Testicular Metastasis From Prostatic Adenocarcinoma Presenting as Recurrent Epididymo-orchitis

A young patient with prostatic carcinoma with testicular metastasis

Prostate cancer is one of the most frequent cancers in males and commonly a disease of the older population, but it is increasingly seen among older adolescents and young adults. The common sites of metastasis of prostatic carcinoma are bones and regional lymph nodes. Testicular metastasis from prostatic carcinoma is an infrequent presentation. We report a case of a young patient with prostatic carcinoma and multiple metastases, including bilateral testis. A 40-year-old male presented with lower urinary tract voiding symptoms and back pain for three months. His prostate-specific antigen level was elevated at 13.98 ng/ml. A magnetic resonance imaging of the prostate revealed two PIRADS V lesions and metastases in multiple bones and regional lymph nodes. On follow up, the patient complained of bilateral testicular swelling and ultrasound scan of the testes revealed bilateral testicular metastasis. Fine needle aspiration cytology of right-side testicular lesion revealed malignant cells compatible with metastasis from prostate cancer. Later involvement of multilevel vertebral and skull metastases was identified by magnetic resonance imaging. A T_3bN₁M1_c staging of prostate cancer was made, androgen deprivation therapy followed by chemo and radiotherapy was instituted, following extensive discussion with the patient. Unfortunately the patient succumbed to the illness during the course of treatment. This case report is of a patient with rare presentation of bilateral testicular metastasis with prostate cancer in young age.

Atypical Metastases in the Abdomen and Pelvis From Biochemically Recurrent Prostate Cancer: 11C-Choline PET/CT Imaging With Multimodality Correlation

PET imaging with targeted radiotracers has become integral for mapping the location and burden of recurrent disease in patients with biochemical recurrence (BCR) of prostate cancer (PCa). PET with 11C-choline is part of the National Comprehensive Cancer Network and European Association of Urology guidelines for evaluation of BCR. With advances in PET technology, increasing use of targeted radiotracers, and improved survival of patients with BCR due to novel therapeutics, atypical sites of metastases are being increasingly encountered, challenging the conventional view that PCa rarely metastasizes beyond bones or lymph nodes. We describe such atypical metastases in the abdomen and pelvis on 11C-choline PET (including in the liver, pancreas, genital tract, urinary tract, peritoneum, and abdominal wall, as well as perineural spread), presenting multimodality imaging features and relevant imaging pitfalls. Given atypical metastases' inconsistent relationship with serum PSA and non-specific presenting symptoms, they are often first detected on imaging. Awareness of their imaging features is important as their detection impacts clinical management, patient counseling, prognosis, and clinical trial eligibility. Such awareness is particularly critical as the role of radiologists in the imaging and management of BCR will continue to increase given the expanding regulatory approvals of other targeted and theranostic radiotracers.

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.