A rare case of isolated castrate resistant bilateral testicular metastases in advanced prostate cancer

Testicular metastasis of prostate adenocarcinoma: the other side of orchiepididymitis

Background

Metastatic prostate adenocarcinoma is a rare event and there are few references to this topic. We report an unusual case of prostate cancer metastasis and review of contemporary literature. Moreover, we discuss the pathogenesis and the clinical aspects of this event.

Case presentation

A 70-year-old patient was admitted to the hospital for right scrotal pain. The ultrasound examination described an increase in testicular size, suggesting the possibility of orchiepididymitis. Past medical history reported a previous prostate adenocarcinoma. Inflammatory blood tests were normal. Importantly, PSA was 3.3 ng/ml. PET scan positivity in the scrotum raised suspicion of a relapse. Therefore, he underwent right orchiectomy.

Conclusion

Although metastatic prostate adenocarcinoma is rare, a correct diagnosis is of paramount importance because the therapy changes accordingly. Patients who complain of scrotal pain need to be examined accurately. Although the most common cause behind this symptom is infectious, the patient's past medical history should be reviewed to exclude previous malignancies.

[Secondary tumors localized in testis]

Testis tumors are uncommon in oncology, and testicular metastasis from distant solid tumors are even rarer. We present two cases encountered in our department of pathology in CHU de Rennes, France. Moreover, we collected all reported cases in the Medline/PubMed databases of non-hematopoietic secondary testis tumors in adults, excluding autopsy studies, to propose an integrative study on this topic. In total, we report 98 cases of secondary testis lesions to prostate (n=38, 38.77 %), colorectal (n=19, 19.39%), gastric (n=12, 12.24%), kidney (n=7, 7.14%), lung (n=6, 6.12%) and other primary cancers. The median age at diagnosis was 66.5 years. We identified significantly more prostate adenocarcinoma (P<0.0001) when the primary tumor was known and significantly more colorectal adenocarcinoma (P=0.035) and pancreatic adenocarcinoma (P=0.002) when the primary tumor was unknown. The age at diagnosis was older when the primary tumor was known (P=0.007). We present the challenges for the diagnosis and propose some elements for diagnosis orientation. Finally, we discuss the possible ways of metastatic dissemination from primary site to testis, as illustrated by the two cases we present.

Prostate cancer metastatic to bilateral testicles: case report and literature review

PURPOSE

Hormone-refractory prostate cancer (PCa) has a high incidence of metastasis with common secondary site locations. Our case report describes a rare metastatic site of PCa infiltrating bilateral testicles in the absence of definitive radiologic evidence.

MATERIALS AND METHODS

Following the patient's consent and IRB exemption, we report the clinical, radiological, and pathological presentation of the patient treated at our institution. We also conducted an inclusive literature review of PCa with bilateral testicular metastases.

RESULTS

Our patient is a 54-year-old male who presented to the emergency room with lower urinary tract symptoms and failure to void. A full workup including digital rectal examination, PSA (580 ng/ml), and a transrectal ultrasound (TRUS) biopsy performed afterward revealed an adenocarcinoma of the prostate. The metastatic workup at presentation was negative. After failure to comply with treatment guidelines, the patient was referred back to us with bilateral testicular masses. Without clear evidence of the origin of the masses, bilateral orchiectomy was performed, and pathological analysis confirmed it was metastatic prostate adenocarcinoma. Post-orchiectomy, the patient was again lost to follow up. Three years later the patient returns and placed in palliative care.

CONCLUSIONS

This case report highlights that PCa can have a highly variable course and progression can occur in the absence of adherence to treatment. Any evidence of disease relapse and clinical suspicion of metastasis should be investigated, especially in patients with advanced and metastatic disease or poor adherence to surveillance protocol.

Current Imaging Techniques for and Imaging Spectrum of Prostate Cancer Recurrence and Metastasis: A Pictorial Review

Relapsing level of prostate-specific antigen (PSA) after initial curative-intent local therapy for organ-confined prostate cancer is often the first sign of recurrence. However, PSA level recurrence does not enable accurate differentiation of locally recurrent tumor from metastatic disease or a combination of both. Metastatic prostate cancer most frequently involves bones and lymph nodes, followed by other organs such as the liver, lung, pleura, adrenal gland, ureter, peritoneum, penis, testis, and meninges. Conventional imaging including CT and bone scintigraphy has long been the standard of care but has limited sensitivity in depicting early local recurrence or metastatic disease. Multiparametric MRI has been shown to be more sensitive in detecting locally recurrent tumor in the prostatectomy bed as well as in situ recurrence in a prostate gland that has been treated with radiation therapy or thermal ablation. In addition, lesions detected with multiparametric MRI may be amenable to targeted biopsy for definitive diagnosis of recurrence. PET/CT or PET/MRI using the U.S. Food and Drug Administration (FDA)-approved tracers carbon 11 choline or fluorine 18 fluciclovine has demonstrated markedly increased sensitivity and specificity for diagnosis of early metastatic disease such as small-volume lymph node metastasis, as have a range of investigational gallium 68 prostate-specific membrane antigen (PSMA) radioactive PET tracers. With recent advances in imaging modalities and techniques, more accurate early detection, localization, and characterization of recurrent prostate cancer have become possible. The authors present a contemporary review of the strengths and limitations of conventional and advanced imaging modalities in evaluation of patients with recurrent prostate cancer and a systematic review of the clinical and imaging features of locally recurrent and metastatic disease.^©RSNA, 2020See discussion on this article by Barwick and Castellucci.