Despite the high incidence of prostatic adenocarcinoma and its ability for wide dissemination, metastatic involvement of testis is rather uncommon. We report two cases (aged 76 and 55 years, respectively), where unilateral testicular metastasis was incidentally discovered after bilateral orchiectomy following detection of adenocarcinoma prostate in six-quadrant trucut specimen. Both patients had obstructive voiding symptoms, hard nodular prostate on direct rectal examination and raised serum prostate-specific antigen levels, without associated systemic or testicular symptoms. Extensive evaluation excluded any other possible primary, although axial skeletal metastasis was detected on radionucleotide bone scans, in the first case. These cases highlight the need for proper evaluation of testes and para-testicular structures, for accurate staging of these tumors and to exclude any possible metastasis.
Prostatic adenocarcinoma is one of the most frequently diagnosed tumors in the male population. The most common sites of secondary involvement are pelvic lymph nodes, bones and lungs, and rarely bladder, liver and brain.1 Testis is an uncommon site, with less than 200 cases described till date,2 whereas epididymal involvement is unusual.3 Further, simultaneous involvement of testis and epididymis is exceptional.4
We report two cases of testicular metastasis from prostatic carcinoma, which was incidentally detected on histopathological evaluation of bilateral orchiectomy specimen.
A 76-year-old man presented with a history of gradually progressive obstructive voiding symptoms and generalized malaise of 2 years duration. There was no associated systemic illness. Examination of general condition and per abdomen was normal. Digital rectal examination (DRE) revealed grade III hard nodular prostate with obliteration of median sulcus. Serum prostate-specific antigen (PSA) was 36 ng/ml. Ultrasonographic studies (USS) showed prostate weighing 56 g with multiple hypoechoic areas, and 70 ml post-void residual urine. Six-quadrant trucut biopsy specimen showed adenocarcinoma prostate (Gleason score 7). Radionucleotide bone scan revealed multiple hot spots suggestive of metastasis in axial skeleton. In view of obstructive voiding symptoms and multiple metastases, bilateral orchiectomy was carried out, within next 10 days, as first hormonal manipulation.
Both testes appeared normal on external gross examination. Cut section of right testis showed a cyst measuring 1 × 0.5 cm, containing yellowish fluid, whereas that of left testis appeared normal. Histopathology of right testis showed adenocarcinoma metastasis displaying a ductal pattern, primarily involving the rete testis, with presence of large atypical cells in the interstitium (Figure 1). Rest of the testis showed atrophic change, along with moderate mixed inflammatory infiltrates. Left side showed atrophic change and nonspecific chronic inflammation, without evidence of metastatic deposits.
Currently, after 8 months of regular follow-up, patient is asymptomatic, with 1.2 ng/ml PSA.
A 55-year-old man was referred to this center with 2 years history of gradually progressive obstructive voiding symptoms, with acute urinary retention refractory to α-blockers. There was no associated systemic illness. DRE revealed grade IV hard nodular prostate with obliteration of median sulcus, with multiple hypoechoic areas and weighing 76 g on USS. Serum PSA was 35 ng/ml. Six-quadrant trucut biopsy specimen showed adenocarcinoma prostate (Gleason score 6). Extensive investigations excluded malignancy in any other site. Patient consented for bilateral orchiectomy, which was performed within a fortnight of initial surgery.
Both testes were normal in size. However, right testis appeared firm in consistency along with ill-defined nodularities. Cut surface of right testis revealed a cyst measuring 3 × 2 cm filled with gelatinous material (Figure 2a), with reduction of testicular parenchyma. Cyst wall showed multiple fine nodularities. Left testis also showed a cyst measuring 2 × 2 cm, filled with clear fluid (Figure 2a), and reduction of testicular parenchyma. Histopathology showed atrophic changes in both testes. However, right testis revealed adenocarcinoma deposits, with predominantly a ductal pattern with focal adenomatoid change (Figure 2).
Currently, after 2 months regular follow-up, patient is asymptomatic, with 4 ng/ml PSA.
With the exception of infiltrations by leukemias and lymphomas, secondary malignant tumors in testis are uncommon. Primary neoplasm in these cases is commonly located in the prostate, lungs and kidneys, whereas metastases from stomach, pancreas, bladder, rectum or penis are rare.1 Despite the proximity, high frequency of primary tumors and its ability for dissemination, prostate carcinoma seldom metastasizes to the testis, which is aptly reflected by less than 200 cases reported till date.1
Unlike primary testicular tumors, secondaries usually develop later in life (between 50 and 60 years of age), and in most instances are unilateral,5 with rare bilateral involvement.6 Although an occasional report had noted scrotal swelling,7 most cases are detected either incidentally after therapeutic orchiectomies or during autopsies.8 In one report,9 a 54-year-old man was detected to have testicular secondaries from prostate carcinoma after 7 years of hormonotherapy and chemotherapy.
Similarly, both cases being reported were elderly males, lacked testicular symptoms or signs, and had unilateral testicular secondaries in orchiectomy specimen following detection of adenocarcinoma prostate.
Tu et al.10 evaluated one of the largest reported series comprising 12 patients of prostate carcinoma with testicular or penile metastasis, and noted that these cases were predisposed to developing persistent or recurrent urinary symptoms and visceral metastases. In two of 10 evaluable patients, serum PSA was low or undetectable (<4 ng/ml), whereas histopathology of seven of eight cases where specimens were available showed predominantly a ductal or endometrioid pattern. Interestingly, both cases being reported in the present study had raised serum PSA levels, with evidence of axial skeletal metastases in one.
Histopathology of testis showed predominance of ‘ductal’ pattern, unlike that of the primary prostate biopsies. The presence of testicular metastasis despite a very high Gleason score, as evident in both cases, is an uncommon feature. This may probably be attributed to either a sampling bias of the initial six-quadrant trucut prostate biopsy, or possibly be a reflection of the dyssynchrony between the morphological and genetic aspects of the tumor.
To conclude, we report two more rare cases of unilateral testicular metastasis originating from prostate adenocarcinoma. These cases also highlight the need for proper evaluation of testicular and para-testicular structures for accurate staging and early detection of possible metastasis, especially in a setting of elevated serum PSA.
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Deb, P., Chander, Y. & Rai, R. Testicular metastasis from carcinoma of prostate: report of two cases. Prostate Cancer Prostatic Dis 10, 202–204 (2007). https://doi.org/10.1038/sj.pcan.4500942
- prostate carcinoma