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Case Report |
1 Department of Radiology, Lahey Clinic, 41 Mall Rd., Burlington, MA
01805.
2 Department of Urology, Lahey Clinic, Burlington, MA 01805.
Received March 25, 2002;
accepted after revision May 23, 2002.
Address correspondence to D. Rusch.
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-blocker. Findings at physical examination were normal except for an
extremely enlarged prostate gland with multiple lobulations discovered during
the digital rectal examination. Values from the routine laboratory tests were
all normal. The prostate-specific antigen level was 2.0 ng/mL. A urinalysis
revealed an RBC of 2-5 x 106 µL per high-power field.
Results of the urine culture were negative. The postvoid residual volume was
elevated at 342 mL. A contrast-enhanced CT scan showed an approximately 15-cm cystic mass in the pelvis that appeared to be originating from the prostate, displacing the bladder anteriorly and the sigmoid colon laterally. The mass had multiple septations with some soft-tissue components (Fig. 1A). Endorectal sonography confirmed the presence of a large multilocular cyst arising from the prostate (Fig. 1B). Aspiration yielded 300 mL of hemorrhagic fluid. Cytologic examination of the fluid showed only RBCs and histiocytes with no malignant cells. Biopsy of the prostate revealed benign prostatic tissue with cystic dilatation of glands and no evidence of malignancy.
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During exploration through a midline peritoneal incision, surgeons located and removed a mass with a thin fibrous capsule, leaving intact the normal-appearing portion of the prostate, seminal vesical, and vas deferens (Fig. 1C). Histologic examination of the specimen revealed glands and cysts lined by cuboidal and low-columnar epithelial cells with basally located nuclei. The pathologic findings were consistent with giant multilocular prostatic cystadenoma. At follow-up 18 months later, the patient remained free of lower urinary tract symptoms.
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Our second case involves a 41-year-old man who had undergone an incomplete excision of a giant multilocular prostatic cystadenoma 1 year earlier at another institution (Fig. 2A). He presented to our hospital with acute urinary retention. CT and MR imaging showed an approximately 15-cm multiseptated cystic mass in the pelvis (Figs. 2B and 2C). The patient underwent surgical excision of the mass and required a urinary diversion. Pathologic examination confirmed the mass was a benign prostatic cystadenoma.
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Multiple entities can produce cysts in the prostate [7]. Some of these lesions have characteristic features that can aid one in differentiating them from giant multilocular cystadenoma. Cystic degeneration in benign prostatic hyper-plasia and retention cysts typically are small and, hence, are usually asymptomatic and discovered incidentally on endorectal sonography. Müllerian duct cysts and prostatic utricle cysts are identifiable because of their midline location. Cavitary prostatitis and prostatic abscesses usually occur in patients with clinical signs and symptoms of infection.
On the other hand, giant multilocular cystadenoma can resemble less common lesions such as a parasitic cyst, phyllodes variant of atypical prostatic hyperplasia, and cystic carcinoma. In addition, although giant multilocular cystadenoma typically arises in the prostate, it has been reported to occur in sites that are completely separate from the gland [1]. For this reason, giant multilocular cystadenoma should be included in the broader differential diagnosis of cystic retrovesical and retroperitoneal masses in men (i. e., lymphangioma, teratoma, cystic sarcoma, and multilocular peritoneal inclusion cyst). However, a key point to remember is that radiographic evidence of local invasion essentially excludes the possibility of giant multilocular prostatic cystadenoma.
Despite its benign nature, giant multilocular cystadenoma of the prostate can regenerate and produce recurrent symptoms after an incomplete resection. This was the case in the second patient we presented, and Maluf et al. [1] reported the case of a 38-year-old man who developed a recurrence 16 months after the initial operation. Therefore, the treatment of choice for giant multilocular prostatic cystadenoma is complete surgical excision, which provides a pathologically confirmed diagnosis as well as a cure.
Acknowledgments
We thank St. Mary's Regional Medical Center, Lewiston, ME, for providing
images for this article.
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