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Unusual metastasis of carcinoma of the prostate (a case report).
Carcinoma of the prostate invading the rectal wall has been reported by a few authors.[1], [3], [6] Sometimes it can cause rectal symptoms and mimic the primary rectal carcinoma, the urinary symptoms being minimal. We are describing below a case which presented with progressive constipation due to extra-rectal deposits from prostatic carcinoma.
A 60 year old Hindu male was admitted with complaints of dysuria and progressive constipation for the past 3-4 months. The patient had also one to two bouts of painless hematuria. There were no other abdominal complaints. On examination, the patient was found to be of average build and anaemic. No lymph nodes were palpable. There was no edema of the feet. Pulse, blood pressure and body temperature were within normal limits. Abdominal examination showed an empty bladder. No lump was palpable. On per rectal examination, anteriorly the prostate was found to be hard, nodular and fixed and adherent to the rectal mucosa. Through the posterior wall of the rectum, an extra-rectal mass could be felt near the sacral promontary; it was hard and had rounded margins. It was fixed to the bone but the rectal wall was intact. The tumour was projecting into the lumen and about 3/4 th of the lumen was occluded [Fig. 1] Investigations revealed hemoglobin to be 7.8 gm%. Blood urea was 40 mg% and serum creatinine 1 mg%. Urine examination showed 10-12 pus cells and a similar number of RBCs per high power field. Serum acid phosphatase was 4.6 K. A units. X-rays of the chest and pelvis were normal. Clinically, the patient was diagnosed as a case of carcinoma of the prostate with extra-rectal metastatic deposits causing rectal obstruction. A biopsy was taken from the extra-rectal mass which proved to be metastatic anaplastic adenocarcinoma of the prostate. The patient underwent bilateral subcapsular orchidectomy followed by stilboestrol therapy. He improved subjectively though no regression in the extra-rectal mass was seen. The patient was subsequently lost to follow-up.
Rectal involvement is a rare event in the course of prostatic carcinoma. In a series of 81 cases of prostatic carcinoma, Graves and Militzer[3] have reported on 5 cases with rectal involvement to occlude its lumen. Hallopaeu[4] reported one case with ulceration of rectum. Engelbach[2] described a rectal type of prostatic cancer in absence of vesical symptoms. Lazarus[6] had described 3 ways of rectal involvement in prostatic carcinoma. First is the prostato-pelvic carcinoma involving various pelvic organs; second one extends into the wall of the rectum with intact mucosa but occludes the lumen. The third is the full thickness involvement with ulceration of mucosa and fungating mass. Jackman and Anderson[5] had put forward the following classification of carcinoma prostate: (a) The first type produces extrarectal mass that bulges into the lumen of the rectum and causes obstruction. (b) The second type encircles the rectum causing annular stricture, and (c) the third type invades the mucosa with or without either of the first two manifestations. The present case belonged to the first type of the above classification. Jackman and Anderson[5] have further stressed that cystoscopy is mandatory in any case of suspected primary carcinoma of the rectum with urinary symptoms and if the prostate cannot be felt separately from the tumour mass.
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