Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 53-55

Mucinous adenocarcinoma of the prostate found incidentally in adenomectomy specimen complicated with vesicocutaneous fistulae


Ygeias Melathron Hospital, TYPET, Palodeia, Cyprus

Date of Submission17-Sep-2021
Date of Decision19-Sep-2021
Date of Acceptance20-Sep-2021
Date of Web Publication26-May-2022

Correspondence Address:
Spinos Theodoros
Apollonos 57 ,Pallini
Cyprus
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_34_21

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  Abstract 


Primary mucinous tumors of the prostate gland are rare, including mucinous adenocarcinoma, prostatic adenocarcinoma with mucinous features, and mucinous adenocarcinoma of the prostatic urethra. In this report, we present a case of a locally advanced mucinous variant of prostatic ductal adenocarcinoma, found incidentally during pathology examination of an adenomectomy specimen, after bladder outlet obstruction surgery. Recent large studies indicated that mucinous adenocarcinoma of the prostate, treated by radical prostatectomy, is not more aggressive than ordinary nonmucinous prostatic adenocarcinoma. In our case, the rapid deterioration of our patient, the return of tumor in its initial size soon after surgery, in addition to its distal metastatic spread should be attributed not only to the mucinous variant of prostatic adenocarcinoma but also to the advanced stage during initial diagnosis and the noncompliance of the patient with the suggested treatment after surgery, omitting radiotherapy, and hormonal maneuvers.

Keywords: Adenocarcinoma, fistulae, mucinous, prostate, vesicocutaneous


How to cite this article:
Theodoros S, Michail L, Grigorios K, Anastasios T, Iason K. Mucinous adenocarcinoma of the prostate found incidentally in adenomectomy specimen complicated with vesicocutaneous fistulae. Hellenic Urology 2021;33:53-5

How to cite this URL:
Theodoros S, Michail L, Grigorios K, Anastasios T, Iason K. Mucinous adenocarcinoma of the prostate found incidentally in adenomectomy specimen complicated with vesicocutaneous fistulae. Hellenic Urology [serial online] 2021 [cited 2022 Jun 25];33:53-5. Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/2/53/346057




  Introduction Top


Primary mucinous tumors of the prostate gland are rare, representing approximately 0.2%–0.4% of prostatic adenocarcinomas.[1],[2],[3] The primary mucinous tumors involving the prostate include mucinous adenocarcinoma, prostatic adenocarcinoma with mucinous features, and mucinous adenocarcinoma of the prostatic urethra. Mucinous adenocarcinoma of the prostate is characterized by the presence of at least 25% of the tumor consisting of glands with extraluminal mucin. However, this diagnosis can only be made in radical prostatectomy specimens, because the whole tumor must be present to report that the extraluminal mucinous component is more than 25%. In cases of radical prostatectomy specimens, where extraluminal mucinous component represents <25% of the tumor, the diagnosis of prostatic adenocarcinoma with mucinous features is set. It is worth noting that, all cases of prostatic adenocarcinoma with extraluminal mucinous components, found in prostate needle core biopsies and in transurethral resection of the prostate specimens, are characterized as prostatic adenocarcinomas with mucinous features. Up to one-third of prostatic adenocarcinomas include intraluminal mucin. These cases should not be considered mucinous adenocarcinomas or prostatic adenocarcinomas with mucinous features.[4] Concerning the molecular basis and pathogenesis of prostatic mucinous adenocarcinomas, these tumors have been found to express MUC2 (goblet-type, secretory-type, or gel-forming-type mucin). MUC2 forms strong bonds with the stroma and contributes to the morphology and the slow growth of mucinous adenocarcinomas.[5],[6] Mucinous prostatic adenocarcinomas and prostatic adenocarcinomas with mucinous features have also been shown to express PTEN. Loss of PTEN expression is associated with aggressive high-grade prostatic adenocarcinoma.[4],[7] Recently, there has been increased interest in the magnetic resonance (MR) features of prostatic mucinous adenocarcinoma, enabling its noninvasive diagnosis. Mucinous adenocarcinomas of the prostate have been shown to differentiate from the usual characteristics of nonmucinous tumors on T2-weighted magnetic resonance imaging (low-signal intensity) and MR spectroscopy (increased choline and decreased citrate peaks), as a result of the extracellular mucin which they include. Nevertheless, these imaging studies carry many limitations and thus no conclusion can be safely drawn.[8] In this report, we present a case of a locally advanced mucinous variant of prostatic ductal adenocarcinoma, found incidentally during pathology examination of an adenomectomy specimen, after bladder outlet obstruction surgery. The bad progression of this patient's health condition, in combination with the extremely rare nature of mucinous prostatic adenocarcinoma, raised questions as to whether these tumors are more aggressive and associated with worse prognosis.


  Case Report Top


A 62-year-old male patient presented to the emergency department of our hospital with bilateral hydronephrosis and acute kidney injury with concomitant urinary retention. The radiological evaluation identified an extremely large prostate of 420 ml and an overdistended urinary bladder with more than 1 l of urine. A urinary catheter was inserted and renal function gradually returned to normal. Prostate-specific antigen (PSA) levels were 10.26 ng/dL 1 month after catheterization and digital rectal examination was unremarkable. Subsequently, the patient was subjected to laparoscopic adenomectomy.

Surgical technique

After the establishment of an extraperitoneal access with the use of a balloon, 5 trocars were inserted into the extraperitoneal space under direct vision. A midline bladder incision was made and the bladder trigone was exposed. A vertical incision of the mucosa above ureteral orifices was made and enucleation of the adenoma was performed. Since the beginning of enucleation an atypical behavior of the adenoma was evident with the presence of large intraprostatic cavities that were breaking open during laparoscopic maneuvers. Opening of one of these cavities at the posterior aspect of the intracapsular dissection plane led to entrance into the underlying bowel, as evidenced by retrograde infusion of saline in the rectum returning saline into the operative field. A general surgeon was called into the theater and assisted into the suturing of the bowel defect in two layers. A urinary catheter was inserted into the bladder and the bladder wall opening was closed in a single layer using Vlock 2/0 sutures. Postoperative course was uneventful. The patient stayed fasten for 2 days and was discharged with the catheter in place for 10 days on postoperative day 4. A low-fiber diet was advised for 1 week time.

Pathology examination of the 300 ml specimen, revealed the presence of mucinous variant of prostatic ductal adenocarcinoma infiltrating the underlying bowel wall.

Three months after surgery, PSA levels were 14.92 ng/dL and no evidence of distant metastases was documented in scintigraph and radiological evaluation. Androgen deprivation treatment was initiated with SC leuprorelin 11.25 mg every 3 months and PSA levels dropped to 0.38 ng/dL 1 month later. While immediate radiotherapy would be a suitable treatment option for this patient, it was decided to delay treatment for 6 months, due to the bowel perforation observed during surgery. After 3 sessions of radiotherapy, the patient was lost to follow-up.

Two years later, he presented to the emergency department of our hospital due to urine leakage through his anterior abdominal wall. A computed tomography (CT) evaluation confirmed the presence of a vesicocutaneous fistula due to an infiltrating prostatic mass of 400 ml size running through the bladder wall toward the anterior abdominal wall. Large retroperitoneal lymph node masses were also evidenced in the CT scan [Figure 1]. After a multidisciplinary team meeting including oncologists, general surgeons, and urologists-bilateral nephrostomies were placed and a docetaxel regimen chemotherapy was initiated. The patient returned home after the first cycle of chemotherapy but passed away 10 days later at home.
Figure 1: A computed tomography evaluation of the patient confirmed the presence of a vesicocutaneous fistula due to an infiltrating prostatic mass of 400 ml size running through the bladder wall toward the anterior abdominal wall. Large retroperitoneal lymph node masses were also evidenced in the computed tomography scan

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  Discussion Top


Traditionally, most mucinous adenocarcinomas of the prostate were considered to be aggressive tumors.[9],[10],[11] Nevertheless, recent large studies indicated that mucinous adenocarcinoma of the prostate, treated by radical prostatectomy, is not more aggressive than ordinary nonmucinous prostatic adenocarcinoma. Surprisingly, data from these studies demonstrated that it may potentially even be less aggressive.[12],[13],[14],[15],[16],[17] It is very possible that the extracellular mucin, accumulated in the stroma of these tumors, surrounding cancer cells, and interferes with their ability to spread.[6] Similarly, some pathologists in the past, were convinced that all of these tumors should get a high Gleason score. Moreover, whether these tumors should be graded with a Gleason score was an object of debate. Recent data suggest assigning prostatic mucinous adenocarcinomas a Gleason score based on their underlying architectural pattern, like common prostatic adenocarcinomas, rather than hypothesizing that all of these tumors are aggressive.[12],[16],[17] In our case, the rapid deterioration of our patient, the return of tumor in its initial size of 400 g soon after surgery in addition to its distal metastatic spread should be attributed not only to the mucinous variant of prostatic adenocarcinoma but also to the advanced stage during initial diagnosis (as evidenced by bowel infiltration) and the noncompliance of the patient with the suggested treatment after surgery, omitting radiotherapy and hormonal maneuvers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moch H, Humphrey PA, Ulbright TM, Reuter VE. WHO Classification of Tumors of the Urinary System and Male Genital Organs. Lyon: IARC; 2016.  Back to cited text no. 1
    
2.
Enciu M, Aşchie M, Deacu M, Poinăreanu I. Morphological characteristics of a mucinous adenocarcinoma of the prostate: Differential diagnosis considerations. Rom J Morphol Embryol 2013;54:191-4.  Back to cited text no. 2
    
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Prendeville S, Nesbitt ME, Evans AJ, Fleshner NE, van der Kwast TH. Variant histology and clinicopathological features of prostate cancer in men younger than 50 years treated with radical prostatectomy. J Urol 2017;198:79-85.  Back to cited text no. 3
    
4.
Osunkoya A. Mucinous and secondary tumors of the prostate. Mod Pathol 2018;31:80-95.  Back to cited text no. 4
    
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Osunkoya AO, Adsay NV, Cohen C, Epstein JI, Smith SL. MUC2 expression in primary mucinous and nonmucinous adenocarcinoma of the prostate: An analysis of 50 cases on radical prostatectomy. Mod Pathol 2008;21:789-94.  Back to cited text no. 5
    
6.
Adsay NV, Merati K, Nassar H, Shia J, Sarkar F, Pierson CR, et al. Pathogenesis of colloid (pure mucinous) carcinoma of exocrine organs: Coupling of gel-forming mucin (MUC2) production with altered cell polarity and abnormal cell-stroma interaction may be the key factor in the morphogenesis and indolent behavior of colloid carcinoma in the breast and pancreas. Am J Surg Pathol 2003;27:571-8.  Back to cited text no. 6
    
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Bertsch EC, Magi-Galluzzi C, Cheng L, Osunkoya AO. PTEN Expression in Mucinous Prostatic Adenocarcinoma, Prostatic Adenocarcinoma With Mucinous Features, and Adjacent Conventional Prostatic Adenocarcinoma: A Multi-institutional Study of 92 Cases. Appl Immunohistochem Mol Morphol. 2018;26:225-30. doi: 10.1097/PAI.0000000000000417. PMID: 29621096.  Back to cited text no. 7
    
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Westphalen AC, Coakley FV, Kurhanewicz J, Reed G, Wang ZJ, Simko JP. Mucinous adenocarcinoma of the prostate: MRI and MR spectroscopy features. AJR Am J Roentgenol. 2009;193:W238-43. doi: 10.2214/AJR.08.1495. PMID: 19696265; PMCID: PMC2801739.  Back to cited text no. 8
    
9.
Epstein JI, Lieberman PH. Mucinous adenocarcinoma of the prostate gland. Am J Surg Pathol 1985;9:299-308.  Back to cited text no. 9
    
10.
Franks LM, O'Shea JD, Thomson AE. Mucin in the prostate: A histochemical study in normal glands, latent, clinical, and colloid cancers. Cancer 1964;17:983-91.  Back to cited text no. 10
    
11.
Ro JY, Grignon DJ, Ayala AG, Fernandez PL, Ordonez NG, Wishnow KI. Mucinous adenocarcinoma of the prostate: Histochemical and immunohistochemical studies. Hum Pathol 1990;21:593-600.  Back to cited text no. 11
    
12.
Moch H, Cubilla AL, Humphrey PA, Reuter VE, Ulbright TM. The 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs-Part A: Renal, Penile, and Testicular Tumours. Eur Urol. 2016;70:93-105. doi: 10.1016/j.eururo.2016.02.029. Epub 2016 Feb 28. PMID: 26935559.  Back to cited text no. 12
    
13.
Osunkoya AO, Nielsen ME, Epstein JI. Prognosis of mucinous adenocarcinoma of the prostate treated by radical prostatectomy: A study of 47 cases. Am J Surg Pathol 2008;32:468-72.  Back to cited text no. 13
    
14.
Marcus DM, Goodman M, Jani AB, Osunkoya AO, Rossi PJ. A comprehensive review of incidence and survival in patients with rare histological variants of prostate cancer in the United States from 1973 to 2008. Prostate Cancer Prostatic Dis 2012;15:283-8.  Back to cited text no. 14
    
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Osunkoya AO. Update on prostate pathology. Pathology 2012;44:391-406.  Back to cited text no. 15
    
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Lane BR, Magi-Galluzzi C, Reuther AM, Levin HS, Zhou M, Klein EA. Mucinous adenocarcinoma of the prostate does not confer poor prognosis. Urology 2006;68:825-30.  Back to cited text no. 16
    
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Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, Humphrey PA, et al. The 2014 international society of urological pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: Definition of grading patterns and proposal for a new grading system. Am J Surg Pathol 2016;40:244-52.  Back to cited text no. 17
    


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