PMC6899263_01
Trending of PSA levels over the 16-year time span, from the diagnosis of prostate cancer to the discovery of isolated testicular metastasis.
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Consequently, his PSA dropped down to less than 0.02 ng/mL yet rose back up to a level of 1.06 ng/mL in November 2010, i.e., seven years post operation (Figure 1). PSA levels were steadily increasing; an abrupt rise in PSA to 3.9 ng/mL was noted in January 2019, sixteen years post operation (Figure 1). Physical exam at the time revealed a normal genitourinary examination along with a flat prostatic fossa upon digital rectal examination.
(a) 68Gallium prostate-specific membrane antigen-based PET maximum-intensity projection images demonstrating patient with a single left testicular metastasis (arrow); no other metastasis lesions were identified elsewhere. (b) 68Gallium prostate-specific membrane antigen-based PET/CT axial fusion image demonstrating again a single uptake within the left testicle, holding a SUVmax of 9.3 mSv, consistent with metastasis. (c) Coronal image of a T2-weighted (T2W) magnetic resonance image (MRI) showing several hypointense lesions involving the left testicle (arrow), suggestive of metastasis. (d) Axial image of a T2W MRI showing again several hypointense metastatic depositions within the left testicle.
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A single focal radiotracer uptake was noted in the left testicle with a maximal SUV of 9.3 mSv (Figures 2(a) and 2(b)). Several poorly defined hypointense left testicular lesions were found, the largest one measuring 1.8 cm, at the level of the rete testis (Figures 2(c) and 2(d)).
(a) Gross image of bilateral simple orchiectomy specimens revealing sectioned left testicle with multiple intraparenchymal hard nodules (arrow), ranging from 0.2 to 2.5 cm in the greatest dimension, having a tan-white hard cut surface. (b) (Hematoxylin and Eosin stain, 4x magnification) Metastatic prostate adenocarcinoma infiltrating the testicular interstitium and sparing seminiferous tubules (top right). Lymphovascular invasion in tunica albuginea (bottom left). (c) (10x magnification) Prostate-specific antigen (PSA)-positive immune-histochemical stain, highlighting the infiltration of the left testicle with metastatic prostate adenocarcinoma. The tumor is mostly made of small monolayered back-to-back acini (Gleason pattern 3). Fewer foci with cribriform glands (Gleason pattern 4) are noted. This corresponds to Gleason score 7 = 3 + 4 (grade group 2 of 5).
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Following a multidisciplinary tumor board meeting, consensus was to proceed with bilateral simple orchiectomy for the purpose of surgical castration as well as pathologic examination of this left testicular lesion (Figure 3(a)). Pathology studies revealed a metastatic adenocarcinoma of prostatic origin (Figures 3(b) and 3(c)).