轉移性攝護腺癌以陰囊水腫初期表現之案例報告及文獻探討

廖偉創¹、高國維²、薛又仁²、黃建榮²、賴昱維²

¹臺北市立聯合醫院忠孝院區外科部泌尿科

²臺北市立聯合醫院仁愛院區外科部泌尿科

Testicular hydrocele as the initial manifestation of metastatic prostate adenocarcinoma: a case report and literature review

Wei-Chuang Liao¹, Kuo-Wei Kao ², Thomas Y. Hsueh², Andy C. Huang², Yu-Wei Lai ²

¹Division of Urology, Department of Surgery, Taipei City Hospital, Zhongxiao Branch

²Division of Urology, Department of Surgery, Taipei City Hospital, Renai Branch

Introduction

The most commonly documented sites for metastasis from a prostatic cancer origin are to regional lymph nodes and bone, followed by the lungs, liver, and adrenal glands. Manifestations of metastatic disease include bone pain, pathologic fractures, anemia, and lower extremity edema, less common are paraneoplastic syndromes and paralysis. We reported a case of metastatic prostate cancer presenting as testicular hydrocele and left leg edema initially.

Case presentation

A 55-year-old man with a medical history of hypertension, type II diabetes mellitus and alcoholic liver disease presented with bilateral swelling scrotum for one month. He denied fever, dysuria, shortness of breath or decreased urine output. Physical exam revealed scrotal edema without tenderness, left leg pitting edema grade II, and digital rectal exam (DRE) revealed enlargement and hardness of the prostate without tenderness. Testicular ultrasound showed bilateral hydroceles. Blood biochemical test showed testosterone value of 441 ng/dL, normal AFP, beta-HCG and LDH, but extremely high PSA level (851 ng/ml). Abdomen CT scan reported right hydronephrosis, generalized lymphadenopathy along para-aortic, bilateral iliac chains, right pelvic side wall and pre-sacral regions, and bilateral testicular hydroceles with right engorged spermatic cord (Figure 1). He underwent transrectal ultrasound-guided prostate biopsy and right ureteral stent placement via ureteroscopy. Pathology report demonstrated that left prostatic adenocarcinoma with Gleason score 4+3 and right prostatic adenocarcinoma with Gleason score 4+4. Whole body bone scan showed increased radioactivity at thoracic vertebrae T6-9, ribs, pelvic bone and left proximal femur. MRI reported prostate cancer with bilateral seminal vesicles involvement and generalized lymphadenopathy. We described a case of metastatic prostatic adenocarcinoma manifesting as testicular hydrocele and lower extremity edema initially, then this patient received Enzalutamide plus androgen deprivation therapy (ADT) and Denosumab for multiple bone metastases.  

Discussion

Prostate cancer rarely causes symptoms at an early stage. Metastatic prostate cancer presenting at initial diagnosis as a large pelvic mass with generalized lymphadenopathy is rare, without PSA screening, this can easily be mistaken for lymphoma [1]. The lymph nodes in the pelvic region are the most common sites for lymphatic metastasis in prostate cancer, followed by the para-aortic lymph nodes [2]. Nevertheless, most researchers consider the Gleason score in adenocarcinoma as a significant determinant of prognosis. The presence of generalized lymph node metastases does not influence the response to hormonal therapy, according to the previous studies [3]. Current ARCHES study have indicated that the combination of ADT and Enzalutamide may improve metastatic prostate cancer overall survival [4]. As in this case, it is important to have highly suspicion for metastatic prostate cancer in men with coexist clinical testicular hydrocele and unilateral lower extremity edema. 

Conclusion

Prostate cancer is the most frequently diagnosed neoplasm in men. Locally advanced and metastatic disease are uncommon presentations because of widespread screening with PSA testing and DRE. When prostate cancer was considered, PSA screen and DRE should be performed in a man presented with swelling scrotum and lower extremity edema.