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 Table of Contents  
Year : 2022  |  Volume : 55  |  Issue : 2  |  Page : 67-69

Colonic perforation due to advanced prostate cancer in prostate-specific antigen era

1 Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Pathology, All India Institute of Medical Sciences, Patna, Bihar, India
3 Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission30-Nov-2021
Date of Decision09-Mar-2022
Date of Acceptance09-Mar-2022
Date of Web Publication25-Apr-2022

Correspondence Address:
Manoj Kumar
Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_238_21

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Prostate cancer presentation with perforation peritonitis due to rectal infiltration is quite rare. We report a 53-year-old man who presented with rectal growth resulting in bowel obstruction and transverse colon perforation, for which emergent exploration was performed. Postoperative evaluation with imaging, serum tumor markers, and histopathological examination including immunohistochemistry revealed it to be prostate cancer infiltrating to surrounding structures including the rectum. It is rare to observe such advanced cases in the era of serum prostate-specific antigen screening, but a high index of suspicion is necessary for adequate diagnosis and treatment, eventually benefitting the patient.

Keywords: Case report, colonic perforation, prostate cancer

How to cite this article:
Kumar M, Sahu RS, Sinha R, Priyadarshi RN. Colonic perforation due to advanced prostate cancer in prostate-specific antigen era. Formos J Surg 2022;55:67-9

How to cite this URL:
Kumar M, Sahu RS, Sinha R, Priyadarshi RN. Colonic perforation due to advanced prostate cancer in prostate-specific antigen era. Formos J Surg [serial online] 2022 [cited 2022 May 26];55:67-9. Available from: https://www.e-fjs.org/text.asp?2022/55/2/67/343818

  Introduction Top

Prostate cancer is among the most common cancers in men and accounts for 7.3% of all cancer cases diagnosed worldwide.[1] The presentation of the disease has been shifted from advanced and metastatic disease to early stage due to readily available prostate-specific antigen (PSA) screening. This has led to a reduction of patients with advanced disease without prior history of cancer. The advanced disease includes T3/T4 or M1 stages with involvement of rectum, bladder, and other pelvic structures or metastasis to distant sites. Such presentations have become uncommon for prostate cancer. However, rectal cancer can still present with obstructing rectal growth,[2] hence, it becomes important to differentiate these two for appropriate treatment of the disease. The differentiation can be challenging based on clinical findings, as both can present with similar complaints of rectal bleeding, tenesmus, altered bowel habits with rectal growth on examination.[3] Rectal cancer can invade the prostate and vice versa. Evaluation with imaging and pathology becomes paramount for these cases. These lesions might cause complete bowel obstruction and may lead to perforation of the dilated bowel if intervention is not performed timely. To the best of our knowledge, no such case was reported in the literature due to prostate cancer. Here, we describe a case of a 53-year-old man with advanced prostate cancer presenting as rectal growth causing bowel obstruction, resulting in perforation of the dilated transverse colon. This case report is in line with the SCARE guidelines.[4]

  Case Report Top

A 53-year-old man presented to our outpatient department with complaints of abdominal pain and distension as well as nonpassage of flatus and stool for 2 days. He also complained of altered bowel habits, feeling of incomplete evacuation of stool, and increased frequency of urination for 2 months. Examination revealed a tense, distended abdomen with generalized tenderness and muscle guarding. Digital rectal examination revealed a proliferative growth 4 cm from the anal verge, not admitting the tip of the finger. X-ray images for the chest and abdomen suggested intestinal perforation. Due to unstable vital parameters, emergent exploratory laparotomy was performed which revealed a hard irregular rectosigmoid growth with multiple large necrotic retroperitoneal lymph nodes [Figure 1]a and a 2 cm × 1 cm transverse colon perforation [Figure 1]b with fecal peritonitis. The perforation site was inflamed but did not show any growth or metastatic deposit. The rest of the bowel, liver, and spleen surfaces were normal. Loop transverse colostomy was performed. Biopsy of mass was taken through the per rectal route intraoperatively, histopathological examination of the lesion was suggestive of adenocarcinoma. The postoperative period was uneventful. Contrast-enhanced computed tomography of the thorax and abdomen was performed in the postoperative period [Figure 2], suggesting a rectosigmoid tumor growth infiltrating sigmoid mesocolon, mesorectum, prostate, seminal vesicle, urinary bladder, and the lateral pelvic wall along with a small enhancing nodule in the right lung. Carcinoembryonic antigen (CEA) was 1.77 ng/mL (normal range 0–2.5 ng/mL), whereas PSA was >100 ng/mL (normal range 0–4 ng/mL). Transrectal ultrasound-guided biopsy of prostate was performed due to raised PSA, which was suggestive of adenocarcinoma [Figure 3]. To differentiate the origin of the rectosigmoid growth, immunohistochemistry (IHC) was performed. Tumor cells were strongly diffuse positive for PSA but negative for CK-7 and CK-20 [Figure 4]. The tumor had Gleason grade group 5 (Gleason score 5 + 5). Diagnosis of prostate carcinoma (T4N1M1, stage IVB) was made and the patient is currently in follow-up for further management.
Figure 1: Intraoperative photograph showing large necrotic retroperitoneal lymph node marked with the forceps (a) and transverse colon perforation (b)

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Figure 2: Contrast-enhanced axial CT image showing enhanced soft tissue involving both prostate and rectum

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Figure 3: Photomicrograph showing solid sheets of malignant cells (arrow) along with normal glands (arrowhead) (H and E, ×100) (a). Enlarged view of tumor cells arranged in sheets surrounding gland-like structures (H and E, ×400) (b)

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Figure 4: On immunohistochemistry (×100), the tumor cells show diffuse granular cytoplasmic positivity for PSA (a), but tumor cells are negative for CK7 (b) and CK20 (c)

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  Discussion Top

Prostate cancer is one of the most common cancers in men, diagnosed usually after the fifth decade of life. There is a shift in the diagnosis of early-stage tumors in relatively younger patients due to readily available PSA screening. In literature before PSA screening, 1%–12% of cases have shown rectal involvement.[5] There are no recent data available regarding rectal involvement in prostate cancer. In the recent era, patients already diagnosed with prostate cancer present with rectal involvement due to disease progression. An initial presentation directly as a rectal growth without any antecedent history of prostate cancer is rarely observed. Only a few cases were reported in the recent literature.[6],[7] Rectal growth, stricture, and ulceration in these patients make it difficult to differentiate prostate cancer from primary rectal cancer based solely on clinical examination.[8] As rectal involvement occurs in advanced stages of the disease, it is usually associated with metastasis at distant sites. Imaging studies might help in identifying the origin, but confirmation with histopathological evidence becomes necessary. PSA, CK20, CDX2, and β-catenin are some IHC markers that help in the differentiation between prostate cancer and rectal cancer.[9] Treatment for advanced disease includes medical or surgical castration and chemotherapeutic agents.

Our case presented with mainly obstructive features related to rectal growth with perforation of the dilated large bowel mandating an emergent exploration. Intraoperative findings suggested rectosigmoid tumor. Diagnosis of prostate cancer was not considered initially. Postoperative imaging showed a growth involving both rectum and prostate, hence, PSA was performed. Due to raised PSA and normal CEA levels, biopsy and IHC became necessary for the diagnosis of the primary site.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-49.  Back to cited text no. 1
Saidi HS, Karuri D, Nyaim EO. Correlation of clinical data, anatomical site and disease stage in colorectal cancer. East Afr Med J 2008;85:259-62.  Back to cited text no. 2
Tang T, Yang Z, Zhang D, Qu J, Liu G, Zhang S. Clinicopathological study of 9 cases of prostate cancer involving the rectal wall. Diagn Pathol 2017;12:8.  Back to cited text no. 3
Agha RA, Franchi T, Sohrabi C, Mathew G, Kerwan A, SCARE Group. The SCARE 2020 guideline: Updating Consensus Surgical CAse REport (SCARE) guidelines. Int J Surg 2020;84:226-30.  Back to cited text no. 4
Guo CC, Pisters LL, Troncoso P. Prostate cancer invading the rectum: A clinicopathological study of 18 cases. Pathology 2009;41:539-43.  Back to cited text no. 5
Chang MD, Davidson AJ, Sutherland T, De Fontgalland D, Johnson D, Wong LM. Unusual presentation of advanced prostate cancer masquerading as metastatic and obstructing rectosigmoid cancer. ANZ J Surg 2017;87:417-9.  Back to cited text no. 6
Salako A, Badmus T, Komolafe A, David R, Igbokwe M, Laoye A, et al. Unusual presentation of advanced prostate cancer in a black population of South-Western Nigeria. Pan Afr Med J 2019;32:15.  Back to cited text no. 7
Bowrey DJ, Otter MI, Billings PJ. Rectal infiltration by prostatic adenocarcinoma: Report on six patients and review of the literature. Ann R Coll Surg Engl 2003;85:382-5.  Back to cited text no. 8
Owens CL, Epstein JI, Netto GJ. Distinguishing prostatic from colorectal adenocarcinoma on biopsy samples: The role of morphology and immunohistochemistry. Arch Pathol Lab Med 2007;131:599-603.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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