Case Presentation: 85-year-old male with a history of hypertension, hyperlipidemia, coronary artery disease, and advanced dementia presented to the hospital with altered mental status and right-sided weakness and, was found to have left-sided acute on chronic subdural hematoma of the left frontal lobe and underwent a craniotomy and clot evacuation surgery. During the hospitalization, the patient was also found to have urinary retention and a Foley catheter was placed. Urology was consulted. A computed tomography scan of the abdomen and pelvis showed severe bilateral hydronephrosis and a retroperitoneal soft tissue mass surrounding the distal ureters with differentials including ureteral neoplastic process, lymphoma, and retroperitoneal fibrosis. On day 7 of hospitalization, the patient was found to have severe abdominal pain with deterioration of mental status. Physical examination was remarkable for abdominal tenderness and guarding, with vitals for tachypnea (33 per min) and hypotension (88/66 mmHg). X-ray abdomen showed pneumoperitoneum, which was confirmed on a CT scan of the abdomen and pelvis and the patient underwent exploratory laparotomy and surgical repair of 2.5 x 2.5 cm perforation with surrounding inflamed necrotic tissue of post-pyloric first segment of the duodenum. Biopsy from the ulcer showed adenocarcinoma compatible with a prostate primary. Tumor cells were positive for pan-cytokeratin AE1/AE3, NKX3.1 and CK19. Oncology was consulted. Only androgen deprivation therapy was recommended due to the patient’s poor ECOG performance status wherein the patient remained bedridden and had advanced dementia. PSA (332.0 ng/mL) and testosterone (25 ng/dL) levels were obtained. A nuclear medicine bone scan also showed foci of intense activity in the skull and increased activity in the left sixth and seventh ribs indicating diffuse metastasis. Palliative care was consulted and after an inter-disciplinary discussion, the patient was discharged to hospice care.
Discussion: The second most common cancer in men is prostate cancer which commonly metastasizes to bone, lymph nodes, lungs, and liver. Metastasis in the small intestine is rare and only few reported cases of metastasis to duodenum were found [1, 2]. They are often diagnosed late with non-specific clinical presentation like weight loss, nausea vomiting, dyspepsia, epigastric pain, and associated with concurrent metastases, indicating advanced prostate cancer. Our patient had duodenal metastasis of prostate origin with skull and rib lesions. Treatment options include androgen deprivation therapy, orchiectomy, and intestinal surgery, which can also be considered palliatively. Given our patients’ poor performance status and advanced dementia along with concurrent metastatic disease further invasive testing or therapies were not considered. Palliative androgen deprivation therapy was considered, but eventually, hospice care was opted for.
Conclusions: We report a novel case of duodenal metastasis compatible with primary prostate cancer. This case should help raise awareness of the possibility of unusual metastatic sites with a prostate primary.
