A male with voiding difficulties that had been progressed came into outpatient clinic of our institution in February 2006. Past history and family review revealed no remarkable findings. Physical examination including digital rectal examination (DRE) discovered enlarged prostate gland with the size of more than approximately 40 g. International Prostate Symptom Score (IPSS) of 19 and the level of prostate-specific antigen (PSA) of 21.73 were discovered and followed by transrectal ultrasonography (TRUS) of the prostate gland that revealed the volume of 61 cc, that is, prostate-specific antigen density of 0.36, with a noticeable hypoechoic lesion in the peripheral zone. TRUS-guided needle biopsy of the prostate gland was, thus, carried out exhibiting adenocacinoma with Gleason score of 10 (5+5), ranging from the score of 7 at left apex to the score of 10 at right base, mid and apex (Fig. 1). Results of cytology including cytospin continuously reported clusters of atypical cells, consistent with carcinoma. Imaging modalities of prostate magnetic resonance imaging (MRI) (Fig. 2) and radionuclide bone scan was conducted to evaluate the stage of prostate cancer. T2 weighted image of prostate MRI revealed a lesion with diffuse low signal intensity at both peripheral zones from apex to base and both seminal vesicle as well as a lesion suspicious of invasion into the bladder neck without definite image of any mass in the bladder in addition to several enlarged obturator and right external iliac lymph nodes. Any involvement of upper urinary tract was not evidenced by radionuclide bone scan that unveiled traumatic rib lesions.

The patient was diagnosed as having stage T4aN2M0 of prostate cancer and was immediately begun with hormonal therapy of bicalutamide and leuproreline acetate. In the course of treatment, the patient was readmitted in June 2006 with painless gross hematuria and worsened voiding difficulties that was alleviated with alpha-blocker developed in May 2006. Physical examination discovered multiple palpable masses located in suprapubic area with increased serum creatine level in laboratory result. Kidney and bladder ultrasonography was, then, performed unveiling both hydronephrosis. Failure of indwelling ureteral catheter on both sides, due to multiple bullous masses and severe degree of erythematous trabeculation in the bladder hampering the procedure of locating ureteral orfices, ensure the procedure of percutaneous nephrostomy on both sides. Abdominopelvic computed tomography (CT) disclosed about 14.5×10.3 cm sized multilobulated heterogenous enhancing soft tissue mass in pelvic cavity, involving bladder and prostate gland that was not visible in previous study of prostate MRI, as well as a hepatic mass suspicious of metastasis at both lobes. Enlarged lymph nodes were also detected in obturator area and perilesional area with increased size of previously detected right external iliac lymph node.

Cystoscopy was performed owing to persistent hematuria and specimen for biopsy was obtained from multiple bullous masses in the bladder. According to the report of biopsy, microscopically, cells were consistent with finding of small cell carcinoma without evidence of transitional cell or squamous cell carcinoma. Study of immunohistochemistry (Fig. 3) was conducted to confirm neuroendocrine activity of small cell carcinoma and showed the tumor cells were positive for CD56, weakly positive for synaptophysin, while negative for cytokeratin, chromogranin, leukocyte common antigen (LCA), T-cell (UCHL-1), CD3, CD20, and PSA.

Thoracic CT was available to detect any other primary and metastatic lesion in lung and other organs and visualized calcified nodule in left upper lobe with fibrotic bands, probably, sequelae of tuberculosis, a tiny dense nodule in right upper lobe, suspicious of granuloma, focal bronchiectasis with linear atelectasis in right middle lobe and small sized lymph nodes in mediastinum. The patient refused further treaments and was lost during follow up period while additional treatment options were considered.