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Resolution of hepatic metastases fromcarcinoma of prostate with stilbestrol
RESOLUTION OF HEPATIC METASTASES FROM CARCINOMA OF PROSTATE WITH STILBESTROL B. BLYTH, M.D. C. U. McRAE, M.B., CH.B. J. G. TURNER, M.D. From the Departments of Urology and Nuclear Medicine, Christchurch Hospital, Christchurch, New Zealand
A B S T R A C T - - A case is presented in which a man with hepatic metastases from cc proslate demonstrated a dramatic response to hormonal therapy.
~rhile the prognosis of disseminated carcinoma of the prostate is generally dismal, there are ease, reports of long-term survival. 1,2 We report herein a ease with evidence of hepatic metastases with a dramatic response to hormone therapy. Case Report A seventy-three-year-old man presented with a six-month history suggesting urinary outflow obstruction. Digital rectal examination of his prostate detected a T2 carcinoma which was confirmed by transreetal biopsy. Histologie examination showed a well-differentiated prostatie adenoeareinoma. Biochemical screening tests w e r e acid p h o s p h a t a s e ( e n z y m a t i c method) 1.3 IU/L (normal <2.0), alkaline phosphatase 77 IU/L (30-120), gamma glutamy1 transferase 18 IU/L (<35), ereatinine 0.11 rnmol/L (<0.11). A teehnetium-99m-methylene diphosphonate bone scan showed no areas of abnormal uptake. An intravenous urogram showed no evidence of urinary tract dilatation or renal abnormality, and a chest x-ray film showed only normal lung field markings. The patient was considered to have localized disease and underwent a course of radiotherapy receiving a total of 5,000 eGy to his prostatic bed. During the course of his radiotherapy urinary retention developed requiring catheterization, and he underwent a transurethral resection at the completion of his treatment. Histology con-
574
firmed prostatic adenocareinor moderate grade of differentiatic One year after initial prese turned with perineal, serotal, ," costal pain. Ctinieal hepatomeg with his prostatic remnant hard chemical evaluations revealed serum acid phosphatase 24.3 phosphatase 404 IU/L, gamma and ereatinine 0.16 mmol/L. Z film now demonstrated mul throughout both lung fields. liver scan showed multiple filli! 1A), while a repeat bone scan s increased uptake in ribs on the riorly, the midthoraeie vertebra out the pelvis. An ultrasound the kidneys showed a dilated 1 although the level of obstru further investigated. With evidence of widspread present (although not eonfir~ diagnoses) he was started on diethylstilbestrol 1 mg TID wit] his serotal, perineal, and costal He remained symptom-free twelve months. Clinical exam time revealed a normal-sized i function tests within the norma His serum acid phosphatase I normal levels with ereatinine 0 repeat liver scan of both anteric
UROLOGY
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JUNE 1991
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VOLUME :_
lateral (not shown) views showed marked resolution of his hepatic filling defects. A repeat chest x-ray film no longer showed any abnormal opacities. At twenty-four months from the time of diagnosis of metastases the patient continues to be symptom-free. Comment This case is presented because of the unique response of advanced metastatic carcinoma of the prostate to hormone manipulation. The resolution of pulmonary metastases has been previously reported ~,~ and has been seen on other occasions at this institution, but there are no references in the literature to a response of hepatic metastases to hormone manipulation. Although these filling defects within the liver have not been proved to be metastatic carcinoma of the prostate by biopsy, the response to subsequent therapy leaves little doubt as to their nature. The resolution of the disordered hepatic function tests is also supportive evidence of resolving metastatic disease. This unique response to hormonal therapy suggests a population of neoplastic cells that are highly estrogen sensitive.
A
B
Christchurch, New Zealand (DR. BLYTH) References
~IGURE 1. A 99'~Tc-phytate liver scan, anterior ~iew, (A) showing multiple filling defects consistent ~ i t h metastatic disease, and (B) after twelve months ~ f stilbestrol therapy.
~r-dROLOGY /
JUNE 1991
/
VOLUME XXXVII, NUMBER 6
1. Bolton BH: Pulmonary metastases from carcinoma of the prostate: incidence and ease report of a long remission, J Uro194: 73 (1965). 2. Falkowski WS, and O'Conor VJ Jr: Long-term survivor of prostatic carcinoma with lung metastases, J Urol 125:260 (1981).
575
A B S T R A C T - - A case is presented in which a man with hepatic metastases from cc proslate demonstrated a dramatic response to hormonal therapy.
~rhile the prognosis of disseminated carcinoma of the prostate is generally dismal, there are ease, reports of long-term survival. 1,2 We report herein a ease with evidence of hepatic metastases with a dramatic response to hormone therapy. Case Report A seventy-three-year-old man presented with a six-month history suggesting urinary outflow obstruction. Digital rectal examination of his prostate detected a T2 carcinoma which was confirmed by transreetal biopsy. Histologie examination showed a well-differentiated prostatie adenoeareinoma. Biochemical screening tests w e r e acid p h o s p h a t a s e ( e n z y m a t i c method) 1.3 IU/L (normal <2.0), alkaline phosphatase 77 IU/L (30-120), gamma glutamy1 transferase 18 IU/L (<35), ereatinine 0.11 rnmol/L (<0.11). A teehnetium-99m-methylene diphosphonate bone scan showed no areas of abnormal uptake. An intravenous urogram showed no evidence of urinary tract dilatation or renal abnormality, and a chest x-ray film showed only normal lung field markings. The patient was considered to have localized disease and underwent a course of radiotherapy receiving a total of 5,000 eGy to his prostatic bed. During the course of his radiotherapy urinary retention developed requiring catheterization, and he underwent a transurethral resection at the completion of his treatment. Histology con-
574
firmed prostatic adenocareinor moderate grade of differentiatic One year after initial prese turned with perineal, serotal, ," costal pain. Ctinieal hepatomeg with his prostatic remnant hard chemical evaluations revealed serum acid phosphatase 24.3 phosphatase 404 IU/L, gamma and ereatinine 0.16 mmol/L. Z film now demonstrated mul throughout both lung fields. liver scan showed multiple filli! 1A), while a repeat bone scan s increased uptake in ribs on the riorly, the midthoraeie vertebra out the pelvis. An ultrasound the kidneys showed a dilated 1 although the level of obstru further investigated. With evidence of widspread present (although not eonfir~ diagnoses) he was started on diethylstilbestrol 1 mg TID wit] his serotal, perineal, and costal He remained symptom-free twelve months. Clinical exam time revealed a normal-sized i function tests within the norma His serum acid phosphatase I normal levels with ereatinine 0 repeat liver scan of both anteric
UROLOGY
/
JUNE 1991
/
VOLUME :_
lateral (not shown) views showed marked resolution of his hepatic filling defects. A repeat chest x-ray film no longer showed any abnormal opacities. At twenty-four months from the time of diagnosis of metastases the patient continues to be symptom-free. Comment This case is presented because of the unique response of advanced metastatic carcinoma of the prostate to hormone manipulation. The resolution of pulmonary metastases has been previously reported ~,~ and has been seen on other occasions at this institution, but there are no references in the literature to a response of hepatic metastases to hormone manipulation. Although these filling defects within the liver have not been proved to be metastatic carcinoma of the prostate by biopsy, the response to subsequent therapy leaves little doubt as to their nature. The resolution of the disordered hepatic function tests is also supportive evidence of resolving metastatic disease. This unique response to hormonal therapy suggests a population of neoplastic cells that are highly estrogen sensitive.
A
B
Christchurch, New Zealand (DR. BLYTH) References
~IGURE 1. A 99'~Tc-phytate liver scan, anterior ~iew, (A) showing multiple filling defects consistent ~ i t h metastatic disease, and (B) after twelve months ~ f stilbestrol therapy.
~r-dROLOGY /
JUNE 1991
/
VOLUME XXXVII, NUMBER 6
1. Bolton BH: Pulmonary metastases from carcinoma of the prostate: incidence and ease report of a long remission, J Uro194: 73 (1965). 2. Falkowski WS, and O'Conor VJ Jr: Long-term survivor of prostatic carcinoma with lung metastases, J Urol 125:260 (1981).
575