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Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome is mostly associated with neuroendocrine tumors and small cell carcinoma of the lung. This syndrome of prostate cancer is rare and has been reported in only a few cases. We report a patient with ectopic ACTH production associated with metastatic prostate cancer. A 70-year-old patient with metastatic prostate cancer was admitted to our hospital with septic shock. He had a history of hormonal therapy and transurethral prostatectomy. Adrenocortical function was checked due to consistent fever and poor general condition, which revealed markedly increased levels of basal plasma ACTH and serum cortisol. The patient did not present typical signs of the Cushing's syndrome, however, hypokalemia and a history of hypertension were found. He died in days as a result of multi-organ failure. On pathology, the prostatectomy specimen showed a tumor composed of mixed populations of adenocarcinoma and small cell carcinoma. The tumor cells in the small cell component were positive for chromogranin and ACTH. Although neuroendocrine differentiation in prostate cancer is rare, etopic ACTH production should be considered in patients with prostate cancer as well as in clinical features of ACTH hypersecretion.
Figures and Tables
Fig. 1
The progression of the prostate cancer. (A) Chest computed tomography (CT) taken 6 weeks ago showed pulmonary lymphangitic metastasis (arrows) with multiple metastatic mediastinal lymph nodes (circles), and (B) hepatic metastasis (arrows). (C) After 2 weeks, spine magnetic resonance imaging revealed epidural extension of T9 metastatic lesion with spinal cord compression, and (D) additional metastatic lesions in pancreas (circles) and both adrenal glands (arrows) were found in abdominal CT.
Fig. 2
Imaging studies at the emergency room. (A) Chest X-ray shows bilateral increased opacity. (B) Chest computed tomography reveals diffuse consolidation, ground-glass opacity and air-bronchogram at both lungs with increased size of mediastinal lymph nodes. Small amount of pleural effusion (bilateral) is shown. There was no evidence of pulmonary thromboembolism.
Fig. 3
Histologic and immunohistochemical features. (A) The tumor is composed of mixed populations of small cells (small cell carcinoma component) and glandforming clear cells (adenocarcinoma component) (H&E stain, × 200). (B) Chromogranin is expressed in the small cell carcinoma component, not in the adenocarcinoma component (immunohistochemistry, × 200). (C) In contrast, expression of prostate-specific antigen is confined to the adenocarcinoma component (immunohistochemistry, × 200). (D) A few tumor cells in small cell carcinoma component are reactive to adrenocorticotropic hormone (immunohistochemistry, × 400).
Table 1
Case reports of ectopic ACTH syndrome in prostate cancer
*The patient was diagnosed as prostate cancer through his autopsy; †The hepatic metastasis was progressed rapidly, resulted in fulminant hepatic failure; ‡The reason of acute respiratory failure was unknown. The patient died in spite of management for pneumonia, acute heart failure, and pulmonary thromboembolism; §The result is only seen in the small cell carcinoma component (PSA was expressed in the adenocarcinoma component); llThe result is from autopsy specimen. In the initial diagnostic biopsy tissue, the IHC staining result was PSA (+), NSE (-).
ACTH, adrenocorticotropic hormone; ADC, adenocarcinoma; Bilat., bilateral; CGA, chromogranin A; Dx, diagnosis; EAS, ectopic ACTH syndrome; HTN, hypertension; IHC, immunohistochemistry; M/D, moderately differentiated; MOF, multi-organ failure; NSE, neuron specific enolase; PSA, prostate specific antigen; TUR-P, transurethral prostatectomy; Tx, treatment.
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