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A case of sarcomatoid carcinoma of the prostate in a 51-year-old male


Jerzy Hankus1, Katarzyna Gronostaj2, Krzysztof Januszewski3, Szymon Zięba4, Anna Kruczak5, Piotr Chłosta2, Janusz Ryś5, Krzysztof Okoń1



Introduction

Sarcomatoid carcinoma of the prostate (SCP) is a malignant neoplasm containing epithelial and mesenchymal components [1, 2]. SCP is a rare (<1% of all prostate neoplasms) tumour occurring in elderly men. It presents with urinary tract obstruction. Some patients have a history of prior prostate adenocarcinoma diagnosis and radiation or hormone therapy. The prognosis is poor, due to high range of recurrence and metastases. Five-years survival with local disease is about 55%; overall survival with bladder invasion – 9 months and metastatic disease – 7.1 months [3-6].


Patient description

A 51-year-old Caucasian male reported to the outpatient clinic of the Urology Department because of lower abdominal pain. He confirmed a history of lower urinary tract symptoms but haematuria was negative. The digital rectal examination revealed a palpable, fixed tumour of the prostate. On CT the gland was sized 5.4×5.2 cm with heterogeneous tissue density. Colonoscopy showed no abnormalities. Biopsy of the prostate was done. The tissue samples obtained during the core biopsy were fragmented; total length up to 14mm and contained spindle cell component with marked atypia and foci of necrosis. On immunohistochemistry tumour cells were positive for vimentin and weakly positivity do SMA, CD99 and S100 while ER, PR, CD45, CK, AMACR, p63, CD34 MyoD1, CD117, CD34, EMA, CK AE1/AE3 and ALK were negative. Basing on these findings suspicion of stromal tumour of uncertain malignant potential was raised. The case was reviewed in the Pathology Department of University Hospital in Kraków and the impression of mesenchymal lesion was confirmed, with the proposed differential diagnosis of stromal prostatic malignancy or solitary fibrous tumour; the diagnosis of sarcomatoid carcinoma was deemed less likely because of negative epithelial markers. MRI done after biopsy showed a polycyclic contrast enhancing tumour sized 8.6×7.6×10 cm, located between the bladder and rectum and infiltrating almost the entire prostate and right seminal vesicle. Within the lesion, fluid areas and foci of necrosis were seen (Fig. 1 a-c).


figure1a
figure1b
figure1c

Figure 1 a–c. MRI showed a polycyclic contrast enhancing tumour sized 8.6×7.6×10 cm, located between the bladder and rectum and infiltrating almost the entire prostate and right seminal vesicle. Within the lesion, fluid areas and foci of necrosis were seen. [please click on the images to enlarge]


Treatment

The patient was transferred to the Urology Department of the University Hospital in Kraków and cystoprostatectomy was performed; the resected material was sent to the Pathology Department. The specimen was sized 6×9×7 cm, consisted of prostate gland and the urinary bladder. The dissection revealed a solid, whitish-gray infiltrate involving prostate and adjacent portion of the bladder (Fig. 2). On microscopic examination the lesion was composed of polygonal medium-sized cells in some areas with hyperchromatic nuclei and prominent nucleoli (Fig. 3). The other areas consisted of spindle cells arranged in fascicles (Fig. 4). This gave the tumour a vaguely biphasic look. Foci of necrosis were present. In contrast to the biopsy material, both components were positive for CK AE1/AE3, while epithelioid component showed also positivity for CK18, ERG and PSA (Fig. 5, 6), while sarcomatoid element was positive for vimentin, CD99 and bcl2. For ruling out synovial sarcoma, FISH examination for t(X;18) translocation was done, which produced negative results. Basing on these findings the diagnosis of sarcomatoid carcinoma was given. The tumour stage was pT4 N0 R1 LV1. Postoperative course was uncomplicated. Two months after surgery, nephrostomy was needed because of hydronephrosis. By the date of publication, the patient underwent adjuvant therapy because of local recurrence and metastases to the lymph nodes and lungs.


Conclusions

The diagnosis of sarcomatoid carcinoma is difficult, especially biopsy material. It should be however taken into account in case of suspected primary sarcoma of the urinary organs.




















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figure2

Figure 2. The specimen was sized 6×9×7 cm, consisted of prostate gland (right side) and urinary bladder (left side). The dissection revealed a solid, whitish-gray infiltrate involving the prostate and adjacent portion of the bladder.
[please click on the image to enlarge]


figure3

Figure 3. On microscopic examination the lesion was composed of polygonal medium- sized cells in some areas with hyperchromatic nuclei and prominent nucleoli (100×).
[please click on the image to enlarge]


figure4

Figure 4. The other areas consisted of spindle cells arranged in fascicles. This gave the tumour a vaguely biphasic look. Foci of necrosis were present (100×).
[please click on the image to enlarge]


figure5

Figure 5. CK18 positivity in epithelioid component (400×).
[please click on the image to enlarge]


figure6

Figure 6. ERG positivity in epithelioid component (400×).
[please click on the image to enlarge]


References

[1] Rogers CG, Parwani A, Tekes A, et al. Carcinosarcoma of the prostate with urothelial and squamous components. J Urol 2005; 173:439-40.
[2] Delahunt B, Eble JN, Nacey JN, et al. Sarcomatoid carcinoma of the prostate: progression from adenocarcinoma is associated with p53 over-expression. Anticancer Res 1999;19:4279-83.
[3] Hansel DE, Epstein JI. Sarcomatoid carcinoma of the prostate: a study of 42 cases. Am J Surg Pathol 2006; 30:1316-21.
[4] Markowski MC, Eisenberger MA, Zahurak M, Epstein JI, Paller CJ. Sarcomatoid Carcinoma of the Prostate: Retrospective Review of a Case Series From the Johns Hopkins Hospital. Urology 2015; 86:539-43.
[5] Furlan SR, Kang DJ, Armas A. Prostatic Carcinosarcoma with Lung Metastases. Case Rep Oncol Med 2013; 2013:790790.
[6] Perez N, Castillo M, Santos Y, et al. Carcinosarcoma of the prostate: two cases with distinctive morphologic and immunohistochemical findings. Virchows Arch 2005; 446:511-16.

Conflict of interest: none declared

Author’s affiliation:
1 Department of Pathology, Jagiellonian University Medical College, Kraków
2 Department of Urology and Oncologic Urology, University Hospital, Kraków
3 Independent Public Clinical Hospital No. 7 of the Silesian Medical University, Katowice
4 Provincial Specialistic Hospital No. 5, Sosnowiec
5 Department of Tumor Pathology, Centre of Oncology,
M. Sklodowska-Curie Memorial Institute, Kraków

Corresponding author:
Jerzy Hankus
Department of Pathology
Jagiellonian University Medical College
ul. Grzegórzecka 16
31-531 Krakow, Poland
e-mail: jerzy.hankus@uj.edu.pl
ph: +4812 61 99 624

To cite this article: Hankus J, Gronostaj K, Januszewski K, Zięba S, Kruczak A, Chłosta P, Ryś J, Okoń K. A case of sarcomatoid carcinoma of the prostate in a 51-year-old male. World J Med Images Videos Cases 2017; 3:e49-54.

Submitted for publication: 4 September 2017
Accepted for publication: 29 September 2017
Published on: 23 November 2017



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