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MALIGNANT ASCITES : AN EXTREMELY RARE MANIFESTATION OF PROSTATE CANCER Deligiannis Georgios MD 1, Papadatos Stamatis MD 1, Zisis Christos MD 1, Milonas Stephanos MD 1 1 2 nd Clinic of Internal Medicine, General Hospital of Trikala, Greece

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INTRODUCTION - DESCRIPTION Prostate cancer is one of the most common types of cancer and the second cause of cancer related deaths in men. Some patients have prolonged survival, even after the cancer has metastasized to distant sites, such as to bones. 1 Hematogenous metastases are present in 35% of patients with prostate cancer, with most frequent involvement sites being bone (90%), lymph nodes, lung, liver and adrenals. 2 3 4 The peritoneum is an extremely rare metastatic site for prostatic adenocarcinoma, with only a few cases published to date. Effusions (either pleural or abdominal) are relatively uncommon in this disease, but usually occur as a result of soft tissue lesions. 2 Malignant ascites, a manifestation of advanced malignant disease, usually follows peritonitis carcinomatosa, indicating the presence of malignant cells in the peritoneal cavity. 5 Malignant ascites is usually caused by intra-abdominal tumors, and ovarian cancer is the most common one. Only a minority of malignant ascites are caused by prostate cancer. Prostate Specific Antigen (PSA) in serum and the ascetic fluid are useful to screen the possibility of prostate cancer in a patient with malignant ascites. We were confronted with a case of ascites in a man with known heart failure and prostate cancer with bone metastasis. In such a case, the investigation of the origin of the ascetic fluid is very important, as a malignant effusion associated with prostate cancer may change the therapeutic plans and confer a poorer outcome. The chart below shows the cancer survival rates for patients with metastatic prostate cancer, who were diagnosed between 2000 and 2011. The SEER (Surveillance, Epidemiology, and End Results Program) data represent national results over a large number of institutions.

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CASE REPORT A 69 year old man with moderate heart failure (NYHA III) and prostate cancer with bone metastasis presented in our emergency department in January 2015 complaining of abdominal fullness and dyspnea. ___________________________________________ Physical examination revealed distended abdomen with shifting dullness Abdominal ultrasound revealed ascites with no evidence of cirrhosis Serology for viral hepatitis was negative and LFTs were within normal limits Laboratory investigation showed increased serum PSA levels of 115.23ng/mL The diagnosis of prostatic adenocarcinoma had been made four years ago (Gleason grade 4+3=7/10). At that time the patient underwent radiation therapy. In September 2014 he was diagnosed with bone metastasis, along with rise of serum PSA and therefore started receiving hormonal therapy (bicatulamide and triptorelin) 3 The patient was admitted to our department for further investigation of the ascites. _______________________________________________ A diagnostic and therapeutic abdominal paracentesis were performed A full body CT scan showed no new secondary sites other than the bone metastases and an enlarged prostate gland Chemical analysis of the ascetic fluid revealed its exudative nature ( albumin gradient SAAG100.00ng/mL) measured in the peritoneal fluid confirmed the diagnosis of ascites secondary to prostate cancer

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4 Petrakis D et al., An unusual presentation of a patient with advanced prostate cancer, massive ascites and peritoneal metastasis: Case report and literature review, J Adv Res (2014), http://dx.doi.org/10.1016/j.jare.2014.05.002

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DISCUSSION - CONCLUSIONS Around 10% of all cases of ascites are malignant. 6 In addition to clinical history and physical examination tumor markers and cytologic analysis may be useful in identifying the primary origin of the malignancy. Ultrasonography, CT and MRI are helpful for detecting the presence of solid tumor in the abdomen. Exploratory laparoscopy can also be performed during the investigation of ascites. Carcinoma of the prostate can metastasize to nearly every organ in 35% of cases, with a marked predilection for osseous spread. Malignant effusions, whether pleural or peritoneal, are extremely rare clinical manifestations of prostate cancer and may be the only signs of recurrence of prostate cancer or may constitute the initial manifestation of prostatic adenocarcinoma. Invasion of the mesothelial lining by malignant cells is considered to be a triggering factor in the pathogenesis of a body cavity effusion such as ascites. It is also suggested that the effusion may develop secondary to the obstruction of lymphatics, or that may be the result of prostatic lymphatic carcinomatosis. To conclude, since an unusual presentation like malignant effusions may be encountered, therefore, oncologists, urologists and primary care physicians should be aware of this complication of the prostate cancer. PSA measurement in the ascetic fluid may be a valuable adjunctive study for the diagnosis effusions in prostate cancer. 5

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LITERATURE CITED 1. American Cancer Society. Cancer Facts and Figures 2004. Atlanta, Ga: American Cancer Society; 2004. 2. Bubendorf L, Schopfer A, Wagner U, Sauter G, Moch H, Willi N, et al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol 2000;31(5):57883. 3. Conti G, La Torre G, Cicalese V, Michaletti G, Ludovico MG, Cottonaro G, et al. Prostate cancer metastases to bone: observational study for the evaluation of clinical presentation, course and treatment patterns. Presentation of the METAURO protocol and of patient baseline features. Arch Ital Urol Andro 2008;80(2):5964. 4. Saiton H, Hida M, Shimbo T, Nakamura K, Yamagata J, Satoh T. Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved. Cancer 1984;54(12): 307884. 5. Tamsma JT, Keizer HJ, Meinders AE. Pathogenesis of malignant ascites: Starling's law of capillary hemodynamics revisited. Ann Oncol. 2001 Oct; 12(10): 1353-7. 6. Runyon BA: Care of patients with ascites. N Engl J Med 1994; 330: 337-342. 6 THANK YOU FOR YOUR ATTENTION