A 64-year-old male patient with a serum PSA value of 51.91 ng ml−1 and an magnetic resonance imaging scan suggestive of prostate cancer was admitted with bilateral hydronephrosis and anemia. A suprapubic cystostomy had been inserted 6 months earlier, owing to voiding difficulties. The patient was found to have huge multiple bladder stones and a massively thickened bladder wall. A sectio alta with bladder stone removal and bilateral ureteral stenting was performed. Histopathological examination revealed the growth of prostate cancer cells in the cystostomy tube needle tract.
A 64-year-old male patient was referred to our clinic with fatigue and clinical signs of anemia. He was suspicious of having prostate cancer due to distinctly elevated serum PSA values. MR spectroscopy was performed half a year before admission, with evidence of prostate cancer.
The patient had refused pathological confirmation of diagnosis by prostate biopsy and rejected curative treatment options, as well as androgen deprivation. Owing to progressive subvesical obstruction, a suprapubic cystostomy tube had been inserted 6 months before admission. The suprapubic catheter was also used for self-administration of herbal medications and of an anticholinergic medication, which is not exactly known to the authors. There was no comorbidity or concomitant medication.
On admission, digital-rectal examination was highly suspicious for prostate cancer. With the exception of some discomfort in the suprapubic region, the patient was free of any pain. Ultrasonographic examination showed multiple bladder stones surrounded by a tremendously thickened bladder wall and bilateral hydronephrosis. Blood tests showed a serum creatinine level of 5.2 mg dl−1 and a serum PSA level of 51.91 ng ml−1. Native magnetic resonance imaging scan of the abdomen and pelvis revealed multiple huge bladder stones (Figure 1), which filled out the whole bladder. Bilateral dilatation of the upper urinary tract was most likely caused by the massively thickened bladder wall. With regard to tumor staging, the magnetic resonance imaging scan was suspicious for locally advanced prostate cancer, with no signs of lymph node involvement.
The following day, an open vesicotomy was performed to remove a huge mass of bladder stones and to bilaterally insert ureteral stents. The macroscopic appearance of the bladder neck was not suspicious for cancer infiltration. The tissue surrounding the suprapubic cystostomy tube was excised and sent for pathological examination.
The final histopathological examination of the excised catheter tract showed a growth of prostate cancer cells surrounded by ragged red muscle fibers of the abdominal wall (Figure 2). The neoplastic cells appeared highly invasive and poorly differentiated, with large prominent nucleoli. Immunohistochemistry for PSA revealed strong positivity of almost all tumor cells, which confirmed the diagnosis of prostate cancer in the needle tract.
Here, we describe for the first time the seeding of prostate cancer cells in the tract of a suprapubic catheter. In the literature there are infrequent case reports about the spreading of prostate cancer cells along the needle tract after fine-needle biopsy.1, 2, 3, 4, 5, 6, 7, 8, 13, 14 In most studies prostate cancer recurrence in the biopsy tract occurred after perineal biopsy,3, 4, 5, 6, 8, 14 but there are also some descriptions of its occurrence after transrectal biopsy.1, 2, 7, 13 In two publications prostate cancer infiltration of the rectal wall was described after both transrectal prostate biopsy and radical prostatectomy, querying the possibility that tumor spilling at the time of radical prostatectomy caused the local recurrence.1, 7 Added to this, there is another case described in the literature with an implantation metastasis of prostate cancer in the abdominal wall after laparoscopic pelvic lymphadenectomy for nodal positive prostate cancer.9
On the other hand, the phenomenon of needle tract infiltration is well known in transitional cell cancer,10, 11, 12 which is a generally accepted contraindication for the insertion of a suprapubic cystostomy.
Whether prostate cancer can grow in needle tracts might be dependent on multiple factors. For example, the Gleason sum could potentially have a positive correlation with the invasive ability of the tumor cells. In our case the Gleason sum unfortunately is not known, as the patient had refused a prostate biopsy, but the above-mentioned histology shows that it is a poorly differentiated carcinoma.
Furthermore, it could not be determined in this case whether the prostate cancer was already infiltrating the bladder wall at the time of insertion of the suprapubic cystostomy or whether the cancer cells had the capability to invade the needle tract. It can only be said that there was no gross infiltration of the bladder wall and the bladder neck. Finally, the question as to what makes the needle tract tissue more vulnerable for tumor involvement than the remaining macroscopic normal bladder tissue remains unanswered.
This case can be seen as a confirmation of the fact that prostate cancer cells occasionally grow in needle tracts, as infrequently shown by the recurrence of prostate cancer infiltration in the needle tract after transrectal or perineal prostate biopsy. This is the first case describing the growth of prostate cancer cells in the needle tract of a suprapubic cystostomy tube.
This finding may be contemplated when counseling patients with advanced and aggressive prostate cancer for suprapubic catheterization.