|Year : 2020 | Volume
| Issue : 3 | Page : 136-138
Accidentally found metastatic adenocarcinoma of prostate in an incised inguinal hernia sac
Shang-Rong Zhong1, Yu-Wei Lai2, Yih-Yiing Wu3
1 Division of Urology, Taipei City Hospital Renai Branch, Taipei, Taiwan
2 Division of Urology, Taipei City Hospital Renai Branch; Department of Urology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
3 Division of Pathology, Taipei City Hospital Renai Branch, Taipei, Taiwan
|Date of Submission||03-Dec-2019|
|Date of Decision||18-Dec-2019|
|Date of Acceptance||17-Jan-2020|
|Date of Web Publication||26-Jun-2020|
Division of Urology, Taipei City Hospital Renai Branch, No. 10, Sec. 4, Ren'ai Rd., Da'an Dist., Taipei 106
Source of Support: None, Conflict of Interest: None
An 83-year-old male patient received hernioplasty, and the submitted specimen was incidentally found to microscopically have adenocarcinoma of prostatic. He received transrectal ultrasound-guided prostate biopsy and prostate adenocarcinoma with confirmed Gleason score 4 + 5. Inguinal hernia sacs obtained from hernioplasty are routinely sent for pathological examination in some medical facilities although meaningful results are rare. A retrospective study released in 2014 presented only 11 cases (0.35%) of malignancy in a total of 3117 specimens, while one-third of the patients had preexisting malignancies before operations. There were only sporadic cases reports on the prostate cancer disclosed in hernia sacs, while nearly all cases displayed metastasis that was found in the inguinal hernia sac. These findings suggested the advanced nature of the disease and diminished survival time. This report reminds us of the polymorphic characteristics of prostate cancer and its possibility of metastasis in an unusual way.
Keywords: Inguinal hernia, metastasis, prostate cancer
|How to cite this article:|
Zhong SR, Lai YW, Wu YY. Accidentally found metastatic adenocarcinoma of prostate in an incised inguinal hernia sac. Urol Sci 2020;31:136-8
| Introduction|| |
Prostate cancer with inguinal hernia sac metastasis is a rare event. The spread of the prostate neoplasm involved direct, lymphatic, or hematogenous dissemination. Through direct proliferation, the cancer cells may invade the adjacent tissues such as bladder neck, seminal vesicles, urinary sphincters, or the rectum. On some occasions, they might also find a way to invade the easily ignored peritoneum. This kind of advanced nature might denote other occult metastasis and thus insinuating the poor prognosis of the victim. To clarify the necessity of regular microscopic examination of the hernia sac, debate is ongoing, trading off between the cost and efficiency. We are reporting a rare case of prostate cancer with inguinal hernia metastasis.
| Case Report|| |
An 83-year-old male patient was admitted for hernia repair due to a left inguinal bulging mass. The reducible mass had emerged 3 months ago. It was growing in size and getting tender as time went on. There were no abdominal pain, vomiting, constipation, hematochezia, or any other signs of an incarcerated hernia. The patient received hernioplasty then. The submitted specimen of the left hernioplasty was grossly unremarkable. However, microscopically, there were small foci of hyperchromatic atypical cells growing in complex glandular structures or scattering individually [Figure 1]a. The atypical cells were immunopositive for CK (pan-cytokeratin), PSA, and P504S but immunonegative for CK7, CK20, calretinin, and WT-1 [Figure 1]b, [Figure 1]c, [Figure 1]d. Accordingly, a secondary (metastatic or invaded) adenocarcinoma of prostatic origin was diagnosed first.
|Figure 1: Adenocarcinoma in the hernia sac. (a) Scattered and complex glands of hyperchromatic atypical cells (H and E, ×200). (b-d) Immunopositivity of CK (b), PSA (c) and P504S (d) (×100)|
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Tracing back the patient's history, he was generally healthy albeit for hypertension, which was under medical control. He had undergone three times of transurethral resection of the prostate for benign prostate hypertrophy with notable lower urinary tract symptoms in the latest 10 years. He also received a right-side inguinal herniorrhaphy 1 year ago. No malignancy was found in the delivered specimen. He denied abnormal weight loss, bone pain, urinary difficulty, or other aberrancies.
One week later, after the pathological results, the digital examination revealed the rubbery texture of the prostate with no nodule. The transrectal ultrasound showed that the prostate size was 38.7 ml with some hyperechoic lesions. Yet, the serum PSA level was detected to reach 40.37 ng/ml. To further evaluate the possible metastatic nature, we arranged a whole-body bone scan and pelvic magnetic resonance imaging with contrast. Under the T2-weighted image, diffuse low-signal intensity over bilateral lobes of the prostate with equivocal extracapsular and seminal vesicle extension was found. No obvious metastasis was noted in both image modalities following bilateral prostatic specimens that were obtained by transrectal ultrasound-guided prostate biopsy. Histopathologically, characteristic features of acinar adenocarcinoma and Gleason score 9 (patterns 4 + 5) were noted [Figure 2]. Perineural invasion and associated high-grade prostatic intraepithelial neoplasia were also seen. This patient will receive androgen deprivation and radiation therapies over the prostate and inguinal areas at our department as a victim of prostate cancer with distant metastasis.
|Figure 2: Prostatic acinar adenocarcinoma, Gleason score 9 (patterns 4 + 5). (H and E, ×200)|
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| Discussion|| |
Inguinal hernia sacs obtained from the hernia repairs are routinely sent for pathological examination in some medical facilities although meaningful results are rare. Moreover, whether to keep the routine procedure is still in debate. Many kinds of unexpected malignant lesions can be found in the inguinal hernia sacs, and gastrointestinal neoplasm accounts for the majority of cancer origin. A retrospective study that was released in 2014 presented only 11 cases (0.35%) of malignancy in a total of 3,117 specimens attained from all herniorrhaphy. Moreover, as in our case, one-third of the patients were initially diagnosed with cancer through the incidental findings. Although merely one of the 11 patients was derived from an inguinal hernia case, the author still advocated routine examination of all kinds of hernia sacs as a peritoneal biopsy.
Another retrospective study focused on inguinal hernias indicated an even lower rate of metastatic findings among 22,816 patients. Barely 15 cases, consisted of 0.07%, had metastatic tumors in their inguinal hernia sacs. In spite of excluding grossly normal sacs into evaluating histologically in the first place, they approved selective microscopic examinations for inguinal hernia sacs with grossly apparent abnormalities to justify the expense and avoid missing occult malignancy. The latest review left the decision of microscopic examination of inguinal hernia sacs to the choices of pathologists due to the lower percentage of unseen malignancy compared to abdominal hernia sacs. Existing case reports on prostate cancer disclosed in hernia sacs are scarce. Interestingly, nearly all cases in the literature displayed metastasis found in the inguinal hernia sac, instead of abdominal or femoral hernia to our knowledge.,,,,] The spermatic cord might provide a direct path for the localized spread of the tumor and explain the phenomenon. These discoveries suggested the advanced nature of the disease and diminished survival time. However, the primary prostate carcinomas stand out with a relatively longer survival period (mean: 53 months) compared with other cancer origins.
This patient reminds us of the polymorphic characteristics of prostate cancer and its possibility of metastasis in an unusual way, providing us with chances to consider new standards of procedure to enhance the patient health after pondering the diagnostic value of incised hernia sacs, which can be regarded as an opportunity of peritoneal evaluation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]