A 61-year-old male with no significant past medical history presented to
the emergency department with suprapubic discomfort and urinary
retention. The patient has a twenty-five-pack-year smoking history, a
family history of breast, pancreatic, and lung cancer, and no family
history of prostate cancer. A pelvic/bladder ultrasound revealed an
enlarged prostate gland measuring 8.6 cm x 7.9 cm x 9 cm, which was
heterogenous with a weight of 320 g. PSA was measured to be 1.4 ng/mL.
The patient continued to have frequent visits to the emergency
department for lower urinary tract symptoms, after which he underwent an
elective simple open prostatectomy. There was a 2.5 cm circumferential
necrotic appearance to the right hemiprostate and asymmetric growth on
the right side. In addition, pathology reported an incidental finding of
leiomyosarcoma.
Immunohistochemical stains showed calponin (+ve), SMA (focal), Desmin
(patchy), smooth muscle myosin heavy chain (+ve), caldesmon (+ve,)
vimentin patchy, CD34 (-ve) and PR (-ve), CK5/6 (-ve). In addition, TSC2
and BRCA 1 genomic alternations were detected. The post-surgical course
was complicated by hematuria, which was resolved with continuous bladder
irrigation.
Computed tomography (CT) of the chest/abdomen and pelvis (CTAP) showed
multiple nodular densities in the left and right lungs. A lobular
contour cyst in the liver measures about 1 cm x 0.59 cm, along with
cysts in the right and left kidneys. In addition, tiny nodes in the
retroperitoneum with prominent vessels are noted. There was a small
amount of intra-abdominal and pelvic ascites noted. The prostate gland,
enlarged with low attenuated lesions in the transitional and central
zones, measures about 4.6 cm x 2.9 cm on the right, and the left
measures about 1.9 cm in the transitional zone. The prostate measures
about 8.1 cm x 8.3 cm x 7.1 cm. NM bone scan revealed heterogeneous
uptake in the right posterior iliac spine, right scapular region, and
right distal region, indicating osseous metastases. The patient was
started on chemotherapy with a doxorubicin regimen every three weeks.
The patient continued to have recurrent hospitalizations for urinary
retention, suprapubic pain, worsening hematuria, and urinary tract
infections. He was treated with antibiotics and multiple blood
transfusions. Further course was complicated by left-sided
hydronephrosis, requiring left-sided nephrostomy tube placement.
The patient is currently being managed with an outpatient chemotherapy
regimen.