ANTICANCER RESEARCH 30: 1747-1750 (2010) Solitary Testicular Metastasis from Prostate Cancer: A Rare Case of Isolated Recurrence after Radical Prostatectomy STEFAN JANSSEN1, JOACHIM BERNHARDS2, ARISTOTELIS G. ANASTASIADIS3 and FRANK BRUNS1 1Department of Radiation Oncology, Hannover Medical School, Hannover, Germany; 2Department of Pathology, Robert Koch Krankenhaus Gehrden, Germany; 3Department of Urology, Großburgwedel Hospital, Germany Abstract. Background: The prognosis of prostate cancer spread of prostate cancer to the testis is commonly accepted (PC) is mainly determined by the presence or absence of as a sign of advanced disease and is often accompanied by metastases. An isolated testicular metastasis of PC is rare. multiple metastases to other organs, especially to the skeletal Case Report: A 71-year-old patient with PC presented with system (4). an increased serum prostate-specific antigen (PSA) level of We report the case of a 71-year-old patient who presented 2.07 ng/ml two and a half years after radical prostatectomy. with a solitary testicular metastasis of prostate cancer two Assuming a local recurrence in the prostatic fossa, local and a half years after prostatectomy. The patient remains free radiotherapy with 64.8 Gy was performed. Unfortunately, the of disease two years after unilateral orchiectomy. PSA level rose again, accompanied by a swelling of the left testis approximately one month after radiotherapy. A Case Report unilateral orchiectomy was then performed, presenting a testicular metastasis of the PC. After orchiectomy, the PSA A 71-year-old Caucasian male consulted his family doctor decreased to <0.07 ng/ml. Two years later, the patient is still complaining of haematospermia. Because of a rising serum tumour-free. Conclusion: Careful clinical follow-up of prostate-specific antigen (PSA) level of 7.66 ng/ml a prostate patients with rising serum PSA level is important to biopsy was performed one month later and a locally advanced recognize isolated, locally treatable metastastic disease. In prostate tumour was detected. Neoadjuvant androgen particular, rare metastatic sites such as the testis or the deprivation (goserelin 10.8 mg monthly injection, additional epididymis should be taken into account before treatment of bicalutamide 50 mg/d for the first three weeks) was then biochemical recurrence is initiated. started for three months, followed by a radical prostatectomy including pelvic lymphadenectomy. Histopathology showed Prostate cancer continues to be a major health problem in a cribriform adenocarcinoma of the prostate with a Gleason developed countries. Approved approaches to prostate cancer score of 3+3=6. Because of an infiltration of the left seminal include radical prostatectomy, radiotherapy, endocrine vesicle and the surrounding fat tissue, the tumour stage was treatment, and watchful waiting, depending on the risk pT3b pN0 M0 G2 R0, corresponding to an UICC stage III. category (1, 2). Surgery was complicated by a deep venous thrombosis of the The prognosis of prostate cancer is mainly determined by vena poplitea, and anticoagulation with phenprocoumon was the presence or absence of metastases. In particular, prostate initiated for six months. cancer synchronously or metachronously metastasizing to the Two and a half years later, the PSA level rose from <0.07 testis is unusual and reports of these kinds of metastasis were ng/ml to 2.07 ng/ml, indicating a biochemical recurrence. more frequent in the past, when this kind of neoplasm was Because no metastases were detected at this time, external often treated with bilateral orchiectomy (3). The metastatic beam radiotherapy of the prostatic fossa was performed, with a total dose of 64.8 Gy (1.8 Gy, five times a week). Besides mild acute irradiation side-effects, the treatment was well tolerated. Correspondence to: Stefan Janssen, MD, Department of Radiation One month after completing radiotherapy, the PSA level Oncology, Hannover Medical School, Carl Neuberg Straße 1, 30625 rose to 3.08 ng/ml. At this time, the patient complained of a Hannover, Germany. Tel: +49 5115322731, Fax: +49 5115323796, e-mail: [email protected] progressive, painful swelling of his left testicle. He had no urinary symptoms. The lower pole of the left testicle was Key Words: Testicular metastasis, isolated recurrence, prostate painful on palpation. The scrotal skin showed no evidence of cancer, prostatectomy. inflammation. The ultrasound of the testis (Figure 1) revealed 0250-7005/2010 $2.00+.40 1747 a 31.5×18×19.5 mm mass at the lower pole of the left testicle, with solid and liquid formations. A unilateral orchiectomy was then performed. Macroscopic examination of the operative Janssen et al: Isolated Testicular Metastasis from Prostate Cancer Figure 4. Chronological course of PSA level (cut-off level 0.07 ng/ml) 1: Initial diagnosis (Dec 2002); 2: shortly after prostatectomy (Feb 2003); 3: biochemical recurrence (Nov 2005); 4: semicastration (Feb 2006). Figure 3. Immunohistochemistry of intratubular tumour formation with an antibody to the prostate-specific antigen (source: Dako Cytomation) reveals strong positivity (dark cytoplasmatic staining). Counterstaining: hematoxylin, ×20. 5 Bubendorf L, Schopfer A, Wagner U, Sauter G, Moch H, Willi N, Gasser TC and Mihatsch MJ: Metastatic patterns of prostate cancer: An autopsy study of 1589 patients. Hum Pathol 31: 578- 583, 2000. Conclusion 6 Manikandan R, Nathaniel C, Reeve N and Brough RJ: Bilateral testicular metastases from prostatic carcinoma. Int J Urol 13: This case report highlights the need for careful clinical 476-477, 2006. follow-up of patients with prostatic cancer. As well as a local 7 Anastasiadis AG, Ebert T, Gerharz CD and Ackermann R: recurrence after prostatectomy or metastasis in the typical Epididymal metastasis of a prostatic carcinoma. Urologia Internationalis 60: 124-125, 1998. locations, one should also include rare metastatic sites such 8 Deb P, Chander Y and Rai RS: Testicular metastasis from as the testis and para-testicular structures in follow-up carcinoma of prostate: Report of two cases. Prostate Cancer evaluation when the serum PSA level rises. Therefore, the Prostatic Dis 10: 202-204, 2007. involvement of an urologist is mandatory in the follow-up of 9 Cookson MS, Aus G, Burnett AL, Canby-Hagino ED, D’Amico prostate cancer patients. 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Br J Urol 66: 205- 207, 1990. 4 Patel SR, Richardson RL and Krols L: Metastasis of cancer to Received March 22, 2010 the testis: A report of 20 cases and review of the literature. Revised April 27, 2010 J Urol 142: 1003-1005, 1989. Accepted April 27, 2010 1749.