Paraneoplastic syndromes in prostate cancer

A systematic review of cytoreductive prostatectomy outcomes and complications in oligometastatic disease

Objective

To analyze outcomes and complications of cytoreductive prostatectomy (CRP) for oligometastatic prostate cancer (PCa) in order to elucidate its role in this space.

Methods

We performed a systematic literature search using three databases (Medline, Scopus, and Web of Science). The primary endpoints were oncologic outcomes. The secondary endpoints were complication rates and functional results.

Results

In all studies, overall survival was better or at least comparable variable in the groups with CRP compared to no local treatment. The greatest benefit from CRP in 5-year overall survival in one study was 67.4% for CRP versus 22.5% for no local treatment. Cancer-specific survival (CSS) showed the same trend. Several authors found significant benefits from CSS in the CRP group: from 79% vs. 46% to 100% vs. 61%. CRP was a predictor of better CSS (hazard ratio 0.264, p=0.004). Positive surgical margin rates differed widely from 28.6% to 100.0%. Urinary continence in CRP versus RP for localized PCa was significantly lower (57.4% vs. 90.8%, p<0.0001). Severe incontinence occurred seldom (2.5%-18.6%). Total complication rates after CRP differed widely, from 7.0% to 43.6%. Rates of grades 1 and 2 events prevailed. Patients on ADT alone also showed a considerable number of complications varying from 5.9% to 57.7%.

Conclusion

CRP improves medium-term cancer control in patients with oligometastatic PCa. The morbidity and complication rates of this surgery are comparable with other approaches, but postoperative incontinence rate is higher compared with RP for localized disease.

Paraneoplastic Syndromes in Neuroendocrine Prostate Cancer: A Systematic Review

Neuroendocrine prostate cancer (NEPC) is a rare subtype of prostate cancer (PCa) that usually results in poor clinical outcomes and may be accompanied by paraneoplastic syndromes (PNS). NEPC is becoming more frequent. It can initially manifest as PNS, complicating diagnosis. Therefore, we reviewed the literature on the different PNS associated with NEPC. We systematically reviewed English-language articles from January 2017 to September 2023, identifying 17 studies meeting PRISMA guidelines for NEPC and associated PNS. A total of 17 articles were included in the review. Among these, Cushing's Syndrome (CS) due to ectopic Adrenocorticotropic hormone (ACTH) secretion was the most commonly reported PNS. Other PNS included syndrome of inappropriate Anti-Diuretic Hormone secretion (SIADH), Anti-Hu-mediated chronic intestinal pseudo-obstruction (CIPO), limbic encephalitis, Evans Syndrome, hypercalcemia, dermatomyositis, and polycythemia. Many patients had a history of prostate adenocarcinoma treated with androgen deprivation therapy (ADT) before neuroendocrine features developed. The mean age was 65.5 years, with a maximum survival of 9 months post-diagnosis. NEPC is becoming an increasingly more common subtype of PCa that can result in various PNS. This makes the diagnosis and treatment of NEPC challenging. Further research is crucial to understanding these syndromes and developing standardized, targeted treatments to improve patient survival.

Recalcitrant Paraneoplastic Pemphigus Associated With Prostate Adenocarcinoma: Spectacular Evolution Under Androgen Deprivation

Paraneoplastic pemphigus (PNP) is a rare, autoimmune, blistering condition defined by severe stomatitis, polymorphous cutaneous eruptions, and underlying neoplasms. PNP associated with solid cancer is extremely rare. An association with prostate adenocarcinoma remains exceptional. We describe a 69-year-old patient with recalcitrant PNP associated with prostate adenocarcinoma showing spectacular response immediately after associating hormonotherapy with conventional immunosuppressive drugs.

Paraneoplastic Syndromes from Head to Toe: Pathophysiology, Imaging Features, and Workup

Patients often have symptoms due to the mass effect of a neoplasm on surrounding tissues or the development of distant metastases. However, some patients may present with clinical symptoms that are not attributable to direct tumor invasion. In particular, certain tumors may release substances such as hormones or cytokines or trigger an immune cross-reactivity between malignant and normal body cells, resulting in characteristic clinical features that are broadly referred to as paraneoplastic syndromes (PNSs). Recent advances in medicine have improved the understanding of the pathogenesis of PNSs and enhanced their diagnosis and treatment. It is estimated that 8% of patients with cancer develop a PNS. Diverse organ systems may be involved, most notably the neurologic, musculoskeletal, endocrinologic, dermatologic, gastrointestinal, and cardiovascular systems. Knowledge of various PNSs is necessary, as these syndromes may precede tumor development, complicate the patient's clinical presentation, indicate tumor prognosis, or be mistaken for metastatic spread. Radiologists should be familiar with the clinical presentations of common PNSs and the selection of appropriate imaging examinations. Many of these PNSs have imaging features that can assist with arriving at the correct diagnosis. Therefore, the key radiographic findings associated with these PNSs and the diagnostic pitfalls that can be encountered during imaging are important, as their detection can facilitate early identification of the underlying tumor, reveal early recurrence, and enable monitoring of the patient's response to therapy. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Foreign accent syndrome as a heralding manifestation of transformation to small cell neuroendocrine prostate cancer

A man in his 50s with metastatic hormone-sensitive prostate cancer, receiving androgen deprivation therapy and abiraterone acetate/prednisone, presented with an uncontrollable 'Irish brogue' accent despite no Irish background, consistent with foreign accent syndrome (FAS). He had no neurological examination abnormalities, psychiatric history or MRI of the brain abnormalities at symptom onset. Imaging revealed progression of his prostate cancer, despite undetectable prostate-specific antigen levels. Biopsy confirmed transformation to small cell neuroendocrine prostate cancer (NEPC). Despite chemotherapy, his NEPC progressed resulting in multifocal brain metastases and a likely paraneoplastic ascending paralysis leading to his death. We report FAS as the presenting manifestation of transformation to small cell NEPC, a previously undescribed phenomenon. His presentation was most consistent with an underlying paraneoplastic neurological disorder (PND), despite a negative serum paraneoplastic panel. This report enhances the minimal existing literature on FAS and PNDs associated with transformed NEPC.

Severe Cholestatic Jaundice (Stauffer Syndrome) as a Rare Paraneoplastic Manifestation in Adrenocortical Carcinoma

Background

Adrenocortical carcinoma (ACC) is a rare malignancy arising from the adrenal cortex. While ACC can be associated with adrenal hormone excess syndromes, classic paraneoplastic syndromes are rarely seen. Stauffer syndrome, a paraneoplastic phenomenon characterized by reversible cholestasis in the absence of liver metastases, has been described with renal carcinoma and other malignancies but has not been previously reported in ACC.

Case Presentation

A 38-year-old man presented with emesis, painless jaundice, pruritus, and weight loss. Laboratory evaluation demonstrated elevated total bilirubin of 8.7 mg/dL (N&lt;1.3). Computed tomography revealed a 20.4-cm left adrenal mass without evidence of liver metastases. The patient's condition deteriorated rapidly with progressive renal failure and worsening hyperbilirubinemia. The patient underwent left adrenalectomy, nephrectomy, ureterolysis, and wedge liver biopsy. Histopathology showed necrotic ACC with tumor invasion into the adrenal capsule, no lymphovascular invasion, uninvolved margins, and Ki-67 of 40%. Kidney parenchyma exhibited diffuse pigment casts. The liver specimen contained diffuse bile deposits and minimal chronic inflammation in the portal tracts. He tested positive for pathogenic variant of folliculin (FLCN) gene consistent with Birt-Hogg-Dubé syndrome. Renal function recovered after surgery, and bilirubin level normalized after several weeks. Based on clinical presentation and absence of other etiologies, reversible cholestatic jaundice was attributed to Stauffer syndrome.

Conclusions

This is the first report of a unique presentation of paraneoplastic-related hyperbilirubinemia in the setting of ACC. While extremely rare, Stauffer syndrome should still be considered in differential diagnosis in patients with ACC with liver dysfunction and jaundice without evidence of liver metastases.

Endocrine and paracrine characteristics of neuroendocrine prostate cancer

Prostate cancer is a common malignancy affecting men worldwide. While the vast majority of newly diagnosed prostate cancers are categorized as adenocarcinomas, a spectrum of uncommon tumor types occur including those with small cell and neuroendocrine cell features. Benign neuroendocrine cells exist in the normal prostate microenvironment, and these cells may give rise to primary neuroendocrine carcinomas. However, the more common development of neuroendocrine prostate cancer is observed after therapeutics designed to repress the signaling program regulated by the androgen receptor which is active in the majority of localized and metastatic adenocarcinomas. Neuroendocrine tumors are identified through immunohistochemical staining for common markers including chromogranin A/B, synaptophysin and neuron specific enolase (NSE). These markers are also common to neuroendocrine tumors that arise in other tissues and organs such as the gastrointestinal tract, pancreas, lung and skin. Notably, neuroendocrine prostate cancer shares biochemical features with nerve cells, particularly functions involving the secretion of a variety of peptides and proteins. These secreted factors have the potential to exert local paracrine effects, and distant endocrine effects that may modulate tumor progression, invasion, and resistance to therapy. This review discusses the spectrum of factors derived from neuroendocrine prostate cancers and their potential to influence the pathophysiology of localized and metastatic prostate cancer.

Prostate Cancer Presenting With an Unusual Presentation of Rectal Pain and Bleeding

We report an atypical case of prostate cancer with rectal involvement presenting with gastrointestinal symptoms predominately and a rectal mass. A 51-year-old male patient came to the hospital with abdominal pain and rectal bleeding. Imaging revealed prostate enlargement, perirectal lymphadenopathy, and multiple hepatic and pulmonary nodules. The patient also had an elevated prostate-specific antigen (PSA) of 502 ng/mL (against normal range 0.6-0.7 ng/mL). Biopsies were performed on tissue samples taken from the rectum and prostate gland, which confirmed the diagnosis of prostate adenocarcinoma. The lack of urinary symptoms and close clinical similarity to colorectal cancer presented a diagnostic challenge for us. Familiarity with this specific presentation of prostate cancer is necessary to avoid misdiagnoses and guide correct treatment.

Exfoliative Dermatitis as a Para-neoplastic Syndrome of Prostate Adenocarcinoma: A Rare Case Report With Literature Review

BACKGROUND/AIM

This study aimed to report a rare case of erythroderma or exfoliative dermatitis as a paraneoplastic syndrome of prostate adenocarcinoma. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. It is a clinical manifestation and usually associated with various underlying cutaneous disorders, drug induced reactions and malignancies.

CASE REPORT

Herein we report a case of 55-year-old male patient who presented with progressively diffuse scaling and erythematous rash of 3 months duration. He was diagnosed with untreated prostate adenocarcinoma about 2 months prior his admission. Skin biopsy confirmed exfoliative erythroderma diagnosis. He was investigated extensively for other pathologies, however all work up remained negative except a CT finding of large heterogeneous prostate gland with elevated PSA which was consistent with prostate cancer. Daily oral prednisone for one week and hydrocortisone cream provided partial clinical improvement. The patient was discharged on tapering steroid to follow-up with urology and oncology for further underlying prostate carcinoma management.

CONCLUSION

We concluded that the ongoing erythroderma was a paraneoplastic syndrome of prostate adenocarcinoma. Hence, early detailed history and routine screening of malignancy-related biomarkers is warranted on any individuals presenting with such symptoms.

Dermatological manifestation of metastatic prostate cancer

A 59-year-old man presented to the urology department with increased urinary urgency, frequency, poor urinary flow and unintentional weight loss. He had a 25-year history of idiopathic urticaria episodes which had increased in frequency over the previous 2 months. On investigation, he was found to have a raised prostate-specific antigen level. He was investigated further with a multiparametric MRI, a local anaesthetic transperineal prostate biopsy, a CT scan of chest/abdomen/pelvis with contrast and a nuclear medicine bone scan. He was diagnosed with metastatic adenocarcinoma of the prostate and commenced on a luteinising hormone-releasing hormone antagonist and referred to oncology for further treatment. Since starting treatment, he has experienced no further episodes of urticaria.

Metastatic Parathyroid Hormone-Secreting Prostate Adenocarcinoma Mimicking Ectopic Parathyroid Adenoma Demonstrated on 99mTc-MIBI Image

Tc-MIBI has long been used to localize hyperfunctioning parathyroid tissue in patients with hyperparathyroidism. This tracer can also concentrate in various neoplastic tissues including prostate adenocarcinoma. We herein report a case with parathyroid hormone-secreting metastatic prostate cancer mimicking an ectopic parathyroid adenoma on the Tc-MIBI scan. We conclude that metastatic prostate cancer should be included as one of the differential diagnoses when interpreting Tc-MIBI scan.

Paraneoplastic hyperbilirubinemia in metastatic prostate cancer and review of the current literature

Paraneoplastic syndromes are functional clinical disorders caused by the direct effect of the primary tumor or metastasis. The initial presenting symptom of the patients may be associated with paraneoplastic manifestations. Paraneoplastic cholestasis is most frequently defined in association with renal cell carcinoma (Stauffer's syndrome), but it is an extremely rare clinical entity seen in association with prostate cancer. Etiology of cholestasis was investigated in the case diagnosed as metastatic prostate cancer who applied to the gastroenterology outpatient clinic due to complaints of ascites and jaundice that established the diagnosis of paraneoplastic hyperbilirubinemia. We observed improvement of his cholestasis with hormonotherapy used for prostate cancer.

A blind spot in urology: Prostate cancer associated retinopathy

Paraneoplastic syndromes associated with prostate cancer that cause visual disturbances are rare. We present the case of a 71 year old man with a history of adenocarcinoma of the prostate who developed cancer associated retinopathy concomitant with small cell transformation. This represents an unusual paraneoplastic syndrome that may be progressive and irreversible, requiring prompt diagnosis and treatment to preserve visual function and guide further oncological care.

Clinical characteristics, treatment outcomes and potential novel therapeutic options for patients with neuroendocrine carcinoma of the prostate

Background

Neuroendocrine carcinomas of the prostate (NEPCs) are rare tumors with poor prognosis. While platinum and etoposide-based chemotherapy regimens (PE) are commonly applied in first-line for advanced disease, evidence for second-line therapy and beyond is very limited.

Methods

Retrospective analysis of all patients with NEPCs including mixed differentiation with adenocarcinoma component and well differentiated neuroendocrine tumors (NETs, carcinoids) at two high-volume oncological centers between 12/2000 and 11/2017.

Results

Of 46 identified patients 39.1 % had a prior diagnosis of prostatic adenocarcinoma only, 43.5 % had a mixed differentiation at NEPC diagnosis, 67.4 % developed visceral metastases, 10.9 % showed paraneoplastic syndromes. Overall survival (OS) from NEPC diagnosis was 15.5 months, and significantly shorter in patients with a prior prostatic adenocarcinoma (5.4 vs. 32.7 months, p=0.005). 34 patients received palliative first-line systemic therapy with a median progression-free survival (PFS) of 6.6 months, mostly PE. Overall response rate (ORR) for PE was 48.1 %. 19 patients received second-line therapy, mostly with poor responses. Active regimens were topotecan (1 PR, 3 PD), enzalutamide (1 SD), abiraterone (1 SD), FOLFIRI (1 SD), and ipilimumab+nivolumab (1 PR). One patient with prostatic carcinoid was sequentially treated with octreotide, peptide receptor radionuclide therapy and everolimus, and survived for over 9 years.

Conclusions

EP in first-line shows notable ORR, however limited PFS. For second-line therapy, topotecan, FOLFIRI, enzalutamide, abiraterone and immune checkpoint blockade are treatment options. Prostatic carcinoids can be treated in analogy to well differentiated gastrointestinal NETs.

Co-occurrence of Dermatomyositis and Polycythemia Unveiling Rare de Novo Neuroendocrine Prostate Tumor

We present a case of dermatomyositis together with polycythemia as initial manifestations of a particularly rare type of prostate cancer. A 69-year-old man was hospitalized for facial erythema and symptoms of fatigue. Physical evaluation, serum creatinine phosphokinase and electromyography were consistent with dermatomyositis. In parallel, the hemoglobin level was 18.5 g/dL, serum erythropoietin levels were low normal and no JAK2 mutation was found. Given a strong suspicion of a paraneoplastic syndrome the patient underwent abdominal computed tomography revealing a prostate mass, enlarged iliac lymph nodes and a fracture of L1 due to metastasis. The unusual paraneoplastic manifestations prompted a more thorough immunohistologic examination of the needle biopsy specimen taken from the prostate, which led to the diagnosis of large cell neuroendocrine prostate carcinoma. It is a most rare type of prostate cancer, carrying a poor prognosis. To our knowledge, this is the first case in the literature associating a neuroendocrine cancer of the prostate with dermatomyositis.

Stauffer's syndrome: A comprehensive review and proposed updated diagnostic criteria

BACKGROUND

Stauffer's syndrome corresponds to a set of clinical and analytical changes of paraneoplastic nature firstly recognized more than 50 years ago, in association to renal cell carcinoma. A definitive review including universal diagnostic criteria and updated knowledge since the original description is lacking.

BASIC PROCEDURES

The authors conducted a comprehensive bibliographical review and propose updated diagnostic criteria to standardize diagnosis for clinical practice purposes and avoid misclassification.

MAIN FINDINGS

Although having been described in association with renal cell carcinoma, the syndrome has been reported in correlation with other malignancies-either solid or hematological tumors. Additionally, a variant syndrome presenting with jaundice has also been characterized, but appears to have a similar clinical course to that of the classical Stauffer's syndrome. Although often described as rare, it may be more frequent than previously recognized. Stauffer's syndrome etiopathogenesis is still poorly understood, but immune mechanisms seem to play a role underscored by the malignancies to which the syndrome is associated, several of which having immunotherapy drugs approved for their treatment.

PRINCIPAL CONCLUSIONS

A set of diagnostic criteria should be used to simplify, broaden and standardized diagnosis, under the entity characterized by reversible paraneoplastic intrahepatic cholestasis. Clinicians should be aware of the syndrome, namely consider further investigation if a plausible cause for unexplained intrahepatic cholestasis in an otherwise healthy patient is not found. Even though no universal approach is available, investigation should be considered regarding metastatic disease after resection of a primary tumor which has revealed persistence or recurrence of symptoms.

Paraneoplastic sensorimotor polyneuropathy in prostatic adenocarcinoma: A case report

RATIONALE

Paraneoplastic syndrome is a very rare syndrome among prostate cancer patients. In particular, paraneoplastic sensorimotor neuropathy has never been reported as a complication of prostatic adenocarcinoma.

PATIENT CONCERNS

A 75-year-old man who was diagnosed with prostatic adenocarcinoma with multiple metastases received cancer treatment. But, numbness and tingling sensations in both sides of the upper and lower limbs got progressively worse.

DIAGNOSESE

He was diagnosed with positive anti-Hu antibodies paraneoplastic sensorimotor polyneuropathy caused by prostatic adenocarcinoma.

INTERVENTIONS

The patient received physical therapy, occupational therapy, and opioid medication during 3 weeks at cancer rehabilitation department during 3 weeks.

OUTCOMES

There was no improvement in functional outcome in this patient. But, the patient's neuropathic pain was improved by the use of opioid agents.

LESSONS

This case report is the first to report anti-Hu antibody-positive paraneoplastic sensorimotor neuropathy in a patient with adenocarcinoma of the prostate.

Metastatic Prostate Cancer Manifesting as Cholestatic Jaundice: A Case Report and Review of the Literature

A paraneoplastic syndrome can often present as the first manifestation of an underlying malignancy. We report a patient who presented with cholestatic jaundice as a paraneoplastic syndrome from his newly diagnosed metastatic prostate cancer. He received initial treatment with androgen deprivation therapy followed by six cycles of docetaxel resulting in resolution of his cholestatic process, normalization of liver enzyme levels, and excellent biochemical and radiographic response. To the best of our knowledge, this is the first reported case of metastatic prostate cancer with cholestatic jaundice as a paraneoplastic phenomenon to be safely treated with androgen deprivation therapy and upfront docetaxel, reflecting the latest shift in the treatment of metastatic prostate cancer.

Diagnostic Value of Positron Emission Tomography Combined with Computed Tomography for Evaluating Critically Ill Neurological Patients

Purpose

¹⁸F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) is a promising new tool for the identification of inflammatory, infectious, and neoplastic foci. The aim of our work was to evaluate the diagnostic value of FDG-PET/CT in patients treated on a neurological/neurosurgical ICU or stroke unit.

Methods

We performed a single-center, 10-year, retrospective evaluation of the value of FDG-PET/CT in critically ill adult patients with severe neurological disease.

Results

42 patients underwent FDG-PET/CT. Of these, 15 were ventilated and 10 were under vasopressor support. We identified four indications for performing FDG-PET/CT: (1) excluding a paraneoplastic etiology in an otherwise unexplained encephalitis, encephalopathy or neuropathy, (2) detecting a large-vessel vasculitis in patients with ischemic stroke, (3) detecting an infectious focus in sepsis, and less frequently (4) evaluating cerebral metabolism. In 22 patients who were evaluated for an unknown malignancy, 5 scans revealed either a previously unknown tumor or unknown metastases of a previously treated malignancy. Of 11 patients investigated for large-vessel vasculitis, 2 showed an inflammation of arteries supplying the brain. Of six sepsis cases, FDG-PET/CT identified an infectious focus in four.

Summary

We found FDG-PET/CT to be a helpful tool in critically ill neurological patients. The results of the FDG-PET/CT had direct therapeutic consequences in the 12 true-positive cases. In 24 of the 29 negative cases, FDG-PET/CT helped exclude alternative diagnoses and/or influenced therapy. Our findings demonstrate the feasibility and diagnostic benefit of FDG-PET/CT in this group of patients.

Cohort study of mesenteric panniculitis and its relationship to malignancy

Background

Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure.

Methods

This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured.

Results

A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524).

Conclusion

MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

Alcohol-responsive Action Myoclonus of the Leg in Prostate Cancer: A Novel Paraneoplastic Syndrome?

Background

Paraneoplastic movement disorders in prostate cancer are rare, and to our knowledge paraneoplastic myoclonus has not previously been reported.

Case Report

We report two men with adenocarcinoma of the prostate who developed isolated alcohol-responsive action myoclonus of one leg. Myoclonus was absent at rest but triggered by movement, standing, or walking. Evaluations excluded malignant invasion of the nervous system, and testing for commercial paraneoplastic antibodies in serum and cerebrospinal fluid were unrevealing. Both patients experienced significant improvement with alcohol, and sodium oxybate was used in one patient with good initial benefit.

Discussion

Alcohol-responsive leg myoclonus might be a novel paraneoplastic syndrome associated with prostate cancer. The nature of the syndrome and the source of the myoclonus are currently unknown.

Hematoma of the psoas muscle, in prostatic cancer patient: a case report

We report a case of 64-year-old male with prostate cancer and coagulation disorder presented with abdominal distension. He underwent abdomen and pelvis ultrasound for assessment of ascites, which showed localized fluid collections identified at the left and right iliac fossa. After that, non enhanced abdomen and pelvis CT scan was performed and showed heterogeneous organized collections identified along the psoas muscles bilaterally, causing focal contour bulge representing haematoma.

Distal phalangeal necrosis in the extremities as a paraneoplastic syndrome in prostate cancer: an extremely rare case

Paraneoplastic syndromes (PNSs) are rare disorders which are triggered by an altered immune system response to a neoplasm. Although prostate cancer (PCa) is the second most common urological malignancy associated with PNSs, literature is lacking in defining the cases representing different PNSs in PCa. Herein, we present a 50-year-old man with fulminant distal phalangeal necrosis in the lower extremities after a diagnosis of PCa. Additionally, we review the literature in light of this case.

Cholestatic jaundice as a paraneoplastic manifestation of prostate cancer

Paraneoplastic syndrome associated with prostate cancer is extremely rare. We report a patient who presented with cholestatic jaundice without biliary duct obstruction, hepatic involvement, or infection. After a few detailed examinations, prostate cancer was diagnosed. After treatment with bicalutamide and leuprolide, the patient's symptoms and laboratory abnormalities were reversed. Cholestatic jaundice was regarded as a paraneoplastic manifestation in this patient. The patient remains symptom-free after 14-month followup. Paraneoplastic syndrome should be considered in case of cholestatic jaundice without biliary duct obstruction, hepatic involvement, or infection.

Prostate cancer may trigger paraneoplastic limbic encephalitis: a case report and a review of the literature

We present a case of a previously healthy and active 64-year-old man who experienced a rapid neuropsychiatric decline. All tests for metabolic causes, neuroinfection, intracranial infarction or tumor were negative. By the means of magnetic resonance imaging, electroencephalography and the anti-Hu antibody test the patient was diagnosed with paraneoplastic limbic encephalitis related to prostate cancer. The patient died within 6 months. We review the literature on prostate cancer-related paraneoplastic limbic encephalitis. High-risk prostate cancer can trigger paraneoplastic limbic encephalitis, a rapidly progressive neurological syndrome with a bad prognosis.

A prospective study of total and ionized serum calcium and time to fatal prostate cancer

BACKGROUND

Higher levels of total and ionized serum calcium have been shown to predict fatal prostate cancer in prospective studies. Because the follow-up time in these studies was relatively short, these associations could reflect the effect of clinically significant but occult prostate tumors on serum calcium levels. If this were true, prostate cancer mortality rates among men with higher levels of serum calcium should be higher during the early follow-up period and should decline thereafter.

METHODS

We tested this hypothesis by estimating the relative risk of death from prostate cancer in the National Health and Nutrition Examination Survey III for incremental increases in total and ionized serum calcium using Cox proportional hazards regression with time-dependent effects.

RESULTS

Forty-nine (49) fatal prostate cancers occurred over 204 months of follow-up and 1,069,327 person-months of observation. Men with higher total serum calcium and higher serum ionized calcium had increased risks of fatal prostate cancer during the first 96 months of follow-up [Relative Hazard (RH) = 1.50 per 0.1 mmol/L total serum calcium, 95% confidence interval (CI) = 1.04-2.17; RH = 1.72 per 0.05 mmol/L ionized calcium, 95% CI = 1.11-2.66]. Evidence of an association between total and ionized serum calcium and prostate cancer deaths was not significant after 96 months.

CONCLUSIONS

Our analyses support the hypothesis that the elevated risk for fatal prostate cancer observed in men with high serum calcium is because of the presence of extant, but occult prostate cancer.

IMPACT

These findings have implications for the potential use of serum calcium in the detection of clinically significant prostate cancer.

Bilateral paraneoplastic optic neuropathy and unilateral retinal compromise in association with prostate cancer: a differential diagnostic challenge in a patient with unexplained visual loss

We report a 77-year-old Caucasian man with a 1-year complaint of unexplained visual loss and a 4-year history of prostate cancer. A complete ophthalmologic exam, Goldmann visual fields (GVFs), intravenous fluorescein angiography (IVFA), macular and disc optical coherence tomography (OCT), pattern-reversal visual evoked potentials (PVEPs), and flash electroretinograms (ERGs) were performed. On examination, visual acuity was reduced bilaterally. Fundus exam showed juxtapapillary changes (OS > OD) and, in OS, disc pallor, peripheral RPE dropout and whitish retinal discoloration along the arcades. OCTs were normal OU. Cancer-associated retinopathy (CAR) was suspected. A flash ERG was normal OD and markedly reduced and electronegative OS. An IVFA showed bilateral juxtapapillary staining and changes highly suggestive of sequelae of central retinal artery occlusion (CRAO) OS , in which a cilioretinal artery existed along the papillomacular bundle. GVFs showed bilateral blind spot enlargement and centrocecal scotomas, and PVEPs were delayed. These findings suggested cancer-associated optic neuropathy (CAON), confirmed by presence of anti-optic nerve autoantibodies (auto-Abs). No anti-retinal auto-Abs were found. CAON is a less common paraneoplastic manifestation than CAR and it is rarely observed in association with prostate cancer. A combination of visual function testing methods permitted the recognition, in this highly unusual case, of the concurrent presence of unilateral ERG changes most likely attributable to CRAO complications in OS, in all likelihood unrelated to CAON, and not to be confused with unilateral CAR. Auto-Ab testing in combination with visual function tests helps achieve a better understanding of the pathophysiology of vision loss in paraneoplastic visual syndromes.

Paraneoplastic neurological and hematological syndromes associated with prostate cancer

Paraneoplastic neurological syndromes are defined as the remote effects of cancer on the nervous system. Here we report a 68-year-old man who initially presented with worsening paresthesia in the lower extremities. Although the culprit lesion remained to be identified, he coincidentally had diagnosis of prostate cancer by an annual prostate-specific antigen examination. Leukocytosis and elevated granulocyte colony-stimulating factor in serum were also detected. Neurological symptoms and leukocytosis improved after initiation of androgen-deprivation therapy followed by external beam radiotherapy. A total of 9 months after treatment, the patient showed no evidence of cancer recurrence or neurological signs. Paraneoplastic neurological syndromes are rare in prostate cancer and therefore have received little attention. We should be aware that when paraneoplastic neurological syndromes occur, they usually occur as the first sign of or during progression of prostate cancer. Furthermore, we should take into account the existence of malignancy when the cause of neurological symptoms cannot be specified.