選擇性攝護腺根除手術
在寡轉移性攝護腺癌合併雙側性腎水腫及直腸侵犯的臨床案例
黃烱焜1、林子平1,2,3、黃志賢1,2,3
台北榮民總醫院 泌尿部1；國立陽明大學醫學院 泌尿學科2
書田泌尿科學研究中心3
Elective radical prostatectomy for huge prostate cancer
with bilateral obstructive uropathy、rectal invasion
and oligometastasis of bone
Chiung-Kun Huang1, Tzu-Ping Lin1,2,3, William J.S. Huang1,2,3
Department of Urology, Taipei Veterans General Hospital1; School of Medicine2 and Shu-Tien Urological Institute3, National Yang-Ming University, Taiwan
Introduction:
Uncontrolled locally advanced prostate cancer (PCa) is debilitating with up to 54% of patients experiencing symptoms of bladder outlet obstruction or ureteric obstruction and pelvic pain while up to 61% of patients require at least one palliative treatment in the form of radiation, transurethral resection of the prostate, or upper tract procedures. Current clinical practice guidelines based on prospective studies recommend radiation plus androgen deprivation therapy (RT plus ADT) for treatment of T4N0M0 PCa with consideration of surgery for younger patients. For T4N1M0 patients, RT plus ADT remains the first line treatment with ADT alone as a secondary option. How to determine local therapy (radiation, surgery, or combined radiation plus surgery) compared to systemic therapy (ADT or chemotherapy alone) is truly a clinical dilemma.
Case presentation:
A 69-year-old man has no notable medical history. He had no known drug allergies. He drank alcohol occasionally and did not smoke. there was no other family history of cancer.
He initially presented with acute urinary retention in 2017/3. Prostate cancer was diagnosed at Mackay Memorial Hospital with initial prostate-specific antigen (PSA) level of 459 ng/ml. A diagnosis of adenocarcinoma of the prostate was made by biopsy, with a Gleason score of 8 (grade 4 plus grade 4). Computed tomographic (CT) scan of the pelvis showed huge fungating prostate size about 9 cm in diameter with no definite enlarged lymphadenopathy at pelvis cavity. Bone scan revealed no bony metastasis. Palliative transurerthral resection of prostate (TURP) for acute urinary retention was performed. The pathologic also showed Gleason score of 8 (grade 4 plus grade 4, 25%). The patient elected androgen-deprivation therapy (ADT) with gonadotropin-releasing hormone (GnRH) agonist one month after surgery. The level of PSA decreased to 75ng/ml.
Disease progressed to metastatic castration resistant prostate cancer(mCRPC) 9 months after ADT. Acute urine retention and loose blood-tinged stool occurred. PSA rise to 1252 ng/ml, testosterone was 0.32 ng/ml. Pelvic CT showed enlarging prostate 13cm in diameter and invade posterior wall of urinary bladder and left lower third ureter causing upstream hydronephroureterosis. No obvious pelvic lymphadenopathy, nor visceral metastasis was found but osteoblastic lesion around 2.7cm at right iliac bone was seen, suspect bone metastasis.(cT4N0M1b, AJCC 7th 2010) Left percutaneous nephrostomy(PCN) for obstructive uropathy was performed. Colonoscopy for blood tinged stool revealed tumor external compression 5-10 cm from anal verge. The rectal mucosa was intact. Disease progressed with right side hydronephrosis, persisted blood-tinged stool and deteriorated defecation difficulty. He received transverse loop colostomy and right percutaneous nephrostomy for urinary and fecal diversion 14 months after diagnosis. After considering the potential benefits and harms, elective radical prostactectomy for locally advanced prostate cancer with oligometastasis (right iliac bone) was considered. Upfront chemotherapy for symptomatic mCRPC with biweekly Docetaxel (50mg/m2) for 14 cycles started after transverse loop conlostomy from 2018/06/01 to 2018/12/14.
After chemotherapy, Post-treatment study showed decreased PSA level and prostate size (PSA: 1252 to 149 ng/ml; Prostate size 13 cm to 9cm in diameter, estimated 701 to 247gm). No interval change of right iliac bone lesion nor new metastatic lesions. Bilateral PCN was removed smoothly owing to smaller prostate size. He was under fair performance status, ECOG grade I.
He received radical cystoprostatectomy with ileal conduit urinary diversion on 2019/3/15 (2 years after diagnosis, 3 months after chemotherapy). Pre-operative serum biochemistry showed within normal limit except mild anemia (Hgb: 11 g/dl) and hypoalbuminemia (2.7 g/dl). But rising PSA (149 to 344.7 ng/ml) and disease progressed after complete chemotherapy. Pre-operative CT showed enlarging prostate and bilateral recurrent hydronephrosis. Besides rectal invasion was also suspected. CRS doctor was consulted, colonoscopy showed irregular mucosa at anterior wall of lower rectum. Low anterior resection was also performed during operation. Pathology reported adenocarcinoma of prostate with urinary bladder and rectal muscle invasion, pT4N0M1b with oligometastasis of bone. Gleason score grade 4 plus grade 4. Surgical margin was free but with vascular invasion. Total operation time was 645 minutes. Low anterior resection of rectum took 180 minutes. Total blood loss about 2450 ml.
Flatus passage from T-loop colostomy presented on post-operative day 3. Oral diet resumed gradually. Right and left single-J stent was removed separately on post-operative day 12 and 13 with adequate urine amount. He was discharged under stable condition with ileal conduit and T-loop colostomy and regular OPD follow-up. Post-operative PSA level and image study will be arranged.
Conclusion:
Despite these guideline recommendations, treatment to focally PCa is nuanced as patients are at high risk for progression and have up to 41.3% 10-years Pca specific mortality if treated with noncurative intent.
Potential complications of treatment including rectal injury and ureteral injury with surgical treatment, long term bowel and bladder symptoms with radiation treatment, and decreased libido, gynecomastia, and metabolic disturbance with ADT. Thus, the optimal treatment strategy for these high-risk patients remains uncertain. How to balance cancer symptom burden, life expectancy, health-related quality of life and potential complications of treatment should be considered cautiously.