CASE REPORTS
ADENOCARCINOMA
OF PROSTATE
AND MALIGNANT
PERICARDIAL
RICARDO
GONZALEZ,
M.D.
RICHARD
WILLIAMS,
M.D.
ELWIN
E. FRALEY,
EFFUSION
M.D.
From the Department of Urologic Surgery, University of Minnesota, College of Health Sciences, Minneapolis, Minnesota
ABSTRACT -A case of widespread adenocarcinoma of the prostate presenting as a symptomatic pericardial effusion is reported. The administration of high doses of estrogen produced a marked objective response in this patient.
Adenocarcinoma of the prostate rarely metastasizes to the pericardium.‘” The only previous documentation of prostatic cancer metastasizing to the pericardium was based on autopsy findings.4*5 Thus, this is the first reported case of adenocarcinoma of the prostate seen with a symptomatic malignant pericardial effusion in which the pericardial effusion was the first sign of the disease.
cyte sedimentation rate, serum electrolytes, acid and alkaline phosphatases. The blood urea nitrogen was 71 mg. and serum creatinine 4.2 mg. per 100 ml. A roentgenogram of the chest revealed diffusely enlarged cardiac silhouette and clear lung fields (Fig. 1A). Initial treatment with digitalis and diuretic drugs produced a 19pound weight loss, but there was no change in symptoms, cardiomegaly, or renal function tests. Echocardiography and heart scan suggested that the patient had pericardial effusion. Pericardiocentesis revealed 500 ml. of straw-colored fluid with normal chemical constituents. An aliquot was sent for cytologic examination. Following pericardiocentesis the patient became asymptomatic. An intravenous urogram showed nonvisualization of the right kidney and partial obstruction of the left ureter with moderate pyelocaliectasis (Fig. 1B). An intravenous urogram in 1969 was normal. Cystoscopy and retrograde pyelography showed bilateral midureteral obstruction (Fig. 1C). Bimanual examination and examination of the abdomen with the patient under anesthesia revealed a large retroperitoneal periaortic mass. Cytologic examination of pericardial fluid showed nests of neoplastic cells and gland-like formation suggesting metastatic adenocarcinoma (Fig. 2). An exploratory laparotomy was done and revealed a retroperitoneal mass which histologically was poorly differentiated adenocarcinoma. A left
Case Report A sixty-two-year-old white man had a six-week history of interscapular pain which initially had been associated with a flu-like febrile illness. Symptomatic treatment was unsuccessful, and the pain increased in severity during the six weeks prior to hospital admission. A radiograph of the chest revealed cardiomegaly, and the patient was admitted with a diagnosis of congestive heart failure. Past medical history revealed that the patient had a prostatic nodule which had been followed up conservatively by two urologists for more than ten years. Physical examination revealed a blood pressure of 140 mm. Hg systolic and 80 diastolic; heart rate was 80 per minute and regular. Auscultation of the heart was unremarkable, and the lungs were clear. The prostate was slightly enlarged, and there was a nodule in the superior portion ofthe right lobe. Initial laboratory studies included a normal complete blood count, erythro-
UROLOGY
/ FEBRUARY
1975 / VOLUME
V, NUMBER
2
233
FIGURE 1. (A) Roentgenogram of the chest on hospital admission; (B) intravenous admission; (C) retrograde ureteropyelogram. nephrostomy tube was placed and immediately following laparotomy a transperineal needle biopsy of the prostate was done. Results of needle biopsy were negative for tumor; however, it was
FIG~JRE 2. Cytologic
234
appearance
of pericardial fluid.
urogram
on hospital
presumed that the most likely diagnosis was adenocarcinoma of the prostate metastatic to the retroperitoneum with a malignant pericardial effusion. In view of the extent of the disease the patient was given a six-day course of intravenous diethylstilbestrol diphosphate (Stilphostrol*) (2 Gm. per day) initiated on the first postoperative day. The patient was then continued on oral diethylstilbestrol diphosphate 50 mg. per day. A repeat needle biopsy of the prostate done transrectally revealed a small focus of welldifferentiated adenocarcinoma of the prostate. A repeat acid phosphatase was normal as was the metastatic bone series. Two weeks postoperatively a repeat urogram revealed visualization of the previously nonfunctioning right kidney and a decrease in the hydronephrosis of the left kidney. This improvement in renal function was presumed to be a response to estrogens. The nephrostomy tube was removed. Four weeks postoperatively a repeat urogram showed increased visualization of the right kidney and minimal hydronephrosis on the left (Fig. 3). Blood urea nitrogen and creatinine clearance at this time were 20 and 1.4 mg. per 100 ml., respectively. Six months later the patient remains asymptomatic, serum creatinine is normal, and the intravenous urogram reveals no obstruction. *Dome Laboratories, West Haven, Connecticut.
UROLOGY / FEBRUARY 1975 / VOLUME V, NUMBER 2
If this is the case, it appears appropriate to treat extensive metastatic disease with larger dosages than those required to bring serum testosterone down to castration levels. Of course, it is possible that castration or low doses of estrogens could have accomplished the same dramatic response in this patient, but we are impressed with the result obtained thus far in our experience with the initial use of large doses of estrogens in patients with extensive disease. Further laboratory and clinical studies are necessary to document the validity of these observations.
A-595 Mayo Memorial Building, Box 394 Minneapolis, Minnesota 55455 (DR. GONZALEZ)
FIGURE
3.
1ntruvenou.s
urogrmn
four
week,
/
References
operatively.
1. BIRAN, S., HOCHMAN, A., LEVIJI, I. S., and STERN, S.: Clinical diagnosis of secondary tumors of the heart and pericardium, Dis. Chest 55: 203 (1969). 2. LOCKICH, J. J.: The management of malignant pericardial effusion, J.A.M.A. 224: 1401 (1973). 3. NAKAYAMA, R., YONJXYAMA,T., TAKATANI, O., and KIMURA, K. : A study of metastatic tumors to the heart, pericardium and great vessels, Jap. Heart J. 7: 227 (1966). 4. LEWIS, J. F., BAKER, T. D., and DELVAUX, T. C.: Carcinoma of the prostate metastatic to the heart, South. Med. J. 60: 781 (1967). 5. MCCREA, L. E., and KARAFIN, L. : Carcinoma of the prostate: metastases, therapy and survival, J. Internat. Coil. Surg. 29: 723 (1958). 6. HERBST, W. P.: The effect of estradiol dipropionate and diethylstilbestrol on malignant prostatic tissue, rrans. Am. Assoc. Genitourin. Surg. 34: 195 (1941). 7. HUGGINS, C., and HODGES, C. V.: Studies on prostatic cancer. I. The effect of castration, of estrogen, and androgen injection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res. 1: 293 (1941). 8. NESBIT, R. M., and BAUN, W. C.: Endocrine control of prostatic cancer, J.A.M.A. 143: 1317 (1950). 9. BLACKARD, C. E., and MELLINGER. G. T.: Current status of estrogen therapy in prostatic carcinoma, Postgraduate Med. 51: 140 (1972). 10. SHEARER, R. J., HENDRY, W. F., SOMMERVILLE, I. F., and FERGUSON, J. D.: Plasma testosterone; an accurate monitor of hormone treatment in prostate cancer, Br. J. Urol. 45: 668 (1973). 11. The Veterans Administration Cooperative Urology Research Group: Treatment and survival of patients with cancer of the prostate, Surg. Gynecol. Obstet. 124: 1011 (1967). A direct effect of estrogens in 12. FARNSWORTH, W. E.: prostatic metabolism of testosterone, Invest. Ural. 6: 423 (1969). 13. SINHA, A. A., BLACKARD, C. E., Dow, R. P., and SEAL, U. S.: In vitro localization of H3 estradiol in human prostatic cancer, Cancer 31: 682 (1973).
Comment The case described here is unique in its p entation with a symptomatic pericardial effu: as the first manifestation of carcinoma of prostate. In addition it illustrates several portant points with regard to this disease. First, it points out the well-established that the consistency of a prostatic nodule on re palpation is not reliable to exclude a maligr lesion and only biopsies can provide an ansv Secondly, it emphasizes the value of camp: examination of the aspirated pericardial fl including cytology which in this case sugges the histologic type ofthe primary tumor. Fur0 more, carcinoma of the prostate should be c sidered in the differential diagnosis in any ac man with bilateral ureteral obstruction. T therapy with estrogens in a case ofretroperiton adenocarcinoma may be justified when the 1 mary site cannot be determined. Confronted with a patient with extens carcinoma of the prostate it is our policy to sl treatment with high doses ofparenteral estrogc as the effectiveness of estrogens in the treatm’ of carcinoma of the prostate is well accepted The dosages used however are still a controver issue. s-11Recent evidence indicates that estrog molecules bind to the prostate cancer cells, zI it has been suggested that the effect of estrogc on the growth of prostatic carcinoma is due I only to suppression of serum testosterone but a to a direct effect on the prostatic tumor cells.’
UROL0C.Y
’ FEBRUARY 1975 / VOLUME V, NUMES
!
235
ADENOCARCINOMA
OF PROSTATE
AND MALIGNANT
PERICARDIAL
RICARDO
GONZALEZ,
M.D.
RICHARD
WILLIAMS,
M.D.
ELWIN
E. FRALEY,
EFFUSION
M.D.
From the Department of Urologic Surgery, University of Minnesota, College of Health Sciences, Minneapolis, Minnesota
ABSTRACT -A case of widespread adenocarcinoma of the prostate presenting as a symptomatic pericardial effusion is reported. The administration of high doses of estrogen produced a marked objective response in this patient.
Adenocarcinoma of the prostate rarely metastasizes to the pericardium.‘” The only previous documentation of prostatic cancer metastasizing to the pericardium was based on autopsy findings.4*5 Thus, this is the first reported case of adenocarcinoma of the prostate seen with a symptomatic malignant pericardial effusion in which the pericardial effusion was the first sign of the disease.
cyte sedimentation rate, serum electrolytes, acid and alkaline phosphatases. The blood urea nitrogen was 71 mg. and serum creatinine 4.2 mg. per 100 ml. A roentgenogram of the chest revealed diffusely enlarged cardiac silhouette and clear lung fields (Fig. 1A). Initial treatment with digitalis and diuretic drugs produced a 19pound weight loss, but there was no change in symptoms, cardiomegaly, or renal function tests. Echocardiography and heart scan suggested that the patient had pericardial effusion. Pericardiocentesis revealed 500 ml. of straw-colored fluid with normal chemical constituents. An aliquot was sent for cytologic examination. Following pericardiocentesis the patient became asymptomatic. An intravenous urogram showed nonvisualization of the right kidney and partial obstruction of the left ureter with moderate pyelocaliectasis (Fig. 1B). An intravenous urogram in 1969 was normal. Cystoscopy and retrograde pyelography showed bilateral midureteral obstruction (Fig. 1C). Bimanual examination and examination of the abdomen with the patient under anesthesia revealed a large retroperitoneal periaortic mass. Cytologic examination of pericardial fluid showed nests of neoplastic cells and gland-like formation suggesting metastatic adenocarcinoma (Fig. 2). An exploratory laparotomy was done and revealed a retroperitoneal mass which histologically was poorly differentiated adenocarcinoma. A left
Case Report A sixty-two-year-old white man had a six-week history of interscapular pain which initially had been associated with a flu-like febrile illness. Symptomatic treatment was unsuccessful, and the pain increased in severity during the six weeks prior to hospital admission. A radiograph of the chest revealed cardiomegaly, and the patient was admitted with a diagnosis of congestive heart failure. Past medical history revealed that the patient had a prostatic nodule which had been followed up conservatively by two urologists for more than ten years. Physical examination revealed a blood pressure of 140 mm. Hg systolic and 80 diastolic; heart rate was 80 per minute and regular. Auscultation of the heart was unremarkable, and the lungs were clear. The prostate was slightly enlarged, and there was a nodule in the superior portion ofthe right lobe. Initial laboratory studies included a normal complete blood count, erythro-
UROLOGY
/ FEBRUARY
1975 / VOLUME
V, NUMBER
2
233
FIGURE 1. (A) Roentgenogram of the chest on hospital admission; (B) intravenous admission; (C) retrograde ureteropyelogram. nephrostomy tube was placed and immediately following laparotomy a transperineal needle biopsy of the prostate was done. Results of needle biopsy were negative for tumor; however, it was
FIG~JRE 2. Cytologic
234
appearance
of pericardial fluid.
urogram
on hospital
presumed that the most likely diagnosis was adenocarcinoma of the prostate metastatic to the retroperitoneum with a malignant pericardial effusion. In view of the extent of the disease the patient was given a six-day course of intravenous diethylstilbestrol diphosphate (Stilphostrol*) (2 Gm. per day) initiated on the first postoperative day. The patient was then continued on oral diethylstilbestrol diphosphate 50 mg. per day. A repeat needle biopsy of the prostate done transrectally revealed a small focus of welldifferentiated adenocarcinoma of the prostate. A repeat acid phosphatase was normal as was the metastatic bone series. Two weeks postoperatively a repeat urogram revealed visualization of the previously nonfunctioning right kidney and a decrease in the hydronephrosis of the left kidney. This improvement in renal function was presumed to be a response to estrogens. The nephrostomy tube was removed. Four weeks postoperatively a repeat urogram showed increased visualization of the right kidney and minimal hydronephrosis on the left (Fig. 3). Blood urea nitrogen and creatinine clearance at this time were 20 and 1.4 mg. per 100 ml., respectively. Six months later the patient remains asymptomatic, serum creatinine is normal, and the intravenous urogram reveals no obstruction. *Dome Laboratories, West Haven, Connecticut.
UROLOGY / FEBRUARY 1975 / VOLUME V, NUMBER 2
If this is the case, it appears appropriate to treat extensive metastatic disease with larger dosages than those required to bring serum testosterone down to castration levels. Of course, it is possible that castration or low doses of estrogens could have accomplished the same dramatic response in this patient, but we are impressed with the result obtained thus far in our experience with the initial use of large doses of estrogens in patients with extensive disease. Further laboratory and clinical studies are necessary to document the validity of these observations.
A-595 Mayo Memorial Building, Box 394 Minneapolis, Minnesota 55455 (DR. GONZALEZ)
FIGURE
3.
1ntruvenou.s
urogrmn
four
week,
/
References
operatively.
1. BIRAN, S., HOCHMAN, A., LEVIJI, I. S., and STERN, S.: Clinical diagnosis of secondary tumors of the heart and pericardium, Dis. Chest 55: 203 (1969). 2. LOCKICH, J. J.: The management of malignant pericardial effusion, J.A.M.A. 224: 1401 (1973). 3. NAKAYAMA, R., YONJXYAMA,T., TAKATANI, O., and KIMURA, K. : A study of metastatic tumors to the heart, pericardium and great vessels, Jap. Heart J. 7: 227 (1966). 4. LEWIS, J. F., BAKER, T. D., and DELVAUX, T. C.: Carcinoma of the prostate metastatic to the heart, South. Med. J. 60: 781 (1967). 5. MCCREA, L. E., and KARAFIN, L. : Carcinoma of the prostate: metastases, therapy and survival, J. Internat. Coil. Surg. 29: 723 (1958). 6. HERBST, W. P.: The effect of estradiol dipropionate and diethylstilbestrol on malignant prostatic tissue, rrans. Am. Assoc. Genitourin. Surg. 34: 195 (1941). 7. HUGGINS, C., and HODGES, C. V.: Studies on prostatic cancer. I. The effect of castration, of estrogen, and androgen injection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res. 1: 293 (1941). 8. NESBIT, R. M., and BAUN, W. C.: Endocrine control of prostatic cancer, J.A.M.A. 143: 1317 (1950). 9. BLACKARD, C. E., and MELLINGER. G. T.: Current status of estrogen therapy in prostatic carcinoma, Postgraduate Med. 51: 140 (1972). 10. SHEARER, R. J., HENDRY, W. F., SOMMERVILLE, I. F., and FERGUSON, J. D.: Plasma testosterone; an accurate monitor of hormone treatment in prostate cancer, Br. J. Urol. 45: 668 (1973). 11. The Veterans Administration Cooperative Urology Research Group: Treatment and survival of patients with cancer of the prostate, Surg. Gynecol. Obstet. 124: 1011 (1967). A direct effect of estrogens in 12. FARNSWORTH, W. E.: prostatic metabolism of testosterone, Invest. Ural. 6: 423 (1969). 13. SINHA, A. A., BLACKARD, C. E., Dow, R. P., and SEAL, U. S.: In vitro localization of H3 estradiol in human prostatic cancer, Cancer 31: 682 (1973).
Comment The case described here is unique in its p entation with a symptomatic pericardial effu: as the first manifestation of carcinoma of prostate. In addition it illustrates several portant points with regard to this disease. First, it points out the well-established that the consistency of a prostatic nodule on re palpation is not reliable to exclude a maligr lesion and only biopsies can provide an ansv Secondly, it emphasizes the value of camp: examination of the aspirated pericardial fl including cytology which in this case sugges the histologic type ofthe primary tumor. Fur0 more, carcinoma of the prostate should be c sidered in the differential diagnosis in any ac man with bilateral ureteral obstruction. T therapy with estrogens in a case ofretroperiton adenocarcinoma may be justified when the 1 mary site cannot be determined. Confronted with a patient with extens carcinoma of the prostate it is our policy to sl treatment with high doses ofparenteral estrogc as the effectiveness of estrogens in the treatm’ of carcinoma of the prostate is well accepted The dosages used however are still a controver issue. s-11Recent evidence indicates that estrog molecules bind to the prostate cancer cells, zI it has been suggested that the effect of estrogc on the growth of prostatic carcinoma is due I only to suppression of serum testosterone but a to a direct effect on the prostatic tumor cells.’
UROL0C.Y
’ FEBRUARY 1975 / VOLUME V, NUMES
!
235
