 prostate cancer but in only 6% of specimens with Gleason score 5 to 7. Oefelein et al.2 used PSA reverse transcriptase-polymerase chain
1007.e18
1. Kassabian VS, Bottles K, Weaver R, et al: Possible mechanism for seeding of tumor during radical prostatectomy. J Urol 150: 1169 – 1171, 1993. 2. Oefelein MG, Kaul K, Herz B, et al: Molecular detection of prostate epithelial cells from the surgical field and peripheral circulation during radical prostatectomy. J Urol 155: 238 –242, 1996. 3. Moul JW, Miles BJ, Skoog SJ, et al: Risk factors for perineal seeding of prostate cancer after needle biopsy. J Urol 142: 86 – 88, 1989.
UROLOGY 70 (5), 2007
P
elvic seeding is an unusual complication of radical retropubic prostatectomy (RRP). Adenocarcinoma of the prostate generally metastasizes to bone, lung, liver, and lymph nodes. Local recurrence typically appears in the area of the prostate bed. We describe a patient who presented with a prostate-specific antigen (PSA) recurrence and was found to have a solitary metastasis adjacent to his pubic bone 9 years after RRP.
density just medial and anterior to the left superior pubic ramus (Fig. 1). The patient underwent open excision of the mass, which was densely adherent to the pubic bone but did not involve the bladder. Pathologic examination revealed adenocarcinoma, which stained positive for PSA (Fig. 2). Postoperatively, the patient’s PSA level decreased to 0.35 ng/mL, and he underwent adjuvant external beam radiotherapy. Eighteen months later, his PSA level was undetectable.
CASE REPORT A 67-year-old man had initially presented in 1994 with a rising PSA level and a left prostate nodule found on digital rectal examination. He had an initial negative biopsy for a PSA level of 6 ng/mL. One year later, with a PSA level of 9 ng/mL, he underwent a repeat biopsy that showed Gleason score 3 ⫹ 4 adenocarcinoma on the left side. He underwent RRP with bilateral pelvic lymph node dissection in August 1995. The pathologic examination again showed Gleason score 3 ⫹ 4 adenocarcinoma on the left (pT2N0M0). Bone scans and ProstaScint scans were negative for metastatic disease. The patient began high-dose bicalutamide (Casodex) in a clinical trial. From December 1997 to March 2004, his PSA level increased from an initial value of 0.5 ng/mL to an eventual level of 12.95 ng/mL. During that period he was given flutamide, which resulted in only a modest decrease in the PSA level. He was also given goserelin acetate, but his PSA level increased from 5 to 12.95 ng/mL with that regimen. The bone scan and ProstaScint scan findings were negative. The physical examination revealed an empty prostatic fossa. Computed tomography of the abdomen and pelvis demonstrated an enhancing 3-cm soft-tissue From the Department of Surgery, Division of Urology, University of California, San Diego, Medical Center, San Diego, California Address for correspondence: Joseph D. Schmidt, M.D., F.A.C.S., c/o Trisha Lane, Division of Urology, University of California, San Diego, Medical Center, 200 West Arbor Drive (8897), San Diego, CA 92103-8897. E-mail: [email protected] Submitted: January 10, 2007; accepted (with revisions): August 10, 2007
© 2007 Elsevier Inc. All Rights Reserved
COMMENT Pelvic seeding is a rare complication of RRP. Our patient had an early PSA increase after RRP but had no evidence of metastatic disease (negative bone and ProstaScint scan findings) and no evidence of local recurrence on digital rectal examination. The patient did not have a preoperative computed tomography scan to look for metastatic lesions. At RRP, no abnormal soft-tissue masses were noted, and his lymph nodes were negative. Nine years later, after multiple courses of hormonal therapy had failed, he was found to have a solitary metastasis near the left pubic ramus. A suggestion has been made in published reports that prostatic secretions shed at RRP con-
Figure 1. Computed tomography scan showing mass at left superior pubic ramus. 0090-4295/07/$32.00 1007.e17 doi:10.1016/j.urology.2007.08.026
Figure 2. Pathologic examination of excised mass revealed adenocarcinoma with positive PSA stain. Hematoxylin-eosin stain, original magnification ⫻10.
reaction assay evaluation of operative site cells to assess for evidence of tumor spillage with operative manipulation during RRP. They identified tumor cells in 20 of 22 samples, again suggesting that this might represent one mechanism for failure after RRP.2 Published reports have also documented several instances of rare perineal seeding after needle biopsy.3 No gross violation of the prostate was noted at RRP in our patient. His case is a rare example of prostate cancer recurrence in the pelvis documented by surgical resection. Our patient represents the unusual case of a surgically documented recurrence of prostate adenocarcinoma in the pelvis 9 years after RRP. Patients presenting with PSA recurrence after RRP, even after an interval of many years, should be examined using computed tomography for the possible presence of a pelvic recurrence. References
tain malignant cells and might account for some instances of surgical failure. In an analysis of fresh prostatic secretions from RRP specimens, Kassabian et al.1 found positive malignant cytology findings in 55% of specimens containing Gleason score 8 to 10 prostate cancer but in only 6% of specimens with Gleason score 5 to 7. Oefelein et al.2 used PSA reverse transcriptase-polymerase chain
1007.e18
1. Kassabian VS, Bottles K, Weaver R, et al: Possible mechanism for seeding of tumor during radical prostatectomy. J Urol 150: 1169 – 1171, 1993. 2. Oefelein MG, Kaul K, Herz B, et al: Molecular detection of prostate epithelial cells from the surgical field and peripheral circulation during radical prostatectomy. J Urol 155: 238 –242, 1996. 3. Moul JW, Miles BJ, Skoog SJ, et al: Risk factors for perineal seeding of prostate cancer after needle biopsy. J Urol 142: 86 – 88, 1989.
UROLOGY 70 (5), 2007