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Osteogenesis Occurring in Carcinoma of the Prostate
THE JOURNAL OF UROLOGY
Vol. 62, No. 1, July 1949 Printed in U.S.A.
OSTEOGENESIS OCCURRING IN CARCINOMA OF THE PROSTATE EDWARD CRAIG COATS
AND
JAMES R. LISA
From the Laboratory of Pathology, City Hospital, Welfare Island, Dept. of Hospitals, New York, N. Y.
Bone formation occurring in prostatic carcinoma has rarely been noted. Barringer and Woodward encountered one such instance. Ashburn recorded the second case. It seems a rare enough event to warrant the publication of another report. CASE REPORT
A white man, 57 years of age, first came under observation in June 1946 because of low back pain, weight loss of 30 pounds in 2 months, anorexia, swelling of the left ankle and foot, and chest pain with productive cough. There were no urinary disturbances. The pertinent physical findings were a hard, fixed, slightly enlarged, nontender prostate; tenderness over the spine from the third lumbar to the first thoracic vertebra; mild left costovertebral tenderness; liver edge palpable 3 finger breadths below the costal margin; and pitting edema of the left lower leg. There was no residual urine, anemia was moderate (Hb. 10.2 gm., red blood cells 3.4), ESR 128 mm/h, and acid phosphatase 5.5 B.U. Roentgenological examination revealed ground glass density of the lower three lumbar vertebrae, upper sacrum, left ischium and base of left ilium. The large bowel had a redundant sigmoid extending into a left inguinal hernia and a constant narrowing of midrectum. He was discharged on July 3, and remained under observation at a clinic where he was placed on stilbestrol therapy. The second hospital admission was from November 12 to December 28, because of fever and back and joint pains for 2 days. The temperature returned to normal by the third day. X-rays showed considerable extention of the osteoblastic process, all the vertebrae and pelvic bones, the right shoulder, upper humerus and many ribs being involved. Since orchiectomy was refused, stilbestrol was continued. He was discharged somewhat improved symptomatically, with less pain, able to walk moderately well and having gained 9½ pounds in weight. The blood chemical findings were: Date
Acid Phosphatase
Nov. 13 20 25 27 Dec. 2 4 6 " 9
8.3 14.7 16.3 17.6 25.7 21.2 14.5 14.7
Alkaline Phosphatase
21.4 21.9
He was seen a few times in the clinic for left shoulder and leg pain and remained 58
OSTEOGENESIS IN CARCINOMA OF THE PROSTATE
59
under stilbestrol therapy. On August 1, 1947, he was admitted to City Hospital, where he died 8 days later. During this period of observation he developed signs of small bowel obstruction. X-rays showed small bowel obstruction and extensive bony metastases. At operation, a Richter hernia containing a loop of obstructed large bowel was found and repaired. The course was progressive and death occurred 2 days later. The total stilbestrol administered between August 9, 1946 and July 31, 1947 was 4095 mg. Autopsy (No. 7978): The pertinent findings only are given. The prostate had a large carcinoma and there were extensive bony metastases, metastases to
FIG. 1. Lesion of prostate, showing regression of tumor cells, marked fibrotic response and bone formation.
one adrenal and extensive invasion of the soft tissues of the pelvis causing ureteral obstruction and pyelonephritis. The microscopy of the primary tumor showed extensive regressive changes of the neoplasm with marked fibrosis. In some areas the fibrosis had become hyalinized and calcified, resembling bone in its morphological pattern (fig. 1). COMMENT
The pathogenesis of the formation of bone in prostatic carcinoma is obscure. Huggins in 1931 showed that the epithelium of the urinary bladder has osteogenic properties and suggested the possibility that the same may be true of the prostatic epithelium. Experimental proof was lacking. Histologically the present case resembled Huggins' findings very closely. The effect of stilbestrol therapy in bone production probably is slight,
60
EDWARD CRAIG COATS AND JAMES R. LISA
although definite conclusions cannot be advanced in view of the paucity of data. In the cases of Barringer and Woodward and of Ashburn, stilbesterol was not administered. It is of interest to note, however, that in the present case and in that of Barringer and Woodward, the levels of alkaline serum phosphatase activity were high. SUMMARY
A case of osteogenesis in a prostatic carcinoma is reported and the literature of this unusual event reviewed.
65 E. 66 St., New York 21, N.Y. (E.C.C.) City Hospital, Welfare Island, New York 17, N.Y. (J.R.L.) REFERENCES ASHBURN, L. L.: New bone formation in a primary carcinoma of the prostate. Arch. Path. 28: 145--150, 1939. BARRINGER, B. S. AND WOODWARD, H. C. Prostatic carcinoma with extensive intraprostatic calcification. Trans. Amer. Assoc. Genito-Urin. Surg., 31: 363-369, 1938. HUGGINS, C.: Formation of bone under the influence of the epithelium of the urinary tract. Arch. Surg., 22: 377-408, 1931. HUGGINS, C. Personal communication.
Vol. 62, No. 1, July 1949 Printed in U.S.A.
OSTEOGENESIS OCCURRING IN CARCINOMA OF THE PROSTATE EDWARD CRAIG COATS
AND
JAMES R. LISA
From the Laboratory of Pathology, City Hospital, Welfare Island, Dept. of Hospitals, New York, N. Y.
Bone formation occurring in prostatic carcinoma has rarely been noted. Barringer and Woodward encountered one such instance. Ashburn recorded the second case. It seems a rare enough event to warrant the publication of another report. CASE REPORT
A white man, 57 years of age, first came under observation in June 1946 because of low back pain, weight loss of 30 pounds in 2 months, anorexia, swelling of the left ankle and foot, and chest pain with productive cough. There were no urinary disturbances. The pertinent physical findings were a hard, fixed, slightly enlarged, nontender prostate; tenderness over the spine from the third lumbar to the first thoracic vertebra; mild left costovertebral tenderness; liver edge palpable 3 finger breadths below the costal margin; and pitting edema of the left lower leg. There was no residual urine, anemia was moderate (Hb. 10.2 gm., red blood cells 3.4), ESR 128 mm/h, and acid phosphatase 5.5 B.U. Roentgenological examination revealed ground glass density of the lower three lumbar vertebrae, upper sacrum, left ischium and base of left ilium. The large bowel had a redundant sigmoid extending into a left inguinal hernia and a constant narrowing of midrectum. He was discharged on July 3, and remained under observation at a clinic where he was placed on stilbestrol therapy. The second hospital admission was from November 12 to December 28, because of fever and back and joint pains for 2 days. The temperature returned to normal by the third day. X-rays showed considerable extention of the osteoblastic process, all the vertebrae and pelvic bones, the right shoulder, upper humerus and many ribs being involved. Since orchiectomy was refused, stilbestrol was continued. He was discharged somewhat improved symptomatically, with less pain, able to walk moderately well and having gained 9½ pounds in weight. The blood chemical findings were: Date
Acid Phosphatase
Nov. 13 20 25 27 Dec. 2 4 6 " 9
8.3 14.7 16.3 17.6 25.7 21.2 14.5 14.7
Alkaline Phosphatase
21.4 21.9
He was seen a few times in the clinic for left shoulder and leg pain and remained 58
OSTEOGENESIS IN CARCINOMA OF THE PROSTATE
59
under stilbestrol therapy. On August 1, 1947, he was admitted to City Hospital, where he died 8 days later. During this period of observation he developed signs of small bowel obstruction. X-rays showed small bowel obstruction and extensive bony metastases. At operation, a Richter hernia containing a loop of obstructed large bowel was found and repaired. The course was progressive and death occurred 2 days later. The total stilbestrol administered between August 9, 1946 and July 31, 1947 was 4095 mg. Autopsy (No. 7978): The pertinent findings only are given. The prostate had a large carcinoma and there were extensive bony metastases, metastases to
FIG. 1. Lesion of prostate, showing regression of tumor cells, marked fibrotic response and bone formation.
one adrenal and extensive invasion of the soft tissues of the pelvis causing ureteral obstruction and pyelonephritis. The microscopy of the primary tumor showed extensive regressive changes of the neoplasm with marked fibrosis. In some areas the fibrosis had become hyalinized and calcified, resembling bone in its morphological pattern (fig. 1). COMMENT
The pathogenesis of the formation of bone in prostatic carcinoma is obscure. Huggins in 1931 showed that the epithelium of the urinary bladder has osteogenic properties and suggested the possibility that the same may be true of the prostatic epithelium. Experimental proof was lacking. Histologically the present case resembled Huggins' findings very closely. The effect of stilbestrol therapy in bone production probably is slight,
60
EDWARD CRAIG COATS AND JAMES R. LISA
although definite conclusions cannot be advanced in view of the paucity of data. In the cases of Barringer and Woodward and of Ashburn, stilbesterol was not administered. It is of interest to note, however, that in the present case and in that of Barringer and Woodward, the levels of alkaline serum phosphatase activity were high. SUMMARY
A case of osteogenesis in a prostatic carcinoma is reported and the literature of this unusual event reviewed.
65 E. 66 St., New York 21, N.Y. (E.C.C.) City Hospital, Welfare Island, New York 17, N.Y. (J.R.L.) REFERENCES ASHBURN, L. L.: New bone formation in a primary carcinoma of the prostate. Arch. Path. 28: 145--150, 1939. BARRINGER, B. S. AND WOODWARD, H. C. Prostatic carcinoma with extensive intraprostatic calcification. Trans. Amer. Assoc. Genito-Urin. Surg., 31: 363-369, 1938. HUGGINS, C.: Formation of bone under the influence of the epithelium of the urinary tract. Arch. Surg., 22: 377-408, 1931. HUGGINS, C. Personal communication.