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Transrectal ultrasound appearance of hematolymphoid malignancies involving the prostate
PRELIMINARY COMMUNICATION
ELSEVIER
TRANSRECTAL ULTRASOUND APPEARANCE OF HEMATOLYMPHOID MALIGNANCIES INVOLVING THE PROSTATE MARTHA K. TERRIS AND FUAD S. FREIHA
ABSTRACT Objectives. Although the clinical presentation and physical examination findings in patients with lymphoma or leukemia involving the prostate have been described previously, the transrectal ultrasound appearance of hematolymphoid malignancies involving the prostate has not been previously described. Methods. Nine patients with prostate cancer diagnosed by transrectal ultrasound-guided prostate biopsies were found to have hematolymphoid malignancies involving the prostate at the time of subsequent radical prostatectomy and pelvic lymph node dissection. The ultrasound images and prostate needle biopsy results are presented. Results. Prospective analysis of transrectal ultrasound images revealed no abnormality other than hypoechogenicity typical of prostate cancer in 7 of the 9 patients (77.8%). In 2 patients, the ultrasound images were free of any abnormalities. In 2 of the 9 patients (22.2%), the prostate needle biopsies demonstrated suspicious lymphocytic infiltrate in addition to prostate cancer. Conclusions. Transrectal ultrasound does not detect hematolymphoid malignancies involving the prostate. Ultrasound-guided biopsies of the prostate have a very low rate of detecting these malignancies. UROLOGY 51: 339-341, 1998. © 1998, Elsevier Science Inc. All rights reserved.
n autopsy series of men with leukemia, 17 of 53 (32.1%) were found to have prostatic involvement. Of the 10 patients in that study with chronic lymphocytic leukemia (CLL), 4 (40.0%) had prostatic involvement. 1 In another study of 12 patients with CLL who required prostate procedures for outlet obstruction, 6 (50.0%) were found to have leukemic infiltrate involving the prostate specimen. 2 Although the clinical presentation and physical examination findings in patients with lymphoma or leukemia involving the prostate have been described previously, 3,4 the transrectal ultrasound appearance of hematolymphoid malignancies involving the prostate has not been previously described. Prostatic needle biopsy has been reported as successful in some cases of prostatic leukemia
I
From the Department of Urology, Stanford University Medical Center, Stanford, California; and the Section of Urology, Palo Alto Veterans Affairs Medical Center, Palo Alto, California Reprint requests: Martha K. Terris, M.D., Department of Urology ($287), Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5118 Submitted: May 5, 1997, accepted (with revisions): August 12, 1997 © 1998, ELSEVIERSCIENCEINC. ALLRIGHTSRESERVED
and lymphoma but false-negative results have also been reported. 3-s The ultrasound images and prostate needle biopsy results in 9 patients with this malignancy are presented. MATERIAL AND METHODS Nine men were found to have hematolymphoid malignancies involvingthe prostate at the time of radical prostatectomy
and pelvic lymph node dissection for prostatic adenocarcinoma. The patients ranged in age from 59 to 69 years old (mean 68, median 66). All 9 patients underwent preoperative transrectal ultrasound and ultrasound-guided prostate biopsies. Transrectal ultrasound images were obtained with the Bruel & Kj~r (Na~rum, Denmark) 1846 ultrasound consolewith the 7-MHz 1850 and 8538 or 8537 transrectal ultrasound transducers. The model 1850 axial transducer was mounted onto a ratcheted stepping device (Bruel and Kja~rmodel UA 0651) that allowed transverse images to be recorded at 2 to 4-mm intervals from the level of the seminal vesicles to the apex of the prostate. All studies were videotaped in their entirety for future review and comparisonwith surgical specimens. Transrectal ultrasound-guided biopsies were performed in the sagittal plane with the Bruel & Kj~er 8537 or 8538 transducer fitted with a biopsy guide (model UA 0875) through which an 18-gauge Bard Biopty-Cut needle (C.R. Bard, Covington, GA) was driven by the spring-loaded Bard Biopty gun. All patients underwent systematic sextant biopsies as previ0090-4295/98/$19.00 PII S0090-4295(97)00504-9
339
FIGURE 1. Transverse trunsrecta/ ultrasound image of the prostate reveals a hypoechoic lesion corresponding to the palpable nodule (arrow) and biopsies positive for prostatic carcinoma. The surrounding prostatic parenchyma appears normal.
ously described.6 Two patients required additional biopsies of lesions that were observed outside the plane of the systematic sextant biopsies. All biopsies were fixed in 10% formalin and labeled and submitted separately for histologic preparation. Each specimen was embedded in paraffin, sectioned longitudinally, and stained with hematoxylin and eosin for microscopic analysis. Radical retropubic prostatectomy was performed in all 9 patients. The prostate specimens were fixed in formalin and serially blocked transversely at 3 mm. The blocks were sectioned at 5 km and stained with hematoxylin and eosin for microscopic examination. From these sections, a pictorial reconstruction of the prostate together with the adenocarcinoma was displayed by the Stanford technique as previously described.7 The pattern of prostatic involvement with malignant hematolymphoid infiltrate was classified as either diffuse or focal. Those areas of focal involvement were noted on the pictorial reconstruction. These step-sectioned prostatic maps as well as the systematic sextant biopsies were compared with the step-sectioned ultrasound images. This section-to-section comparison provides an accurate means to correlate pathologic conditions with the corresponding ultrasound appearance (Figs. 1,2).
RESULTS Prospective analysis of transrectal ultrasound images revealed no abnormality other than hypoechogenicity typical of prostate cancer in 7 of the 9 patients. This hypoechogenicity corresponded to palpable nodularity and biopsy proven prostatic adenocarcinoma (Fig. 1). In 2 patients, the ultrasound images were free of any abnormalities. In 2 of the 9 patients, the prostate needle biopsies demonstrated suspicious lymphocytic infiltrate in addition to prostate cancer. The radical prostatectomy specimens of the 9 patients revealed Hodgkin’s disease in 2 patients, 2 patients had chronic lymphocytic leukemia, and 5 340
FIGURE 2. Corresponding histologic section from radical prostatectomy specimen at the same level as the ultrasound image reveals the prostate cancer (outlined) corresponding to the hypoechoic lesion. The square indicates the area from which the higher magnification image [Fig. 3) was taken.
High magnification in an area uninvolved with prostatic adenocarcinoma demonstrates prostatic stromal infiltration by lymphocytes. This infiltration was present throughout the prostate gland despite the normal appearance of corresponding ultrasound images. FIGURE 3.
had small lymphocytic leukemia. The 2 patients with Hodgkin’s disease demonstrated areas of focal lymphocytic infiltrate in both the transition zone and peripheral zone of the prostate; this malignant infiltrate was not detected by the prostate needle biopsies in either patient. The prostate glands of the 7 patients with chronic lymphocytic leukemia and small lymphocytic leukemia were diffusely involved with malignant lymphocytic infiltrate throughout the prostate (Figs. 2,3). The preoperative systematic sextant biopsies revealed abnormal infiltrate in 1 patient with chronic lymphocytic leukemia and another patient with small lymphocytic leukemia. Retrospective review of the transrectal ultrasound images following diagnosis of these lymphoproliferative disorders involving the prostate in all 9 patients confirmed the lack of evidence of any abnormality not attributable to the patients’ prostate cancer. UROLOGY 51 (2),1998
COMMENT The presence of malignant lymphocytic infiltrate could not be detected on prostate ultrasound in all 9 of the patients examined. This finding is surprising since lymphocytic infiltrate secondary to chronic and acute prostatitis as well as other inflammatory conditions such as granulomatous prostatitis are commonly apparent on ultrasound images.839 Unlike chronic inflammation of the prostate which is characterized by periglandular lymphocytic infiltrate, malignant lymphocytic infiltrate occurs within the smooth muscle stroma of the prostate (Fig. 2). 10This suggests that the hypoechogenicity associated with prostate cancer and inflammatory lymphocytic infiltrate is due to the echotexture of the glands and periglandular area rather than abnormal cellularity within the stroma of the prostate or homogeneity of the tissue as has previously been proposed.11J2 Transrectal ultrasound-guided prostate needle biopsies exhibited a sensitivity of only 22.2% for detecting hematolymphoid malignancies involving the prostate. This lack of diagnostic accuracy has been attributed to the irregular nature of prostatic infiltration by malignant lymphocytes,3 but may also be due to difficulty of confirming the pathologic diagnosis secondary to the relatively small size prostate needle biopsies and common occurrence of benign lymphocytic infiltrate of the prostate. REFERENCES 1. Lucia SP, Mills H, Lowenhaupt E, and Hunt ML: Visceral involvement in primary neoplastic diseases of the reticuloendothelial system. Cancer 5: 1193-1200, 1952.
UROLOGY
51 (21, 1998
2. Butler MR, and O’Flynn JD: Prostatic disease in the leukemic patient-with particular reference to leukemic infiltration of the prostate-a retrospective clinical study. Br J Urol 45: 179-183,1973. 3. Dajani YF, and Burke M: Leukemic infiltration of the prostate: a case study and clinicopathological review. Cancer 38: 2442-2446,1976. 4. Bostwick, DG, and Mann RB: Malignant lymphomas involving the prostate. A study of 13 cases. Cancer 56: 29322938,1985. 5. Horan AH, and Tarjoman J: Life-threatening leukopenia following flutamide during downstaging of a PSA falsepositive lymphoma invading the prostate. 72nd Annual Meeting Western Section American Urological Association, July 1996, San Diego, California. 6. Hodge KK, McNeal JE, Terris MK, and Stamey TA: Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 142: 71-74, 1989. 7. Stamey TA, McNeal JE, Freiha FS, and Redwine E: Morphometric and clinical studies on 68 consecutive radical prostatectomies. J Urol 139: 1235-1241, 1988. 8. Hodge KK, McNeal JE, and Stamey TA: Ultrasound guided transrectal core biopsies of the palpably abnormal prostate. J Urol 142: 66-70, 1989. 9. Mukamel E, Konichezky M, Engelstein D, Cytron S, Abramovici A, and Servadio C: Clinical and pathological findings in prostates following intravesical bacillus CalmetteGuerin instillations. J Urol 144: 1399-1400, 1990. 10. Bernstein J, and Churg J: Urinary Tract Pathology. New York, Raven Press, 1992, pp 217-218. 11. Rifkin MD, McGlynn ET, and Choi H: Echogenicity of prostate cancer correlated with histologic grade and stromal fibrosis: endorectal US studies. Radiology 170: 549-552, 1989. 12. Goldstone LM, Egawa S, and Scardino PT: Prostate cancer: echo characteristics, tumor location, and tumor size, in Resnick MI (Ed): Prostatic Ultrasonography. Philadelphia, BC Decker, 1990, p 55.
341
ELSEVIER
TRANSRECTAL ULTRASOUND APPEARANCE OF HEMATOLYMPHOID MALIGNANCIES INVOLVING THE PROSTATE MARTHA K. TERRIS AND FUAD S. FREIHA
ABSTRACT Objectives. Although the clinical presentation and physical examination findings in patients with lymphoma or leukemia involving the prostate have been described previously, the transrectal ultrasound appearance of hematolymphoid malignancies involving the prostate has not been previously described. Methods. Nine patients with prostate cancer diagnosed by transrectal ultrasound-guided prostate biopsies were found to have hematolymphoid malignancies involving the prostate at the time of subsequent radical prostatectomy and pelvic lymph node dissection. The ultrasound images and prostate needle biopsy results are presented. Results. Prospective analysis of transrectal ultrasound images revealed no abnormality other than hypoechogenicity typical of prostate cancer in 7 of the 9 patients (77.8%). In 2 patients, the ultrasound images were free of any abnormalities. In 2 of the 9 patients (22.2%), the prostate needle biopsies demonstrated suspicious lymphocytic infiltrate in addition to prostate cancer. Conclusions. Transrectal ultrasound does not detect hematolymphoid malignancies involving the prostate. Ultrasound-guided biopsies of the prostate have a very low rate of detecting these malignancies. UROLOGY 51: 339-341, 1998. © 1998, Elsevier Science Inc. All rights reserved.
n autopsy series of men with leukemia, 17 of 53 (32.1%) were found to have prostatic involvement. Of the 10 patients in that study with chronic lymphocytic leukemia (CLL), 4 (40.0%) had prostatic involvement. 1 In another study of 12 patients with CLL who required prostate procedures for outlet obstruction, 6 (50.0%) were found to have leukemic infiltrate involving the prostate specimen. 2 Although the clinical presentation and physical examination findings in patients with lymphoma or leukemia involving the prostate have been described previously, 3,4 the transrectal ultrasound appearance of hematolymphoid malignancies involving the prostate has not been previously described. Prostatic needle biopsy has been reported as successful in some cases of prostatic leukemia
I
From the Department of Urology, Stanford University Medical Center, Stanford, California; and the Section of Urology, Palo Alto Veterans Affairs Medical Center, Palo Alto, California Reprint requests: Martha K. Terris, M.D., Department of Urology ($287), Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5118 Submitted: May 5, 1997, accepted (with revisions): August 12, 1997 © 1998, ELSEVIERSCIENCEINC. ALLRIGHTSRESERVED
and lymphoma but false-negative results have also been reported. 3-s The ultrasound images and prostate needle biopsy results in 9 patients with this malignancy are presented. MATERIAL AND METHODS Nine men were found to have hematolymphoid malignancies involvingthe prostate at the time of radical prostatectomy
and pelvic lymph node dissection for prostatic adenocarcinoma. The patients ranged in age from 59 to 69 years old (mean 68, median 66). All 9 patients underwent preoperative transrectal ultrasound and ultrasound-guided prostate biopsies. Transrectal ultrasound images were obtained with the Bruel & Kj~r (Na~rum, Denmark) 1846 ultrasound consolewith the 7-MHz 1850 and 8538 or 8537 transrectal ultrasound transducers. The model 1850 axial transducer was mounted onto a ratcheted stepping device (Bruel and Kja~rmodel UA 0651) that allowed transverse images to be recorded at 2 to 4-mm intervals from the level of the seminal vesicles to the apex of the prostate. All studies were videotaped in their entirety for future review and comparisonwith surgical specimens. Transrectal ultrasound-guided biopsies were performed in the sagittal plane with the Bruel & Kj~er 8537 or 8538 transducer fitted with a biopsy guide (model UA 0875) through which an 18-gauge Bard Biopty-Cut needle (C.R. Bard, Covington, GA) was driven by the spring-loaded Bard Biopty gun. All patients underwent systematic sextant biopsies as previ0090-4295/98/$19.00 PII S0090-4295(97)00504-9
339
FIGURE 1. Transverse trunsrecta/ ultrasound image of the prostate reveals a hypoechoic lesion corresponding to the palpable nodule (arrow) and biopsies positive for prostatic carcinoma. The surrounding prostatic parenchyma appears normal.
ously described.6 Two patients required additional biopsies of lesions that were observed outside the plane of the systematic sextant biopsies. All biopsies were fixed in 10% formalin and labeled and submitted separately for histologic preparation. Each specimen was embedded in paraffin, sectioned longitudinally, and stained with hematoxylin and eosin for microscopic analysis. Radical retropubic prostatectomy was performed in all 9 patients. The prostate specimens were fixed in formalin and serially blocked transversely at 3 mm. The blocks were sectioned at 5 km and stained with hematoxylin and eosin for microscopic examination. From these sections, a pictorial reconstruction of the prostate together with the adenocarcinoma was displayed by the Stanford technique as previously described.7 The pattern of prostatic involvement with malignant hematolymphoid infiltrate was classified as either diffuse or focal. Those areas of focal involvement were noted on the pictorial reconstruction. These step-sectioned prostatic maps as well as the systematic sextant biopsies were compared with the step-sectioned ultrasound images. This section-to-section comparison provides an accurate means to correlate pathologic conditions with the corresponding ultrasound appearance (Figs. 1,2).
RESULTS Prospective analysis of transrectal ultrasound images revealed no abnormality other than hypoechogenicity typical of prostate cancer in 7 of the 9 patients. This hypoechogenicity corresponded to palpable nodularity and biopsy proven prostatic adenocarcinoma (Fig. 1). In 2 patients, the ultrasound images were free of any abnormalities. In 2 of the 9 patients, the prostate needle biopsies demonstrated suspicious lymphocytic infiltrate in addition to prostate cancer. The radical prostatectomy specimens of the 9 patients revealed Hodgkin’s disease in 2 patients, 2 patients had chronic lymphocytic leukemia, and 5 340
FIGURE 2. Corresponding histologic section from radical prostatectomy specimen at the same level as the ultrasound image reveals the prostate cancer (outlined) corresponding to the hypoechoic lesion. The square indicates the area from which the higher magnification image [Fig. 3) was taken.
High magnification in an area uninvolved with prostatic adenocarcinoma demonstrates prostatic stromal infiltration by lymphocytes. This infiltration was present throughout the prostate gland despite the normal appearance of corresponding ultrasound images. FIGURE 3.
had small lymphocytic leukemia. The 2 patients with Hodgkin’s disease demonstrated areas of focal lymphocytic infiltrate in both the transition zone and peripheral zone of the prostate; this malignant infiltrate was not detected by the prostate needle biopsies in either patient. The prostate glands of the 7 patients with chronic lymphocytic leukemia and small lymphocytic leukemia were diffusely involved with malignant lymphocytic infiltrate throughout the prostate (Figs. 2,3). The preoperative systematic sextant biopsies revealed abnormal infiltrate in 1 patient with chronic lymphocytic leukemia and another patient with small lymphocytic leukemia. Retrospective review of the transrectal ultrasound images following diagnosis of these lymphoproliferative disorders involving the prostate in all 9 patients confirmed the lack of evidence of any abnormality not attributable to the patients’ prostate cancer. UROLOGY 51 (2),1998
COMMENT The presence of malignant lymphocytic infiltrate could not be detected on prostate ultrasound in all 9 of the patients examined. This finding is surprising since lymphocytic infiltrate secondary to chronic and acute prostatitis as well as other inflammatory conditions such as granulomatous prostatitis are commonly apparent on ultrasound images.839 Unlike chronic inflammation of the prostate which is characterized by periglandular lymphocytic infiltrate, malignant lymphocytic infiltrate occurs within the smooth muscle stroma of the prostate (Fig. 2). 10This suggests that the hypoechogenicity associated with prostate cancer and inflammatory lymphocytic infiltrate is due to the echotexture of the glands and periglandular area rather than abnormal cellularity within the stroma of the prostate or homogeneity of the tissue as has previously been proposed.11J2 Transrectal ultrasound-guided prostate needle biopsies exhibited a sensitivity of only 22.2% for detecting hematolymphoid malignancies involving the prostate. This lack of diagnostic accuracy has been attributed to the irregular nature of prostatic infiltration by malignant lymphocytes,3 but may also be due to difficulty of confirming the pathologic diagnosis secondary to the relatively small size prostate needle biopsies and common occurrence of benign lymphocytic infiltrate of the prostate. REFERENCES 1. Lucia SP, Mills H, Lowenhaupt E, and Hunt ML: Visceral involvement in primary neoplastic diseases of the reticuloendothelial system. Cancer 5: 1193-1200, 1952.
UROLOGY
51 (21, 1998
2. Butler MR, and O’Flynn JD: Prostatic disease in the leukemic patient-with particular reference to leukemic infiltration of the prostate-a retrospective clinical study. Br J Urol 45: 179-183,1973. 3. Dajani YF, and Burke M: Leukemic infiltration of the prostate: a case study and clinicopathological review. Cancer 38: 2442-2446,1976. 4. Bostwick, DG, and Mann RB: Malignant lymphomas involving the prostate. A study of 13 cases. Cancer 56: 29322938,1985. 5. Horan AH, and Tarjoman J: Life-threatening leukopenia following flutamide during downstaging of a PSA falsepositive lymphoma invading the prostate. 72nd Annual Meeting Western Section American Urological Association, July 1996, San Diego, California. 6. Hodge KK, McNeal JE, Terris MK, and Stamey TA: Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 142: 71-74, 1989. 7. Stamey TA, McNeal JE, Freiha FS, and Redwine E: Morphometric and clinical studies on 68 consecutive radical prostatectomies. J Urol 139: 1235-1241, 1988. 8. Hodge KK, McNeal JE, and Stamey TA: Ultrasound guided transrectal core biopsies of the palpably abnormal prostate. J Urol 142: 66-70, 1989. 9. Mukamel E, Konichezky M, Engelstein D, Cytron S, Abramovici A, and Servadio C: Clinical and pathological findings in prostates following intravesical bacillus CalmetteGuerin instillations. J Urol 144: 1399-1400, 1990. 10. Bernstein J, and Churg J: Urinary Tract Pathology. New York, Raven Press, 1992, pp 217-218. 11. Rifkin MD, McGlynn ET, and Choi H: Echogenicity of prostate cancer correlated with histologic grade and stromal fibrosis: endorectal US studies. Radiology 170: 549-552, 1989. 12. Goldstone LM, Egawa S, and Scardino PT: Prostate cancer: echo characteristics, tumor location, and tumor size, in Resnick MI (Ed): Prostatic Ultrasonography. Philadelphia, BC Decker, 1990, p 55.
341