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To the Editor:
With a reported prevalence as low as 0.56 per cent, the diagnosis of prostatic carcinoma with rectal invasion may not be immediately obvious or even suspected.
We report a case of highly aggressive prostatic carcinoma with widespread local and rectal invasion in a patient who then underwent a total pelvic exenteration to control symptoms. He is presently disease free.
A 60-year-old man presented in June 2006 with a 1year history of a 20-pound weight loss and nocturia of three to four times. A urologist performed a right-sided prostate core biopsy. The tissue was 100 per cent replaced with carcinoma, having a Gleason score of 8. The prostate-specific antigen (PSA) was 80.4. A bone scan was negative for metastatic disease.
He was treated with Lupron Depot® (TAP Pharmaceuticals, Lake Forest, IL) and Casodex® (AstraZeneca, Boston, MA). Flomax® (Astellas Pharma Technologies, Norman, OK) was eventually added in an attempt to ameliorate a weak urine stream with urine straining. His PSA decreased to 10.6 in November 2006. However, in February 2007, his PSA was 97.
A CT scan of the pelvis was obtained. It showed a 9 cm x 9.5 cm x 9.5-cm mass arising from the prostate gland, extending to the right pelvic sidewall with invasion into and compression of the distal rectum (Fig. 1). The mass extended into the right ischiorectal fossa. No evidence of distant metastatic disease was noted. An MRI showed tumor extension into the bladder neck with invasion into the upper anal canal and puborectalis.
His PSA was now 149. In June 2007, external beam irradiation was administered.
Because of the continued rapid growth of his tumor and progression of his symptoms, including...