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Isolated Pleural Involvement in Recurrent Metastatic Prostate Cancer: A Case Report FREE TO VIEW

Abhay Vakil, MD; Hineshkumar Upadhyay, MD; Khalid Sherani, MD; Kelly Cervellione, PhD; Mohammed Babury, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Chest. 2014;145(3_MeetingAbstracts):308A. doi:10.1378/chest.1826362
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SESSION TITLE: Cancer Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Prostate cancer is known to metastasize to bones, lung, liver and the adrenals. Forty-six percent of patients with metastatic prostate cancer have pulmonary involvement. Of these patients, 21% have concomitant involvement of the pleura. However, isolated pleural involvement is rare, occurring in only 2.3- 5% of cases. Metastatic prostate disease is typically accompanied by elevations of serum and pleural fluid PSA levels. We are reporting the case of an elderly man with previously treated prostate cancer who presented with a left-sided pleural effusion.

CASE PRESENTATION: A 73-year-old man with a history of prostate cancer diagnosed 6 years ago, treated by radical prostatectomy, presented with gradual onset left-sided pleuritic chest pain and shortness of breath over 7 days. He denied fever, cough, night sweats, weight loss, and changes in patterns of excrement. Physical exam revealed decreased air entry and decreased tactile vocal fremitus on the left side. Radiologic studies revealed massive left sided effusion with no mediastinal or inguinal lymphadenopathy. Thoracocentesis revealed hemorrhagic exudative fluid. Cytology was positive for poorly differentiated adenocarcinoma. PSA staining was negative; CEA and Chromogranin A staining were positive, suggesting metastasis from the prostate. Serum and pleural fluid PSA levels were within normal range. The patient was started on appropriate hormonal therapy.

DISCUSSION: Literature review suggests that patients with metastatic prostate cancer and normal PSA levels tend to have a worse prognosis. This case illustrates the importance of vigilance in the scenario of normal serum PSA in previously treated prostate cancer. Recurrence presenting as new pleural effusion with negative pleural fluid PSA is rare. Clinical awareness of the variety of scenarios that recurrence can present may lead to earlier detection, treatment, and possibly improved outcomes. In the event of negative pleural fluid cytology, thoracoscopy is recommended as further diagnostic intervention.

CONCLUSIONS: Isolated pleural involvement as the site of recurrent metastatic prostate cancer is rare. Clinical vigilance, even in the absence of elevated serum and/or pleural fluid PSA, is necessary for the best patient outcome.

Reference #1: Shantanu Singh and Ashish Singh, Metastasis of Prostate Cancer to Pleura J Pulmon Resp Med 2013, 3:1

Reference #2: Takagi Y, Hashimoto J, Kurokawa T, et al. Prostate cancer with multiple pulmonary and pleural metastases: a case report (in Japanese) Rinsho Hinyokika. 2004;58:769-771.

Reference #3: Bubendorf L, Schöpfer A, Wagner U, Sauter G, Moch H, et al. (2000) Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol 31: 578-583.

DISCLOSURE: The following authors have nothing to disclose: Abhay Vakil, Hineshkumar Upadhyay, Khalid Sherani, Kelly Cervellione, Mohammed Babury

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