CASE REPORT

Prostate Cancer Metastasis to the Stomach: 9 Yearsafter the Initial Diagnosis—Case Report and a LiteratureReview

Raman Mehrzad & Archana Agarwal & Garrey T. Faller &

Joseph A. Fiore

# Springer Science+Business Media New York 2013

Introduction

Prostate cancer is one of the most common types of cancer inmen [1]. It usually grows slowly and remains confined to theprostate gland, in which it need minimal or no treatment.However, metastatic prostate cancer many times results inpoor outcome [2]. Common places of metastasis are to thebones and lymph nodes [3]. Visceral metastases are rare, butwhen they occur, they commonly involve the liver and lungs[3]. Moreover, involvement of the gastrointestinal (GI) tract isextremely rare. There are only a few cases of prostate cancermetastasis to the GI tract reported, including small bowel [4],esophagus [5, 6], and stomach [7–11]. The route of metastasisto the GI tract is unknown, although spread via the lymphaticchannels has been postulated [12].We report a case of prostatecancer with metastasis to the stomach, 9 years after the initialdiagnosis.

Case Report

A 71 year-old-patient with past medical history ofgastroesophageal reflux disease (GERD) was diagnosed withprostate cancer at age 60. He underwent radical prostatectomythe same year of diagnosis and remained symptom free. Nineyears later, the patient developed hip pain. Plain radiograph ofthe hip was concerning for a lytic lesion. Hewas found to havea prostate-specific antigen (PSA) of greater than 2,000 IU andmetastases to the lymph nodes of the hip and pelvis. The

patient received complete androgen blockade therapy withZoladex/Casodex, followed by palliative radiation therapy tothe hip. However, PSA continued to increase. Palliative che-motherapy with Taxotere was started, and Zometa was addedto his regiment. PSA reached to a level of 200 IU, and thepatient’s hip pain improved.

Five months later, the PSA subsequently reached to2,250 IU. Restaging bone scan revealed significant diseaseprogression involving the ribs, spine, and pelvis. This time,the patient presented with nausea and anorexia. Vital signs atthat time were stable (afebrile, BP 124/78, HR 66, RR 16, andO2 sat 98 % on room air), and physical exam wasunremarkable. Labs were significant for WBC 12.0 K/ul,Hgb 12.3 g/dl, Hct 31.8 %, and platelets 335 k/ul. His symp-toms were assumed to be a part of his GERD, and the patientwas prescribed omeprazole. The patient came back on afollow up appointment 1 month later, and his nausea persisted,and hematemesis unrelated to meals or time of the day wasnoted. Physical exam was unremarkable, and labs were sig-nificant for Hgb 11.0 g/dl and Hct of 30.2 %. His PPI treat-ment was continued, and he was referred to a gastroenterolo-gist. A month later, the patient underwent an esophagogas-troduodenoscopy (EGD), which showed superficial gastriculcerations and a 5-mm nodule (Fig. 1). Biopsies were takenfrom four different sites including the nodule. All biopsieswere negative, except for the nodule which showed adenocar-cinoma. The gastric mucosa did not show any dysplasticchanges to support a gastric primary. The neoplastic cellsinvaded the mucosa in a diffuse manner and appeared to beinvading from below. A panel of immunohistochemical stainswas performed. The tumor cells were positive for AE1/AE3keratins, PSA, and prostatic alkaline phosphatase. CK7, C20,and CDX2 were negative. This pattern was consistent with aprostate metastasis (Figs. 2, 3, and 4).

The patient started salvage chemotherapy treatment withmitoxantrone along with Aloxi (palonosetron HCI injections)and dexamethasone. Twomonths after the EGD confirmed the

R. Mehrzad :A. Agarwal :G. T. Faller : J. A. FioreDepartment of Internal Medicine, Steward Carney Hospital, Boston,MA, USA

R. Mehrzad (*)Steward Carney Hospital, 2100 Dorchester Ave, Boston, MA 02124,USAe-mail: raman_m1@hotmail.com

J Gastrointest CancDOI 10.1007/s12029-013-9527-1

diagnosis, the patient had been receiving his second cycle ofchemotherapy with mitoxantrone, and his GI symptoms re-solved, along with an increased sense of appetite. He contin-ued the same treatment. However, 2 weeks later, the patient’ssymptoms recurred, as there was persistent daily vomiting. Healso noticed fatigue and unsteady gait, and there was a cogni-tive decline. A CT scan of the head was ordered but did notshow any metastatic lesions. Compazine was added to hisregimen with a slight improvement of the nausea and vomiting.During the clinical course, the patient had significant hip pain,which had now radiated to his lower back. No cord compres-sion was noted on the MRI of the spine. Ultimately, all symp-toms, including his GI-complaints, progressed, and the patientdied 16 months after initially presenting with hip pain and12 months after the GI symptoms presented.

Discussion

We present this unusual case of metastatic prostate cancer tothe stomach that presented 9 years after the initial diagnosis.Most of the previous cases described have had similar presen-tations and outcomes [7–9]. All cases were diagnosed in a latephase of the disease. Here, we discuss these previously re-ported cases in regards to symptoms, diagnosis, treatments,and outcomes (Table 1).

Symptoms

Once the prostate cancer metastasized to the stomach, thepresenting symptoms previously reported includes nauseaand vomiting [7–10], abdominal discomfort [7, 9], anorexia[10, 11], and weakness/generalized malaise [8, 10]. Othersymptoms reported include decreased appetite, hematemesis,melena, dysphagia, anasarca, and back pain [7–11].

Of the six previous cases reported, all patients, except in one,had prior metastasis within the bones [7, 8, 10, 11], and two ofthem had previous metastasis to the brain [7, 8]. The severity ofsymptoms was dependent on the stage of the primary tumor.Notably, patients were more likely to present with numerous andmore severe GI-symptoms if previousmetastasis was present priorto the stomach metastasis [7–9]. Interestingly, physical exam wasnormal, except for an enlarged prostate, in most cases [7–10].

Diagnosis

In all cases, some form of upper gastrointestinal symptom waspresent [7–11]. Thus, symptoms such as nausea, epigastric pain,decreased appetite, or dysphagia ultimately lead to a diagnosticprocedure with an EGD and biopsy. The most common

Fig. 1 Five millimeter gastric body nodule

Fig. 2 PSA immunohistochemical stain. The top left aspect of thisimages show benign gastric glands. The reminder consists of malignantglands which stain for PSA. The positive staining areas are brown

Fig. 3 H&E slide: medium power. This micrograph shows the malignantglands intimately admixed with some benign gastric glands. The benignglands are located top left

Fig. 4 H&E stain: high power. This micrograph is of the malignantglands. The once cell in the middle shows a prominent nucleolus whichis a common albeit nonspecific findings in prostate adenocarcinoma

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endoscopic finding was gastric ulceration [7, 8, 11]. Otherendoscopy findings included poorly distensible stomach with

prominent rugal folds, irregular mucosal folds, marked conver-gence ofmucosa folds, and friable lesions extending through the

Table 1 Summary of all reported cases of prostate metastasis to the stomach

Age andpresentingsymptoms

Stage ofprostatecancer atdiagnosis

Gleason’sscore

Findings on EGD Histology Treatment Prognosis and cause of death Ref.

88 year old.Decreasedappetite,vomiting,epigastricdiscomfort

N/A 2+5 (7) Large gastric folds Gastritis with inflammatory,atypia, and PSA positive

NA Non reported 5

66 year old.Abdominaldiscomfort,nausea andvomiting

Multiplebonemetastasis

5+4 (9) Elevated mucosalulceration on theanterior wall ofthe gastric antrum

Undifferentiated carcinoma.Biopsies showedinfiltration of neoplasticcells with marked atypicalnucleoli and abundanteosinophilic cytoplasm.PSA stained positive.

Chemotherapy Deceased 23 months afterinitial diagnose of prostatecancer and 5 months afterthe symptoms started

1

57 year old.Decline inhealth,weakness,nausea,vomiting,decreasedappetite

Nometastasis

5+4 (9) Prominent rugalfolds andulcerations distalto thegastroesophagealjunction and alongthe lessercurvature.

Biopsy revealed clusters ofmonotonous neoplasticcells with round nuclei andamphophilic cytoplasm.Tumor wasimmunoreactive for PSAand cytokeratin

TAB GI symptoms started15 years after theelevation of PSA. Onemonth follow up visit afterthe diagnosis of metastaticstomach, cancer wassettled and treated, thepatient was asymptomatic.PSA dropped from 1,660to 58.6, and furtherprognosis was notrevealed.

2

89 year old.Hematemesis.

Metastasisto thebrain andskeleton

N/A >5 cm board basedulceratedexophytic lesionin the gastric body

The biopsy of the lesion wasimmunoreactive for PSA.

TAB GI symptoms started19 months after the initialdiagnose of prostatecarcinoma, and the patientdeceased 9 months afterthe presenting GIsymptoms and thediagnosis of stomachcancer

2

67 year old.Anorexia,poor physicalcondition,and nausea.

Metastaticlesionsaffectingthe entirespine andboth hips

N/A Multiple tumor-suspicious lesionsin the stomach

Poorly differentiatedadenocarcinoma of theprostate with positive PSAstains

TAB PSA dropped from 171 to 44in 9 days. Furtherprognosis was notrevealed.

6

69 year old.Anorexia andupper GIbleed.

Multiplebonemetastasis

3+4 (7) Multiple ulcerationsin the gastric body

Infiltration of the neoplasticcells with round nuclei andabundant eosinophilic toamphophilic cytoplasm.The neoplastic cellsstrongly immunoreactivefor PSA

TAB Stable at 7 months afterdiagnosis.

11

71 year old.Nausea andanorexia.

Multiplebonemetastasis

N/A Superficialulcerations and a5 mm nodule

Infiltrative IHC panelstrongly positive for AE1/AE3 with diffusemoderate intensity stainfor PSA

Chemotherapyand TAB

Deceased 12 years afterinitial diagnose of prostatecancer and 12 monthsafter the diagnosis ofstomach metastasis

NA not applicable, TAB triple androgen blockade

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mucosa [7–11]. Ultimately, a biopsy established the final diag-nosis in all mentioned cases. PSA immunohistochemical stainswere positive.

Notably, all patients had a PSA above 100 IU, whereas in twocases (including our case), the PSA level was >1,000 IU [8].

Treatment

In previous reported cases, the treatment was mainly with che-motherapy and hormonal therapy [7–11]. In regards to chemo-therapy, docetaxel, combinedwith prednisone, was among in thementioned therapies [7]. Leuprolide, bicalutamide, Dutasteride,and flutamide were among thementioned hormonal therapies [7,8, 10, 11]. One case reported treatment with radiation therapy[8]. Moreover, Ondansetron and corticosteroids was given fornausea and vomiting, megestrol was given as an appetite stim-ulant, and morphine was given for pain [8, 10, 11].

Prognosis

The prognosis of prostate cancer metastasis to the stomach issupposedly poor. Previous cases report an overall low survivalrate (5 to 12 months) from discovery of metastasis to the GItract to the patient’s death [7, 8]. However, in two cases, one inwhich GI symptoms started 15 years after the elevation ofPSA, the patient was asymptomatic 1 month after the initialdiagnosis was confirmed, and treatment was started, with adrop in PSA from 1,660 to 58.6 IU [10]. In the second case,the patient was stable with no symptoms 7 months after theinitial diagnosis of stomach metastasis [11]. One case did notreveal a final outcome [9].

Conclusion

Prostate cancer metastasis to the gastrointestinal tract is veryrare, and its prognosis is supposedly poor [7, 8]. Generalcomplains of nausea, vomiting, and abdominal pain can benonspecific in patients with prostate cancer. However, westress that these symptoms should be obtained as a part ofthe full history on every follow up visit to help assess anysigns of this rare type of metastasis. Moreover, asking aboutGI symptoms when patients present with bone or brain me-tastasis, and/or a very high PSA, should also be emphasized.

Common symptoms of primary stomach cancer includeheartburn, abdominal discomfort, nausea, vomiting, loss ofappetite, weakness, and fatigue [13, 14], all of which aresimilar to metastatic cancer to this visceral organ. Similarly,

these symptoms are subjective and nonspecific, and usuallyguide physicians to more benign disorders, making it difficultto establish a diagnosis of stomach cancer metastasis.

Ultimately, gastric biopsies established the final diagnosisin all described cases, even though obvious endoscopy find-ings of a tumor was not always present [7, 10, 11]. Thus, whilemacroscopic findings are not always present, biopsies shouldbe obtained when suspicion is there.

Conflict of Interest The authors declare that they have no conflict ofinterest.

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