Dramatic outcome of a patient with prostate adenocarcinoma with brain and dural metastases: a case report and review of the literature
Yen Ho1, Syuan-Hao Syu1, Liang-Ming Lee1, Yu-Ching Wen1,2, Ke-Hsun Lin1, Yung-Wei Lin1,2, Hung-Jen Shih1,2, Chung-Howe Lai1
Department of Urology, Taipei Municipal Wan Fang Hospital1
Department of Urology, School of Medicine, College of Medicine, Taipei Medical University2
Background: Prostate cancer is the second most common malignancy in men worldwide. However, brain and dural metastases are extremely rare. The main objective of this study is to demonstrate an unexpectedly preferable outcome in a patient of prostate adenocarcinoma with brain and dural metastases.
Case Report: A 65-year-old Asian male first presented dysuria and other LUTS symptoms in November 2015. Prostate adenocarcinoma with initial PSA level of 285.6 was diagnosed initially. Distant lymph nodes around aortocaval region and multiple central bone metastases were noted in pelvic MRI and whole body bone scan. Different regimens of androgen deprivation therapy including Androcur, Eligard, Casodex and Zytiga were administered throughout 2016 to 2018. Bilateral subcapsule orchiectomy was carried out in January 2019 consequently. Due to disease progression, the chemotherapy with docetaxel was administered for total 14 cycles. The patient then received Radium-223 dichloride starting in March 2020. However, sudden onset of unsteady gait and slurred speech were noticed in August 2020. Brain CT scan revealed right-side brain tumor with intracranial hemorrhage. Brain MRI revealed dural metastases over the occipital skull and right C1/C2 lateral region. Dramatic change of consciousness down to E1V1M5 with nasogastrol tube and Foley dependent. Palliative radiation therapy was preferred due to high-risk for surgical resection. Consciousness improved gradually as radiation therapy was done. Follow-up brain CT scan revealed significant improvements. At the time when the article was authored, he became completely alert with intermittent irritable mood and improving left hemiplegia.
Discussion: For prostate cancer, bone and lymph node metastases have been recognized to be the most typical pattern of extraprostatic spread. Intracranial metastasis is uncommon in the natural history of prostate cancer but with significant prognostic impact. Initially reported incidence is estimated to be 0.6% which is increasing as life expectancies for metastatic prostate cancer patients improve. The prognosis after development of brain metastases remains poor with 2-year survival rates below 10%, with median survivals reported from 4 to 13 months. Particular attention should be paid to patients with metastatic prostate cancer presenting neurologic symptoms. Most cancer patients presenting with cerebral metastases receive radiation therapy, most commonly whole-brain radiation therapy (WBRT). The reviewed literature suggests that outcomes of prostate cancer intracranial metastases appear similar to those of intracranial metastases from other histologies, and stereotactic radiosurgery (SRS) should be preferred in patients with a limited number of lesions but more associated data and studies are needed.
Conclusion: Our case demonstrated that favorable outcomes are attainable with adequate management despite poor prognosis as a common consensus in patients with brain or dural metastasis.