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case_images: Imaging and pathology findings at the patient's first visit. (A) The prostate MRI at T2-weighted images revealed the presence of nodular patchy hypointense lesion in the migratory zone in the direction of points 9-11; (B) Chest CT showed a solid nodule was observed in the apical segment of the upper lobe of the right lung, which was considered a primary lesion; (C) scattered solid nodules were observed in the middle lobe of the right lung, suggesting metastasis; (D) HE staining. The glands exhibit irregular and fused, or small infiltrating glands with varying shapes and prominent nucleoli (4x); (E) Immunohistochemical staining revealed positive expression of PSA (10x). The site of the lesion was marked with a red circle.
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case_images: The prostate magnetic resonance imaging (MRI) enhancement showed an abnormal signal in the migratory zone 9-11 points of the prostate, T2-weighted images indicated an equal/slightly hypointense lesion, and the PI-RADS score was 3 ( Figure 1A ). Chest computed tomography (CT) showed a solid nodule in the apical segment of the upper lobe of the right lung, with unclear boundaries and adhesion to the adjacent pleura, the size of which was about 2.8cmx2.3cm, and a suspicious metastatic lesion in the middle lobe ( Figures 1B, C ). Pathological examination showed that prostate adenocarcinoma, Gleason score was 7 (4 + 3), WHO/ISUP group 3 ( Figures 1D, E ).
case_images: Trends in patient PSA and NSE. (A) Total PSA; (B) NSE.
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case_images: Figure 2A ). Furthermore, there was no observed increase in levels of neuron-specific enolase (NSE) ( Figure 2B ). The tPSA level was measured at 0.59ng/mL ( Figure 2A ), while the NSE level was recorded as 35.59ng/mL ( Figure 2B ).
case_images: Pathological results of the patient after LRP. HE staining (A-C) showed that the simultaneous presence of adenocarcinoma and LCNEPC components; The cells exhibited large size, with palisade-like structures surrounding cell nests. The nuclei appeared large and deeply stained, indicating high mitotic activity, a low nuclear-to-plasma ratio, and extensive cell necrosis; IHC was positive for (D) CD56, (E) CDX -2, (F) SSTR2, and negative (G-J) for (G) CgA, (H) Syn, (I) NSE, (J) Ki-67 was strongly positive (90%) (10x).
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case_images: Subsequent routine pathological examination indicated the presence of PRAD [Gleason score 8 (4 + 4)] with LCNEPC (approximately 10%) ( Figures 3A, B ), with LCNEPC identified in the bladder wall and the right bladder neck ( Figure 3C ). A (CgA), synaptophysin (Syn), and NSE ( Figures 3G-I ), Ki-67 was strongly positive expression (+ 80%) ( Figure 3J ). After surgery, the patient did not receive further androgen blockade therapy and chemotherapy for personal reasons.
case_images: Imaging changes after patient progression, intraoperative conditions and postoperative findings. (A, B) CTU scans revealed the recurrence of bladder and pelvic tumors; (C) upper abdomen CT indicated hepatic metastasis; (D) chest CT showed multiple metastases; (E) WBBS indicated bone metastases; (F) intraoperative cystoscopy reveals tumor at 12 o'clock in the bladder; (G) typical LCNEPC presentation, no adenocarcinoma component, IHC was positive for (H) SSTR2 and (I) Ki-67 (90%), and negative for (J) CD56, (K) CgA, (L) Syn, (M) NSE and (N) P504S (10x).
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case_images: Computed Tomography urography (CTU) revealed the presence of enlarged masses in the region of the previous prostate and bilateral seminal vesicles, and significant space-occupying lesion on the right lateral wall of the bladder, considering tumor recurrence ( Figures 4A, B ). Intrahepatic nodules of small size were observed ( Figure 4C ). The chest CT scan revealed new multiple scattered nodules in both lungs compared to the previous scan ( Figure 4D ), indicating potential metastases. A WBBS indicated the presence of new metabolically active foci in the left acetabulum, as well as new osteolytic lesions in the pubic joint and bilateral ischium, suggesting bone metastases ( Figure 4E ). On August 17th, 2023, a subsequent transurethral resection of bladder tumor (TURBT) revealed the presence of a tumor measuring 8 x 6 x 6cm ( Figure 4F ) on the top wall of the bladder, visible from the 12 o'clock position. Postoperative pathological examination indicated that the tumor exhibited characteristics consistent with LCNEPC without an acinar adenocarcinoma component ( Figure 4G ). IHC results demonstrated positive staining for SSTR2 and Ki-67 (90% +) ( Figures 4H, I ), negative staining for CD56, CgA, Syn, NSE, and P504S ( Figures 4J-N ).