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CASE REPORT  
Year : 2011  |  Volume : 54  |  Issue : 4  |  Page : 800-802
The synchronous primary carcinomas of the rectum and prostate


1 Department of Pathology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey
2 Department of Surgery, Faculty of Medicine, Celal Bayar University, Manisa, Turkey

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Date of Web Publication6-Jan-2012
 

   Abstract 

The diagnosis of synchronous prostatic and rectal carcinomas is uncommon. To make a correct diagnosis, biopsies of both sites are mandatory. Pathological slides should be compared and immunohistochemical staining should be taken into consideration. In this paper, an unexpected case of synchronous rectal and prostatic carcinomas arising in an 84-year-old male with hematemesis and pelvic pain is reported. These two tumoral components have a distinctive histological appearance. Immunohistochemical evaluation confirmed the diagnosis of these synchronous tumors. This case emphasizes that rectal and prostatic carcinomas can arise simultaneously. In this situation, providing clinicopathological correlation and deciding the necessity of intraoperative consultation in proper time are extremely important.

Keywords: Prostatic carcinoma, rectal carcinoma, synchronous

How to cite this article:
Ayhan S, Ozdamar A, Nese N, Aydede H. The synchronous primary carcinomas of the rectum and prostate. Indian J Pathol Microbiol 2011;54:800-2

How to cite this URL:
Ayhan S, Ozdamar A, Nese N, Aydede H. The synchronous primary carcinomas of the rectum and prostate. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Apr 24];54:800-2. Available from: http://www.ijpmonline.org/text.asp?2011/54/4/800/91513



   Introduction Top


Prostatic and colorectal carcinomas are the most common cancers in the world. Both of them have peak incidence in the elderly and similar etiological factors related to genetic alterations, environmental influences and dietary products, play important role in their pathogenesis. [1],[2] Additionally, hormonal factors have some effects on the development of prostatic carcinoma. [2] Although the diagnosis of synchronous rectal and prostatic carcinomas is not rare, it is usually surprising for the surgeons. [3],[4],[5],[6]

Synchronously arising colorectal and prostatic carcinomas presented in this case report is confusing because of the lack of any clinical information about the presence of two primary tumors.


   Case Report Top


An 84-year-old male with hematemesis and pelvic pain was admitted to the hospital. Although no abnormality on the anal region was detected by physical examination, a digital rectal examination revealed a rigid and painful mass encircled the lumen of intestine and located 4 cm away from the anal verge. The patient was then referred to a colorectal surgeon. No other lesion within the rectum or colon was visualized via colonoscopy. A biopsy of the rectal mass confirmed a well-differentiated adenocarcinoma of rectum and a computed tomography (CT) scan of abdomen and pelvis demonstrated that the tumor was circumferentially located up to 5 cm from the proximal anus, particularly on the left postero-lateral wall of distal rectum. The size of the conterminous prostate tissue was evaluated in consistent with the age of the patient. Any diagnostic approach for prostate was not needed in the absence of clinical findings or complaints. Miles operation was performed and surgical specimen was sent to pathology department. Unfortunately, the patient was lost postoperatively because of complicating of pulmonary edema and pneumonia. No post-mortem examination was performed.

The surgical specimen was fixed in 10% neutral buffered formalin and representative tissue samples were processed by conventional methods. Sections cut at 5 μm were stained with hematoxylin and eosin. Immunoperoxidase staining was performed using the antibodies cytokeratin 20 (CK20, clone K s 20.8, Novocastra Laboratories, Newcastle, UK) and prostate-specific antigen (PSA, clone ER-PR8, DAKO Corporation, Carpinteria, CA).

Macroscopical Findings

A 27.5 cm long segment of the large bowel was received for pathological examination. A perforated area of 3 cm in diameter was detected at 4 cm distance from the distal surgical margin right lateral bowel wall. Opening the bowel revealed an annular, ulcerated tumor measuring 7.5 cm in greatest dimension that located 2 cm away from the distal surgical margin. The tumor extended through all layers of the bowel wall and pericolic fatty tissue, reaching the serosal surface. The cut surface of the tumor was firm and white in color with geographical areas of necrosis, as well as pale yellow and white patches in the perforation region [Figure 1].
Figure 1: Gross appearance of transverse section of the large bowel with tumor. Note yellowish areas of the lateral wall of large bowel on the left side

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Microscopical Findings

The tumor was composed of cribriform glands of varying size adjacent with normal colonic mucosa, back-to-back in configuration. The covered epithelium of the malignant glands was consisted of discohesive, atypical cells with eosinophilic cytoplasm, oval-round nuclei and prominent nucleolei as seen in traditional colonic adenocarcinoma [Figure 2]. Perineural invasion and infiltration through the full thickness of the bowel wall and the pericolic fatty tissue were conspicuous. Circumferential surgical margins were also involved. Extensive cytoplasmic staining in tumor cells with CK20 was observed [Figure 3]. Interestingly, the samples taken from the perforation area revealed a second tumor with histomorphological properties in contrast with rectal adenocarcinoma. This tumor contained smaller, irregular neoplastic glands surrounded by fibromuscular stroma. These glands were lined with a single layer of uniform cuboidal cells with enlarged nuclei, prominent nucleolei, and pale clear cytoplasm with a distinctive amphophilic appearance. There was a strong cytoplasmic staining in tumor cells with PSA [Figure 4], but not with CK20. With these features the second tumor was diagnosed as prostatic adenocarcinoma with a Gleason score of 7 (3+4).
Figure 2: Conventional hematoxylin and eosin-stained section shows the areas of mixture of traditional colonic adenocarcinoma on the bottom and prostate adenocarcinoma on the top (hematoxylin and eosin, ×40)

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Figure 3: Diffuse cytoplasmic staining with CK20 in colonic neoplastic glands but negative in prostatic neoplastic glands (CK20, ×200)

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Figure 4: Strong cytoplasmic expression of PSA in the areas of prostate adenocarcinoma but no staining in colonic neoplastic glands (PSA, ×200)

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Additionally, peroperative wedge resection biopsy taken from the liver and six lymph nodes dissected from the pericolic fatty tissue were diagnosed as metastatic rectal adenocarcinoma. Final diagnosis was made as synchronous double pelvic malignancies; an adenocarcinoma of rectum with a clinical stage of T3N1M1, metastatic to liver and lymph nodes, and an adenocarcinoma of the prostate with a clinical stage of T2N0M0.


   Discussion Top


As a consequence of the boost of risk factors, the frequency of malignant tumors and the possibility of simultaneous detection of multiple malignant tumors in the same patient are increasing at present. [7] Actually, there are many common factors concerning the etiology of rectal and prostatic adenocarcinomas; particularly environmental, genetical, hormonal, and nutritional factors. [1],[2] Simultaneous tumors related to hereditary and genetical factors was reported previously. [3],[4],[5],[6] This case is another example, wishing to add to the literature.

Although it is surprising to find two different neoplastic components in the same surgical specimen, the distinctive morphological appearance of the tumors is helpful for the accurate pathological approach. In our case, while the rectal adenocarcinoma exhibited larger cribriform glands with apparent basophilic staining, the prostatic carcinoma displayed a contradictious microscopical appearance with pale-pink stained small glands. Furthermore, CK20+/PSA- tumoral cells for rectal adenocarcinoma and CK20-/PSA+ tumoral cells in prostatic adenocarcinoma confirmed the diagnosis immunohistochemically.

Even though there was no problem about the pathological diagnosis, the patient was lost because of post-operative clinical complications, losing the opportunity for a radical prostatectomy. From this point of view, this case is very instructive for realizing the necessity of clinicopathological correlation. It should be remembered that the screening tests performed pre-operatively are not always efficacious in every case. Therefore, it is extremely important to perceive the need for intraoperative consultation in proper time and to keep the probability of simultaneous multiple tumors in mind, as observed in the present case.

 
   References Top

1.Weisburger JH. Causes, relevant mechanisms, and prevention of large bowel cancer. Semin Oncol 1991;18:316-36.  Back to cited text no. 1
[PUBMED]    
2.Nelson WG, de Marzo AM, Isaacs WB. Prostate cancer: Mechanisms of disease. N Engl J Med 2003;349:366-81.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Iarumov N, Toshev S, Angelov K, Lukanova TS, Gribnev P, Sokolov M. Multiple primary carcinomas of the colon and associated extracolonic primary malignant tumors. Chirurgica 2007;4:5-9.  Back to cited text no. 3
    
4.Colonias A, Farinash L, Miller L, Jones S, Medich DS, Greenberg L, et al. Multidisciplinary treatment of synchronous primary rectal and prostate cancers. Nat Clin Pract Oncol 2005;2:271-4.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Klee LW, Grmoljez P. Combined radical retropubic prostatectomy and rectal resection. Urology 1999;54:679-81.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Baur H, Frimberger M, Altwein JE. Simultaneous radical prostatectomy and partial rectum resection without colostomy. Eur Urol 1997;31:380- 1.  Back to cited text no. 6
[PUBMED]    
7.Ganguly R, Mitra S, Datta AK. Case Report: Synchronous occurrence of anaplastic, follicular and papillary carcinomas with follicular adenoma. Indian J Pathol Microbiol 2010;53:337-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  

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Correspondence Address:
Semin Ayhan
112 Sk., No:33-A, 35050, Evka-3, Bornova, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.91513

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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