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Massive Leiomyoma of Prostate: Case Report
MASSIVE LEIOMYOMA OF PROSTATE: CASE REPORT D. W. McINTYRE
While small, multiple, myomatous nodules situated in glandular or adenomatous areas are probably much more common than reported, the massive displacement of prostatic glandular structure in whole, or part, by neoplastic proliferation of the stroma, is very rare, most urological writers agree. CASE REPORT
C. A., a white man aged 71, was admitted to St. Luke's Hospital, Cleveland on November 3, 1946 with acute urinary retention. Symptoms started 10 months ago, when urinary frequency, dysuria and nocturia developed. He had dribbling occasionally. Nocturia and frequency became progressively worse. For the past 4 months he had wet himself frequently and passed pink urine occasionally. Recently, he had to strain at stool. He said that he felt like something was in the rectum. The stools were string-like. He passed blood by rectum. He had not had diarrhea. Except for typhoid fever at the age of 18 years, the past history was essentially negative. The blood pressure was 170 /105; pulse 68; respiration 20; temperature 37 .6 °. Examination of the head showed nothing remarkable; the lungs were clear throughout. The left border of the heart was in the anterior-axillary line, sixth interspace. A systolic murmur was present over the entire precardium, radiating to the axilla, loudest at the second right interspace. The bladder was percussable and palpable 4 fingers above the symphysis; a spherical mass was present in the midline above the symphysis. The external genitalia were normal. Rectal examination disclosed an enormous mass in the region of the prostate which seemed to partly encircle the rectum and push into the rectum. The top of the mass, which extended upwards into the region of the seminal vesicles, could not be felt. The mass was nodular and fixed. On admission the white blood count was 9,650; hemoglobin 14.9 gm; blood sugar 102; non protein nitrogen 38.2; CO2 48 per cent; NaCl 620; acid phosphatase 1 unit alkaline phosphatase 5.8 units; Mazzini test negative. Urine obtained by means of a catheter had a specific gravity of 1.015, a trace of protein, and was negative for sugar; microscopic examination showed 2 to 6 red blood cells and 10 to 25 white blood cells per high power field. A plain x-ray showed both renal and psoas shadows well outlined and normal in appearance, extensive degree of spondylosis of the lumbar spine, considerable calcification of the abdominal aorta and common iliac vessels. No opaque shadows were seen in the renal areas, but there were 2 shadows, one about 4 cm., in the right pelvis overlying the third sacral segment. Another shadow, about 5 cm. in diameter, was seen in the lower left true pelvis. Intravenous urography showed normal visualization of both renal calyces and pelvis. The right ureter, fairly well outlined, was shown in the lower right true 1198
MASSIVE LEIOJVIYOJVIA OF PROSTATE
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pelvis and was seen to overlie the opaque shadow described in that region. The left ureter was only well shown in its upper two-thirds. The possibility of a vesical calculus in a diverticulum was considered so cystograms were taken 1 hour after injection of dye. No diverticula were seen. The shadows previously seen were obscured and faintly visible through the dye. There ,vas a marked elevation of the floor of the bladder; also the outline was irregular. An electrocardiogram showed left ventricular enlargement and myocardial disease. An x-ray of the chest showed that the heart was 35 per cent enlarged. There was an elongation and dilatation of the aorta with calcification of the ascending aorta strongly suggesting luetic aortitis. A fusiform shadow 6 by 3 cm. in the right lung was thought to represent an aneurysm of one of the great vessels. As the catheter was continually blocking, it was decided to do a suprapubic cystotomy. A midline incision was made above symphysis for a distance of 4 inches. The incision was carried down to the rectus fascia, which was opened. The recti muscles were separated in the midline. The preperitoneal fat was stripped off the bladder. The wall, which was very thick, was opened between Allis clamps. Two large and 4 small stones were removed. The base of the bladder and the trigone were elevatei by a mass -which extended from prostate. The mass was fixed and nodular. The urethra was almost blocked by tumor pressing up on its posterior wall. There was a large diverticulum opening off of lower left lateral wall. A No. 32 Pezzar catheter was inserted. No biopsy was taken because the patient was not doing well, and I was afraid of hemorrhage. The patient was discharged November 13, following a smooth convalescence, with suprapubic drainage, to return at a later date for the second operation. Because of the enormous size of the tumor, and the fact that it was fixed, I decided to do a transurethral resection. On re-admission January 3, 1947, the hemoglobin and blood chemistry were normal. The urine was alkaline, contained 1 plus protein, 2 to 3 red blood cells and 4 to 10 white blood cells per high power field. Blood sugar was 120; nonprotein nitrogen 36.2; CO 2 52.5; plasma NaCl 569 mg.; protein 6.2; bleeding time 4 minutes; clotting time 6 minutes. On January 5, 1947 a transurethral resection was done, 47 gm. tissue being removed. Considerable bleeding occurred, and was controlled with difficulty. A blood transfusion was given. The patient did well until 11 hours postoperative, when the blood pressure rose to 265/140. There was considerable bleeding and both catheters became blocked, and even after evacuating the clots, there was considerable red blood. Under sodium pentothal anesthesia, I re-opened part of the suprapubic incision and packed with oxy-cellulose gauze, which controlled the hemorrhage. Both catheters were removed on the sixth day. The incision was healed by the eleventh day, and he was discharged January 18. The patient was last seen March 5. He was voiding every 1½to 2 hours and
1200
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had a good stream. His main complaint was that if he did not urinate immediately when he had the urge, he might dribble some. The dribbling did not bother him at night. He had 40 cc residual urine. The urine contained 2 to 5 white blood cells per high power field with an occasional clump. Microscopic sections showed the characteristic ·whorl appearance of interlacing bundles (fig. 1).
FIG. 1. A, Low power view between 2 adjacent nodules. Notice characteristic interlacing bundles of smooth muscle cells with absence of normal glandular tissue. B, High power, showing characteristic interlacing smooth muscle bundles. COMMENT
According to Hinman, benign mesothelial tumors (leiomyoma, fibroma etc.) constitute less than 0.5 per cent of prostatic tumors. MacCallum found 8 prostatic leiomyoma in 14,000 autopsies. Twenty cases of this type of tumor were reported up to 1939 and none since, probably because of restricted writing during the war. Two types are recognized: one, massive in size, involving and obscuring the prostate, the pelvis and surrounding rectum; the other, mostly pedunculated and
MASSIVE LEIOMYOMA OF PROSTATE
1201
may be closely associated with urethra and bladder, and cause obstruction of bladder and ejaculatory ducts. That small leiomyomatous nodules occur more frequently than recognized clinically is stressed by Patch and Rhea. These observers, using large whole sections of prostate gland with differential stains found an incidence of 25 per cent in 181 cases. Gross and microscopic patholog-ic changes are strikingly like those of leiomyomata of the uterus. The tissue is firmer than the usual hypertrophy; of a greyish yellow color, and on cross section, has a characteristic whorl appearance of interlacing bundles. Encapsulation of small and large nodules is nearly the rule. Occasionally the muscle tissue may assume an infiltrating character. If growth is intraprostatic, normal glandular tissue may be entirely obliterated or compressed to the periphery of the tumor. There may be urethral compression or trigonal elevation. When a nodule is located on the periphery of prostatic growth, it may extend upwards towards the seminal vesicles or toward rectum. Microscopically, one finds interlacing bundles of smooth muscle cells, with a complete absence of glandular tissue, in leiomyomatous areas. A network of interlacing tissue may occur. Blood vessels may be infrequent and towards the periphery, or as large vascular channels throughout the tumor. Necrotic areas, with calcification and old hyalinized scars, have been noted. The growths are usually benign. Sarcomatous change is infrequent, even in large glands. Several theories have been brought out, as to the origin of these tumors. Blum and Rubritus based their theory on the fact that, since normal elements of prostate are 1) 50 per cent glandular, 2) 25 per cent muscle, 3) 25 per cent connective tissue, they would then designate growths as glandular, leiomyomatous and fibrous. The :fibromyomata have been recognized, since inception of microscopy. However, Virchow, Jacoby and Welman differentiate true leiomyomata from these fibromuscular areas occuring in areas of benign hypertrophy. Paul Klemperer states that leiomyomata are adenomata, in which the glands have been abolished. Tandler and Zuckerkandl hypothesize that infection may transform adenomatous masses into smooth muscle. Examination of the specimens from the youngest reported cases (4 and 24 years) give no support to this, in that infection was not found in these cases. Virchow and Klebs expressed the view that, when the testicle ceases secreting certain hormones, a proliferation of muscular and fibrous parts of the prostate follows. Experimental work of Lower on hormones, however, failed to produce any evidence of muscular hypertrophy. Ewing, in a study of uterine myomata, concludes the essential factor of etiology is an embryonic disturbance in structure of the uterus. It would seem that the endocrinal (X) factor, stimulating growth of uterine fibroids, may also effect rudimentary muscular rests within posterior urethra. His view is supported by the fact that the embryological anlagen, of the region of the verumontanum and uterus, are essentially the same. Of the 20 previously reported cases, 14 had primarily urinary symptoms; 5
1202
D. W. MCINTYRE
had, chiefly, perineal or rectal symptoms; 1 had the main symptom of painful, persistent erections. One of the rectal cases, reported by Magoun, had a colostomy done for obstipation, with no bowel movement for a week. Of the 20 reported cases, 12 cases had a suprapubic prostatectomy; 5 cases had a perineal prostatectomy; 2 cases had a combined operation; a transurethral resection was done in 1 case. Many of the operators talk of difficulty in a number of cases of getting a line of cleavage, especially in the large retroperitoneal type. The possibility that tumor regression might follow deep x-ray therapy as in uterine myoma was considered. However, Bugbee tried it in his case, where the tumor could not be entirely removed operatively, without any encouraging results. Seven of the 20 patients died from the operation; a mortality rate of 35 per cent. Five of these died from shock or hemorrhage. Most of these cases were operated upon many years ago and more modern techniques would probably lower mortality considerably. CONCLUSIONS
While small leiomyomata of the prostate are probably not infrequent, the extensive and massive types are rare, 21 cases having been reported. Attempt at removal of the massive retroperitoneal type carries a high mortality rate. These tumors are almost entirely benign; they cause symptoms by pressure. In this particular case, while the urinary symptoms are under control, the patient still complains considerably of constipation. This, I am sure, comes from rectal compression. If his symptoms increase, I intend to give x-ray therapy.
9400 Euclid Ave., Cleveland, 0. REFERENCES AKIN, R.H.: Urol. & Cutan. Rev., 40: 558-559, 1936. DIAL, D. L. AND HALPERT, B.: Arch. Path., 16: 332, 1933. HINMAN, F.: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935. KARSNER, H. T.: Human Pathology. Philadelphia: J. B. Lippincott, 1942, 6th ed. KEEN, M. R.: J. Urol., 42: 158, 1939. KOENIG, G. H.: Urol. & Cutan. Rev., 40: 545, 1936. MAGOUN, J. A.H.: Am. J. Surg., 44: 474, 1939. MrMPRISS, T. W.: Brit. J. Surg., 23: 863, 1936. PATCH, F. S. AND RHEA, L. J.: Brit. J. Urol., 7: 213, 1935. PRATT, J. G.: New Orleans M. & Surg. J., 88: 763, 1936. ScHWEIZ, J. W.: Med. Wchnschr., 69: 339, 1939.
While small, multiple, myomatous nodules situated in glandular or adenomatous areas are probably much more common than reported, the massive displacement of prostatic glandular structure in whole, or part, by neoplastic proliferation of the stroma, is very rare, most urological writers agree. CASE REPORT
C. A., a white man aged 71, was admitted to St. Luke's Hospital, Cleveland on November 3, 1946 with acute urinary retention. Symptoms started 10 months ago, when urinary frequency, dysuria and nocturia developed. He had dribbling occasionally. Nocturia and frequency became progressively worse. For the past 4 months he had wet himself frequently and passed pink urine occasionally. Recently, he had to strain at stool. He said that he felt like something was in the rectum. The stools were string-like. He passed blood by rectum. He had not had diarrhea. Except for typhoid fever at the age of 18 years, the past history was essentially negative. The blood pressure was 170 /105; pulse 68; respiration 20; temperature 37 .6 °. Examination of the head showed nothing remarkable; the lungs were clear throughout. The left border of the heart was in the anterior-axillary line, sixth interspace. A systolic murmur was present over the entire precardium, radiating to the axilla, loudest at the second right interspace. The bladder was percussable and palpable 4 fingers above the symphysis; a spherical mass was present in the midline above the symphysis. The external genitalia were normal. Rectal examination disclosed an enormous mass in the region of the prostate which seemed to partly encircle the rectum and push into the rectum. The top of the mass, which extended upwards into the region of the seminal vesicles, could not be felt. The mass was nodular and fixed. On admission the white blood count was 9,650; hemoglobin 14.9 gm; blood sugar 102; non protein nitrogen 38.2; CO2 48 per cent; NaCl 620; acid phosphatase 1 unit alkaline phosphatase 5.8 units; Mazzini test negative. Urine obtained by means of a catheter had a specific gravity of 1.015, a trace of protein, and was negative for sugar; microscopic examination showed 2 to 6 red blood cells and 10 to 25 white blood cells per high power field. A plain x-ray showed both renal and psoas shadows well outlined and normal in appearance, extensive degree of spondylosis of the lumbar spine, considerable calcification of the abdominal aorta and common iliac vessels. No opaque shadows were seen in the renal areas, but there were 2 shadows, one about 4 cm., in the right pelvis overlying the third sacral segment. Another shadow, about 5 cm. in diameter, was seen in the lower left true pelvis. Intravenous urography showed normal visualization of both renal calyces and pelvis. The right ureter, fairly well outlined, was shown in the lower right true 1198
MASSIVE LEIOJVIYOJVIA OF PROSTATE
1199
pelvis and was seen to overlie the opaque shadow described in that region. The left ureter was only well shown in its upper two-thirds. The possibility of a vesical calculus in a diverticulum was considered so cystograms were taken 1 hour after injection of dye. No diverticula were seen. The shadows previously seen were obscured and faintly visible through the dye. There ,vas a marked elevation of the floor of the bladder; also the outline was irregular. An electrocardiogram showed left ventricular enlargement and myocardial disease. An x-ray of the chest showed that the heart was 35 per cent enlarged. There was an elongation and dilatation of the aorta with calcification of the ascending aorta strongly suggesting luetic aortitis. A fusiform shadow 6 by 3 cm. in the right lung was thought to represent an aneurysm of one of the great vessels. As the catheter was continually blocking, it was decided to do a suprapubic cystotomy. A midline incision was made above symphysis for a distance of 4 inches. The incision was carried down to the rectus fascia, which was opened. The recti muscles were separated in the midline. The preperitoneal fat was stripped off the bladder. The wall, which was very thick, was opened between Allis clamps. Two large and 4 small stones were removed. The base of the bladder and the trigone were elevatei by a mass -which extended from prostate. The mass was fixed and nodular. The urethra was almost blocked by tumor pressing up on its posterior wall. There was a large diverticulum opening off of lower left lateral wall. A No. 32 Pezzar catheter was inserted. No biopsy was taken because the patient was not doing well, and I was afraid of hemorrhage. The patient was discharged November 13, following a smooth convalescence, with suprapubic drainage, to return at a later date for the second operation. Because of the enormous size of the tumor, and the fact that it was fixed, I decided to do a transurethral resection. On re-admission January 3, 1947, the hemoglobin and blood chemistry were normal. The urine was alkaline, contained 1 plus protein, 2 to 3 red blood cells and 4 to 10 white blood cells per high power field. Blood sugar was 120; nonprotein nitrogen 36.2; CO 2 52.5; plasma NaCl 569 mg.; protein 6.2; bleeding time 4 minutes; clotting time 6 minutes. On January 5, 1947 a transurethral resection was done, 47 gm. tissue being removed. Considerable bleeding occurred, and was controlled with difficulty. A blood transfusion was given. The patient did well until 11 hours postoperative, when the blood pressure rose to 265/140. There was considerable bleeding and both catheters became blocked, and even after evacuating the clots, there was considerable red blood. Under sodium pentothal anesthesia, I re-opened part of the suprapubic incision and packed with oxy-cellulose gauze, which controlled the hemorrhage. Both catheters were removed on the sixth day. The incision was healed by the eleventh day, and he was discharged January 18. The patient was last seen March 5. He was voiding every 1½to 2 hours and
1200
D. vY. McINTYRE
had a good stream. His main complaint was that if he did not urinate immediately when he had the urge, he might dribble some. The dribbling did not bother him at night. He had 40 cc residual urine. The urine contained 2 to 5 white blood cells per high power field with an occasional clump. Microscopic sections showed the characteristic ·whorl appearance of interlacing bundles (fig. 1).
FIG. 1. A, Low power view between 2 adjacent nodules. Notice characteristic interlacing bundles of smooth muscle cells with absence of normal glandular tissue. B, High power, showing characteristic interlacing smooth muscle bundles. COMMENT
According to Hinman, benign mesothelial tumors (leiomyoma, fibroma etc.) constitute less than 0.5 per cent of prostatic tumors. MacCallum found 8 prostatic leiomyoma in 14,000 autopsies. Twenty cases of this type of tumor were reported up to 1939 and none since, probably because of restricted writing during the war. Two types are recognized: one, massive in size, involving and obscuring the prostate, the pelvis and surrounding rectum; the other, mostly pedunculated and
MASSIVE LEIOMYOMA OF PROSTATE
1201
may be closely associated with urethra and bladder, and cause obstruction of bladder and ejaculatory ducts. That small leiomyomatous nodules occur more frequently than recognized clinically is stressed by Patch and Rhea. These observers, using large whole sections of prostate gland with differential stains found an incidence of 25 per cent in 181 cases. Gross and microscopic patholog-ic changes are strikingly like those of leiomyomata of the uterus. The tissue is firmer than the usual hypertrophy; of a greyish yellow color, and on cross section, has a characteristic whorl appearance of interlacing bundles. Encapsulation of small and large nodules is nearly the rule. Occasionally the muscle tissue may assume an infiltrating character. If growth is intraprostatic, normal glandular tissue may be entirely obliterated or compressed to the periphery of the tumor. There may be urethral compression or trigonal elevation. When a nodule is located on the periphery of prostatic growth, it may extend upwards towards the seminal vesicles or toward rectum. Microscopically, one finds interlacing bundles of smooth muscle cells, with a complete absence of glandular tissue, in leiomyomatous areas. A network of interlacing tissue may occur. Blood vessels may be infrequent and towards the periphery, or as large vascular channels throughout the tumor. Necrotic areas, with calcification and old hyalinized scars, have been noted. The growths are usually benign. Sarcomatous change is infrequent, even in large glands. Several theories have been brought out, as to the origin of these tumors. Blum and Rubritus based their theory on the fact that, since normal elements of prostate are 1) 50 per cent glandular, 2) 25 per cent muscle, 3) 25 per cent connective tissue, they would then designate growths as glandular, leiomyomatous and fibrous. The :fibromyomata have been recognized, since inception of microscopy. However, Virchow, Jacoby and Welman differentiate true leiomyomata from these fibromuscular areas occuring in areas of benign hypertrophy. Paul Klemperer states that leiomyomata are adenomata, in which the glands have been abolished. Tandler and Zuckerkandl hypothesize that infection may transform adenomatous masses into smooth muscle. Examination of the specimens from the youngest reported cases (4 and 24 years) give no support to this, in that infection was not found in these cases. Virchow and Klebs expressed the view that, when the testicle ceases secreting certain hormones, a proliferation of muscular and fibrous parts of the prostate follows. Experimental work of Lower on hormones, however, failed to produce any evidence of muscular hypertrophy. Ewing, in a study of uterine myomata, concludes the essential factor of etiology is an embryonic disturbance in structure of the uterus. It would seem that the endocrinal (X) factor, stimulating growth of uterine fibroids, may also effect rudimentary muscular rests within posterior urethra. His view is supported by the fact that the embryological anlagen, of the region of the verumontanum and uterus, are essentially the same. Of the 20 previously reported cases, 14 had primarily urinary symptoms; 5
1202
D. W. MCINTYRE
had, chiefly, perineal or rectal symptoms; 1 had the main symptom of painful, persistent erections. One of the rectal cases, reported by Magoun, had a colostomy done for obstipation, with no bowel movement for a week. Of the 20 reported cases, 12 cases had a suprapubic prostatectomy; 5 cases had a perineal prostatectomy; 2 cases had a combined operation; a transurethral resection was done in 1 case. Many of the operators talk of difficulty in a number of cases of getting a line of cleavage, especially in the large retroperitoneal type. The possibility that tumor regression might follow deep x-ray therapy as in uterine myoma was considered. However, Bugbee tried it in his case, where the tumor could not be entirely removed operatively, without any encouraging results. Seven of the 20 patients died from the operation; a mortality rate of 35 per cent. Five of these died from shock or hemorrhage. Most of these cases were operated upon many years ago and more modern techniques would probably lower mortality considerably. CONCLUSIONS
While small leiomyomata of the prostate are probably not infrequent, the extensive and massive types are rare, 21 cases having been reported. Attempt at removal of the massive retroperitoneal type carries a high mortality rate. These tumors are almost entirely benign; they cause symptoms by pressure. In this particular case, while the urinary symptoms are under control, the patient still complains considerably of constipation. This, I am sure, comes from rectal compression. If his symptoms increase, I intend to give x-ray therapy.
9400 Euclid Ave., Cleveland, 0. REFERENCES AKIN, R.H.: Urol. & Cutan. Rev., 40: 558-559, 1936. DIAL, D. L. AND HALPERT, B.: Arch. Path., 16: 332, 1933. HINMAN, F.: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935. KARSNER, H. T.: Human Pathology. Philadelphia: J. B. Lippincott, 1942, 6th ed. KEEN, M. R.: J. Urol., 42: 158, 1939. KOENIG, G. H.: Urol. & Cutan. Rev., 40: 545, 1936. MAGOUN, J. A.H.: Am. J. Surg., 44: 474, 1939. MrMPRISS, T. W.: Brit. J. Surg., 23: 863, 1936. PATCH, F. S. AND RHEA, L. J.: Brit. J. Urol., 7: 213, 1935. PRATT, J. G.: New Orleans M. & Surg. J., 88: 763, 1936. ScHWEIZ, J. W.: Med. Wchnschr., 69: 339, 1939.