Primary transitional cell carcinoma of the prostate presenting as a rectal ulcer

Primary transitional cell carcinoma of the prostate is a rare clinicopathological entity. It is an aggressive tumor with a poor prognosis. Presentation is usually late, with obstructive voiding complaints. Radical surgery offers locoregional control of the disease. We report a case with an atypical presentation of bleeding per rectum and associated obstructive voiding symptoms. Examination revealed a rectal ulcer overlying an enlarged prostate and fixed to it. Histopathology showed a picture of transitional cell carcinoma of the prostate infiltrating the rectum. Imaging studies revealed an enlarged prostate with altered echo pattern with locoregional spread, infiltrating the rectum. Bladder involvement and distant metastases were not evident. External beam radiotherapy achieved good local control. At 3 months of follow-up, the patient was free of urinary symptoms and his rectal ulcer had healed. The patient declined subsequent treatment.     

Postradiation therapy adenosquamous cell carcinoma of the prostate

The objective of this study was to present two cases of adenosquamous cell carcinoma of the prostate following radiation therapy. Two patients with history of prostate cancer treated with radiation therapy presented with rectal bleeding and a large ulcerated rectal mass. The rectal biopsy revealed on both cases squamous cell carcinoma. The initial diagnosis was invasive squamous cell carcinoma from anal origin. Both patients underwent pelvic exenteration with continent urinary diversion. After extensive histological sampling and immuno-histochemisty, they were correctly diagnosed of adenosquamous cell carcinoma of the prostate with invasion of the rectum. The patients died 6 and 16 months after surgery with widespread metastases. A review of the literature is presented. Adenosquamous cell carcinoma of the prostate is an unusual histological variant of prostate cancer. To our knowledge, only three cases of adenosquamous cell carcinoma of the prostate following radiation therapy have been reported. The unusual clinical and histopathological features of the two cases reported here led to an initial mistaken diagnosis. Adenosquamous cell carcinoma of the prostate should be considered in the differential diagnosis when a patient with prostate cancer develops a rectal mass or rectal bleeding following radiation therapy and the rectal biopsy reveals squamous cell carcinoma. Prostate Cancer and Prostatic Diseases (2000) 3, 53-56     

Oat cell carcinoma of lung masquerading as prostatic carcinoma

We believe this is the second case of oat cell carcinoma metastatic to the prostate to be reported. The patient was treated for prostatic carcinoma diagnosed by rectal examination. Subsequent biopsy confirmed oat cell carcinoma and led to the discovery of pulmonary carcinoma. Tumors metastatic to the prostate are rare and are identified when they result in urologic symptoms. A review of tumors metastatic to the prostate is presented.     

Value of transrectal prostate ultrasonography pre-transurethral prostatectomy in screening for occult prostate carcinoma

A total of 311 patients who underwent consecutive transurethral resection of prostate (T URP) for obstructive voiding symptoms were reviewed. All patients had benign prostate glands by digital rectal examination. Results of preoperative ultrasound screening of the prostate in 65 of 311 patients showed 41 with nonmalignant prostate, but pathologic examination showed cancer in 11 and benign hyperplasia in 30. Of seven ultrasounds interpreted as suspicious for cancer, pathologic examination revealed benign hyperplasia in all seven. Of 17 patients with ultrasound interpretations consistent with prostate cancer, 14 had transrectal ultrasound-guided prostate biopsies prior to T URP. Biopsy specimens revealed benign hyperplasia without carcinoma in all 14 patients. Two of 17 patients refused biopsies, and 1 underwent TURP without biopsy for urinary retention and did have cancer. Sensitivity of prostate ultrasound in evaluation of occult prostate carcinoma in this group of patients was 8.3 percent and specificity was 56.6 percent. Our results indicate that transrectal prostate ultrasound performed on men with obstructive voiding symptoms and benign glands as evidenced by digital rectal palpation has little value in predicting the presence or absence of occult prostate cancer.     

A case of giant transitional cell carcinoma of the prostate

A 69-year-old man presented with a complaint of pollakisuria, dysuria and anal pain. Digital rectal examination, transrectal ultrasonography and tumor marker of the prostate indicated a giant benign prostate hypertrophy (BPH), but urethrocystogram and magnetic resonance imaging (MRI) of the prostate was not typical of BPH. A diagnosis of giant BPH was made by transrectal needle biopsy of the prostate. However, symptoms of dysuria and anal pain became severe and then a catheter was indwelt into his bladder. A biopsy performed, 3 months later revealed transitional cell carcinoma in the specimens, but he suddenly died of pulmonary infarction.     

Invasive carcinoma of prostate presenting as rectal carcinoma

Prostate carcinoma occasionally can present with rectal obstructive symptoms and an annular constricting lesion of the rectum. Discriminating between primary rectal carcinoma and prostate carcinoma locally invasive to the rectum is of obvious importance because of the different treatments and prognoses. History and physical examination play only a marginal role in differentiating between these two lesions. The diagnosis of prostatic malignancy in patients in this circumstance can be supported by an elevated serum acid phosphatase as well as a bone scan that demonstrates a pelvic/vertebral distribution of bony metastases. The rectal mucosa is usually spared, and a barium enema often will demonstrate tapered margins as opposed to a tumor edge in primary rectal malignancy. Excretory urography often demonstrates hydronephrosis. Rectal biopsy with immunohistochemical staining for prostate specific antigen can direct the origin of a poorly differentiated adenocarcinoma to the prostate. Treatment involves hormonal manipulation with estrogen therapy or orchiectomy. Radiation therapy to the obstructed rectum has provided satisfactory palliation when hormonal manipulation fails.     

Study on frequency of prostate carcinoma and benign prostatic hypertrophy by mass screening in Hokkaido]

We conducted mass screenings for prostate diseases on male subjects over fifty years of age in three separate areas in Hokkaido. Prostate carcinoma and benign prostatic hypertrophy were searched in the 1,764 participants. Histopathologically proven prostate carcinoma was found in twenty-two (1.25%) of the 1,764 participants. This frequency of carcinoma was higher than any other carcinoma found in the mass screenings for gastric, uterine, breast and lung carcinoma in Hokkaido. Of the 22 prostate carcinomas found, 68% were in the early stage (stage B). This stage distribution was clearly distinct from that of prostate carcinoma found on the hospital visit, most of which had already progressed to an advanced stage. These results indicate that mass screening for prostate carcinoma on greater than or equal to 50 year old-male subjects is efficient in finding carcinoma of all stages but, in particular, carcinoma of early stage, when compared with mass screening for other carcinomas. BPH, defined as a moderately or markedly enlarged prostate on rectal palpation, was found in 10% of the participants. Questionnaire on subjective symptoms of voiding disturbance in the participants has confirmed that these symptoms, mainly elicited by BPH, become manifested in fifties and more frequent with age. Of thirteen patients with prostate carcinoma who received both rectal examination and prostate-related markers measurement in serum at the time of mass screening, three without induration of the prostate were diagnosed as having carcinoma from an abnormal value of the serum markers. This result suggests that the marker(s) is one of the useful screening tests for detecting carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary squamous cell carcinoma of the prostate: a rare clinicopathological entity. Report of 2 cases and review of literature

Primary squamous cell carcinoma of the prostate is an uncommon clinicopathological entity. It differs from more common adenocarcinomas in its cell of origin, biological behavior, therapeutic response to the usual hormonal manipulation and prognosis. The review shows that squamous cell carcinoma is biologically more aggressive than adenocarcinoma. Despite the agreement on its uniqueness, a controversy exists on the exact histopathogenesis, diagnostic criteria and modality of treatment. We report on 2 patients with primary squamous cell carcinoma of the prostate. One patient presented with lower urinary tract symptoms with a hard nodular prostate on digital rectal examination, and the other with acute urinary retention on normal digital rectal examination. The evaluation revealed metastasis in the pelvic and right femur in both cases. Palliative transurethral resection of the prostate with chemotherapy (Adriamycin based) was given in both the cases. However, both the patients died at 4 and 5 months of follow-up, respectively.     

前列腺小细胞神经内分泌癌一例报告

分析1例前列腺小细胞神经内分泌癌临床资料。患者60岁,因排尿困难1个月入院,直肠指检发现前列腺质硬肿块。前列腺穿刺活检病理诊断为小细胞神经内分泌癌。行化疗和放疗联合治疗有效,患者症状明显改善,患者确诊后15个月死亡。前列腺小细胞神经内分泌癌预后差,化疗在治疗中占有重要地位。     

Transrectal ultrasonography in the diagnosis and staging of carcinoma of the prostate

Transrectal prostatic ultrasonography is a potentially valuable means to evaluate the prostate of men with suspected carcinoma. We studied 118 patients with this modality before histological evaluation of the prostate (20 underwent radical prostatectomy, 75 core needle biopsy and aspiration cytology, and 23 transurethral resection of the prostate). Transrectal ultrasonography was more efficient than digital rectal examination in the staging of carcinoma of the prostate before radical prostatectomy. The value of transrectal ultrasonography in the diagnosis of prostatic cancer in men with an abnormal-feeling prostate on digital rectal examination is less certain, since 10 of 75 patients (13 per cent) in this group had a falsely positive scan. The predictive value of a scan positive for malignancy was 37 per cent. Further refinements in the technique of transrectal prostatic ultrasonography are needed to realize fully the diagnostic potential of this imaging modality.     

Rectal ejaculation and prostatic carcinoma

A case of carcinoma of the prostate causing fistulous communication between the rectum and the prostatic ducts is presented. The patient's initial symptoms included gradual onset of inability to ejaculate and the complaint of ejaculation per rectum. Appropriate urologic studies demonstrated a fistulous connection between the area of the ejaculatory duct and the rectum. Microscopic studies of rectal discharge confirmed that semen was exiting through his rectum. All genitourinary symptoms in patients with carcinoma of the prostate warrant thorough investigation.     

以直肠癌症状为表现的前列腺癌诊疗体会及文献复习

目的 探讨以直肠癌症状为表现的前列腺癌诊治要点。方法 回顾性分析我院诊治的3例以直肠癌症状为表现的前列腺癌患者临床病理特征、随访情况,总结现有文献讨论诊治心得。结果 3例患者均是因胃肠道症状至本院胃肠外科就诊,患者2直肠指检未见异常,患者1和患者3直肠指检均可触及肿物;CT及MRI均可见肿物累及前列腺和直肠;肠镜见环周肿物,肠腔狭窄;组织学为高/低分化腺癌;所有患者初步诊断均为直肠癌。患者1血清PSA:2.532 ng/ml,行Miles术,术后Gleason评分：5+4=9,免疫组化：PSA/P504s（+）,最终确诊为前列腺癌,术后追加内分泌治疗。患者2和患者3在泌尿外科会诊后,血清PSA分别为>100 ng/ml和153.49 ng/ml,Gleason评分分别为5+3=8和4+3=7,免疫组化PSA/P504s均为（+）,确诊为前列腺癌,进行了内分泌治疗和全盆腔脏器切除。结论 前列腺癌诊断应结合病史、检查、组织学及免疫组织化学,警惕误诊。     

Impact of routine screening for adenocarcinoma of the prostate on stage distribution

The impact of routine screening with digital rectal examination for carcinoma of the prostate on stage distribution of the disease was assessed in the primary treatment population of our medical center. Two, 5-year periods were compared: 1974 to 1978--before the onset of routine screening and 1979 to 1983--during the period of routine screening of this population. The clinical stage distribution of prostatic cancer before the onset of routine screening was not significantly different from national averages. Routine screening during the latter period significantly increased the percentage of patients with clinically curable carcinoma of the prostate. Pathologically, the disease was upstaged in many patients in both series. Digital rectal examination can have a significant impact on early detection of carcinoma of the prostate within a given population but it cannot be interpreted as a panacea for this disease.     

Digital rectal examination and carcinoma of the prostate

Urologists have considered themselves to be the experts in the use of digital rectal examination for the evaluation of diseases of the prostate. However, without close attention to the teaching of this examination, it probably is inaccurate and unreliable. Moreover, many patients who are destined to die of prostate cancer never develop a palpable abnormality. In patients with prostate cancer, a palpable abnormality usually indicates the presence of carcinoma, but the majority of patients will be upstaged by pathologic examination. In patients undergoing a digitally guided biopsy, it appears critical that those with a negative biopsy be followed closely, as they have a measurable risk of developing overt carcinoma. It is unclear how transrectal ultrasound will interface with digital rectal examination because of the multiple echo patterns this disease can exhibit.     

雄激素阻断治疗后前列腺腺癌转化为小细胞癌1例报告并文献复习

目的：探讨前列腺小细胞癌的临床、病理特征及诊治方法．方法：分析1例前列腺小细胞癌患者的临床资料：患者男．54岁。因“尿频、尿急、排尿困难1个月”入院。直肠指诊前列腺Ⅲ。大．质硬,表面不光滑。血PSA为175．08ng／ml。B超及MRI检查均提示前列腺癌．前列腺穿刺活检诊断为前列腺腺癌．行最大限度雄激素阻断治疗。9个月后症状加重,复查血PSA为7．4mg／ml。MRI提示前列腺腺癌,行前列腺电切术,病理检查为前列腺小细胞癌。免疫组织化学示CD56（＋）,NSE（＋）,CgA（-）．LCA（-）。遂以GP方案化疗：吉西他滨1800mg,DDP150mg,采用4周方案,一共行4个疗程。从第2个疗程开始同步局部放疗（3D-CRT。每次3Gy,总量60Gy）。结果：复查CT前列腺局部肿瘤消失,排尿通畅,但在随访的过程中。患者死于急性心肌梗死。结论：雄激素阻断治疗后,前列腺腺癌可能转化为小细胞癌,前列腺小细胞癌少见,恶性程度高,确诊需依靠临床及病理表现。强调早发现,早治疗。治疗以化疗为主,可辅以放疗,早期前列腺小细胞癌,也可行前列腺癌根治加化疗。     

Organ-confined prostate cancer: treatment with high doses of radioterapy (intensity modulated radiotherapy)

PurposeTo report toxicity and local control in patients with localized prostate cancer, treated with high dose radiotherapy.Materials and methodsThe records of 100 consecutive patients with clinically localized prostate cancer treated between june 2003 and may 2006 were reviewed. They received 80 Gy to the target volume with a biphasic technique (3DCRT + IMRT). The median pretreatment PSA was 9. The median follow-up time was 12 months.ResultsEighteen (18%) developed acute Grade 2 rectal toxicity, and no patient experienced acute grade 3 or higher rectal symptoms. Forty-four (44%) developed acute Grade 2 urinary symptoms while 34% of the patients experienced no GU symptoms (Grade 0) during treatment. Three patients (3%) developed late rectal toxicity grade 2 and eight patients (8%) experienced late urinary toxicity grade 2; any patients experienced more severe symptoms.We recorded biochemical relapse in two patients, both had poor prognostic factors at initial diagnosis of prostate cancer.ConclusionsThe data demonstrate the feasibility and safety of high dose radiotherapy for patients with localized prostate cancer and provide a proof that this method allow safe dose escalation with low severe toxicities to the normal tissues.     

The value of ultrasound-guided multiple systematic biopsies in the early diagnosis of cancer of the prostate]

Endorectal ultrasonography using a 7 mHZ probe was performed in 99 patients with a negative history for surgery of the prostate and either findings on rectal examination suggestive of cancer (T3 stage excluded) or a serum level of prostate-specific antigen of 2.5 mg/ml or more. A biopsy gun was used to harvest 1.5 centimetre long specimens. Ultrasound-guided biopsies were performed in peripheral hypoechogeneic areas; in addition, regardless of the result of the endorectal ultrasonography, routine multiple ultrasound-guided biopsies were performed in both lobes of the prostate (3 per lobe). Morbidity consisted in two cases of prostatitis (2%). Among the 99 patients, ultrasound guided biopsies found 16 carcinomas (16.1%), and routine multiple ultrasound-guided biopsies found 32 (32.3%) carcinomas. Four patients with normal results upon rectal examination and endorectal ultrasonography were found to have carcinoma of the prostate. These findings suggest that the morbidity of routine multiple ultrasound-guided biopsies is low; that routine multiple ultrasound-guided biopsies is more sensitive than ultrasound guided biopsies, with 16/99 (16%) additional carcinomas detected in this study and 56% of carcinomas among those patients with findings upon the rectal examination suggestive of malignant disease; and that routine multiple ultrasound-guided biopsies can allow the detection of carcinomas responsible for isolated elevation of prostate-specific antigen levels without anomalies of the rectal examination or endorectal ultrasonography (8% of the carcinomas in this study).     

Rectal infiltration by prostatic adenocarcinoma: report on six patients and review of the literature

AIMS: To describe the outcome of six patients with rectal infiltration by prostatic adenocarcinoma and review the literature for 1966-2002. PATIENTS AND METHODS: Six patients were identified from prospectively maintained records of a colorectal surgeon and the case records reviewed retrospectively. Information on these patients was collated with that on patients reported in the literature. The Medline database was searched from the years 1966-2002 using the keywords: adenocarcinoma, carcinoma, colon, metastasis, prostate, rectum. Results and Conclusions: Autopsy studies have indicated that rectal involvement by prostatic adenocarcinoma occurs in 4% of patients (range, 1-12%). The rectal infiltration took the form of an anterior rectal mass with or without ulceration in 52%, an annular stricture in 45%, and separate metastasis in 3%. In 40% of patients, a preceding history of prostatic adenocarcinoma was elicited at the time of gastrointestinal presentation, while in 60% it was not elicited. In the study group, 26% of patients underwent surgery; the most commonly performed procedure was a defunctioning colostomy (18%) to alleviate symptoms of large bowel obstruction. Five patients underwent rectal resection because the pre-operative diagnosis was suspected to be primary rectal adenocarcinoma. The median survival was 15 months (95% confidence interval 14-16 months). Survival beyond 30 months was rare.     

Prostatic metastasis of renal cell carcinoma

A 71-year-old man underwent a radical nephrectomy for right renal cell carcinoma in April, 2005. Pathological findings revealed clear cell carcinoma, G3＞G2, pT3a. Three years later, he underwent a craniotomy for tumor resection of solitary brain metastasis. In October, 2008, he came to our hospital because of urinary retention. Benign prostate hypertrophy was diagnosed by ultrasonography and digital rectal examination. Serum prostate specific antigen level was 2.55 ng/dl. While he was treated with oral α 1-blocker initially, a urethral catheter was inserted in December, 2009. Because of frequent obstruction of the catheter by hematuria, transureathral prostectomy was performed. Pathological findings revealed prostatic metastasis of renal cell carcinoma. Metastasis of renal cell carcinoma to the prostate is rare, and only 7 cases including the present case have been reported.     

Combined radical prostatectomy and abdominoperineal resection for locally invasive rectal cancer

INTRODUCTION

An infiltration of urological organs is found in 5–10% of patients with colorectal carcinoma. Total pelvic exenteration is the standard procedure for locally advanced rectal cancer. In selected patients with rectal cancer involving the prostate or seminal vesicles, the bladder can be preserved and en bloc radical prostatectomy with abdominoperineal rectal resection can be performed. We report two patients who treated with this combined approach.

PRESENTATION OF CASE

Two patients with symptoms of rectal bleeding and pelvic pain were investigated. Colonoscopy demonstrated a tumor in the lower rectum. Biopsies revealed adenocarcinoma. Both pelvic MRI and endorectal ultrasound showed tumors that invaded the prostate and the seminal vesicles directly but without invasion of the bladder. After neoadjuvant chemoradiation, combined radical prostatectomy and abdominoperineal amputation was performed. None has developed local recurrence, but one of them was operated on for a single lung metastasis. After a follow-up of 28 and 20 months, respectively, the patients are alive without evidence of local recurrence or distant disease.

DISCUSSION

This procedure obviates the need for urinary diversion without compromising the local tumor control. Intraoperative and postoperative diagnostic difficulties, and clinical aspects in relation to postoperative anastomotic leak and survival of patients are discussed.

CONCLUSION

En bloc radical prostatectomy and proctosigmoidectomy is feasible in selected patients with rectal cancer and invasion limited to the prostate or seminal vesicles because it provides good local tumor control and significantly improves the patient''s quality of life in comparison to total pelvic exenteration.