Prostatic Metastasis: Bypassing the Usual Suspects

ABSTRACT

Introduction: Early diagnosis of prostate cancer is challenging, especially in the homeless population, as many patients are asymptomatic. Prostate cancer is known to metastasize to the lungs in terminal patients. However, isolated lung metastasis without bone or lymph node involvement is quite rare, with minimal reports noted in the literature. Biopsy must be obtained to rule-out other etiologies. Case Report A 57-year-old African American male with a history of homelessness, extensive substance abuse, and schizophrenia presented to the hospital with worsening auditory hallucinations. Plain films of the chest were obtained due to prior COVID-19 infection in April and the presence of a slight dry cough. Multiple new bilateral pulmonary nodules were noted. Computed tomography (CT) of the chest showed bilateral, spiculated, peripheral and centrally located masses, the largest measuring >1 cm. Upon admission, further work-up resulted in negative HIV, Hepatitis C and B, and tuberculosis testing, but UDS demonstrated cocaine and methadone. Testicular ultrasound and echocardiogram were unremarkable. CT of the abdomen and pelvis revealed a mildly enlarged prostate with a nodule projecting towards the bladder. There was no obvious lymphadenopathy or spinal lesions. A CT-guided biopsy of the largest nodule was performed after consultation with pulmonology. He was then discharged to inpatient psychiatry for treatment of his schizophrenia. Biopsy results demonstrated adenocarcinoma consistent with metastatic prostate disease (PSA+, PASP+, GATA3+). No serum PSA was able to obtained for baseline as the patient had left the psychiatric treatment facility prior to biopsy results returning. Discussion: Amongst malignant tumors in men, prostate cancer has the highest incidence and the second highest mortality. Incidence is largest amongst black men. Screening is often based on patient preference and family history of the cancer. The screening test of choice involves prostate-specific antigen (PSA), but this has a relatively low sensitivity and specificity. Symptomatology is not reliable, but in metastatic disease back pain is often the most common initial symptom. Rarely, metastatic prostate cancer manifests with isolated pulmonary involvement with either solitary or multiple pulmonary nodules. Upon discovery of bilateral nodules, biopsy should be performed promptly to rule out malignancy. In prostate cancer, biopsies will be PSA+ and often PSAP+. ' This case highlights the unfortunate reality of the social barriers of healthcare. Furthermore, this case highlights the importance of adhering to a specific and standardized approach when bilateral pulmonary nodules are present. Early biopsy is crucial in ruling out metastatic disease.