Small-cell neuroendocrine carcinoma as a variant form of prostate cancer recurrence: a case report and short literature review

Leptomeningeal carcinomatosis in small cell carcinoma of the prostate

Introduction

Leptomeningeal carcinomatosis in small cell carcinoma of the prostate is rare.

Case presentation

A 69‐year‐old man visited our hospital due to dysuria and edema. Bilateral hydronephrosis and lymph node metastases due to a pelvic tumor were observed. Although the prostate‐specific antigen level was normal, the tumor was suspected to originate from the prostate. He underwent percutaneous nephrostomy and prostate biopsy. Histopathology revealed small cell carcinoma accompanied by increased pro‐gastrin‐releasing peptide and neuron‐specific enolase levels. After receiving systemic chemotherapy with carboplatin and etoposide and radiation therapy for prostate, these lesions gradually decreased in size, and tumor markers normalized. Ten months after the initial diagnosis, he developed consciousness disorder and seizure. Magnetic resonance imaging revealed leptomeningeal carcinomatosis without any other recurrences and elevated tumor markers. He died 4 weeks after these symptoms appeared.

Conclusion

Careful monitoring of the central nervous system should be considered in small cell carcinoma of the prostate patients.

Small cell neuroendocrine carcinoma expressing alpha fetoprotein in the endometrium

Rare small cell neuroendocrine carcinoma (SCNEC) cases showed alpha fetoprotein (AFP) expression in the endometrium. In this study, we reported a case of uterine SCNEC expressing AFP. In addition, a literature review was performed to investigate the potential mechanism and the clinicopathological features of SCNEC to provide clinical guidance. A 65-year-old female was referred to our hospital due to vaginal bleeding for 1 month in November 2020. The clinical features were summarized. After total hysterectomy and removal of bilateral appendages, the histological examination and immunohistochemistry examination were performed. Histological findings showed that the cancer cells were arranged in a nest-like pattern distributed in a lamellar manner. The smooth muscles of the uterus were invaded by cancer cells. Cancer cells were relatively consistent in size. Small glandular duct-like and rosettes-like structures were distinguished, together with necrotic tissues. The deep staining showed that the amount of cytoplasm was lower in the nucleus. Partial cancer cells had small nucleolus with an irregular profile. There were some mitotic figures. Immunohistochemistry examination indicated that there was a diffuse expression of CK, Syn, CgA, CD56, CK8/18, P16, AFP, HepPar-1, Glypican-3, and Ki67 (90%). In this case, we reported a SCNEC patient expressing AFP, Glypican-3, and HepPar-1.

Effective treatment of relapsed prostate small cell carcinoma with amrubicin: report of a case

Standard therapy for metastatic small cell carcinoma of the prostate (SCCP) remains undefined. We have effectively treated relapsed SCCP with amrubicin. A 72-year-old patient, diagnosed with T4N1M0 prostate cancer, started hormonal therapy in May 2012, elsewhere, and his prostate-specific antigen levels remained low. However, pulmonary and hepatic metastases occurred; high neuron-specific enolase levels suggested SCCP, which was confirmed by repeated biopsy at our institution. In October 2016, chemotherapy with irinotecan and cisplatin was initiated for metastases to the lung, liver, and left pelvic lymph nodes, and partial response (PR) was achieved. After six cycles, brain metastases occurred. After ten cycles, his pro-gastrin-releasing peptide levels increased suddenly, and brain and hepatic metastases enlarged. Amrubicin was started in December 2016 and seven cycles were safely completed, with PR and markedly reduced brain metastasis volume, until his pneumonitis-related death in June 2017. Amrubicin may be an effective second-line chemotherapy option for SCCP.

The regulatory pathways leading to stem-like cells underlie prostate cancer progression

Prostate cancer (PCa) is the most common cause of malignancy in males and the third leading cause of cancer mortality in the United States. The standard care for primary PCa with local invasive disease mainly is surgery and radiation. For patients with distant metastases, androgen deprivation therapy (ADT) is a gold standard. Regardless of a favorable outcome of ADT, patients inevitably relapse to an end-stage castration-resistant prostate cancer (CRPC) leading to mortality. Therefore, revealing the mechanism and identifying cellular components driving aggressive PCa is critical for prognosis and therapeutic intervention. Cancer stem cell (CSC) phenotypes characterized as poor differentiation, cancer initiation with self-renewal capabilities, and therapeutic resistance are proposed to contribute to the onset of CRPC. In this review, we discuss the role of CSC in CRPC with the evidence of CSC phenotypes and the possible underlying mechanisms.

A Case of Small Cell Carcinoma of the Prostate and Review of the Literature

Aim and background

Small cell carcinoma of the prostate (SCCP) is a relatively rare entity, an aggressive tumor with a tendency to metastasize early. There is no standard chemotherapy regimen for SCCP. We report the case of a 67-year-old man with an initial diagnosis of prostate adenocarcinoma with bone metastases who subsequently developed a small cell carcinoma of the prostate with liver metastases.

Methods and study design

A review of this case and of the current literature was done with a view to highlighting the ideal approach to such an unusual tumor.

Results and conclusion

The patient was treated with carboplatin and etoposide and after 3 cycles achieved a good response. Unfortunately he developed massive pulmonary embolism which impeded the continuation of treatment and caused his death. By reviewing the literature we found there is no standard of care and new targeted therapies have failed to prove any benefit so far. It is mandatory to persevere in planning trials and exploring new drugs to improve the outcome of patients with SC-C P. It might also be worth creating a register for SCCP where data can be collected to coordinate the management of these patients and to establish better connections among cancer centers.

Small-cell neuroendocrine cancer of the prostate: an atypical presentation of a common disease

A 70-year-old man with a history of prostate cancer, previously submitted to surgical castration and trans-urethral resection of the prostate, was admitted to Accident and Emergency department. He had been suffering from osteoarticular and abdominal pain, and recent weight loss. An abdominal and a pelvic CT showed multiple hepatic metastases and a pelvic mass, but his prostate-specific antigen values were low (0.26 n/mL). A biopsy of a hepatic metastasis and of the pelvic mass revealed a small-cell neuroendocrine prostate cancer, a rare and aggressive androgen-independent form of prostate cancer with a poor prognosis. Our purpose was to report a clinical case of a rare and aggressive variant of a common disease. A high index of suspicion is required to make an early diagnosis and to ensure a proper therapeutic approach.

Rapid progression of mixed neuroendocrine carcinoma-acinar adenocarcinoma of the prostate: A case report

The current study presents the case of a 78-year-old male with mixed neuroendocrine (NE) carcinoma-acinar adenocarcinoma of the prostate. The patient received endocrine therapy (maximal androgen blockade) after the initial diagnosis resulting in a significant decrease in serum prostate-specific antigen (PSA) level. The patient underwent transurethral resection of the prostate after 6 months of androgen-deprivation therapy for extraordinarily salient difficulty in urination, and histopathology demonstrated mixed NE carcinoma-acinar adenocarcinoma once again. The NE prostate cancer progressed rapidly even though the serum PSA was controlled at a low level on account of the endocrine therapy. Previous treatment protocols were replaced by combined chemotherapy and endocrine therapy, and the patient responded well. The patient's serum PSA remained at a low level, however, urethral dilatation for acute urinary retention was required again 5 months later and the lower urinary tract symptoms became increasingly evident. The patient eventually died of cachexia.. These findings indicate that mixed NE carcinoma-acinar adenocarcinoma has a higher degree of malignancy and that endocrine therapy for prostate cancer has a propensity to facilitate progression of this tumor.

[SMALL CELL CARCINOMA OF THE PROSTATE: A CASE REPORT OF RELATIVE LONG-TERM SURVIVAL]

Small cell carcinoma of the prostate (SCCP) is rare, and no standard treatment regimen has yet been established. The overall prognosis remains poor. We experienced a case who obtained relative long-term survival with two types of chemotherapy treatments. A 69-year-old man underwent combined androgen blockade (CAB) with a diagnosis of prostate adenocarcinoma (Gleason score = 5 + 3) that was staged T3bN1M1b (initial PSA = 352 ng/ml). Twenty-five months after hormonal therapy, the level of serum PSA had elapsed remain low, however, FDG-PET/CT revealed high value at the lymph node of para-aortic and pelvic lesion. The levels of serum NSE and Pro-GRP elevated, and a prostate re-biopsy revealed a small cell carcinoma. Therefore, he was treated with 12-cycles of combination chemotherapy consisting of etoposide and carboplatin. Then, disease has progressed, so he was changed to second line chemotherapy with amrubicin. He underwent 12-cycles chemotherapy with amrubicin, but he died of cancer 39 months after the initial treatment of SCCP.

Comprehensive serial molecular profiling of an "N of 1" exceptional non-responder with metastatic prostate cancer progressing to small cell carcinoma on treatment

Importance

Small cell carcinoma/neuroendocrine prostate cancer (NePC) is a lethal, poorly understood prostate cancer (PCa) subtype. Controversy exists about the origin of NePC in this setting.

Objective

To molecularly profile archived biopsy specimens from a case of early-onset PCa that rapidly progressed to NePC to identify drivers of the aggressive course and mechanisms of NePC origin and progression.

Design, setting, and participants

A 47-year-old patient presented with metastatic prostatic adenocarcinoma (Gleason score 9). After a 6-month response to androgen deprivation therapy, the patient developed jaundice and liver biopsy revealed exclusively NePC. Targeted next generation sequencing (NGS) from formalin-fixed paraffin-embedded (FFPE)-isolated DNA was performed from the diagnostic prostate biopsy and the liver biopsy at progression.

Intervention

Androgen deprivation therapy for adenocarcinoma followed by multiagent chemotherapy for NePC.

Main outcomes and measures

Identification of the mutational landscape in primary adenocarcinoma and NePC liver metastasis. Whether the NePC arose independently or was derived from the primary adenocarcinoma was considered based on mutational profiles.

Results

A deleterious somatic SMAD4 L535fs variant was present in both prostate and liver specimens; however, a TP53 R282W mutation was exclusively enriched in the liver specimen. Copy number analysis identified concordant, low-level alterations in both specimens, with focal MYCL amplification and homozygous PTEN, RB1, and MAP2K4 losses identified exclusively in the NePC specimen. Integration with published genomic profiles identified MYCL as a recurrently amplified in NePC.

Conclusions and relevance

NGS of routine biopsy samples from an exceptional non-responder identified SMAD4 as a driver of the aggressive course and supports derivation of NePC from primary adenocarcinoma (transdifferentiation).

Electronic supplementary material

The online version of this article (doi:10.1186/s13045-015-0204-7) contains supplementary material, which is available to authorized users.

Solitary pulmonary metastasis from prostate cancer with neuroendocrine differentiation: a case report and review of relevant cases from the literature

BACKGROUND

Solitary lung metastasis from prostate cancer is rare. There are few reports of such cases with neuroendocrine differentiation.

CASE PRESENTATION

A 50-year-old man presented to our hospital with a chief complaint of dysuria. Histological examination revealed prostate cancer, which was classified as cT4 N0 M0, stage IV adenocarcinoma. Since the patient was at high risk, endocrine and radiation therapies were started. One year after starting radiation therapy, the patient developed bloody sputum. Chest radiography revealed a nodular shadow in his left lung (S5). Although 18-fluoro-2-deoxyglucose positron emission tomography revealed abnormal accumulation in the lesion, the cytological diagnosis was class IIIa, which did not yield a definitive diagnosis. Given that prostate specific antigen (PSA) was not elevated, a primary lung tumor was suspected, and thoracoscopic segmental resection of the lung was performed with lymph node dissection. The final pathological diagnosis was solitary lung metastasis from prostate cancer with neuroendocrine differentiation and mediastinal lymph node metastasis. The specimen showed a mixed pattern of conventional prostatic and neuroendocrine carcinomas.

CONCLUSION

We herein report a case with neuroendocrine differentiation (NED), along with a review of the relevant literature, including histopathological findings. According to previous case reports, some patients with solitary lung metastasis from prostate cancer achieved relatively good long-term survival. We consider establishing the correct diagnosis and implementing an appropriate treatment plan to be essential in prostate cancer patients with oligometastases that have the potential to be neuroendocrine (NE) tumors.

Prostate cancer and neuroendocrine differentiation: more neuronal, less endocrine?

Neuroendocrine differentiation (NED) marks a structural and functional feature of certain cancers, including prostate cancer (PCa), whereby the malignant tissue contains a significant proportion of cells displaying neuronal, endocrine, or mixed features. NED cells produce, and can secrete, a cocktail of mediators commonly encountered in the nervous system, which may stimulate and coordinate cancer growth. In PCa, NED appears during advanced stages, subsequent to treatment, and accompanies treatment resistance and poor prognosis. However, the term “neuroendocrine” in this context is intrinsically vague. This article seeks to provide a framework on which a unified view of NED might emerge. First, we review the mutually beneficial interplay between PCa and neural structures, mainly supported by cell biology experiments and neurological conditions. Next, we address the correlations between PCa and neural functions, as described in the literature. Based upon the integration of clinical and basic observations, we suggest that it is legitimate to seek for true neural differentiation, or neuromimicry, in cancer progression, most notably in PCa cells exhibiting what is commonly described as NED.

UK single centre experience of rare and atypical variant of castrate-resistant prostate cancer: Poorly differentiated neuroendocrine small-cell carcinoma

Background:

We report on the emergence of a rare and atypical variant of castrate-resistant prostate cancer (CRPC) that is characterised by transformation into poorly differentiated neuroendocrine small-cell carcinoma (NSCC). The existence of this variant was previously described in isolated case reports and small case-studies, but as yet there has been no UK series reported in the literature.

Methods:

Between January 2010 and January 2014, eight cases were presented in our local multi-disciplinary team meeting having a diagnosis of NSCC arising on a background of prostate cancer treated with androgen deprivation therapy. We performed a retrospective review of the clinical records of these patients, to identify the mode of presentation, diagnostic investigations, pathological characteristics, and subsequent treatment and survival outcomes.

Results:

The median patient age was 77 years (range, 68 – 84), with a median time interval of 25 months (range, 7 – 83) between the original diagnosis and subsequent transformation to NSCC. The median prostate-specific antigen (PSA) was 4 ng/ml, at presentation. Most patients presented with local progression, combined with high-volume and atypical sites of metastasis (e.g. brain, pancreas and penis). Patients developed a good initial response to platinum-based chemotherapy, but responses were short-lived and prognosis poor, with a median overall survival (OS) of 8 months.

Conclusion:

Prostate NSCC represents an atypical variant of CRPC with significant therapeutic and prognostic implications. Based on our observations, we have proposed a clinical algorithm for early diagnosis and appropriate management of these patients.

Neuroendocrine Prostate Cancer (NEPC) progressing from conventional prostatic adenocarcinoma: factors associated with time to development of NEPC and survival from NEPC diagnosis-a systematic review and pooled analysis

PURPOSE

An often under-recognized late manifestation of prostate adenocarcinoma (PCa) is the development of treatment-related neuroendocrine prostate cancer (NEPC). The aim of this study is to identify the risk factors related to survival after NEPC diagnosis (NEPCS) and time from initial diagnosis of PCa to development of NEPC (TTNEPC).

PATIENTS AND METHODS

A literature search on NEPC was performed using databases such as MEDLINE and EMBASE. Studies were eligible if outcomes data (NEPCS and/or TTNEPC) were reported in patients with a prior history of PCa and histopathologically confirmed NEPC. NEPCS and TTNEPC were evaluated using the Cox regression model with the robust sandwich estimates of the covariance matrix.

RESULTS

There were 54 eligible publications, contributing 123 patients. The median TTNEPC was 20 months. In multivariable analyses, the Gleason score was significantly associated with shorter TTNEPC (hazard ratio [HR], 1.66; P = .032). The median NEPCS was 7 months. In multivariable analyses, the number of organs with metastatic disease at NEPC was significantly associated with shorter NEPCS (HR, 3.31; P = .001). Type of treatment after NEPC was significantly associated with longer NEPCS, with HRs of 0.66 (radiotherapy v palliative therapy; P = .034), 0.38 (chemotherapy v palliative therapy; P = .018), and 0.29 (chemoradiotherapy v palliative therapy; P = .012), respectively.

CONCLUSION

Treatment-related NEPC is an often under-recognized late manifestation of PCa with poor prognosis. Our study found that Gleason score was the only independent factor contributing to TTNEPC. Once NEPC is diagnosed, type of treatment and the number of organs with metastatic disease were the most important factors related to survival.

Expression and function of gastrin-releasing peptide (GRP) in normal and cancerous urological tissues

Gastrin-releasing peptide (GRP) acts as an important regulatory peptide in several normal physiological processes and as a growth factor in certain cancers. In this review we provide a comprehensive overview of the current state of knowledge of GRP in urological tissues under both normal and cancerous conditions. GRP and its receptor, GRP-R, are expressed in the normal kidney and renal cancers. GRP can stimulate the growth of renal cancer cells. GRP and GRP-R are expressed in prostate cancer and GRP can stimulate the growth of prostate cancer cell lines. Importantly, GRP is a key neuroendocrine peptide, which may be involved in the progression of advanced prostate cancer and in the neuroendocrine differentiation of prostate cancer. Recent animal studies have shown that GRP and GRP-R are an integral part of male sexual function and play a crucial role in spinal control of erections and ejaculation.

Small cell carcinoma of the prostate presenting with skin metastasis: a case report

INTRODUCTION

Small cell carcinoma of the prostate is a very rare and aggressive type of prostatic cancer. Most cases are diagnosed at advanced stage due to early metastasis. The bones, liver, regional and distant lymph nodes are the most common sites of metastasis of small cell carcinoma of the prostate. Skin metastasis of small cell carcinoma of the prostate is a very rare entity due to the uncommon metastatic site. Here, we describe the case of a patient with small cell carcinoma of the prostate which metastasized to his skin.

CASE PRESENTATION

A 74-year-old Caucasian man presented to another urology center for mild lower urinary tract symptoms in 2003. His prostate-specific antigen was 23 ng/mL. According to the physical examination signs and prostate-specific antigen, he underwent a transrectal ultrasound-guided prostate biopsy. The pathologic examination of his prostate revealed a Gleason score: 3 + 4 = 7 adenocarcinoma of the prostate. Investigations showed stage T2N0M0 disease and he was treated with radiotherapy to his pelvic lymph nodes and prostate. Six years after the initial diagnosis, he complained of a palpable left-side 2 × 2 cm subcutaneous solitary mass localized just behind his scapula. The results of his laboratory tests including serum acid phosphatase and prostate-specific antigen were in normal ranges. Our general surgery department performed a diagnostic biopsy of the mass and totally excised the lesion. The pathologic examination of the mass showed small cell carcinoma metastasis with chromogranin + and the pathologist advised us to examine the lung or prostate for the primary tumor. The patient undertook a transrectal ultrasound-guided prostate biopsy and the pathologic result revealed small cell carcinoma within residual adenocarcinoma. We investigated the other sites for metastasis and restaging investigations showed a 1cm metastatic lesion in his liver. Our medical oncology department decided to treat him with combination chemotherapy with etoposide and cisplatin in six cycles; however, he died due to disseminated myocardial infarction before starting the fifth combination chemotherapy cycle.

CONCLUSIONS

Clinicians should keep in mind that early diagnosis of this disease is very difficult due to early metastatic spread of small cell carcinoma and lack of concordant elevation of prostate-specific antigen. There is no accepted standard treatment modality for this pathology and overall prognosis is poor.

False-negative bone scan and choline pet/ct study in a case of prostate cancer: the pitfall of the small cell prostate carcinoma variant

We present a rare variant of prostate carcinoma. The patient is a 45-year-old male with elevated prostate-specific antigen levels at screening. Magnetic resonance imaging revealed hyperenhancing lesions throughout the axial skeleton. The fluorine-18 fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) scan showed no abnormal bone findings. Subsequently, a technetium-99 methydiphosphonate (Tc99m-MDP) bone scan was performed, with additional correlative single-photon emission computed tomography (SPECT)/CT imaging of the pelvis and the results were essentially normal. A percutaneous core biopsy of one of the bone lesions in L5 was performed and histology confirmed small cell (neuroendocrine) variant of prostate cancer. Our case illustrates a possible pitfall in molecular imaging of prostate carcinomas, whereby both bone scintigraphy and FCH PET/CT scans showed no definite bone lesions to correlate with marrow signal abnormalities seen on MR imaging. This highlights the need for caution in the diagnostic evaluation of prostate cancers with known small cell variants.

Survival of patients with small cell carcinoma of the prostate during 1973-2003: a population-based study

OBJECTIVE

To describe the survival of patients with primary small cell carcinoma (SCC) of the prostate and assess prognostic factors based on a large population sample.

PATIENTS AND METHODS

A total of 241 cases of SCC of the prostate were reported to the Surveillance, Epidemiology, and End Results (SEER) registries from 1973 to 2003 of which 191 cases were included in our study. We used the Kaplan-Meier method for estimating survival, and Cox proportional hazard regression modelling to evaluate prognostic variables.

RESULTS

The overall age-adjusted incidence rate was 0.278 per 1,000,000 (95% confidence interval, 0.239-0.323). In all, 60.5% presented as metastatic disease compared with 39.5% who presented as local/regional disease (P= 0.012). The 12, 24, 36, 48 and 60 months observed survival rates were 47.9%, 27.5%, 19%, 17% and 14.3% respectively. On univariate analyses, age <60, concomitant low-grade prostatic adenocarcinoma, absence of metastasis, prostatectomy and radiation therapy were favourable prognostic factors. In multivariate regression modelling, age, pathology and stage were strong predictors of survival.

CONCLUSIONS

Using the SEER database, we present the largest study describing the epidemiology of primary SCC of the prostate. We found age, concomitant low-grade prostatic adenocarcinoma, and stage of the disease to be the strongest predictors of survival for patients with prostatic SCC. Future studies evaluating a broader range of clinical and molecular markers are needed to refine the prognostic model of this relatively rare disease.

Small-cell prostate carcinoma: A retrospective analysis of five newly reported cases

Five cases of small-cell carcinoma (SCC) of prostate were identified, at the Rhode Island Hospital and the Miriam Hospital from 1984 to 2006, with an average age of 71 years at the time of diagnosis. Three of these patients had a prior diagnosis of prostatic adenocarcinoma, with all of the five patients receiving anti-androgen treatment. The average time between the diagnosis of adenocarcinoma and of SCC in these patients was 6.7 years. The PSA levels varied greatly, with two patients possessing markedly elevated levels and the remaining patients with normal levels. Approximately 3/5 patients developed liver metastases, 2/5 patients had bone metastases, and 1/5 patients developed carcinomatous meningitis. Of the four patients who expired, the median survival time after diagnosis of SCC was 3.6 months (0.5–12 months).

Combined chemotherapy with carboplatin plus irinotecan showed favorable efficacy in a patient with relapsed small cell carcinoma of the prostate complicated with meningeal carcinomatosis

We report the case of a 65-year-old man with recurrent prostate cancer who presented with meningeal carcinomatosis. In September 2007, he had been diagnosed with mixed type small cell carcinoma and adenocarcinoma at clinical stage T4N1M1 (primary prostate tumor with multiple bone, liver, and lymph node metastases) and hormonal therapy had been administered. Following an increase in the level of pro-gastrin-releasing peptide (ProGRP), combined chemotherapy with cisplatin plus etoposide was implemented and showed efficacy in targeting the small cell carcinoma. In March 2008, he presented with signs of meningeal irritation; his condition deteriorated quickly and multiple brain metastases were confirmed by magnetic resonance imaging (MRI). A sample of cerebrospinal fluid collected by lumbar puncture showed cancer cells and an elevated level of ProGRP. Small cell carcinoma of the prostate complicated with meningeal carcinomatosis was diagnosed. A different chemotherapy regimen was then administered, consisting of a combination of carboplatin plus irinotecan, which is one of the most common first-line treatments for extensive-stage small cell lung carcinoma. From day 20 after the initiation of this therapy, he gradually recovered from the signs of meningeal irritation, and brain MRI showed nearly normal findings; also, the serum level of ProGRP was reduced. In conclusion, we report the efficacy of combined treatment with carboplatin plus irinotecan for small cell carcinoma of the prostate complicated with meningeal carcinomatosis. Because this clinical condition is extremely rare, a gold standard treatment has yet to be established.

Bicalutamide-associated fulminant hepatotoxicity

Abstract Bicalutamide is a nonsteroidal antiandrogen used extensively during the start of androgen deprivation therapy with a luteinizing hormone-releasing hormone agonist to reduce occurrence of the symptoms of tumor flare in patients with metastatic prostate carcinoma. The most common adverse effects of bicalutamide are induced by its pharmacologic property of competitive androgen receptor blockade and include gynecomastia, hot flashes, fatigue, and decreased libido. Although not as common, increases in liver function test results are also seen with bicalutamide therapy. These elevations are typically transient, and patients remain asymptomatic. We describe a 59-year-old man with metastatic prostate carcinoma treated with bicalutamide as part of androgen deprivation therapy before starting chemotherapy. At baseline, his liver function test results and serum creatinine concentration were within normal limits, and an abdominal computed tomographic scan did not demonstrate liver metastasis. After 4 days of bicalutamide therapy, the patient came to the emergency department with complaints of abdominal pain, distension, and tenderness. His liver function tests were abnormal, and bicalutamide was discontinued. After 2 days of increasing liver function tests and symptoms of hepatotoxicity, the patient developed tachycardia and hypotension that was resistant to fluid resuscitation. Multiorgan damage was manifested by an alanine aminotransferase level greater than 40 times the upper limit of normal, serum creatinine concentration of 4.2 mg/dl, and troponin I level of 18 ng/ml. The patient died 8 days after bicalutamide therapy was begun secondary to multiorgan failure, most likely as a result of fulminant hepatotoxicity. The Naranjo adverse drug reaction probability scale showed a probable (score of 5) causal relationship between bicalutamide and fulminant hepatotoxicity. Fulminant hepatotoxicity is a rare but potentially fatal adverse effect of bicalutamide. Liver function tests should be monitored before and during bicalutamide therapy, even for patients who have previously completed a course of this therapy with no signs or symptoms of toxicity.

Pro-neural transcription factors as cancer markers

BACKGROUND

The aberrant transcription in cancer of genes normally associated with embryonic tissue differentiation at various organ sites may be a hallmark of tumour progression. For example, neuroendocrine differentiation is found more commonly in cancers destined to progress, including prostate and lung. We sought to identify proteins which are involved in neuroendocrine differentiation and differentially expressed in aggressive/metastatic tumours.

RESULTS

Expression arrays were used to identify up-regulated transcripts in a neuroendocrine (NE) transgenic mouse model of prostate cancer. Amongst these were several genes normally expressed in neural tissues, including the pro-neural transcription factors Ascl1 and Hes6. Using quantitative RT-PCR and immuno-histochemistry we showed that these same genes were highly expressed in castrate resistant, metastatic LNCaP cell-lines. Finally we performed a meta-analysis on expression array datasets from human clinical material. The expression of these pro-neural transcripts effectively segregates metastatic from localised prostate cancer and benign tissue as well as sub-clustering a variety of other human cancers.

CONCLUSION

By focussing on transcription factors known to drive normal tissue development and comparing expression signatures for normal and malignant mouse tissues we have identified two transcription factors, Ascl1 and Hes6, which appear effective markers for an aggressive phenotype in all prostate models and tissues examined. We suggest that the aberrant initiation of differentiation programs may confer a selective advantage on cells in all contexts and this approach to identify biomarkers therefore has the potential to uncover proteins equally applicable to pre-clinical and clinical cancer biology.

Prostate small cell carcinoma and skin metastases: a rare entity

OBJECTIVES

To report a rare case of small cell carcinoma of the prostate with unusual skin metastasis.

CLINICAL PRESENTATION AND INTERVENTIONS

A 60-year-old was evaluated for difficulty in urinating. Abdominal computed tomography scans revealed a prostatic mass invading the surrounding tissues and multiple perirectal, periprostatic, para-aortic and pericaval lymph nodes. Needle biopsy specimens showed both small cell carcinoma and adenocarcinoma. He was treated with combination chemotherapy: cisplatin and etoposide and bilateral orchiectomy. After six cycles of the chemotherapy, disease progressed and the patient did not respond to salvage therapy; hence, palliative care was instituted. During the follow-up, papillary lesions were observed in the scrotal skin; biopsy showed metastatic small cell carcinoma.

CONCLUSION

Small cell carcinoma of the prostate is an aggressive disease with a highly metastatic potential; but skin metastases are very uncommon. It has poor prognosis despite therapy. Management resembles that of small cell carcinoma of the lung.

Neuroendocrine differentiation in the 12T-10 transgenic prostate mouse model mimics endocrine differentiation of pancreatic beta cells

BACKGROUND

Neuroendocrine (NE) prostate cancer develops as an aggressive disease that does not respond to androgen ablation therapy. It has been demonstrated that the paracrine action of NE cells facilitates the progression of androgen dependent adenocarcinoma to an androgen independent state, suggesting a significant role for NE cells during failure of androgen ablation therapy.

METHODS

To investigate the pathways that are involved in NE differentiation of prostate cancer, we have looked at the expression of genes known to be involved in endocrine differentiation of beta-cells in the pancreas. This study has been performed using the NE prostate cancer mouse model (12T-10) and the derivative allograft model (NE-10).

RESULTS

Immunohistochemical studies have shown that the neuroendocrine prostate tumors express the transcription factors Foxa2, mouse achaete-scute homolog-1 (mash-1), neurogenin3 (Ngn3) and Nkx2.2. These tumors show a loss of hairy/enhancer of split (Hes-1), a gene that inhibits NE differentiation. Human NE prostate cancers also express Foxa2 and human achaete-scute homolog-1 (HASH-1). These genes are expressed in NE prostate tumors in the similar sequential manner as they appear in a pancreatic beta-cell endocrine differentiation. Foxa2 expression is detected in early prostatic intraepithelial neoplasia (PIN). Mash-1 expression is detected in a few clusters within low grade PIN lesions and Nkx2.2 expression is rarely detected in individual scattered cells within the PIN lesion. Ngn3 and Nkx2.2 frequently appear in the invasive NE cancer. Subsequent NE metastasis to lung and liver show a distinct gene expression pattern. The lung metastasis expresses Ngn3 but does not express Nkx2.2 whereas liver metastases do not express Ngn3 but express Nkx2.2.

CONCLUSIONS

These results suggest that Ngn3 and Nkx2.2 expression are markers for site-specific metastasis and/or transcriptionally regulated genes that are required for organ-specific metastasis. This study indicates that a pathway similar to pancreatic beta-cell differentiation is involved in NE differentiation of prostate cancer.