Quaint metastasis and markedly elevated prostate-specific antigen: An unusual manifestation of prostate cancer

Nwachukwu Olusegun Nwachukwu; Ayodeji Akinwunmi Ayeni; Olutomiwa Ayoola Omokore; Adetomilayo Adeotan Arijeniwa; Segun Idris Odejayi; Peter Kehinde Uduagbamen

doi:10.4103/AMJM.AMJM_24_22

CASE REPORT

Year : 2022 | Volume : 18 | Issue : 3 | Page : 96-99

Quaint metastasis and markedly elevated prostate-specific antigen: An unusual manifestation of prostate cancer

Nwachukwu Olusegun Nwachukwu¹, Ayodeji Akinwunmi Ayeni¹, Olutomiwa Ayoola Omokore¹, Adetomilayo Adeotan Arijeniwa¹, Segun Idris Odejayi², Peter Kehinde Uduagbamen¹
¹ Department of Surgery, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
² Department of Surgery, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria; Division of Nephrology and Hypertension, Department of Internal Medicine, Bowen University/Bowen University Teaching Hospital, Ogbomosho, Nigeria; Division of Nephrology and Hypertension, Department of Internal Medicine, Babcock University/Babcock University Teaching Hospital, Ilishan-Remo, Nigeria

Date of Submission	18-Jun-2022
Date of Acceptance	30-Aug-2022
Date of Web Publication	13-Dec-2022

Correspondence Address:
Dr. Peter Kehinde Uduagbamen
Division of Nephrology and Hypertension, Department of Internal Medicine, Bowen University/Bowen University Teaching Hospital, Ogbomosho
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMJM.AMJM_24_22

Abstract

Prostate cancer is one of the most common malignancies in males globally with records of approximately 1.6 million diagnosis and over 0.36 million deaths annually. The discovering and subsequent clinical application of the prostate-specific antigen (PSA) improved the diagnostic rates. Values of PSA (a tissue-specific marker) persistently greater than 4 ng/mL are regarded as abnormal hence histological studies are often required to confirm malignancy. Adenocarcinomatous cells, commonly osteoblastic, typically metastasize to the lumbar region via the veins of Batson. We report a case of prostatic cancer in a 69-year-old Nigerian with markedly elevated PSA, thoracic spine, and pelvic metastasis.

Keywords: Metastasis, prostate cancer, prostate specific antigen, small bowel, thoracic spine

How to cite this article:
Nwachukwu NO, Ayeni AA, Omokore OA, Arijeniwa AA, Odejayi SI, Uduagbamen PK. Quaint metastasis and markedly elevated prostate-specific antigen: An unusual manifestation of prostate cancer. Amrita J Med 2022;18:96-9

How to cite this URL:
Nwachukwu NO, Ayeni AA, Omokore OA, Arijeniwa AA, Odejayi SI, Uduagbamen PK. Quaint metastasis and markedly elevated prostate-specific antigen: An unusual manifestation of prostate cancer. Amrita J Med [serial online] 2022 [cited 2023 Jun 4];18:96-9. Available from: https://ajmonline.org.in/text.asp?2022/18/3/96/363500

Introduction

Prostate cancer is the second most frequent non-melanoma malignancy (after lung cancer) in men. Worldwide, over a billion (1,414,259) new cases are diagnosed, causing 375,304 deaths (3.8% of all cancers in men) in 2020. The incidence and mortality from prostate cancer correlate with aging, with the average age at diagnosis being 66 years.^[1] Prostate cancer could be asymptomatic, particularly in its nascent stages, in which case, a conservative approach or minimal intervention might be adequate. Diagnosis was particularly aided by findings by Wang et al.^[2] who discovered the prostate-specific antigen (PSA) as a serum marker. Common symptoms include difficulty with urination, urinary frequency, and nocturia, symptoms commonly seen in prostatic hypertrophy.^[3] Irritative symptoms are common with supervening infections and in advanced stages, urinary retention and back pain could be prominent.^[4] Treatment is mostly dependent on the disease stage.

Case Report

A 69-year-old Nigerian, male and diabetic, who presented with an eight-month history of lower limb pain, 3 months of lower limb weakness, 3 days of loss of sensation and paralysis of the lower limbs, and 2 days of urinary retention. He had been on treatment for obstructive uropathy (prostatic enlargement) and had uremic symptoms at presentation. The low back pain radiated to the lower limbs but he had no fecal or urinary incontinence. He had been on Dutasteride and Tamsulosin from the referring center.

Power was 0/5 in both lower limbs (using the Medical Research Council scale), there was loss of sensation below first lumbar sensory level and rectal examination was very suggestive of prostate cancer.

Magnetic resonance imaging (MRI) of the spine showed multiple areas of altered signal intensity at multiple levels in both anterior and posterior elements of the vertebral bodies, and the pelvic bones. It showed complete involvement of T1–T3 vertebrae affecting the soft tissue of the posterior epidural space with spinal canal stenosis and dorsal cord compression, all suggestive of a malignancy [Figure 1]. There was also straightening of the cervical and lumbar lordosis, with diffuse disc bulges and bilateral facetalarthropathy at L4–L5 and L5–S1 and left-sided hydroureteronephrosis.

Figure 1: Magnetic resonance imaging of the spine showed multiple areas of altered signal intensity in both anterior and posterior elements of the vertebral bodies, and the pelvic bones (small arrows), with maximal involvement at T1 to T3 levels (big arrows)

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Renal function test was suggestive of chronic kidney disease with an estimated glomerular filtration rate (eGFR) of 61 mL/min. Urine analysis was positive for protein and leucocyte esterase. PSA was markedly elevated with a value of 2,514 ng/mL (normal <4 ng/mL). Histology of biopsied prostate tissue showed distorted lobular architecture, variable clear cytoplasm with vacuolated nuclei and prominent nucleoli and proliferating malignant epithelial cells.

the Pathological Diagnosis Was That of an Infiltrative Adenocarcinoma, with a Gleason Score of 4 + 4 =8, and a Clinical Diagnosis of a Metastatic Prostatic Cancer (Thorax and Spine)

He underwent bilateral orchidectomy, and histology showed a paucity of the seminiferous tubules, peritubular fibrosis, Leydig Cell hyperplasia, and testicular atrophy. He was commenced on oral bicalutamide, calcium, and alendronate.

Post-operative day 2 (POD2), he regained light touch, temperature, and pain sensation over his feet, and could wiggle his toes (Power of 1/5). A repeat PSA on POD5 came out to be 9.8 ng/mL. On POD28, he developed abdominal distension and had five episodes of projectile, bilious vomiting. The bowel sound was hypoactive

The assessment was that of small bowel obstruction secondary to ileus. A plain abdominal X-ray showed dilated bowel loops [Figure 2] and multiple air levels [Figure 3]. He had potassium correction and, with other conservative management, he regained normal bowel function on POD31.

Figure 2: An abdominal X-ray showing centrally located dilated loops of small bowel with valvulae conniventes

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Figure 3: An abdominal X-ray showing multiple air fluid levels

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Three months post-surgery, his clinical and hemodynamics parameters were relatively stable but he had sepsis in the fourth month and died from complications associated with septic shock.

Discussion

Prostate cancer is the second most frequent non-melanoma malignancy (after lung cancer) in men. The age of the index patient agrees with findings from epidemiological studies that showed a positive relationship between the incidence of prostate cancer and age.^[1],[5] The absence of radiological evidence of lumbar metastasis is not in agreement with findings, that within the spine, lumbar metastases are the most common, whereas thoracic metastases are infrequent, as reported by Gandaglia et al.^[6] who in a review of findings in 74,826 patients with metastatic prostate cancer, reported that 84% of all metastases were to bony structures. Kakhki et al.^[7] had also reported that spine and pelvic metastases were the most common location of all bony metastasis.

Prostate cancers are often diagnosed and detected using elevated serum PSA (>4 ng/mL), a glycoprotein secreted by prostate tissue. However, due to its low specificity, a tissue biopsy is often needed to confirm malignancy.^[1],[7] The index patient had a massively elevated PSA (2,514 ng/mL), though factors like urinary tract infection, pelvic instrumentation, and malignancy could cause moderately elevated values.

The reported relative advantage of surgical over medical orchidectomy is supported by the abrupt fall in PSA from 2,514 to 9 ng/dL within the first 5 postoperative day.^[8] Despite the relatively good treatment outcome with surgery, the index patient died and this tends to buttress the reported positive relationship between mortality in prostate cancer and patient’s age.^[6] Fifty-five percent of all deaths from prostate cancer are reported to occur after 65 years.^[9] The association of higher comorbidities and complications with aging, with background poor organ reserve in the elderly, only worsens the treatment outcome in these patients.^[10] Full body scan should be carried out in all cases of prostate cancer to determine other non-clinically-apparent sites of metastasis.

Conclusion

Although unwonted, prostate metastasis can involve the pelvis and thoracic spine. Physicians need a high index of suspicion to diagnose and treat accordingly. It is crucial to do a full-body bone scan in patients with metastatic prostate cancer to determine uncommon sites of metastasis.

Acknowledgement

The authors appreciate the assistances given by the nurses and the supporting staffs.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

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