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Dharmesh H Kaswala, Nitin Patel, Sana Jadallah and Weizheng Wang Metastatic prostate cancer of the duodenum
Dharmesh H Kaswala, Nitin Patel, Sana Jadallah and Weizheng Wang, 04 April 2011

Introduction

Prostate cancer is the 3rd most common cancer in humans and is the most commonly encountered malignancy in clinical practice. In 2009 in the United States there were an estimated 27,360 deaths attributed to prostate cancer and 192,280 new cases were diagnosed. Approximately 1 in 6 men develop prostate cancer and 1 in 35 die of this disease [1].

Prostate cancer behavior ranges from microscopic tumors to aggressive cancer with metastatic potential; approximately 20% of patients present with metastatic disease. While metastasis to bone is relatively common, prostate cancer rarely metastasizes to the cecum, pituitary gland, small bowel, maxillary sinus and skin [2-6].

Our case report presents a rare presentation of metastatic prostate cancer to the duodenum. Our search of the literature found only 2 cases of prostate metastases to duodenum published from 1966 to the present [7]. Metastasis to the duodenum is an unusual phenomenon of prostate cancer, but it can elicit several gastrointestinal complications, such as bleeding or obstruction.

Case report

A 42-year-old man was referred by his primary care physician to the gastroenterology clinic for evaluation of abdominal pain and intermittent blood in stool. He had a history of hypertension, metastatic prostate carcinoma to bone diagnosed in March 2007, lumbar disc herniation since 1998, and chronic kidney disease - obstructive uropathy with bilateral nephrostomies.

The patient complained of intermittent nausea, vomiting, and abdominal pain. His pain was epigastric, lasting about 10 minutes and precipitated by food intake. OTC Zantac provided some mild relief. He denied melena but reported red blood with wiping; blood was not mixed in the stools.

The patient did not have any allergy to medications. Family history was non-contributory. He had a 24 pack per year history of smoking and drank 1 can of alcohol per week. The patient quit alcohol and smoking in 2007 when his cancer was diagnosed. He denied any use of IV drugs. The patient used the following medications: Casodex, Ditropan, Percocet, Duragesic patch, Flomax, and Strovite multivitamins. The patient’s vital signs were stable.

Physical examination revealed bilateralnephrostomy tubes without local infection and mild epigastric tenderness without guarding, rebound or rigidity. Laboratory results were positive for microcytic anemia and stool occult. Further laboratory analysis revealed iron deficiency anemia.

The patient was scheduled for an EGD and colonoscopy. Upper endoscopy revealed a normal esophagus and GE junction. In the stomach, there was mild erythematous antral mucosa without erosions or ulceration from which biopsies were taken. The duodenum appeared normal but biopsies were routinely taken to evaluate for celiac disease.

Colonoscopy revealed a diminutive polyp in the sigmoid and internal hemorrhoids. Biopsy of colonic polyp revealed tubular adenoma.

Biospies taken from the antrum revealed reactive gastropathy with Helicobacter pylori infection. The duodenal biopsies revealed lymphangitic carcinoma consistent with prostatic adenocarcinoma-high grade type.

The patient was treated for H. pylori infection with a triple antibiotic regimen on follow-up and continued chemotherapy for his cancer.

Discussion

Prostate cancer is the second most common cancer in males [1]. The most common metastatic targets for prostate cancer are lymph nodes, bone, lung and liver [8]. However, prolonged survival in patients with prostate cancer results in some unusual metastatic sites. There have only been 2 previous reports of metastasis to the small intestine [5,7].

According to a previous survey, the lymphatic drainage of the prostate determines the location of the initial metastases. Subsequent widespread metastases probably originate from sentinel nodes [9]. Duodenal metastases from prostate carcinoma are rare with only 2 cases of prostate metastases to duodenum published between 1966 and 2010 [7].

A review of the literature reveals few studies of patients with prostate cancer and metastases to the small bowel. Overall, metastatic tumors to the gastrointestinal tract are rare.

Disease can either be intrinsic within the bowel wall or extrinsic in the surrounding tissues. The most common primary tumors to metastasize to the duodenum are lung cancer, renal cell carcinoma, malignant melanoma and breast cancer, especially the lobular subtype. Isolated case reports exist of obstruction secondary to metastases from ovary, prostate, colon, cecum, synovial sarcoma, germ cell tumor of the testis and other tumors of the genital tract. Extrinsic malignant obstruction of the duodenum commonly results from contiguous spread from adjacent organs such as the pancreas and gallbladder.

Metastatic spread from prostate cancer to the gastrointestinal tract is uncommon and tends to be a local manifestation involving the rectum [5-7], although metastases to the duodenum and esophagus have been reported in an autopsy study [10]. In all cases, the gastrointestinal spread was a manifestation of disease recurrence and not a presenting feature. Extensive abdominal involvement was discovered at autopsy in one third of cases. However, involvement of the gastrointestinal lumen alone is exceptional.

Diagnosis of metastatic lesions of the duodenum may be problematic. Common manifestations are abdominal pain, nausea, vomiting and gastrointestinal bleeding. The small intestine may show a mass lesion, mucosal defect or intussusceptions, but is often unremarkable. Endoscopic evaluation of the gastrointestinal tract provides an alternative to radiographic evaluation and should be considered when radiographic diagnostic studies are unrevealing [11]. However, we must keep in mind that detailed small-intestinal studies should be considered if the cause of anemia or occult blood cannot be ascertained.

Clinical diagnosis can be difficult due to nonspecific symptoms like nausea, vomiting, dyspepsia, weight loss and epigastric pain, all of which can be attributable to chemotherapy, radiotherapy or liver metastasis. An endoscopic diagnosis can be difficult due to implantation of the metastatic cells in the sub mucosa.

Late diagnosis of gastrointestinal metastasis is common, and so is the presence of concurrent metastases at the time of the diagnosis. In McLemore’s study of 23 patients with GI metastases, 12 underwent palliative surgery with a median survival of 44 months compared to the median survival of 9 months of patients who were not treated surgically. Surgery did not affect the survival of patients with carcinomatosis [12]. Perioperative mortality has decreased considerably, and the question remains whether surgery should be considered as palliative therapy, and not only for symptomatic patients.

Conclusion

In conclusion, this is the third description of metastatic prostate cancer presenting with duodenal metastasis. Although rare, small intestine metastasis should not be ignored in symptomatic patients with advanced prostate cancer. We have reported an unusual case of a patient with metastatic duodenal tumor caused by primary prostate cancer. The case demonstrates a novel presentation of a common malignancy, and should raise awareness in clinicians and radiologists that prostate cancer can present with distant metastases in the absence of any local lymphadenopathy.

This article was first published on GastroHep.com on February 28th 2011.

Authors

Dharmesh H Kaswala, MD
Nitin Patel, MD
Sana Jadallah, MD
Weizheng Wang, MD

The University Hospital
UMDNJ-New Jersey Medical School
New Jersey, USA

References

  1. National Cancer Institute. US National Institutes of Health. www.cancer.gov/cancertopics/types/prostate (page accessed November 2010).
  2. Patel N, Teh BS, Powell S, et al. Rare case of metastatic prostate adenocarcinoma to the pituitary. Urology 2003; 62(2): 352.
  3. Baseskioglu B, Eskicorapci S, Ekici S, et al. Maxillary sinus metastasis of prostate cancer: a case report. Turkish Journal of Cancer 2006; 362: 79-81.
  4. Kabeer MA, Lloyd-Davies E, Maskell G, et al. Metastatic prostate cancer masquerading clinically and radiologically as a primary caecal carcinoma. World J Surg Oncol 2007; 5: 2.
  5. Lee SW, Lee TY, Yeh HZ, et al. An unusual case of metastatic small intestinal tumor due to prostate cancer. J Chin Med Assoc 2009; 72(5): 271-4.
  6. Wu JJ, Huang DB, Pang KR, et al. Cutaneous metastasis to the chest wall from prostate cancer. Int J Dermatol 2006; 45(8): 946-8.
  7. Malhi-Chowla N, Wolfsen HC, Menke D, et al. Prostate cancer metastasizing to the small bowel. J Clin Gastroenterol 2001; 32: 439-40.
  8. Disibio G, French SW. Metastatic patterns of cancers: results from a large autopsy study. Arch Pathol Lab Med 2008; 132(2): 931–9.
  9. Whitmore WF Jr. Proceedings: The natural history of prostatic cancer. Cancer 1973; 32(5): 1104–12.
  10. Wallmeroth A, Wagner U, Moch H, Gasser TC, et al. Patterns of metastasis in muscle-inavasive bladder cancer (pT2-4): An autopsy study of 367 patients. Urol Int 1999; 62(2): 69-75.
  11. Lewis BS, Kornbluth A, Waye JD. Small bowel tumours: yield of enteroscopy. Gut 1991; 32(7): 763–5.
  12. McLemore EC, Pockaj BA, Reynolds C, et al. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 2005; 12(11): 886–94.

 
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