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The
UNIVERSITY of WESTERN ONTARIO |
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| Title: | Tumour Seeding | |
| Submitted by: | Jackie Williams | |
| Clinical
History:
|
A
71-year-old man, who had previously been treated with external beam
radiation treatment for clinically localized prostate cancer,
presented with severe perineal pain and obstructive urinary symptoms.
It was decided to treat him with cryosurgery for symptomatic relief.
The patient was informed that a cure was unlikely. He underwent 3-D
ultrasound guided cryosurgery,1, 2 during which 4
cryoprobes were inserted into the prostate, and two freeze/thaw cycles
were rendered to the prostate.
Eighteen months later, the patient represented with a palpable tumour in the subcutaneous tissues of the perineum. |
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| Physical Examination: | The tumour was completely surrounded by fat and was located in the path that had been taken by the cryoprobes. It was not present at the time the cryotherapy was administered. The patient has been commenced on hormone therapy. | |
| Lab Findings: | The
patient was found to have bilateral, Gleason Grade 10 disease that had
biopsy-proven spread into both seminal vesicles, through the capsule
and into perineural tissues.
Eighteen months later, biopsy of the mass showed high-grade prostate cancer and there was also recurrent prostate cancer within the prostate. |
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| Imaging: |
Title of Image
Title of Image |
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| Positive Findings: | There were no distant metastases clinically, on bone scan, on computed tomography or chest X-ray. | |
| Diff Diagnosis: | Recurrent prostate cancer. | |
| Actual Diagnosis: | A case of tumour seeding along a tract that was developed to conduct a cryoprobe through the perineum, into the prostate. | |
| Discussion: | To
our knowledge this phenomenon has not been reported previously in
cryotherapy or other transperineal minimally invasive procedures such
as brachytherapy. Prostate cancer seeding along biopsy needle tracts,
although rare, was recognized during the era of transperineal
biopsies, but has not been reported with transrectal biopsies. Most of
those cases occurred in patients with poorly differentiated tumours,
and their prognosis was generally poor.
With the growing popularity of ultrasound-guided, transperineal, minimally invasive therapies for prostate cancer, practitioners should be aware of the potential complication of tumour seeding along the needle tract. Two possible mechanisms for prostate cancer seeding along a needle tract have been proposed. Kassabian et al.3 found that the prostate secretions from 14% of 76 radical prostatectomy specimens contained malignant cells. As this percentage is similar to that of patients having local recurrence after prostatectomy they postulated that malignant cells in prostatic secretions can cause tract seeding. Eschwège et al.4 found that 80% of patients had prostate cells circulating in their vascular system immediately following radical prostatectomy. They believed that manipulation of the prostate during surgery was responsible for shedding cells into the circulation. During cryosurgery, it is probable that tumour cells are liberated into the blood stream when intra-prostatic tracts are fashioned. Subsequent leakage of contaminated blood from the prostate into the needle tracts within the perineum may seed new tumours. |
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| Conclusion: | Based on this case and other literature reports of cancer seeding along needle tracts, we suggest that prostate trauma be minimized by performing as few needle sticks as possible during minimally invasive therapies such as cryosurgery, and ensuring that blood loss is fastidiously controlled. The possibility of local tumour implantation has to be added to the risk-benefit equation. We also believe that a careful clinical evaluation of the perineum should be included in the follow up of all minimally invasive therapy cases. | |
| References: |
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