CASE STUDY JANUARY 2008 VOL 5 NO 1 NATURE CLINICAL PRACTICE UROLOGY 55 www.nature.com/clinicalpractice/uro SUMMARY A case of prostatic adenocarcinoma recurrence presenting as ductal carcinoma of the prostate William H Tu, Kristin Jensen, Fuad Freiha and Joseph C Liao* Vanderbilt Continuing Medical Education online This article offers the opportunity to earn one Category 1 credit toward the AMA Physician’s Recognition Award. THE CASE A 61-year-old man with a history of recurrent prostate cancer presented with obstructive urinary symptoms. At the age of 51 years, a routine physical examination discovered an inci- dentally elevated PSA level of 134 ng/ml. He had a 60-pack-year history of smoking, and reported some urinary urgency but no nocturia or family history of prostate cancer. He underwent a pros- tate needle biopsy that revealed Gleason grade 3 + 3, moderately differentiated adenocarcinoma of the prostate with perineural invasion. CT of the pelvis showed an enlarged, lobulated prostate and fullness in the seminal vesicles extending to the lateral side walls. A bone scan did not show evidence of metastasis, and the patient’s alkaline phosphatase level was normal (67 U/l). He was diagnosed with locally advanced, clinical stage T3NXM0 prostate cancer, and elected to undergo neoadjuvant hormonal therapy with oral fluta- mide and leuprolide injections. His PSA level had decreased to 35.7 ng/ml after 1 month, then decreased further to 1.4 ng/ml after 2 months of treatment. Over the next 2 months, the patient underwent radiation treatments of 4,500 cGy in 25 fractions to the small pelvis field, followed by a three-dimensional formal prostate boost to bring the dose to the prostate and seminal vesicles up to 7,100 cGy in 38 fractions. The patient tolerated the expected adverse effects (i.e. urinary frequency, dysuria and rectal irritation) and responded well with a post-treatment PSA nadir of 0.7 ng/ml. His PSA level remained at its nadir for 6 years without further treatment, then began to rise as high as 10.6 ng/ml; an increase of at least 2 ng/ml above the nadir is indicative of prostate cancer recurrence. He was started on goserelin 10.8 mg every 3 months; the initial response was good, with the patient’s PSA level decreased to Background A 61-year-old man with a history of recurrent prostate cancer presented with obstructive urinary symptoms. He had been diagnosed with locally invasive adenocarcinoma of the prostate 10 years previously and treated with neoadjuvant hormonal and external beam radiation therapies. Because of the patient’s rising PSA level, he had been started on goserelin 6 years after this diagnosis and bicalutamide 6 months before the current presentation. The patient presented to the urology clinic with worsening lower urinary tract symptoms consisting of nocturia, urgency, and weak stream. Investigations Physical examination revealed a largely normal digital rectal examination, although there was slight asymmetry. The post-void residual urine volume was approximately 200 ml. Laboratory tests showed no evidence of urinary tract infection, but confirmed a rising PSA level despite low serum testosterone levels. Cystoscopic examination revealed hypervascular, large lateral prostatic lobes obstructing the bladder neck. The bladder was normal. Diagnosis The patient underwent transurethral resection of the prostate. Soon after the resection started, bilateral papillary tumors arising from the stroma of both prostatic lobes were uncovered. Owing to the diffuse nature of the papillary tumors, complete resection was not possible. Pathologic analysis confirmed the presence of ductal carcinoma of the prostate. Management The patient had an uneventful postoperative course and reported improvement of voiding symptoms. Staging with bone scan and CT of the abdomen and pelvis demonstrated multi-focal bony metastasis. The patient was started on docetaxel-based chemotherapy for hormone refractory recurrence of prostate cancer as ductal carcinoma of the prostate. He remains under close surveillance for clinical response and progression of disease. KEYWORDS ductal carcinoma, lower urinary tract symptoms, metastasis, prostatic adenocarcinoma, transurethral resection WH Tu is a Urology Resident, K Jensen is Assistant Professor of Pathology, F Freiha is Professor Emeritus of Urology and JC Liao is Assistant Professor of Urology at the Stanford University School of Medicine, Stanford, CA. K Jensen is also Associate Director of Cytopathology and JC Liao is Chief of Urology at the Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA. Correspondence *Department of Urology S-287, Stanford University School of Medicine, Stanford, CA 94305-5118, USA jliao@stanford.edu Received 27 May 2007 Accepted 10 September 2007 www.nature.com/clinicalpractice doi:10.1038/ncpuro0994 CME