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Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 65, Num. 4, 2003, pp. 368-369

Indian Journal of Surgery, Vol. 65, No. 4, July-Aug, 2003, pp. 368-369

Case report

Subcutaneous metastasis as first evidence of prostatic cancer

Vikesh Agarwal, Pawan Agarwal, Kishan Das Baghel

Department of Surgery, NSCB Govt. Medical College, Jabalpur, Madhya Pradesh.
Address for correspondence Dr. Pawan Agarwal, 292/293, Napier Town, Jabalpur 482001, Madhya Pradesh. E-mail:drpawanagarwal@yahoo.com

How to cite this article: Agarwal V, Agarwal P, Baghel KD. Subcutaneous metastasis as first evidence of prostatic cancer. Indian J Surg 2003;65:368-70.

Paper Received: August 2002. Paper Accepted: December 2002. Source of Support: Nil

Code Number: is03073

Abstract

A rare case of subcutaneous metastasis from prostatic cancer is presented. Swelling in left inguinal region proved to be adenocarcinoma consistent with carcinoma prostate on histopathology and immunohistochemistry. No primary was identified but was associated with raised prostate specific antigen. Poor response to hormonal ablation and rapid progression to death was observed. Cutaneous and subcutaneous metastases from prostatic cancer are rare. The case reported in the present paper, first evidence of a prostatic cancer, is even more exceptional. The literature on this rare presentation is briefly reviewed.

Key Words: Subcutaneous metastasis, Carcinoma prostate.

Introduction

Subcutaneous and cutaneous metastases from prostatic carcinoma are extremely rare; less than 100 cases are reported in English and Spanish literature. They should be considered in the differential diagnosis of subcutaneous swellings in an old patient even if the prostate gland is clinically normal. These metastases are aggressive and resond poorly to routine palliative treatment. A rare case of subcutaneous metastasis as first evidence of prostatic cancer is presented, with a brief review of the literature.

Case report

A 76-year-old man, who had undergone transvesical prostatectomy for benign prostatic hyperplasia (no evidence of malignancy histologically) 4 months prior presented with a swelling in the left inguinal region with discomfort for the one month. The swelling which situated over the inguinal ligament in the subcutaneous plane had increased progressively in size. It was hard and mobile with a nodular surface; the overlying skin was normal (Figure 1). Abdominal and digital rectal examination was normal. There was no clinical evidence of metastasis to any other site.

Routine blood investigations, urine examination and chest radiograph were normal. Radiograph of the lumbosacral spine, femur and pelvis were normal. Sonography of the abdomen was normal. Prostatic fossa was empty and prostatic urethra was dilated. Sonography of the inguinal swelling revealed a well-defined, uniformly hypoechoic lesion in the subcutaneous plane superficial to external oblique aponeurosis. Serum prostatic specific antigen (PSA) was 16ng/ml. Fine needle aspiration cytology revealed adenocarcinomatous cells of uncertain origin.

Excisional biopsy was undertaken and histopathology revealed sheets of tumour cells arranged in glandular and cribriform fashion. The individual cells possessed ovoid to round nuclei and granular cytoplasm (Figure 2). Histology revealed incomplete and fused gland (grade 4) and well-formed glands (grade 3) and the Gleason score was 7. These cells were positive for PSA on immunohistochemistry. A diagnosis of metastatic prostatic cancer was reached.

Immunohistochemistry was positive for PSA. The patient underwent a bilateral orchiectomy and was discharged with advice for regular follow-up.

The patient presented 2 months later with low backache and severe loss of appetite and weight. There was tenderness over the spine. Clinical examination and inguinal scar was normal. Radiograph of the lumbosacral spine, femur and pelvis revealed diffuse osteosclerotic lesions. Chest radiograph and ultrasound abdomen was normal. Prostatic fossa was empty and prostatic urethra was dilated. Serum PSA was 30ng/ml. Palliative care with radiotherapy to the bones was started but the patient succumbed 1 month later with cancer cachexia.

Discussion

Cutaneous and subcutaneous metastases from internal malignancies are rare and seen in less than 5% of malignant tumours.1 They occur more commonly with mammary, pulmonary, renal and colonic cancers but are seen in less than 0.5% of prostatic cancers.2 Subcutaneous sites are even more uncommon as compared to cutaneous metastasis with less than 50 cases reported in the literature. Such metastases are usually from diagnosed or treated prostatic adenocarcinoma.3 Prostatic cancer presenting with a subcutaneous metastases, as in our case, is even more exceptional.4

Such metastases are usually localized to the lower abdomen, genital area and groin and are few in numbers, solid and rarely ulcerate.1,4 However, uncommon locations like the anterior thigh, breast, scalp and umbilicus have also been reported.4,5 Presentation as morphea-like plaques and acanthosis nigricans is known.4 Other rare manifestations include priapism, penile metastasis, gynaecomastia and breast metastasis.4

Retrograde lymphatic spread and vascular dissemination are the common modes of subcutaneous spread reported in the literature with some reports of implantation at biopsy sites.2 Retrograde spread usually follows previous surgery, irradiation or massive lymphatic metastasis. The most likely route in the presented case appears to be retrograde spread due to surgical manipulation in the retropubic and paravesical areas during transvesical prostatectomy.

Diagnosis in the absence of a primary requires a high index of suspicion. Histopathology shows features of adenocarcinoma of the prostate with predominance of folliculotropic pattern and immunohistochemical positivity for PSA and acid phosphatase confirms the diagnosis.4

A review of the literature has shown that the treatment should be on the same lines as used in a patient who presents with bony or visceral metastases. Only a few reports state a satisfactory response to androgen deprivation or blockade. There is no preference of mode of androgen ablation mentioned in the literature. In addition, preventive radiotherapy or wide excision is a mode of therapy for implantation metastases. Such metastasis signifies an advanced stage with aggressive behaviour and the overall prognosis is grave and usually patients' survival is less than 6 months.3 The case reported in the present paper supports the literature with reference to presentation, response to treatment and prognosis. This rare presentation of prostatic cancer should be considered in the differential diagnosis of subcutaneous swellings in an old patient.

References

1. Azana JM, de Misa RF, Gomez MI, del Hoyo JF, Ledo A. Cutaneous metastases from prostatic cancer. J Dermatol 1993;20:786-8.

2. Katske FA, Waisman J, Lupu AN Cutaneous and subcutaneous metastases from carcinoma of prostate. Urology 1982;19:373-6.

3. Escaf Barmadah S, Capdevila Hernandez JM, Gonzalez Naranjo F. The cutaneous metastasis of prostatic adenocarcinoma. Apropos a case. Arch Esp Urol 1993;46:426-8.

4. Pique Duran E, Paradela A, Farina MC, Escalonilla P, Soriano ML, Olivares M, et al. Cutaneous metastases from prostatic carcinoma. J Surg Oncol 1996;62:144-7.

5. Marcoval J, Moreno A, Jucgla A, Servitje O. Peyri Prostatic adenocarcinoma with cutaneous metastases overlying oestrogen-induced gynaecomastia. Clin Exp Dermatol 1998;23:119-20.

© 2003 Indian Journal of Surgery. Also available online at http://www.indianjsurg.com


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