M. Hammad Ather ( Section of Urology, Department of Surgery, The Aga Khan University, Stadium Road, Karachi. )
Amanullah Memon ( Section of Urology, Department of Surgery, The Aga Khan University, Stadium Road, Karachi. )
Luekemic infiltration of the prostate is unusual. Acute urinary retention as an initial presentation of chronic lymphocytic leukemia is found only in sporadic cases. Organ confmed adenocarcinoma of prostate associated with chronic lymphocytic leukemia and presenting as acute urinary retention is to our knowledge not reported in literature. This report documents a case of acute urinary retention in a 74-year-old man with chronic lymphocytic leukemia and adenocarcinoma of the prostate.
A 74-year-old male presented to the Emergency Room with a 20-hour history of acute urinary retention. He has been troubled with mild to moderate irritative lower urinary tract symptoms, which were not bothersome. When catheterized in the emergency room 1500 cc of urine drained in the first 15 minutes. The past history revealed hypertension (well controlled), coronary artery by-pass grafting in 1984 for ischemic heart disease, although at present, his cardiovascular status was unremarkable. Digital rectal examination showed a moderately enlarged benign feeling prostate with firm consistency but no nodularity. Since past history of Lower Urinary Tract Symptoms (LUTS) was mild, he was given a trial without catheter after commencement of a-blocker (Terazosin). This, however, failed and he was re-catheterized. His preoperative haemoglobin, hematocrit and total leukocyte counts were normal. An uneventful transurethral resection of prostate was done and he was discharged on the second postoperative day after successfully removing the catheter. Later his histopathology revealed leukciiiic infiltration with 10% chips showing a well-differentiated adenocarcinoma of the prostate (Figures 1 and 2).
Gleason sum was 2+1=3. Serum PSA was 2.1 ng/ml (0-Sng/ml). The bone scan was negative for any metastatic disease. The leukernic infiltrate of the prostate was LCA +ve and cytokeratin -ye. The blood film was highly suggestive of chronic lymphocytic leukemia, his post-operative haemoglobin concentration was 13.6 gm%(11 - 15.5 gm/dl), white blood cell count was 6x109 (4-10) with 47% lymphocytes and platelet count was also normal. Consultations with the haematologist and oncologists derived a consensus that no further treatment was indicated at that stage. Regular follow-ups were recommended and further intervention would only be indicated if haemoglobin and platelet counts showed a decline. Watchful waiting was adopted with regular serum PSA and digitial rectal examinations to monitor the prostate cancer status.
Leukemic infiltration of the prostate is unusual. Most commonly encountered pathology is chronic lymphocytic leukemia. In 1973, Butler and O’Flym1 detected 6 cases of CLL among 4863 consecutive prostatectomies. In a necropsy study of 5962 male subjects with various types of cancer, Zein et al2 found 18 cases of CLL infiltrating the prostate gland among 88 cases of CLL (20.4%). Seventy seven patients died of leukemia showed leukemic involvmenet of the prostate among 776 autopsied leukemia patients (10%).
To our knowledge, prostate cancer associated with chronic lymphocytic leukemia has only been reported once3 in a patient with Klinefelter syndrome with XXY karyotype. Terris et al4 assessed the clinical impact of haematolymphoid malignancies in a retrospective review, discovered during 1092 radical prostatectomies. The overall incidence in their experience was 1 .2%. Of these, there were 9 cases of CLL for which no further treatment was needed. In their opinion majority of ahematolymphoid malignancies discovered at radical prostatectomy do not require further treatment.
Well differentiated adenocarcinoma of prostate with a low Gleason sum in a 74 year old male can be managed by expectant means. Clinically, isolated prostatic involvement by leukemia is generally managed by observation alone5. In our patient due to low potential for progression and relatively benign natural history of both conditions, considered separately, we opted for watchful waiting which concurred with the wishes of the patient too.
1. Butler MR. O’Flynn JD. Prostatic disease in leukemic patients with particular reference to leukemic infiltration of the prostate - a retrospective clinical study. Br. J. Urol. 1973;45:179-83.
2. Zein TA, Huben R, Lane W, et al. Secondary tumors of the prostate. J. Urol., 1985;1 33:6 15-16.
3. Pienkos EJ, Meisner LF. Adenocarcinoina of the prostate in a 41 year old man with XXY karyotype and chronic lymphocytic leukemia: report of a case. J. Urol., 1991;145:148-50.
4. Terris MK, Hausdorff J Freiha FS. Hematolyinphoid malignancies diagnosed at the time of radical prostatectomy. J. Urol., 1997;158:1457-9.
5. Mellemgaard A, Geisler CH, Storm HH. Risk of kidney cancer and other second solid malignancies in patients with chronic lymphocytic leukemia. Eur. J. Haematol., 1994;53(4):218-22.