Combined occurrence of prostate carcinoma and malacoplakia

Case report: Prostatic malakoplakia: a rare disease that has a profile mimicking prostate cancer

Prostatic malakoplakia (PMP) is a rare inflammatory disease, and misdiagnosis on imaging is a major reason for unnecessary punctures; however, information on imaging is even rarer. Five patients with PMP between May 2022 and February 2023 were enrolled in this study to summarize the imaging manifestations. All patients underwent ultrasound (US)-guided prostate biopsy and were confirmed by pathology, and the presence of prostate cancer was also excluded by pathology. The five patients, with a median age of 71 years (range = 58-74 years), had a median total prostate-specific antigen (T-PSA) of 10.40 ng/mL (range = 1.74-63.42 ng/mL). In two patients, chest computed tomography showed pulmonary infections. All patients underwent magnetic resonance imaging (MRI). Of these patients, four had a Prostate Imaging-Reporting and Data System (PIRADS) score of 5, while one had a score of 4. The lesions were mostly distributed in the peripheral zone of the prostate and appeared as a high signal on T1-weighted imaging (T1WI) and a low signal on T2-weighted imaging (T2WI). In the US examination, four patients had abnormal prostate morphology, with an unsmooth envelope and non-uniform parenchymal echogenicity. Four patients had increased prostate volume. US showed a hypoechoic nodule with non-uniform internal echogenicity, and an abundant internal blood flow signal was detected by color Doppler US. PSA, MRI, and US were not specific for PMP in our study, but we found that a history of co-infection may be helpful in an accurate diagnosis and to avoid unnecessary biopsy.

Presacral malakoplakia presenting as foot drop: a case report

BACKGROUND

Malakoplakia is a rare condition characterized by inflammatory masses with specific histological characteristics. These soft tissue masses can mimic tumors and tend to develop in association with chronic or recurrent infections, typically of the urinary tract. A specific defect in innate immunity has been described. In the absence of randomized controlled trials, management is based on an understanding of the biology and on case reports.

CASE PRESENTATION

Here we describe a case of presacral malakoplakia in a British Indian woman in her late 30s, presenting with complex unilateral foot drop. Four years earlier, she had suffered a protracted episode of intrapelvic sepsis following a caesarean delivery. Resection of her presacral soft tissue mass was not possible. She received empiric antibiotics, a cholinergic agonist, and ascorbic acid. She responded well to medical management both when first treated and following a recurrence of symptoms after completing an initial 8 months of therapy. Whole exome sequencing of the patient and her parents was undertaken but no clear causal variant was identified.

CONCLUSIONS

Malakoplakia is uncommon but the diagnosis should be considered where soft tissue masses develop at the site of chronic or recurrent infections. Obtaining tissue for histological examination is key to making the diagnosis. This case suggests that surgical resection is not always needed to achieve a good clinical and radiological outcome.

[An unusual association of malakoplakia and adenocarcinoma of the prostate]

Malakoplakia is a chronic inflammatory process caused by a lysosomal defect in bacterial digestion. Although rare, it occurs more frequently in the genitourinary tract and in patients with immune dysfunction. The bladder is the most commonly affected site, although cases have been reported in other organs, including the prostate gland. Clinically, this lesion can be confused with malignant tumours, both on physical examination and imagining techniques. This is particularly pronounced in the prostate, making the differential diagnosis challenging. Histologically, characteristic aggregates of histiocytes with basophilic intracytoplasmic inclusions composed of calcium and iron salts are found. We present a case diagnosed on transrectal biopsy as acinar adenocarcinoma with a Gleason 5 + 5 = 10 score. Prostatectomy revealed an unusual association of diffuse prostate malakoplakia and an area of acinar adenocarcinoma with a Gleason score of 3 + 4 = 7.

Benign mimics of prostatic adenocarcinoma

Benign mimics present either as common challenges in daily routine practice or may cause diagnostic dilemmas because some are less commonly seen and one may be less familiar in recognizing them. There are a multitude of mimics of prostatic adenocarcinoma, which may represent normal gland structures, benign proliferations, atrophic lesions, hyperplastic or metaplastic changes, and inflammatory processes. Some of them are preferentially found in certain anatomic areas of the prostate, either confined to the prostate, or outside of the gland. Various benign mimics of prostatic carcinoma may be also evaluated based on their morphologic similarity to Gleason patterns 3-5 of prostatic adenocarcinoma. Most of the mimics are easily recognizable in larger specimens, such as TUR of the prostate or radical prostatectomy specimens, but they may pose diagnostic problems when the evaluation is done on limited tissue, such as needle-core biopsies or if prostate specimens are infrequently encountered in practice. Therefore, before signing out a report with a diagnosis of prostatic carcinoma, pathologists should carefully consider and rule out the various benign lesions that may mimic carcinoma. This is particularly relevant in the current prostate biopsy practice which relies on using extended biopsy core templates. The awareness and familiarity with the characteristic features of the mimics and judicial use of additional ancillary tests, including immunohistochemistry can prevent overdiagnosis and false-positive interpretation. This review provides a contemporary update on the broad spectrum of the benign prostatic lesions that can mimic prostate adenocarcinoma, outlines their key morphologic and immunohistochemical diagnostic features, and provides a diagnostic, pattern-based approach in establishing a correct diagnosis and distinguishing them reliably from prostatic adenocarcinoma.

Malakoplakia of the Pancreas with Simultaneous Colon Involvement: Case Report and Review of the Literature

Although malakoplakia has been reported to occur at various body sites, pancreatic malakoplakia with simultaneous colonic involvement is very rare. Lesions of malakoplakia can masquerade as tumor masses leading to unwanted resections. Nevertheless, malakoplakia can occur in association with frank carcinomas, especially in the colon. By reporting a case of pancreatic malakoplakia diagnosed by fine needle aspiration cytology, this paper aims to describe cytologic features of malakoplakia and to further review findings from previous reported cases of pancreatic malakoplakia in the literature. With advances in minimally invasive, image-guided aspiration technologies, cytomorphological analyses can diagnose lesions of malakoplakia. This may help avoid surgeries that would have otherwise been carried out due to a misleading impression of tumor. However challenges remain as to the further management of patients diagnosed with this condition. More studies are necessary to determine the probability of malignancies arising in association with malakoplakia, in order to devise appropriate treatment protocols.

[Vesico-cutaneous fistula revealing abdominal wall malakoplakia accompanied by Boeck's sarcoidosis]

Malakoplakia is an acquired granulomatous disorder first described by Michaelis and Gutmann in 1902. The pathogenesis of malakoplakia is hardly known, but it thought to be secondary to an acquired bactericidal defect in macrophages occurring mostly in immunosuppressed patients.

CASE REPORT

63-year-old female patient had been treated with methylprednisolone for ten years, because of pulmonary sarcoidosis. For six month, recurrent abdominal abscess and vesico-cutaneous fistula developed. Histological examination proved malakoplakia, and Escherichia coli was detected in the abscess cavity.

METHODS

Hematoxyline eosin staining, periodic acid-Schiff, Berlin-blue and Kossa reactions were performed.

RESULTS

Microscopically malakoplakia consists of mainly macrophages, known as von Hansemann cells with scattered targetoid intracytoplasmic inclusions known as Michaelis-Gutmann bodies. In our presented case, after urological-surgical intervention and antibiotic therapy, the patient became free from complaints and symptoms.

DISCUSSION

Malakoplakia has been described in numerous anatomic locations, mainly in the urogenital tract. Malakoplakia may be complicated with fistulas in different locations: vesico-coccygeal, rectoprostatic, anorectal fistulas have been were reported in the literature, while 6 cases of malakoplakia with Boeck's sarcoidosis are published.

CONCLUSION

In the presented case sarcoidosis and the 10-year immunosuppressive treatment with methylprednisolone might have been in the background of abdominal wall malakoplakia, complicated by vesico-cutaneous fistula. The patient was successfully treated with surgery and the followed antibiotic therapy.

Malakoplakia outside the urinary tract

CONTEXT

Malakoplakia is a rare granulomatous disease that occurs commonly in the urinary tract. Histologically, it is defined by sheets of histiocytes (Hansemann cells) with accumulation of granular basophilic periodic acid-Schiff-positive, diastase-resistant inclusions and calcified Michaelis-Gutmann bodies, which are pathognomonic but not necessary for diagnosis. In addition to the urinary tract, malakoplakia has been reported in other organs, including the gastrointestinal tract, central nervous system, female genital tract, and the tongue.

OBJECTIVES

To review the literature of reported sites of malakoplakia outside the urinary tract and their variable clinical presentations, and to discuss the main diagnostic features and differential diagnoses of malakoplakia. The pathogenesis and possible etiologic factors are also presented.

DATA SOURCES

Data for this work were collected from the published literature, textbooks, and the Internet.

CONCLUSIONS

It is important to be aware of the existence of this entity in abnormal locations. In many situations, malignancy can be mimicked, especially when the lesion is ulcerated and is accompanied by lymph node involvement. Misinterpreting large, rapidly growing nodules of malakoplakia as tumor might lead to overstaging. Pathologists should be also aware of the possibility of malakoplakia coexisting with other lesions, such as tuberculosis and carcinoma, in the same specimen.

[Malakoplakia in urology: six cases report and review of the literature]

Malakoplakia (MLP) is a rare chronic granulomatous disease that is believed to happen because of an alteration in the bacterial phagocytic system. This entity is characterized by one or multiple tumorations that can appear in any part of the body leading to it's misdiagnosing as a malignant condition. The genitourinary tract is frequently involved. Pathologic study of these lesions shows tissue infiltrated by inflammatory cells (macrophages and hystiocites) with intracytoplasmatic inclusions, which are known as Michaelis-Gutmann bodies. Usually is a benign condition self-limited and is associated with recurrent urinary tract infection (UTI), this condition has a good response to prolonged treatment with fluoroquinolones. We will report six cases that were diagnosed and treatment in our institution during an eight year period. We report still a review of the available literature.