Testicular Metastasis As Isolated Recurrence After Radical Prostatectomy

CASE REPORT Testicular metastasis as isolated recurrence after radical prostatectomy. A first case

F Menchini-Fabris, G Giannarini, G Pomara, M De Maria, F Manassero, A Mogorovich and C Selli

Urology Unit, University of Pisa, Pisa, Italy

Prostate cancer synchronously or metachronously metastasizing to the testis is a rare finding. We herein report on the first case of a solitary testicular metastasis from an organ-confined prostate cancer, diagnosed 6 months after a radical prostatectomy, without evidence of previous or concomitant biochemical and local recurrence. International Journal of Impotence Research (2007) 19, 108–109. doi:10.1038/sj.ijir.3901460; published online 23 March 2006

Keywords: testis; andrological malignancy; prostate

Introduction was palpable. Serum PSA was 15.5 ng/ml. Scrotal ultrasound showed a 35 mm large cyst of the head of Testicular metastases of carcinoma are a rare find- left epididymis, with normal appearing testicular ing, with approximately 200 reported cases, and the parenchyma. A transrectal prostate biopsy was then most common location of the primary tumour is performed, which revealed a Gleason grade 4 prostate, lung and gastrointestinal tract.1 Testicular adenocarcinoma. A CT scan of the abdomen, a bone involvement from prostate cancer, which has been scan and a chest X-ray ruled out regional and distant described in less than 80 patients, is thought to metastases, and the patient underwent a retropubic occur through the vas deferens or via lymphatic radical prostatectomy with pelvic lymph node spread and is associated with an advanced stage of dissection. Histopathological examination with disease, being usually incidentally discovered at whole-mount section revealed an intracapsular, bilateral orchiectomy or at autopsy.2 To the best of bilateral, Gleason score 9 adenocarcinoma of the our knowledge, prostate carcinoma recurrent to the prostate, with no invasion of regional lymph nodes. testis after radical treatment of the primary tumour Serum PSA levels at 1 and 3 months after surgery has been reported only once, simultaneously with were undetectable. At 6 months postoperatively, the local relapse.3 We herein, present the first case of a patient presented with bilateral testicular pain. A solitary testicular metastasis from an organ-confined scrotal ultrasound confirmed the previously diag- prostate cancer, diagnosed 6 months after a radical nosed left spermatocele; in addition, a round, prostatectomy, without evidence of previous or 10 mm, hypoechoic, heterogeneous, vascularized concomitant biochemical and local recurrence. mass of the left testis was noticeable (Figure 1). Serum markers for testis cancer were within normal limits and serum PSA was still undetectable. No Case report local recurrence of prostate cancer was evident. Since both primary and secondary malignancy were A 67-year-old man was referred to our outpatient deemed very unlikely, given the patient’s age and clinic with complaints of LUTS and a slowly clinical history, and since the patient desired to growing scrotal swelling. Physical examination preserve testicular tissue, an inguinal ultrasound- revealed a tender, transilluminable mass within guided testis-sparing procedure was subsequently the left scrotum with normal testes. On digital rectal performed, with removal of the lesion and 2 mm examination, a hard nodule of the right prostate lobe normal appearing surrounding parenchyma. Macro- scopically, the mass was brown in colour, well Correspondence: Dr G Pomara, Urology Unit, University of capsulated, with clear margins and no typical Pisa, S. Chiara Hospital, Via Roma 67, Pisa 56126, Italy. appearance of cancerous tissue, therefore, no E-mail: [email protected] intraoperative frozen sections were performed. Received 14 December 2005; accepted 15 January 2006; Histologically, a poorly differentiated adenocarcino- published online 23 March 2006 ma compatible with metastatic deposit from a Testicular metastasis as isolated recurrence after radical prostatectomy F Menchini-Fabris et al 109 Discussion

Disease recurrence after radical prostatectomy oc- curs in approximately 35% of patients within 10 years following surgery. As a rule, clinical recurrence is anticipated by biochemical failure by a time interval of several years and the most frequent locations of distant relapse are bone, lung and liver. Once it has occurred, the prognosis is usually dismal.4 The peculiarity of the present case is threefold. Firstly, a solitary metastasis developed from an organ-confined prostate cancer, while all the reports so far published included patients in whom the testicular involvement was part of a generalized disseminated disease, the prostatic primary being at an advanced stage. Secondly, the metastasis, albeit expressing PSA, was neither preceded by nor associated with biochemical failure. Very few cases of disease recurrence after radical prostatectomy Figure 1 Scrotal ultrasound scan, showing a round, 10 mm, with undetectable PSA have been described, in- hypoechoic, heterogeneous and vascularized mass within the left 5,6 testis (gray arrow); a simple cyst (white arrow) is noticeable cluding loco-regional and/or distant relapse. As within the head of the ipsilateral epididymis as well. pointed out in such reports, this fact may be explained considering that some prostatic primaries with high Gleason score have a low propensity to produce PSA. Thirdly, the interval between the radical treatment and the recurrence was quite short, approximately 6 months. This should stand for a highly aggressive disease, but up to 1 year of follow-up no new sign of progression became evident. Furthermore, to the best of our knowledge, a testis- sparing surgery has never been performed, either intentionally or incidentally, in a case of metastatic prostate cancer. The short-term follow-up of our patient is promising, but longer observation time is needed to appropriately judge the oncological outcome. In conclusion, based on the present report, we strongly advise that any intratesticular mass should be viewed as potentially malignant, irrespectively of the modality of presentation and regardless of the patient’s age and previous clinical history.

References

1 Han M, Kronz JD, Schoenberg MP. Testicular metastasis of transitional cell carcinoma of the prostate. JUrol2000; 164: 2026. 2 Tu SM, Reyes A, Maa A, Bhowmick D, Pisters LL, Pettaway CA et al. Prostate carcinoma with testicular or penile metastases. Clinical, pathologic, and immunohistochemical features. Can- cer 2002; 94: 2610–2617. 3 Brandon ML, Odom SR, Barone JE, Waxberg JA. Adenocarci- noma of the prostate metastatic to the testis via lymphatic Figure 2 Histological appearance of the intratesticular metasta- invasion: a case report. Conn Med 2005; 69: 69–70. sis (haematoxylin-eosin, original magnification Â 20), with strong 4 Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, positivity for PSA staining (inset, original magnification Â 40). Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999; 281: 1591–1597. 5 Leibman BD, Dillioglugil O, Wheeler TM, Scardino PT. Distant prostatic primary was diagnosed. PSA staining was metastasis after radical prostatectomy in patients without an intensely positive (Figure 2). Metastatic work-up elevated serum prostate specific antigen level. Cancer 1995; 76: was again negative. After a follow-up of 12 months 2530–2534. 6 Oefelein MG, Smith N, Carter M, Dalton D, Schaeffer A. The from testicular surgery, the patient is doing well incidence of prostate cancer progression with undetectable with no biochemical, radiological and clinical sign serum prostate specific antigen in a series of 394 radical of disease progression. prostatectomies. J Urol 1995; 154: 2128–2131.

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