Granulomatous prostatitis, a very critical diagnosis

Giovanni Maria Fusco, Luigi Cirillo, Ernesto Di Mauro, Roberto La Rocca, Luigi Napolitano.

Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, I-80138 Naples, Italy.

Summary

Granulomatous prostatitis (GP) is a benign inflammatory condition of the prostate, which may mimic prostate cancer (PCa). We present a case of GP in a 68-year-old patient with prior abdominal-perineal resection (APR).

KEY WORDS: Prostate cancer; granulomatous prostatitis; abdominal-perneal resection; transperineal biopsy.

Introduction

Prostate cancer (PCa) represents the most diagnosed cancers in men with an incidence of 1.4 million new cases worldwide (1). According to European Guidelines, diagnosis is based on digital rectal examination (DRE) and/or elevated serum prostate specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and prostate biopsy for definitive diagnosis (2). In men without an anal canal screening and diagnosis of PCa are very difficult, since DRE and transrectal ultrasound (TRUS) cannot be performed. Trans perineal, trans gluteal or transabdominal ultrasound guided biopsies have been described. Granulomatous prostatitis (GP) is a benign and rare inflammatory condition of the prostate, which may mimic PCa from a clinical, biochemical, and radiological point of view (3). We present a case of granulomatous prostatitis (GP) in patient with prior abdominal-perineal resection (APR).

Case Report

A 68-year-old man with a family history of prostate and breast cancer presented to our urology department with progressive PSA elevation (6.64 ng/ml reference range: 0–4 ng/ml).

The patient current medical history was relevant for benign prostatic hyperplasia treated with Alpha-blocker 5-

ARI, and hypertension treated with lisinopril. His past medical history was positive for negative prostate biopsy and a rectal cancer.

In 2017 he underwent to neoadjuvant chemo-radiotherapy and APR for rectal adenocarcinoma treated followed by adjuvant chemotherapy, which precluded DRE and TRUS. The patient underwent a 1,5-Tesla prostate multiparametric magnetic resonance imaging (MRI) which determinate the presence of 21 mm nodular lesion characterized by low signal intensity on T2-weighted sequences that involved both the peripheral right lobe and apex (Figure 1A and B).

The lesion was scored according to the Prostate ImagingReporting and Data System v2: PI-RADS 5 and due to high probability of malignancy prostate biopsy was necessary. The patient underwent trans perineal prostate biopsy, that showed aggregates of lymphocytes, plasma cells, histiocytes and epithelioid cells, together multinucleated giant cells. All these aspects were compatible with GP. The patient underwent observation.

Discussion

Several prostate conditions are related to PSA elevation. Among these GP is an important issue, that should be considered. It is usually associated with increased PSA levels and suspicious area to digital rectal exploration and MRI. Histological evaluation is the gold standard to differentiate GP from PCa (3). In patients with APR, pre-biopsy mMRI is safety and subsequently a transperineal biopsy should be performed. Transperineal biopsy seems to be a feasible and important option to detect PCa in previous negative biopsy.

Conclusion

GP represents an urological entity that should be included in the differential diagnosis of PCa, and more studies are necessary to better improve prostate biopsy in patients underwent APR.

References

1. Gandaglia G, Leni R, Bray F, et al. Epidemiology and Prevention of Prostate Cancer. Eur Urol Oncol. 2021; 4(6):877-892.

2. Mottet N, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTROESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021; 79(2):243-262.

3. Gillard R, Médart L, Parisel A. Granulomatous Prostatitis Mimicking Invasive Prostate Cancer. J Belg Soc Radiol. 2022; 106(1):64.

Correspondence

Luigi Cirillo, MD

Department of Neurosciences, Reproductive Sciences and Odontostomatology, Urology Unit, University of Naples “Federico II”, Via Sergio Pansini, 5 - 80131 Naples (NA), Italy

E-mail: cirilloluigi22@gmail.com

Phone: +390817462611 - Fax: +390815452959