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.