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Case Series
1 Department of Urology, Isalaklinieken, Zwolle, The Netherlands
2 Department of Pathology, Isalaklinieken, Zwolle, The Netherlands
Address correspondence to:
Jorik Jop Pat
Dokter van Heesweg 2, 8025AB Zwolle,
The Netherlands
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Article ID: 100015Z15BN2021
Introduction: There are several causes of elevated serum prostate-specific antigen (PSA) levels, including benign prostatic hyperplasia, prostate cancer, urinary retention, and prostate infarction.
Case Series: We present two cases of elevated PSA levels that were caused by prostate infarction following acute rupture of an aortic aneurysm.
Conclusion: Aortic rupture can cause an elevation in serum PSA levels due to prostate infarction. This causes unreliable PSA levels in the weeks following first presentation.
Keywords: Aortic rupture, Biopsy, Prostate infarction, Prostate-specific antigen
Elevated serum prostate-specific antigen (PSA) levels can be caused by several conditions, including benign prostatic hyperplasia, prostate cancer, and prostate infarction. Prostate infarction has been described in patients with benign prostatic hyperplasia, aortocoronary bypass surgery, aortic-iliac aneurysm repair, prolonged surgical hypotension, and sepsis with hypotension, as well as those who smoke or have preexisting cardiovascular disease [1],[2]. Here, we present a case with an elevated PSA due to pathologically confirmed prostate infarction that developed following a ruptured aortic aneurysm. We also present a clinically similar case in which there was no pathological confirmation (prostate biopsy).
Case 1
A 75-year-old male with a history of coronary artery bypass graft presented to the emergency department with acute abdominal pain in hypotensive shock. Abdominal ultrasound revealed signs of a ruptured aortic aneurysm and computed tomography angiography (CT-A) of the abdomen confirmed the diagnosis of a ruptured aneurysm of the abdominal aorta. The patient underwent emergency open surgical repair with an 18/9 mm bifurcation aortic graft, during which there was an estimated 10 L of blood loss necessitating 6 packed cell infusions and 4 units of fresh frozen plasma in addition to cell savage. Postoperatively he received inotropic support for 24 hours.
The CT-A performed at admission showed a sclerotic bone lesion in the eighth rib. Therefore, his serum PSA was measured one week after surgery, at which point it was 65 μg/L (normal, <3 μg/L). On digital rectal exam (DRE), the prostate was significantly enlarged with a small nodule in the left lobe, but there was no suspicion of malignancy and the patient had no symptoms of prostatism. Additional bone scintigraphy revealed no abnormalities, including in the eighth rib. Ten random prostate biopsies were performed, and pathological examination revealed no evidence of prostate malignancy. However, one core showed signs of prostate infarction that was confirmed after a second opinion (Figure 1). A few weeks after surgery, the patient was reviewed in our outpatient clinic, by which time his serum PSA had almost normalized to 3.9 μg/L.
Case 2
A 71-year-old male with a history of kidney donation presented to our emergency department with acute sudden-onset pain in his lower abdomen and weakness in both legs. At presentation, he was sweating, pale, and clammy, but his vital signs were otherwise normal. Due to an absence of femoral pulses, ultrasound was performed to exclude aortic dissection, and this uncovered a thrombus in the abdominal aorta with evidence of rupture. Abdominal CT-A subsequently confirmed the presence of an infrarenal aortic rupture. Endovascular aortic repair was attempted after inguinal endovascular embolectomy, but he eventually required open aortic repair using an 18 mm Dacron tube graft. The patient required 6 units of packed cells, with a further 1 L of blood returned by cell salvage. There was no hypotension either perioperatively or postoperatively.
The abdominal CT-A at admission also revealed possible malignancy in the right upper lobe of the lung with lytic bone lesions in the fifth thoracic vertebra and para-aortic lymphadenopathy. Therefore, tumor markers were determined, and among these, his serum PSA was found to be 200 μg/L one day after surgery. On DRE, the prostate felt moderately enlarged but benign, and despite the high serum PSA, there was a low suspicion of prostate cancer. Consistent with this diagnosis, follow-up serum PSA levels fell rapidly, with levels at 1 week and 2 weeks postoperatively falling to 35 and 4.6 μg/L, respectively. Therefore no prostate biopsies were performed. Concerning the other abnormal findings, a thoracic vertebral biopsy revealed that the lytic lesion was a metastasis of a non-small cell adenocarcinoma. After a few weeks, the patient started treatment for the lung adenocarcinoma.
The prostate is primarily supplied with blood by the middle rectal and inferior vesical arteries, which arise from a common branch of the internal iliac artery. In both cases of this report, rupture of an abdominal aneurysm induced a low-flow state that presumably led to the prostate infarction.
After transurethral resection of the prostate or prostate enucleation, pathologically confirmed prostate infarcts are frequent, with an incidence that ranges between 2.8% and 25%. However, infarcts are rarely described after needle biopsy, where the incidence ranges between 0.0009% and 0.007% [3]. Available literature indicates that the transition zone is most susceptible to infarction given the higher incidence in specimens from transurethral resections and enucleations. This would also explain the low incidence in needle biopsies, although the limited amount of tissue that is sampled is an equally valid explanation.
We did not pathologically confirm prostate infarction in the second case, but the similar clinical course to the first leads us to believe that prostate infarction was the most likely cause of the PSA elevation. Elevated serum PSA levels have been described previously in clinical scenarios following prostate infarction [4]. To the best of our knowledge, however, there is no prior literature concerning PSA elevation and its course following acute repair of a ruptured abdominal aortic aneurysm. In both presented cases, there was a rapid fall in the serum PSA level over a relatively short period after surgery, offering a short follow-up period in which further diagnostic tests for incidentalomas are possible. We strongly advise to consider serum PSA levels unreliable in weeks following acute aortic surgery repair unless the suspicion of prostate cancer is very high.
Aortic rupture disturbs the blood supply of the lower pelvis and the prostate, thereby increasing the risk of a prostate infarction. This can cause a significant and transient elevation in serum PSA levels. Based on the cases above, we suggest that DRE can be performed if bone lesions are found as incidentalomas during the investigation and management of an aortic rupture. If the DRE is normal, PSA levels should be considered non-reliable in the weeks following first presentation.
1.
Strachan JR, Corbishley CM, Shearer RJ. Post-operative retention associated with acute prostatic infarction. Br J Urol 1993;72(3):311–3. [CrossRef]
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Feero P, Nickel JC, Brown P, Young I. Prostatic infarction associated with aortic and iliac aneurysm repair. J Urol 1990;143(2):367–8. [CrossRef]
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Milord RA, Kahane H, Epstein JI. Infarct of the prostate gland: Experience on needle biopsy specimens. Am J Surg Pathol 2000;24(10):1378–84. [CrossRef]
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Brawn PN, Foster DM, Jay DW, et al. Characteristics of prostatic infarcts and their effect on serum prostate-specific antigen and prostatic acid phosphatase. Urology 1994;44(1):71–5. [CrossRef]
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We thank Dr. Robert Sykes (www.doctored.org.uk) for providing editorial services.
Author ContributionsBrechtje MM Nellensteijn - Conception of the work, Design of the work, Acquisition of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Jorik Jop Pat - Conception of the work, Design of the work, Acquisition of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
A Marije Hoogland - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Martijn G Steffens - Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
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