同時並存腺癌和移行上皮細胞癌的攝護腺腫瘤：一個罕見的病例報告

許哲元、林益聖、黃立華、許兆畬、歐宴泉、童敏哲

童綜合醫療社團法人童綜合醫院

A rare case of synchronous adenocarcinoma and urothelial carcinoma of the prostate

Jhe-Yuan Hsu, Yi-Sheng Lin, Li-Hua Huang, Chao-Yu Hsu, Yen-Chuan Ou, Min-Che Tung

Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan

Introduction:

According to GLOBOCAN database, prostate cancer is the second most common cancer in males worldwide with the incidence generally rising with age. Adenocarcinoma is the most common subtype of prostatic carcinoma and can be graded by Gleason score. Another subtype of prostate cancer is prostatic urothelial carcinoma (UC) and usually arises from the urothelium of the prostatic urethra and the proximal portions of the prostatic ducts. To the best of our knowledge, this is the first case report on the co-existing of prostate adenocarcinoma and UC in prostate gland.

Case Presentation:

The case describes an 82-year-old male patient with the past history of hypertension and arrythmia under medication control. He went to another hospital due to acute urinary retention and gross hematuria. After the examination, the digital rectal examination (DRE) revealed prostate firm nodules and elevated prostate specific antigen (PSA) 53 ng/mL was noted. He received transrectal ultrasound guided biopsy and the pathology report revealed UC. Transurethral laser prostatectomy was done later and the pathology report showed prostate adenocarcinoma with Gleason score 3+4 as well as high grade UC. The bone scan revealed no bone metastasis.

He received further treatment with androgen deprivation therapy (ADT) with Leuprorelin and bicalutamide, systemic chemotherapy with Gemcitabine and Cisplatin, and immunotherapy with Nivolumab. The follow-up magnetic resonance imaging (MRI) revealed prostate tumor, cT2cN1M0, stage IVA. Radical cystoprostatectomy was suggested but was refused by the patient. Thus, he was referred to our hospital for second opinion consultation.

In the urology outpatient, the estimated volume of prostate with 25 cm³ under ultrasound and the PSA was 8.877 ng/dl. The cystoscopy disclosed no papillary tumor in urinary bladder and urethra. After we explained the benefits and risks of the surgery, the patient agreed to receive robotic-assisted radical prostatectomy and bilateral pelvic lymph nodes dissection. He was discharged 6 days postoperatively after well recovery and no major complication. The formal pathology report of prostate gland showed adenocarcinoma, acinar type, Gleason pattern 4+3 (grade group 3), pT2N0Mx and high grade UC. He visited the out-patient department regularly with PSA and cystoscopy every three months. No specific urinary discomfort was mentioned or sign of recurrence was noted until latest clinic visiting.

Discussion:

Prostate cancer is an important medical issue with regard to the number of men who are affected, its impact on quality of life, and as a cause of mortality. The symptoms are usually absent at the time of diagnosis or uncommonly present with nonspecific urinary symptoms, hematuria, or hematospermia. However, the suspicion for prostate cancer arises after elevated PSA levels or abnormal finding on digital rectal examination (DRE). The tissue proof obtained from transrectal or transperineal biopsy is gold standard for diagnosis. The majority of malignant prostatic neoplasms are carcinomas which originate and differentiate from epithelial. Amount them, adenocarcinoma is the most common subtype with the three major characteristic of glandular architecture, loss of basal cells, and nuclear features of the glandular lining cells.

Another less common subtype of prostate cancer is UC which is usually concurrent with bladder carcinoma but can still arise as a primary origin sometimes. Pagetoid and undermining spread of the neoplastic urothelial cells within benign prostatic epithelium are featured. Besides, stromal invasion is characterized by irregular nests and cords of pleomorphic tumor cells. The markers to distinct versus prostatic adenocarcinoma include thrombomodulin, GATA3, p63, and high molecular weight cytokeratins.

Once a diagnosis of prostate cancer is established, the staging evaluation and further treatment strategy should be based on multiple factors. The choice of treatment is based on cancer subtype, staging and metastasis. Radical prostatectomy for prostate adenocarcinoma and radical cystoprostatectomy for UC of prostatic urethra are common. The outcomes are based on the staging and compliance to treatment.