Sarcomatoid carcinoma of prostate involving the whole lower urinary tract and rectum
A 64-year-old man presented to his urologist with complaints of voiding symptoms and urinary retention. The initial prostate specific antigen (PSA) level was 9 ng/ml. He was treated with transurethral resection of prostate (TURP) outside our institute which showed high grade prostatic adeno-carcinoma (Gleason score 4 + 5 = 9). The staging workup subsequently showed a locally advanced prostate cancer. He was also started on hormonal therapy with leutinizing hormone releasing hormone (LHRH) analogue. Two months after initial surgery, he again went into painful urinary retention and per urethral catheterization failed, so a re-do TURP was done. The histopathology confirmed it to be adeno-carcinoma with sarcomatoid variant.\nIn the next six weeks, his voiding symptoms got worse again with gross hematuria culminating into urinary retention and obstructive uropathy, so a supra pubic catheter and bilateral percutaneous nephrostomy (PCN) tubes were placed and he was referred to us for further management. The PSA at this stage was 0.5 ng/ml. The patient also developed severe constipation with deep seated pelvic and perineal pain.\nOn physical examination, a stony hard mass was felt in suprapubic area through which suprapubic catheter was coming out. Another hard mass was felt in the perineum involving the bulb of penis. The digital rectal examination revealed a huge irregular stony hard mass with total occlusion of rectal lumen. An abdomino-pelvic magnetic resonance imaging (MRI) was done that showed an abnormal heterogeneous signal intensity mass lesion in the pelvis showing peripheral post contrast enhancement with central necrotic component measuring 13 × 11 × 14 cm in antero-posterior (AP), transverse and cranio-caudal dimensions and extending down into the perineum where it measures 8.9 × 3.8 × 5.2 cms involving the root of penis. Superiorly it was infiltrating into urinary bladder completely filling its lumen, anteriorly abutting the symphysis pubis, posteriorly involving rectum with loss of fat planes and laterally extending up to lateral pelvic wall []. No metastatic lesion was found on computerized tomography (CT) scan of chest and bone scans.\nBecause of extensive involvement of whole pelvis with severe urinary- and bowel-related symptoms, a total pelvic exenteration with pelvic lymphadenectomy along with urinary and fecal diversion with ileal conduit and an end colostomy formation was done. The pelvic tumor was completely resected in two pieces because of difficult dissection without any spillage and gross evidence of disease at the end of procedure. The residual preineal part of tumor was dealt with an elliptical perineal incision and it was removed from pelvic floor with a wide margin of normal tissue along with total penectomy. A margin of tissue was also resected form anterior abdominal wall along the cystotomy tract [].\nThe pelvic floor was repaired and re-enforced with a vicryl mesh. Hence, complete gross clearance was done with no palpable or visible disease.\nThe final histopathology revealed a mixture of carcinomatous and sarcomatous components comprising of diffuse sheets and aggregate of oval and spindle shaped cells arranged in short interlacing fascicles with areas of chondroid, osteogenic, and squamous differentiation. Cytokeratin AE1/AE3 and cytokeratin cam 5.2 immunohistochemical stains were performed on representative blocks, which showed focal positivity. PSA staining was negative. Two of recovered pelvic lymph nodes showed tumor involvement [].\nThe patient made a wonderful recovery and is still alive 4 months after surgery with no evidence of disease recurrence and metastasis on subsequent imaging (CT scan chest, abdomen, and pelvis).