A case of prostatic adenocarcinoma recurrence presenting as ductal carcinoma of the prostate.

Background: A 61-year-old man with a history of recurrent prostate cancer presented with obstructive urinary symptoms. He had been diagnosed with locally invasive adenocarcinoma of the prostate 10 years previously and treated with neoadjuvant hormonal and external beam radiation therapies. Because of the patient's rising PSA level, he had been started on goserelin 6 years after this diagnosis and bicalutamide 6 months before the current presentation. The patient presented to the urology clinic with worsening lower urinary tract symptoms consisting of nocturia, urgency, and weak stream.

Investigations: Physical examination revealed a largely normal digital rectal examination, although there was slight asymmetry. The post-void residual urine volume was approximately 200 ml. Laboratory tests showed no evidence of urinary tract infection, but confirmed a rising PSA level despite low serum testosterone levels. Cystoscopic examination revealed hypervascular, large lateral prostatic lobes obstructing the bladder neck. The bladder was normal.

Diagnosis: The patient underwent transurethral resection of the prostate. Soon after the resection started, bilateral papillary tumors arising from the stroma of both prostatic lobes were uncovered. Owing to the diffuse nature of the papillary tumors, complete resection was not possible. Pathologic analysis confirmed the presence of ductal carcinoma of the prostate.

Management: The patient had an uneventful postoperative course and reported improvement of voiding symptoms. Staging with bone scan and CT of the abdomen and pelvis demonstrated multi-focal bony metastasis. The patient was started on docetaxel-based chemotherapy for hormone refractory recurrence of prostate cancer as ductal carcinoma of the prostate. He remains under close surveillance for clinical response and progression of disease.