Azhar M. Qureshi ( Department of Oncology, Pakistan Institute of Medical Sciences (PIMS), Islamabad. )
While visceral metastases do occur in carcinoma of prostate, its initial presentation as widespread pulmonary metastatic disease is rare1,2. A case of carcinoma prostate which presented as severe, progressive and disabling dyspnoea is reported here.
A 58 years old non-smoker male presented elsewhere with history of progrccsive dyspnoea on exertion for three months. There was no history of hypertension or angina pectoris. He had dry cough but no fever or hemoptysis. He had exertional edema of feet. He was diagnosed as congestive cardiac failure and prescribed oral diuretics, with which there was brisk diuresis but no improvement in dyspnoea. Eventually he was unable to walk and was hospitalised at PIMS. On examination, there was mild cyanosis and pedal edema. Anemia and lymph-adenopathy were absent. Cardiovascular and neurological examination was normal. In the chest, few fine crepitations were heard bilaterally. Abdominal examination revealed no hepatosplenomegaly, masses or ascites. Testes were normal. A hard, enlarged prostate gland was felt on rectal examination. Urinalysis, complete blood picture and liver function tests were normal. Abdominal ultmsound showed no hepatosplenomegaly or hydronephrosis but the prostate was enlarged. Chest X-Ray (Figure I)
showed wide spread bilateral infiltrates, suggesting metastatic disease. A needle biopsy, confirmed adenocarcinorna of prostate. Total acid phosphatase was 40 U/L (Normal upto 11.0), prostatic acid phosphatase (PAP) 10.2 U/L (Normal upto 3.3) and prostate specific antigen (PSA) 260 (normal upto 4.0 ng/ml). He underwent bilateral orchidectomy and semm testosterone fell to anorchid level i.e. 1.1 U/L (normal 10-35.0). To achieve a complete androgen blockade, he was placed on Flutamide (Tab. Eulexin 250 mg), thrice daily, on which he continues todate. The follow-up chest X-mys were taken at monthly intervals and the latest (Figure 2)
showed normal lung fields. P.S.A. and prostatic acid phosphatase have also remained normal. Presently, he is fully active and asymptomatic and has returned back to work. A follow-up bone scan shows no evidence of metastases. A marked reduction in the’ size of prostate is noted in the Ultrasound Scan.
Carcinoma of prostate is usually seen in men over 50 years of age3. The commonest modes of presentation are (a) asymptomatic variety where malignancy is as an incidental finding on chips obtained at T.U.R. for prostatic enlargement4 and (b) bone pains, usually back-ache, due to bony metastases. Visceral metastases area rare presentation of carcinoma of prostate. In the case reported here, there was severe incapacitating dyspnoea with pulmonary metastases. Complete androgen blockade was achieved with bilateral orchiectomy and maintenance therapy with oral flutamide5,6. Completely asymptomatic and fully functional status at 1 year, with normalisation of chest X-ray, bone scan, PSA7 and PAP8 attest to the effectiveness ofFlutamide in the maintenance therapy of metastatic carcinoma of prostate9.
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