Annals of African Medicine

CASE REPORT
Year
: 2012  |  Volume : 11  |  Issue : 4  |  Page : 230--233

Renal metastasis from prostate adenocarcinoma: A potential diagnostic pitfall


Philip O Ibinaiye1, Hyacinth Mbibu2, Sani M Shehu3, Samuel O David4, Modupeola Omotara Samaila3,  
1 Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Correspondence Address:
Philip O Ibinaiye
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria

Abstract

Renal metastasis from prostatic origin is an uncommon event. Advanced prostate cancer locally invades the seminal vesicles, bladder and regional lymph nodes. Other metastatic sites are the lung, bone and other visceral organs. We present a 55-year old, Hausa man from Northern Nigeria who was managed as a case of infected renal cyst which later turned out to be a metastatic prostatic adenocarcinoma with a rare pattern of widespread bony metastases.Renal metastasis from prostate adenocarcinoma is a rare occurrence, however, high level of suspicion is needed in order to avoid potential diagnostic pitfall.



How to cite this article:
Ibinaiye PO, Mbibu H, Shehu SM, David SO, Samaila MO. Renal metastasis from prostate adenocarcinoma: A potential diagnostic pitfall.Ann Afr Med 2012;11:230-233


How to cite this URL:
Ibinaiye PO, Mbibu H, Shehu SM, David SO, Samaila MO. Renal metastasis from prostate adenocarcinoma: A potential diagnostic pitfall. Ann Afr Med [serial online] 2012 [cited 2020 Sep 25 ];11:230-233
Available from: http://www.annalsafrmed.org/text.asp?2012/11/4/230/102854


Full Text

 Introduction



Primary neoplasms that commonly metastasize to the kidney as solitary large masses originate from the lung, breast, esophagus, colon and melanoma. [1] Advanced prostate cancer usually invade contiguous structures such as the seminal vesicles, bladder and regional lymph nodes. Distant metastasis may be seen in the bones and other visceral organs while metastasis to the kidney is a rare event. [1],[2]

 Case Report



A 55-year old Hausa man from Northern Nigeria presented to our hospital with a left flank pain of a month's duration, fever, nausea and a week history of loss of appetite. Physical examination revealed an ill looking man with a temperature of 40°C and a left flank tenderness. His blood parameters, electrolytes and urea levels were essentially normal. Rectal examination was however not done. Renal ultrasound scan showed a well circumscribed rounded left renal cystic 3×4.5 cm mass in the upper pole with multiple low level echoes within it. It was diagnosed as an infected renal cyst. The patient was placed on antibiotics and analgesics.

He represented six months later with severe left flank pain, hematuria, vomiting and a month history of right upper chest and back pain. He was anemic with hemoglobin of 7g/dl. His chest radiograph showed a solitary osteoblastic deposit on the right first anterior rib [Figure 1] while skeletal survey showed osteoblastic deposits on the right pedicle of L1, body of L4 and the pubic bones [Figure 2]. A repeat ultrasound also revealed a lobulated 10.5 × 6.8 cm cystic mass with solid internal component in the upper pole of the left renal parenchyma [Figure 3] which was diagnosed as a renal tumor.{Figure 1}{Figure 2}{Figure 3}

The osteoblastic deposits from the skeletal survey triggered a search for a likely primary site rather than the kidney which is an uncommon organ for this pattern of metastatic deposits. Thus, a transrectal ultrasound scan (TRUS) was done and it revealed nodular prostatic enlargement while a Tru-cut biopsy [Figure 4] showed a poorly differentiated prostatic adenocarcinoma (Gleason score-7). He also had a fine needle aspiration biopsy of the renal mass which showed malignant cells with the cytological appearance of prostate adenocarcinoma and this was handled by two experts and experienced histopathologists. PSA staining was not done on the smears due to non-availability of the reagents in our center. However, the serum prostate specific antigen (PSA) assay was elevated (150 ng/ml). {Figure 4}

He was scheduled for bilateral subcapsular orchidectomy to be followed by 50mg daily of bicalutamide (an anti-androgen). However, the patient refused surgery and absconded against medical advice.

 Discussion



Carcinoma of the prostate is the second most common malignancy in men and may metastasize to any part of the body. Increasing age confers greater risk for the development of this disease. [3],[4] The peak age incidence is 55 years in Black African men and our patient falls within this age group. [4] Prostate cancer commonly metastasize to the bones and lymph nodes while several metastatic sites are rarely discovered ante-mortem. [5] To the best of our knowledge from literature searches, this is the second case of renal metastasis from prostatic adenocarcinoma diagnosed ante-mortem by percutaneous fine needle aspiration. Though, unusual sites of prostatic metastases are widely documented in literature from postmortem findings, Gunlusoy et al[1] and Denti et al[6] respectively reported postmortem findings of bilateral and unilateral renal metastases from prostate carcinoma which was initially misdiagnosed as renal cell carcinoma.

The cytologic and morphologic appearance of primary renal cell carcinoma is quite distinct from prostatic adenocarcinoma and thus, diagnosis can be made on morphology alone as in the index case. The metastatic spread to the kidney from other primary sites have peculiar growth pattern and are usually positive for S-100 protein as seen in index case. The efficacy and accuracy of the fine needle aspiration biopsy technique in the evaluation of palpable masses cannot be over-emphasized. It was the pointer to the prostate in this case. Kutcher et al[2] also confirmed the efficacy and safety of this procedure in the ante-mortem diagnosis of renal metastasis of prostatic origin.

Gholam et al[5] reported an unusual rare combination of metastases from the prostate to both kidneys, both adrenals, both breasts, the head of pancreas and one testis at autopsy without bony involvement. Our case had an unusual focal widespread metastases on the rib, lumbar vertebrae and pelvic bones. To our knowledge, no similar pattern has been reported in literature. Other reported rare sites of metastasis are the brain, larynx, oral cavity and paranasal sinuses. [7],[10]

An understanding of the tumor biology such as tumor aggressiveness and extra-prostatic extension will create better insight to the metastatic pattern of this disease. Early detection also confers better prognostic outcome and a combination of direct rectal examination (DRE), transurethral ultrasonography and serum PSA are invaluable in diagnosis. [11],[12]

Invasive lesions into the rectum have been reported [13],[15] and may mimic primary rectal Carcinoma and thus, a rectal examination is mandatory. DRE could have detected the prostatic mass earlier in this patient. Extra rectal deposits may also present with constipation as documented by Kant et al. [16] Studies have demonstrated that FDG-PET (positron emission tomographic with 18- fluorodeoxyglucose) scanning may play an important role in the evaluation of advanced androgen-independent disease and in the staging and evaluation of response to hormonal manipulations in high-risk localized and locally advanced prostate cancers. [17] This may be helpful in detecting rare metastatic sites ante-mortem.

Metastatic prostate cancer carries a poor prognosis while the effect of the unusual metastatic sites on the management and prognosis is largely unknown. However, management strategy remains the same. Surgical or medical castration is the standard of therapy while hormonal manipulation may not yield any appreciable response. The degree of differentiation may also be a good prognostic indicator in this regard.

 Conclusion



Renal metastasis from prostate adenocarcinoma is a rare occurrence, however, high level of suspicion is needed in order to avoid potential diagnostic pitfall.

 Acknowledgements



The authors appreciate the contribution of the resident doctors and nursing staff of the Radiology, Urology, Medicine and Pathology departments in the management of this patient.

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