Obstructive jaundice as a presenting symptom of metastatic carcinoma of the prostate

Abstract

Liver dysfunction is not an uncommon association with malignancy. However, obstructive jaundice as the first clinical presentation of metastatic carcinoma of the prostate is rare with only a few such cases reported in the literature. The aetiology of obstructive jaundice in these cases can be due to direct invasion of the tumour or external compression of the biliary tree or, rarely, related to a paraneoplastic phenomenon. Here, we report a case of obstructive jaundice being the presenting symptom of metastatic carcinoma of the prostate secondary to lymph node obstruction and review the literature.

BACKGROUND

This case is a good example of how a very common disease can present in an unusual way. Furthermore, the case illustrates an unusual association of disease with these biliary symptoms. Finally, there is an important message that middle-aged or elderly men with obstructive jaundice that has no obvious common cause such as gallstones or sepsis require a prostatic assessment.

CASE PRESENTATION

A previously fit 65-year-old man presented to his general practitioner (GP) with clinical jaundice and non-specific symptoms of malaise, weight loss and bony pain. Initial haematological and biochemical screening revealed normal renal function, anaemia (Hb 10.4 g/dl), deranged liver function (bilirubin 122 μmol/l, alkaline phosphatase 1560u/l, alanine transaminase 230u/l, gamma-glutamyl transpeptidase 1479 u/l) and markedly elevated prostate-specific antigen (PSA) of 537ug/l. An urgent referral was made to the urologist.

Clinical assessment in the urology clinic showed that the patient complained of intermittent paraesthesia in his lower limbs and difficulty in mobilising compared with previously. He did not complain of any lower urinary tract symptoms. Examination revealed no focal neurological deficit with a normal gait. Abdominal examination was unremarkable. Digital rectal examination revealed a malignant-feeling prostate (T3/T4). A chest x ray arranged by the GP showed an abnormality in the thoracic spine; however, on direct questioning, there was a history of thoracic vertebral trauma from a previous road traffic accident.

INVESTIGATIONS

The patient was admitted for urgent investigations. Subsequent MRI of the spine was carried out, which showed no evidence of cord compression but demonstrated extensive bony metastases and a few pre-vertebral lymph node masses (fig 1). Ultrasound scan of the abdomen showed infiltration of the liver at the hilar region with dilatation of the hepatic ducts but non-dilated common bile duct, no evidence of gallstones and bilateral mild to moderate hydronephrosis, left worse than right. A staging CT scan of the abdomen and pelvis showed multiple sclerotic vertebrae and pelvic metastases, retrocrural, para-aortic, mesenteric and iliac lymphadenopathy, and moderate intra-hepatic biliary dilatation, secondary to an ill-defined low-density lymph node mass encasing the portal vessels at the hepatic hilum (fig 2).

Figure 1.

MRI scan of spine demonstrating extensive bony metastases and a few pre-vertebral lymph node masses.

Figure 2.

CT of abdomen and pelvis showing peri-hepatic lymph node mass and intra-hepatic bile duct dilatation.

TREATMENT

The patient proceeded to bilateral subcapsular orchidectomy (BSO). He also underwent trans-rectal ultrasound-guided biopsy of the prostate, which confirmed prostate adenocarcinoma, with a Gleason score of 5+4=9 and focal high-grade prostatic intra-epithelial neoplasia (PIN).

An endoscopic retrograde cholangiopancreatography performed by the gastroenterology team did not clearly demonstrate biliary obstruction. A MR cholangiopancreatogram study performed a few days later also revealed no significant intrahepatic or extrahepatic ductal dilatation. These investigations were carried out following BSO and, therefore, it is possible that the lymph node mass began to regress and, thus, relieve the obstruction initially caused.

OUTCOME AND FOLLOW-UP

His liver function values improved and PSA level declined (see table 1) and he was discharged. Three months later he was reviewed in urology clinic and he remains well. Liver and renal function blood tests are normal and he is symptom free. His last PSA increased to 16 and, therefore, he was started on bicalutamide 50 mg once a day—that is, maximum androgen blockade. He is planned for further follow-up with PSA surveillance and a repeat ultrasound scan of his urinary tract.

Table 1.

Trend of biochemistry results

	Date
	14/1/08	25/1/08	Surgery: bilateral subcapsularorchidectomy (28/1/8)	29/1/08	2/2/08	4/2/08	18/4/08
PSA (ng/ml) range: 0–4.5	537.0	492.1			278.1		11.4
Bilirubin (μmol/l) range: 1–17	122	152		277	104	81	4
ALP (IU/l) range: 42–129	1560	1606		1543	1335	1048	82
ALT (IU/l) range: 0–40	230	150		170	113	78	25
GGT (IU/l) range: 5–60	1479	1038		948	794	662	47

ALP, alkaline phosphatase; ALT, alanine transaminase; GGT, gamma-glutamyl transpeptidase; PSA, prostate-specific antigen.

DISCUSSION

Metastatic carcinoma of the prostate (MCP) can present with a wide range of symptoms, such as weight loss, lethargy, anaemia, bladder outflow obstruction symptoms and bone pain. Biliary signs and symptoms are a rare presenting feature. Previous reports have described obstructive jaundice as a presenting feature of MCP, where the metastasis has been to the head of the pancreas,¹ surrounding the common bile duct causing compression,² a retroperitoneal mass causing compression of the common and pancreatic ducts,³ or secondary to enlarged lymph nodes causing biliary obstruction as in our case.^4,5

Treatment in such cases involves treatments for MCP such as hormonal manipulation and relief of biliary obstruction that may require biliary stenting if the patient is septic. In our case, there were no signs of sepsis and a decision was made to perform a bilateral subcapsular orchidectomy as hormonal treatment was not suitable due to markedly deranged liver function and the possibility of hepatotoxicity.^6,7 Clinically, the patient’s jaundice resolved and his serum liver function tests as well as PSA have all improved suggesting regression of the lymphadenopathy causing obstruction.

Cole et al in their case report where the presenting PSA was 9996 showed that, with the use of maximum androgen blockade, serum liver function blood tests returned to normal within 1–2 weeks and at 1 month the patient’s PSA had reduced to 1028.⁴ Similarly, in another case, with a presenting PSA of 100 and biliary obstruction secondary to lymph nodes from MCP, a combination of flutamide and orchidectomy obtained disease control and reversal of clinical jaundice.⁵ In this case, after 3 years follow-up and a maintenance hormone programme, the patient is well.

The usual differential diagnoses of a previously well patient presenting with obstructive jaundice are that of infectious aetiology, mechanical/anatomical obstruction (for example, gallstones) cholangiocarcinoma or local infiltration of metastases. A paraneoplastic phenomenon is presumed when all of the aforementioned causes have been ruled out. This unusual phenomenon occurs in malignancies that usually do not involve liver metastases.^8,9 The pathophysiology of a paraneoplastic syndrome in prostate carcinoma still remains largely unexplained.

Biliary signs and symptoms are unusual clinical presentation of MCP, which can make the diagnosis difficult. Hence, one should always bear in mind the possible diagnosis of prostate carcinoma, and malignancy of other origin, in male middle-aged or elderly patients presenting with obstructive jaundice that is not due to an infectious aetiology or biliary lithiasis. In such cases we would advocate a digital rectal examination and a PSA blood test to be undertaken.

LEARNING POINTS

• Obstructive jaundice is an unusual clinical presentation of metastatic carcinoma of the prostate.

• The aetiology in such cases can be due to direct invasion of the tumour or external compression of the biliary tree from lymph node compression or, rarely, related to a paraneoplastic phenomenon.

• Middle aged or elderly men presenting with obstructive jaundice that is not due to an infectious aetiology or biliary lithiasis should have a digital rectal examination and a prostate-specific blood test to assess the prostate.