Brief History - tmuh.org.tw · Lower urinary tract symptoms for months, diagnosed of BPH, under medical treatment at 三總Hospital. PSA checked at 三總H. : 2.0 ng /dl (< 4.0) Acute

Brief HistoryBrief History

�� Identification : Identification :

–– Name : Name : 陳陳x x －－ Admission : 94/10/06Admission : 94/10/06

–– Gender : maleGender : male

–– Age : 75 y/o Age : 75 y/o

ChiefChief Complaint : Complaint :

–– Urinary difficulty for months.Urinary difficulty for months.

�� Past History : HTN without regular treatment.Past History : HTN without regular treatment.


�� Lower urinary tract symptoms for months, Lower urinary tract symptoms for months,

diagnosed of BPH, under medical treatment diagnosed of BPH, under medical treatment

at at 三總三總 Hospital.Hospital.

�� PSA checked at PSA checked at 三總三總 H. : 2.0 H. : 2.0 ngng/dl (< 4.0)/dl (< 4.0)

�� Acute urinary retention few days ago.Acute urinary retention few days ago.

�� Admitted on 94/10/06 to receive TURP. Admitted on 94/10/06 to receive TURP.

�� 10/07 : TURP10/07 : TURP


�� Pathology : Pathology :

–– Spindle cell with Spindle cell with hyperchromatichyperchromatic and and pleomorphicpleomorphic nucleus.nucleus.

–– Common with mitotic figures.Common with mitotic figures.

–– VimentinVimentin (+), CK ((+), CK (--), PSA(), PSA(--), ER (), ER (--), PR (), PR (--))

–– Pathologic Diagnosis : SarcomaPathologic Diagnosis : Sarcoma

�� 10/25 : Abdominal and pelvic CT10/25 : Abdominal and pelvic CT

–– No LN or visceral organ involved but local No LN or visceral organ involved but local invasion to rectum cannot be ruled out.invasion to rectum cannot be ruled out.


�� 11/03 : Bone scan11/03 : Bone scan

–– Left ileum bone metastasis was suspected.Left ileum bone metastasis was suspected.

(trauma to left side body 3 months ago)(trauma to left side body 3 months ago)

�� 11/10 : Colonoscopy11/10 : Colonoscopy

–– Biopsy x 5 : Biopsy x 5 : AdenomatousAdenomatous Polyps.Polyps.

�� 11/14 : MRI11/14 : MRI

–– Tumor invades rectum (+)Tumor invades rectum (+)

–– Left iliac wing fracture (+)Left iliac wing fracture (+)

Laboratory DataLaboratory Data

�� PrePre--OP PSA (at OP PSA (at 三總三總) : 2.0 ) : 2.0 ngng/dl/dl

�� 10/06 (admission)10/06 (admission)

–– U/AU/A

–– Glucose : 113 mg/dlGlucose : 113 mg/dl

22--448080--90903+3++/+/--

WBCWBCRBCRBCOBOBProteinProtein

ImagingImaging

�� Abdominal and pelvic CT : (94/10/25)Abdominal and pelvic CT : (94/10/25)

Encapsulated

prostate

mass

Heterogeneous

enhancement

T2W T2W

FSE FSE

sagitalsagital

6.7x5.6x5.5 cm

heterogeneous

enhancement

Suspect

extracapsule

extension

T1W T1W

FSPGR FSPGR

coronalcoronal

Low signal

intensity

prostatic

mass

T2W T2W

FSE FSE

coronalcoronal

High signal

Intensity

prostatic mass

with focal

low attenuation

T1W T1W

FSPGR FSPGR

axialaxial

R/O rectum

invasion

T2WT2W

FSEFSE

AxialAxial

Heterogenous

Appearance —

High intensity

With focal

Low intensity

Differential DiagnosisDifferential Diagnosis

�� Prostate Prostate adenocarcinomaadenocarcinoma

–– TRU : TRU : hypoechoichypoechoic in the peripheral zone.in the peripheral zone.

–– MRI : MRI :

�� T1W T1W -- No No intraprostaticintraprostatic pathology is displayed pathology is displayed

�� T2W T2W -- Low signal intensity in the hyperintense Low signal intensity in the hyperintense

peripheral zone peripheral zone

�� ComedocarcinomaComedocarcinoma

–– TRU TRU ---- hypoechoichypoechoic lesions that contained lesions that contained

multiple small multiple small hyperechoichyperechoic foci.foci.

�� MucinousMucinous CarcinomaCarcinoma

–– The size of the gland lumens is increasedThe size of the gland lumens is increased

–– Mucoid secretions raised the overall T2 signal.Mucoid secretions raised the overall T2 signal.

�� SquamousSquamous CarcinomaCarcinoma

–– bony metastases are usually bony metastases are usually osteolyticosteolytic

�� RhabdomyosarcomaRhabdomyosarcoma ––

CT CT ––

Heterogeneous attenuation. Invasion. Heterogeneous attenuation. Invasion.

Calcification is rareCalcification is rare

MRI MRI ––

Tumor from central area of the prostate.Tumor from central area of the prostate.

Enhance heterogeneouslyEnhance heterogeneously

T2W : wellT2W : well--defined lowdefined low--signalsignal--intensity intensity

pseudocapsulepseudocapsule

�� CystosarcomaCystosarcoma PhyllodesPhyllodes

–– Cystic spaces within the tumorCystic spaces within the tumor

–– A large, relatively noninvasive A large, relatively noninvasive prostaticprostatic massmass

�� Malignant LymphomaMalignant Lymphoma

–– US US ---- large large hypoechoichypoechoic masses within both the masses within both the

central and peripheral zones in a young man.central and peripheral zones in a young man.

–– CT CT ---- homogeneous soft tissue masses.homogeneous soft tissue masses.

–– MRI MRI ---- involvement of the bone marrow involvement of the bone marrow

�� Prostate AbscessProstate Abscess

–– TRU : TRU : �� HypoechoicHypoechoic zone with zone with septationseptation or internal echoes at or internal echoes at

TZ.TZ.

�� Less easily definable during initial phases.Less easily definable during initial phases.

�� Occasional Occasional perilesionalperilesional halo.halo.

�� High High perilesionalperilesional vascularityvascularity detect by Doppler.detect by Doppler.

–– CT : CT : �� Single of multiple Single of multiple hypointensityhypointensity lesion.lesion.

�� PerilesionalPerilesional hyperintensityhyperintensity..

Surgical TreatmentSurgical Treatment

�� 94/12/09 : LPS radical 94/12/09 : LPS radical prostectomyprostectomy

(No rectum involvement)(No rectum involvement)

�� Pathology : Pathology :

–– spindle cells with mild to moderate spindle cells with mild to moderate pleomorphismpleomorphism, ,

frequent mitoses, and prominent tumor necrosis. frequent mitoses, and prominent tumor necrosis.

–– vimentinvimentin (strongly +), CD34 (strongly +), CD117 (strongly +), CD34 (strongly +), CD117

(strongly +), smooth muscle (strongly +), smooth muscle actinactin (weakly +), S(weakly +), S--100 (100 (--), ),

CK (CK (--), PSA (), PSA (--), PR (), PR (--), ER (), ER (--).).

–– Pathology diagnosis : GIST (more favor) or Pathology diagnosis : GIST (more favor) or ProstaticProstatic

stromalstromal sarcoma.sarcoma.

DiscussionDiscussion

GISTsGISTs

Gastrointestinal Gastrointestinal StromalStromal TumorsTumors

IntroductionIntroduction

� The most common mesenchymal neoplasm of the gastrointestinal tract

� From primitive stem cells resemble the native KIT-positive gut pacemaker cell or interstitial cell of Cajal.

� Expression of KIT (CD117), a tyrosine kinasegrowth factor receptor.

� KIT is important to distinguish GISTs from other mesenchymal neoplasms such as leiomyomas, leiomyosarcomas, schwannomas, and neurofibromas.


Am J Surg Pathol 1999; 23:82–87


Am J Surg Pathol 1999; 23:82–87

GISTsGISTs from Prostatefrom Prostate

–– Case report : Case report : Urology. 2005 Feb;65(2):388Urology. 2005 Feb;65(2):388

�� Clinical presentation : Clinical presentation :

–– 49 y/o man with acute urinary retention49 y/o man with acute urinary retention

–– One transient episode of One transient episode of dysuriadysuria

–– Lost 5 kg in 1monthLost 5 kg in 1month.


�� Laboratory tests : Laboratory tests :

–– Elevated white blood cell count and CRP. Elevated white blood cell count and CRP.

–– All other values were normal.All other values were normal.

–– ProstateProstate--specific antigen was 1.36 specific antigen was 1.36 ng/mLng/mL


�� Imaging : Imaging :

–– TRU : TRU :

�� solid mass with focal liquefaction in prostatesolid mass with focal liquefaction in prostate

�� Mass was isolated from surrounding structures.Mass was isolated from surrounding structures.

–– CT & MRI: CT & MRI:

�� The mass not involved the surrounding structures.The mass not involved the surrounding structures.

�� Multiple liver metastasis.Multiple liver metastasis.


Well-defined

Encapsulated

Prostatic tumor


Huge heterogenous

mass Compressing

Bladder anteriorly

And rectum

posteriorly

Imaging of Imaging of stomochstomoch GISTGIST

�� CTCT

–– SubdiaphragmaticSubdiaphragmatic cavitarycavitary mass of heterogeneous mass of heterogeneous attenuation. The cavity (attenuation. The cavity (**) is air) is air--filled. Liver meta (+)filled. Liver meta (+)


�� CTCT

–– Central areas of low attenuation correspond to Central areas of low attenuation correspond to hemorrhage, necrosis, or cyst formationhemorrhage, necrosis, or cyst formation


�� MRIMRI

–– Low signal intensity on T1Low signal intensity on T1--weighted images,weighted images,

–– High signal intensity on T2High signal intensity on T2--weighted images,weighted images,

–– Enhance after administration of gadolinium.Enhance after administration of gadolinium.

–– Hemorrhage within tumor vary from high to low Hemorrhage within tumor vary from high to low signal intensity on both T1W and T2W images, signal intensity on both T1W and T2W images, depending on the age of the hemorrhagedepending on the age of the hemorrhage..

–– MRI is useful in determining the organ of origin MRI is useful in determining the organ of origin and the relationship of the tumor to other organs and the relationship of the tumor to other organs and major blood vessels.and major blood vessels.


�� MRIMRI

–– Focal high signal intensity within mass Focal high signal intensity within mass ---- hemorrhage hemorrhage (arrow).(arrow).

Treatment of GISTTreatment of GIST

�� Surgical resection for the primary diseaseSurgical resection for the primary disease

�� Conventional systemic and Conventional systemic and intraperitonealintraperitoneal

chemotherapy, arterial chemotherapy, arterial chemoembolizationchemoembolization, ,

surgery, and irradiation have been ineffective in surgery, and irradiation have been ineffective in

treating treating metastaticmetastatic and recurrent disease.and recurrent disease.

�� ImatinibImatinib (STI(STI--571, 571, GleevecGleevec) targets the overactive ) targets the overactive

tyrosine receptor ctyrosine receptor c--kit found on all GIST cells, kit found on all GIST cells,

leading regression of leading regression of metastaticmetastatic lesions.lesions.

Prognosis factorPrognosis factor

� Tumor size

� Mitotic rate

� Anatomic site

(best : esophagus ; worse : small bowel)

�� Recurrence indicated poor prognosisRecurrence indicated poor prognosis

But aBut a small number of GISTs recur or metastasize despite a histologically benign appearance (ie, small size and absence of mitoses or low mitotic rate).

ReferenceReference--11

�� Gastrointestinal Gastrointestinal stromalstromal tumors: tumors: radiologicradiologic

features with pathologic correlation. features with pathologic correlation.

RadiographicsRadiographics. 23(2):283. 23(2):283--304, 456; quiz 532, 304, 456; quiz 532,

2003 Mar2003 Mar--Apr.Apr.

�� The The prostaticprostatic gland: malignancies other than gland: malignancies other than

adenocarcinomasadenocarcinomas.. RadiologicRadiologic Clinics of North Clinics of North

America. 38(1):179America. 38(1):179--202, 2000 Jan.202, 2000 Jan.

�� Imaging of Gastrointestinal Imaging of Gastrointestinal StromalStromal Tumors.Tumors. J J

ComputComput Assist Assist TomogrTomogr 2004;28:5962004;28:596––604604.


�� Gastrointestinal Gastrointestinal StromalStromal Tumor of The Tumor of The Prostate.Prostate. Urology 65Urology 65: : 388, 2005.388, 2005.

� Adult prostate sarcoma: the M. D. Anderson Cancer Center Experience.Journal of Urology. 166(2):521-5, 2001 Aug.

�� Sarcomas and related proliferative Sarcomas and related proliferative lesions of specialized lesions of specialized prostaticprostatic stromastroma: a : a clinicopathologicclinicopathologic study of 22 cases.study of 22 cases. Am J Am J SurgSurg PatholPathol 22(2):14822(2):148--62, 1998 Feb.62, 1998 Feb.


�� Prognosis of gastrointestinal smoothPrognosis of gastrointestinal smooth--muscle muscle

((stromalstromal) tumors: dependence on anatomic ) tumors: dependence on anatomic

site. site. Am J Am J SurgSurg PatholPathol 1999; 23:821999; 23:82––87.87.

�� Prostate abscess: Diagnosis and treatment. Prostate abscess: Diagnosis and treatment.

AJR:170, March 1998AJR:170, March 1998

�� Gastrointestinal Gastrointestinal stromalstromal tumor (GIST) tumor (GIST)

presenting as a prostate tumor. presenting as a prostate tumor. Urology Urology

66: 13, September 200566: 13, September 2005

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Brief History - tmuh.org.tw · Lower urinary tract symptoms for months, diagnosed of BPH, under medical treatment at 三總Hospital. PSA checked at 三總H. : 2.0 ng /dl (< 4.0) Acute