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Metastatic prostate cancer presenting as obstructive jaundice
METASTATIC PROSTATE CANCER PRESENTING AS OBSTRUCTIVE JAUNDICE WILLIAM NORMAN
E. BLOCH, L. BLOCK,
From the Department Miami, Florida
M.D. M.D.
of Urology,
University
of Miami,
ABSTRACT-Me&static cancer of the prostate, presenting with carcinomatous obstruction of the common bile duct as a cause of jaundice and abnormal liver function tests is very unusual. The literature suggests an association between abnormal liver function tests and poor survivability in those patients with liver parenchymal metastases. This case illustrates that patients with abnormal liver function tests on the basis of extrahepatic ductal obstruction may have a better prognosis than those with hepatic disease.
Patients with cancer of the prostate presenting initially with hepatobiliary signs and symptoms have rarely been reported in the literature. We present such a case and review of the literature. Case Report A sixty-nine-year-old white man presented with gastrointestinal symptoms consisting of abdominal pain, nausea, vomiting, and increasing jaundice of one week’s duration. Pertinent physical findings revealed cachexia, jaundice, and a large palpable abdominal mass. Rectal examination revealed a 30 g indurated prostate. Pertinent laboratory studies included a blood urea nitrogen of 46 mg/dL (normal lo-20 mgl dL), and a serum creatinine of 3.3 mg/dL (normal 0.9-1.4 mg/dL). Hematocrit was 30.6 percent (normal 34-40 %), and the white blood cell count was 5,500 (normal 4,500-13,000). Liver function tests included total bilirubin of 10.6 mg/dL (normal 0.1-1.0 mg/dL), and direct bilirubin of 9.8 mg/dL (normal 0.0-0.4 mg/dL). Alkaline phosphatase was 117 PlmL (normal 38-126 p/mL), serum glutamic oxaloacetic transaminase (SGOT) was 148 p/mL (normal 5.0-40 p/mL), and serum glutamic pyruvic transaminase (SGPT) was 242 IU/mL (normal 5.0-35 IU/mL). Computerized tomography (CT) scan showed a large mass of tumor
456
1. CT scan shows large retroperitoneal mass (left), and mass involving head of pancreas (right).
FIGURE
extending up to and around the common bile duct (Fig. 1). A transhepatic cholangiogram revealed tumor compressing the common bile duct (Fig. 2). Endoscopic retrograde cholangiopancreatography revealed extrinsic compression of the pancreatic duct, with inability to cannulate the common bile duct. Diagnosis of the retroperitoneal mass was obtained via CT-guided percutaneous needle biopsy, revealing undifferentiated carcinoma. Immunoperoxidase studies revealed the origin of the mass as the prostate. Our patient’s treatment consisted of placement of an internalized
UROLOGY
/ NOVEMBER1992
/ VOLUME40.NUMBERS
and the common bile duct,2 both presenting with jaundice as the predominant symptom. Generally jaundice in a patient with prostatic carcinoma is thought to indicate hepatic parenchymal disease. A definite inverse relationship exists between abnormal liver function tests, secondary to parenchymal metastases from prostate cancer, and survival rates. High values of alkaline phosphatase, bilirubin, SGOT, and SGPT are associated with poor prognosis. All patients in the study of Ishibe, Usui, and Nihira3 were treated with orchiectomy plus estrogen therapy. Their prognosis was generally poor. In the case of abnormal liver function tests due to biliary ductal obstruction, however, similar treatment resulted in rapid normalization of the liver function tests and presumably improved survival. Our patient’s treatment produced dramatically rapid normalization of the liver function studies, with resolution of the clinical jaundice. Treatment results were similar in the previously documented case of biliary metastasis. The response in this case corresponds to the significant improvement generally obtained in the presence of widespread metastatic cancer of the prostate.4 These case reports suggest that liver dysfunction secondary to extrahepatic ductal obstruction by metastases may have a better prognosis as compared with that of metastases to the liver parenchyma.
FIGURE 2. TraGhepatic cholangiogram shows dilated intrahepatic ducts (top arrow), and compressed common bile duct (lower arrow).
biliary stent, bilateral orchiectomy, and antiandrogen therapy. In the immediate postoperative period, the patient showed significant improvement in his general condition, with normalization of liver function tests. The patient was discharged home, and followed up for four months, until his subsequent death.
F’.O. Box 016217 Miami, Florida 33101 (DR. BLOCK)
Comment References
Most patients with prostate cancer present with bone metastases, some with lymph node metastases, an occasional one with visceral metastases, and some present with local lesions without evidence of metastases. Cancer of the prostate presenting with biliary signs and symptoms is most unusual. A search of the literature reveals single case reports of carcinoma of the prostate metastatic to the head of the pancreas,’
UROLOGY
I NOVEMBER
1992
/ VOLUME
40, NUMBER
1. Tolia B, et al: Carcinoma of prostate presenting as retroperitoneal mass, Urology 12: 434 (1978). 2. Ben-Ishay D, Slavin S, Levij I, and Eliakim M: Obstructive jaundice associated with carcinoma of the prostate, Israel J Med Sci 2: 838 (1975). 3. Ishibe T, Usui T, and Nihira H: Prognostic value of liver function tests in carcinoma of the prostate, Urol Int 31: 205 (1976). 4. The Veterans Administration Cooperative Urological Research Group: Treatment and survival of patients with cancer of the prostate, Surg Gynecol Obstet 124: 1011 (1967).
5
457
E. BLOCH, L. BLOCK,
From the Department Miami, Florida
M.D. M.D.
of Urology,
University
of Miami,
ABSTRACT-Me&static cancer of the prostate, presenting with carcinomatous obstruction of the common bile duct as a cause of jaundice and abnormal liver function tests is very unusual. The literature suggests an association between abnormal liver function tests and poor survivability in those patients with liver parenchymal metastases. This case illustrates that patients with abnormal liver function tests on the basis of extrahepatic ductal obstruction may have a better prognosis than those with hepatic disease.
Patients with cancer of the prostate presenting initially with hepatobiliary signs and symptoms have rarely been reported in the literature. We present such a case and review of the literature. Case Report A sixty-nine-year-old white man presented with gastrointestinal symptoms consisting of abdominal pain, nausea, vomiting, and increasing jaundice of one week’s duration. Pertinent physical findings revealed cachexia, jaundice, and a large palpable abdominal mass. Rectal examination revealed a 30 g indurated prostate. Pertinent laboratory studies included a blood urea nitrogen of 46 mg/dL (normal lo-20 mgl dL), and a serum creatinine of 3.3 mg/dL (normal 0.9-1.4 mg/dL). Hematocrit was 30.6 percent (normal 34-40 %), and the white blood cell count was 5,500 (normal 4,500-13,000). Liver function tests included total bilirubin of 10.6 mg/dL (normal 0.1-1.0 mg/dL), and direct bilirubin of 9.8 mg/dL (normal 0.0-0.4 mg/dL). Alkaline phosphatase was 117 PlmL (normal 38-126 p/mL), serum glutamic oxaloacetic transaminase (SGOT) was 148 p/mL (normal 5.0-40 p/mL), and serum glutamic pyruvic transaminase (SGPT) was 242 IU/mL (normal 5.0-35 IU/mL). Computerized tomography (CT) scan showed a large mass of tumor
456
1. CT scan shows large retroperitoneal mass (left), and mass involving head of pancreas (right).
FIGURE
extending up to and around the common bile duct (Fig. 1). A transhepatic cholangiogram revealed tumor compressing the common bile duct (Fig. 2). Endoscopic retrograde cholangiopancreatography revealed extrinsic compression of the pancreatic duct, with inability to cannulate the common bile duct. Diagnosis of the retroperitoneal mass was obtained via CT-guided percutaneous needle biopsy, revealing undifferentiated carcinoma. Immunoperoxidase studies revealed the origin of the mass as the prostate. Our patient’s treatment consisted of placement of an internalized
UROLOGY
/ NOVEMBER1992
/ VOLUME40.NUMBERS
and the common bile duct,2 both presenting with jaundice as the predominant symptom. Generally jaundice in a patient with prostatic carcinoma is thought to indicate hepatic parenchymal disease. A definite inverse relationship exists between abnormal liver function tests, secondary to parenchymal metastases from prostate cancer, and survival rates. High values of alkaline phosphatase, bilirubin, SGOT, and SGPT are associated with poor prognosis. All patients in the study of Ishibe, Usui, and Nihira3 were treated with orchiectomy plus estrogen therapy. Their prognosis was generally poor. In the case of abnormal liver function tests due to biliary ductal obstruction, however, similar treatment resulted in rapid normalization of the liver function tests and presumably improved survival. Our patient’s treatment produced dramatically rapid normalization of the liver function studies, with resolution of the clinical jaundice. Treatment results were similar in the previously documented case of biliary metastasis. The response in this case corresponds to the significant improvement generally obtained in the presence of widespread metastatic cancer of the prostate.4 These case reports suggest that liver dysfunction secondary to extrahepatic ductal obstruction by metastases may have a better prognosis as compared with that of metastases to the liver parenchyma.
FIGURE 2. TraGhepatic cholangiogram shows dilated intrahepatic ducts (top arrow), and compressed common bile duct (lower arrow).
biliary stent, bilateral orchiectomy, and antiandrogen therapy. In the immediate postoperative period, the patient showed significant improvement in his general condition, with normalization of liver function tests. The patient was discharged home, and followed up for four months, until his subsequent death.
F’.O. Box 016217 Miami, Florida 33101 (DR. BLOCK)
Comment References
Most patients with prostate cancer present with bone metastases, some with lymph node metastases, an occasional one with visceral metastases, and some present with local lesions without evidence of metastases. Cancer of the prostate presenting with biliary signs and symptoms is most unusual. A search of the literature reveals single case reports of carcinoma of the prostate metastatic to the head of the pancreas,’
UROLOGY
I NOVEMBER
1992
/ VOLUME
40, NUMBER
1. Tolia B, et al: Carcinoma of prostate presenting as retroperitoneal mass, Urology 12: 434 (1978). 2. Ben-Ishay D, Slavin S, Levij I, and Eliakim M: Obstructive jaundice associated with carcinoma of the prostate, Israel J Med Sci 2: 838 (1975). 3. Ishibe T, Usui T, and Nihira H: Prognostic value of liver function tests in carcinoma of the prostate, Urol Int 31: 205 (1976). 4. The Veterans Administration Cooperative Urological Research Group: Treatment and survival of patients with cancer of the prostate, Surg Gynecol Obstet 124: 1011 (1967).
5
457