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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 3  |  Page : 659

Carcinoma prostate with gastric metastasis: A rare case report


Department of Radiation Oncology Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India

Date of Web Publication9-Oct-2015

Correspondence Address:
Virendra Bhandari
401, Samyak Towers, 16/3, Old Palasia, Indore - 452 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.139389

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 > Abstract 

Prostate carcinoma is the most common malignancy in males and it commonly manifests with bony metastasis in India, but occasionally visceral metastasis to lungs and liver may also be seen. Metastasis to the gastrointestinal tract is very rare. In literature, we could find six cases only. We present here 7 th patient of carcinoma prostate, which metastasized to stomach. He had epigastric pain, which was mistaken initially with analgesic induced acid peptic disease abut later, on endoscopy a gastric nodule was seen. Histopathology and immunohistochemistry of this confirmed it to be metastasis from prostate. This visceral metastasis to stomach usually spreads through lymphatic's rather than by hematogenous route. This case is being presented because of its rare occurrence.

Keywords: Gastric, prostate metastasis, PSA relation


How to cite this article:
Bhandari V, Pant S. Carcinoma prostate with gastric metastasis: A rare case report. J Can Res Ther 2015;11:659

How to cite this URL:
Bhandari V, Pant S. Carcinoma prostate with gastric metastasis: A rare case report. J Can Res Ther [serial online] 2015 [cited 2019 Jul 19];11:659. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/659/139389


 > Introduction Top


Prostate carcinoma is one of the most frequently diagnosed malignancies in men. The usual sites of metastasis from prostate cancer are bones and lymph nodes, but sometimes visceral metastases are also seen in lungs and liver and it rarely spreads to the gastrointestinal tract. We reviewed the literature and could find only six cases of carcinoma prostate, which have metastasized to stomach. We present here a similar case which presented with pain and heaviness in epigastric region of the abdomen and on investigations a nodular mass was found in the stomach. This is a rare site for metastasis from prostate.


 > Case report Top


The present case report is about a 58-year-old male patient who presented in August 2012 to us with the complaints of increased frequency and urgency of micturition with post-void dribbling. There is no past medical history. His sonography showed partially filled urinary bladder with an enlarged prostate of 55 g with calcification. There were multiple enlarged para-aortic lymph nodes. Prostate specific antigen (PSA) was more than 100 ng/ml. Trans rectal core biopsy from prostate showed adenocarcinoma with gleason score of 9. Peri-neural, lympho vascular and extra-prostatic invasion were present. Bone scan showed multiple skeletal metastasis involving bones of axial and appendicular skeleton.

Patient received leuprolide deport 11.5 mg intramuscularly every 3 months along with oral Bi-calutamide 50 mg every day. Patient had a good response to the treatment and his PSA level came down to 2.33 ng/ml in October 2012. He was on regular follow-up and on hormonal treatment and was asymptomatic. In February 2013 patient again developed difficulty in passing urine with increased frequency along with weakness in bilateral lower limb. PSA was 22.4 ng/ml started rising again. Patient also developed pain in epigastric region along with constipation. Testosterone (free and total) was <0.13 and <10 ng/ml. Magnetic resonance imaging whole spine showed altered marrow signal intensity involving all vertebrae along with pelvic bones. There was epidural soft-tissue lesion at L2 level with Inter vertebral disc bulge indenting the thecal sac. This time patient was started on Bi-phosphonates and estramustane 140 mg twice a day. Patient was also given radiotherapy to L2 spine 30 Gy/10 fractions in April 2013. Due to consisted epigastric pain gastroscopy was done, which showed nodular ulcer in the gastric antrum [Figure 1]. Biopsy was taken which showed high grade metastatic adenocarcinoma [Figure 2]. Immuno histochemistry of the specimen confirmed the presence of metastatic deposits of poorly differentiated adenocarcinoma [Figure 3]. PSA stain was positive in the specimen. Cytokeratins-20 (CK-20) is focally positive while CK-7 is negative. Hence, this was labeled as metastasis in the stomach from prostate carcinoma. As the disease is progressing despite hormonal therapy he was labeled hormone resistant and started on with chemotherapy using once weekly docetaxel 80 mg for 4 weeks. His pain in epigastrium had reduced, but later the patient died due to cardio-respiratory arrest after 4 months of diagnosis of gastric metastasis.
Figure 1: Endoscopic view of gastric nodule in the stomach

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Figure 2: Low power microphotograph of gastric biopsy showing normal gastric mucosa with tumour nodule in submucosal tissue

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Figure 3: High power view of tumour nodule showing normal gastric gland with moderately pleomorphic microcytic tumour cells with abundant granular eosinophilic cytoplasm, moderate anisonucleiosis with prominent nucleoli

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 > Discussion Top


The usual sites of metastasis of carcinoma prostate are bone and lymph nodes, but sometimes visceral metastasis is also seen involving lung and liver. However metastasis to the gastrointestinal tract is very unusual involving small bowel [1] and esophagus. [2],[3] However, metastasis to stomach has rarely been reported in the literature. [4],[5],[6],[7],[8]

In a search we could only find six cases of carcinoma prostate metastasizing to the stomach [Table 1]. Two post-mortem studies showed that the incidence of prostate cancer metastasizing to stomach is 1-4%. The most common malignancies which can metastasize to the stomach are lung, pancreas, esophagus, liver, breast, kidney and colon. [9],[10] But only six cases of gastric metastasis from prostate have been reported until date. On literature review only two patients had gastric metastasis as the initial finding at the time of diagnosis [2],[3] whereas in others the diagnosis was made months or years after the primary diagnosis of prostate carcinoma. [1],[3],[4] Nausea vomiting, abdominal or epigastric discomfort were the common presenting symptoms in case of gastric metastasis. [1],[2],[3],[4] Our patient also had gastric discomfort and epigastric pain which was initially thought to be due to analgesics taken for pain due to bone metastasis but on endoscopy a nodular lesion was found in the stomach, which on histology showed metastatic adenocarcinoma and was confirmed by immune histochemistry to be arising from prostate. Two patients presented as hematemesis [3] the median time to gastric metastasis was 33 months (range 15-96 months) in four reported cases and in two it was initial finding. Our patient developed gastric metastasis within 8 months of the diagnosis. The PSA level at the time of diagnosis of gastric metastasis was elevated in all the cases including our case and all the cases were hormone refractory, so we have decided to start him on chemotherapy using weekly docetaxel. The survival in all cases was poor after the diagnosis of metastasis in stomach ranging between 5 months and 23 months. Our patient also died within 4 months ago developing gastric metastasis.
Table 1: Relation of PSA with gastric metastasis


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The mechanism of metastasis of gastrointestinal tract from prostate cancer is unclear. Hematogenous, lymphatic and direct local infiltrations usually lead to metastasis. As prostate is richly supplied with lymphatic channels, metastasis to gastro intestinal tract may occur through lymphatic's. [9] As we have seen that our patient had lymph nodal metastasis at presentation the probability of this route of metastasis may be the cause.

In our case and in most other cases epigastric discomfort and pain, nausea and hematemesis are the common symptoms associated with stomach metastasis hence in a patient of carcinoma prostate with lymph nodal metastasis with a history of abdominal symptoms; a probability of gastric metastasis should be considered and investigated in this line.

 
 > References Top

1.
Malhi-Chowla N, Wolfsen HC, Menke D, Woodward TA. Prostate cancer metastasizing to the small bowel. J Clin Gastroenterol 2001;32:439-40.  Back to cited text no. 1
    
2.
Nakamura T, Mohri H, Shimazaki M, Ito Y, Ohnishi T, Nishino Y, et al. Esophageal metastasis from prostate cancer: Diagnostic use of reverse transcriptase-polymerase chain reaction for prostate-specific antigen. J Gastroenterol 1997;32:236-40.  Back to cited text no. 2
    
3.
Gore RM, Sparberg M. Metastatic carcinoma of the prostate to the esophagus. Am J Gastroenterol 1982;77:358-9.  Back to cited text no. 3
    
4.
Holderman WH, Jacques JM, Blackstone MO, Brasitus TA. Prostate cancer metastatic to the stomach. Clinical aspects and endoscopic diagnosis. J Clin Gastroenterol 1992;14:251-4.  Back to cited text no. 4
    
5.
Christoph F, Grünbaum M, Wolkers F, Müller M, Miller K. Prostate cancer metastatic to the stomach. Urology 2004;63:778-9.  Back to cited text no. 5
    
6.
Onitilo AA, Engel JM, Resnick JM. Prostate carcinoma metastatic to the stomach: Report of two cases and review of the literature. Clin Med Res 2010;8:18-21.  Back to cited text no. 6
    
7.
Hong KP, Lee SJ, Hong GS, Yoon H, Shim BS. Prostate cancer metastasis to the stomach. Korean J Urol 2010;51:431-3.  Back to cited text no. 7
    
8.
Bilici A, Dikilitas M, Eryilmaz OT, Bagli BS, Selcukbiricik F. Stomach metastasis in a patient with prostate cancer 4 years after the initial diagnosis: A case report and a literature review. Case Rep Oncol Med 2012;2012:292140.  Back to cited text no. 8
    
9.
Green LK. Hematogenous metastases to the stomach. A review of 67 cases. Cancer 1990;65:1596-600.  Back to cited text no. 9
    
10.
Oda, Kondo H, Yamao T, Saito D, Ono H, Gotoda T, et al. Metastatic tumors to the stomach: Analysis of 54 patients diagnosed at endoscopy and 347 autopsy cases. Endoscopy 2001;33:507-10.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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