Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome

Aparajit Ram Venkateswaran; Safa F. Elzein; Emilio D. Sulpizio; Bernard Chang; Michael P. Kosty

doi:10.12688/f1000research.121639.1

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Case Report

Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome

[version 1; peer review: 1 approved with reservations]

Aparajit Ram Venkateswaran ^1,2, Safa F. Elzein¹, Emilio D. Sulpizio², Bernard Chang³, Michael P. Kosty²

Aparajit Ram Venkateswaran ^1,2, Safa F. Elzein¹, [...] Emilio D. Sulpizio², Bernard Chang³, Michael P. Kosty²

PUBLISHED 18 Aug 2022

Author details Author details

¹ Department of Internal Medicine, Scripps Clinic, La Jolla, California, 92037, USA
² Department of Hematology-Oncology, Scripps Clinic, La Jolla, California, 92037, USA
³ Department of Pathology, Scripps Clinic, La Jolla, California, 92037, USA

Aparajit Ram Venkateswaran
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Safa F. Elzein
Roles: Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Emilio D. Sulpizio
Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing

Bernard Chang
Roles: Data Curation

Michael P. Kosty
Roles: Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Oncology gateway.

Abstract

Background: Only 32 cases of prostate cancer with peritoneal carcinomatosis and ascites have currently been reported in the literature. We present the first reported case of prostate cancer with peritoneal carcinomatosis and malignant ascites whose treatment was complicated by tumor lysis syndrome along with a literature review evaluating similar cases.
Case: We present a rare case of a 78-year-old retired Caucasian male with recurrent metastatic prostate cancer and malignant ascites. He had previously received definitive radiotherapy for localized prostate cancer but presented with bilateral hydronephrosis and right-sided bladder wall thickening 10 years later. He had imaging evidence of locoregional recurrence with elevated prostate specific antigen (PSA) and was initiated on combined androgen blockade with intramuscular leuprolide and oral bicalutamide. After being transferred to Scripps Clinic, he was found to have a solitary right upper lobe pulmonary lesion for which he completed stereotactic body radiation therapy. Then, 10 months later, he developed new onset malignant ascites and was treated with two cycles of intravenous docetaxel. Treatment resulted in improvement in his ascites and reduction in PSA. Unfortunately, his course was complicated by tumor lysis syndrome, encephalopathy, Escherichia coli bacteremia, and a fatal saddle pulmonary embolism. Conclusions: (1) Occurrence of ascites in prostate cancer patients is associated with worse prognosis than non-ascitic variants. (2) More common etiologies of ascites must be evaluated for. (3) Ascitic fluid prostate specific antigen (PSA) measurement may aid in diagnosis of malignant ascites in cases with diagnostic uncertainty. (4) Patients with advanced disease may benefit from combined hormonal and cytotoxic therapies. (5) Awareness of the occurrence of tumor lysis syndrome (TLS) in patients treated for prostate cancer can help identify patients in whom prophylaxis would be beneficial.

Keywords

Prostate cancer, malignant ascites, tumor lysis syndrome, hemorrhagic ascites, ascites, chylous ascites, metastatic prostate cancer, castrate resistant prostate cancer

Corresponding authors: Aparajit Ram Venkateswaran, Emilio D. Sulpizio

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Venkateswaran AR et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Venkateswaran AR, Elzein SF, Sulpizio ED et al. Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome [version 1; peer review: 1 approved with reservations]. F1000Research 2022, 11:957 (https://doi.org/10.12688/f1000research.121639.1) First published: 18 Aug 2022, 11:957 (https://doi.org/10.12688/f1000research.121639.1) Latest published: 18 Aug 2022, 11:957 (https://doi.org/10.12688/f1000research.121639.1)

Introduction

After skin cancer, prostate cancer is the most common malignancy in men in most of the Western world. Incidence rates in the US rose through the early 1990s and have subsequently decreased, possibly in association with guidelines recommending against use of prostate specific antigen (PSA) for screening.¹^,² It remains the leading cause of cancer death in American men after lung cancer and one in nine American men will be diagnosed with prostate cancer in their lifetime.³ While most cases are localized on presentation, up to 17% of patients may experience metastatic disease associated with increased cancer-specific mortality.⁴ Bone, distant lymph nodes, and abdominal organ metastases are the most common, but peritoneal carcinomatosis with concurrent malignant ascites is exceedingly rare.⁵ Only 32 cases of prostate cancer with peritoneal carcinomatosis and ascites have currently been reported in the literature (Table 1). We present the first reported case of prostate cancer with peritoneal carcinomatosis and malignant ascites whose treatment was complicated by tumor lysis syndrome along with a literature review evaluating similar cases.

Table 1. Cases of prostate cancer with ascites.

Year reported	Author	Ref.	Age, years	Time between first diagnosis and ascites	*Other sites of metastases	Treatment (Pre-ascites)	Treatment (Post-ascites)	Response from diagnosis of ascites	Outcome
1968	Rapoport et al.	⁴³	76	16 years	Lymph nodes, direct invasion of surrounding organs	Orchiectomy + DES	5-FU and IP Thiotepa	Progression	Death at 3 months
1968	Rapoport et al.	⁴³	45	1 year	Seminal vesicles, bladder, and surrounding lymphatics	Total cystectomy	Orchiectomy, DES	Progression	Death in weeks to few months
1973	Megalli et al.	⁷	58	Initial presentation^δ	None		DES, RT	Remission	Resolved ascites, alive at 6 months
1990	Beigel et al.	⁸	29	Initial presentation^β	Bones		Patient Refused	Progression	Death at 1 month
1990	Disdier et al.	²⁵	78	Initial presentation^α	Lymph nodes	None	Orchiectomy, Nilutamide	Remission	Diminished ascites, survival NR
1992	Catton et al.	²⁶	63	Initial presentation	Diffuse visceral, local invasion of periprostatic tissues (on autopsy)		Orchiectomy, hormonal therapy	Remission	Resolution of ascites for 9 months, death at 13 months
1999	Saif et al.	²⁷	70	4 years	None reported	RT, Leuprolide + Flutamide, Leuprolide + Bicalutamide, Thalidomide	NR	Progression	Alive at 2 months
1996	Zhau et al.	²⁸	83	>1 year	Liver, bones	NR	Orchiectomy	Progression	Death at 12 months
2000	Wynn et al.	²⁹	73	9 years	Lymph nodes, sigmoid colon	RT	None	Progression	Death at 3 weeks
2001	Tsai et al.	³⁰	68	15 months^α	Rectal wall	Gosrelin, Flutamide	Interferon alpha-2b and toremifene	Progression	Death at 4 months
2002	Amin et al.	⁹	83	5 years^β	Lymph nodes	Antiandrogen	Withdrawal of antiandrogen therapy	Progression	Death at 6 weeks
2002	Kehinde et al.	¹⁰	76	4 years^δ	None	TURP	Orchiectomy on recurrence	Remission	Resolved ascites in 3 months, alive at 18 months
2004	Appalaneni et al.	¹⁶	60	3 years	Bones, lymph nodes	RT, GnRH Agonist + Antiadrogen, Mitoxantrone + Prednisone	NR	Progression	Death at 6 weeks
2004	Lapoile et al.	³¹	80	10 years	Bone, others	RT, triptorelin, aminoglutethimide and hydrocortisone	None	Progression	Death at 3 months
2007	Madaan et al.	³²	75	3 years^α	Lymph nodes	Gosrelin	DES and ASA	Progression	Death within 4 months
2009	Okouo et al.	³³	81	3 years^α	Brain	None	Triptorelin, cryproterone	Progression	Resolved ascites, death at 3 months
2009	Zagouri et al.	³⁴	75	5 years	None	Gosrelin + bicalutamide, Gosrelin + estramustine	Docetaxel + Estramustine, Docetaxel + prednisone	Remission	Resolution of ascites, alive at 6 months
2010	Benedict et al.	³⁵	67	4 years	None	Orchiectomy and Bicalutamide	Docetaxel	Remission	Diminished ascites, survival NR
2012	Talwar et al.	³⁶	59	Initial presentation	Inguinal and umbilical hernia sacks		Leuprolide	Progression	Death at 3 months
2013	Ani et al.	³⁷	57	Initial presentation	Lymph nodes, bones	Bicalutamide + GnRH agonist	NR	Stable Disease	Stable ascites, decreased PSA, alive at 3 months
2015	Petrakis et al.	¹³	76	16 years	Lymph nodes, bones	TURP, Bicalutamide + Leuprolide	Docetaxel	Remission	Resolved ascites, alive at 10 months
2015	Pradhan et al.	³⁸	70	Initial presentation	Bones, lymph nodes		Hormone therapy	Remission	Ascites response NR, alive at 6 weeks
2015	Saini et al.	¹¹	65	9 years^δ	None	Orchiectomy, Bicalutamide, Fosfestrol, Ketoconazole + Prednisolone	Taxotere-base chemotherapy	NR	NR
2016	Gungor et al.	³⁹	60	3 years	Locally advanced	RT, Antiandrogens	NR	NR	NR
2016	Papadatos et al.	¹²	69	3 years^δ	Bone	RT, Bicalutamide + Triptorelin	None	Progression	Death at 3 weeks
2017	Ladwa et al.	¹⁴	74	NR	None	Docetaxel, Abiraterone	Cabazitaxel	Stable disease	Increased PSA, stable imaging, alive at 10 months
2018	van Roekel et al.	⁴⁰	65	15 months	Ureteral	RT, Bicalutamide, Docetaxel	"Palliative Therapy"	Progression	Death at 3 weeks
2019	Samankan et al.	⁴¹	84	NR	NR	NR	Docetaxel + Enzalutamide	Remission	Diminished ascites, alive at follow up (time NR)
2019	Tareen et al.	¹⁷	70	1 week	Bladder, seminal vesicles, liver	Aborted prostatectomy	Bicalutamide + Leuprolide, Docetaxel, Abiraterone + Prednisone, Cabazitaxel	Progression	Alive at 6 months with transiently diminished symptoms, transitioned to hospice given poor functional status
2020	Present case	N/A	78	8 years^α	Lung, bone	Leuprolide + Bicalutamide	Docetaxel + Bicalutamide	Progression	Diminished ascites for 1 month, death at 3 months
2020	Visconti et al.	¹⁵	77	Initial presentation^δ	Bone	None	GnRH agonist + Bicalutamide	Remission	PSA reduction & reduced ascites at 3 months, death NR
2021	Sagar et al.	⁴²	36	Initial presentation	Bone, liver, lymph nodes	NR	NR	NR	NR
	Median age, years		70

* Excluding peritoneal or omental.

α Hemorrhagic ascites.

β Chylous ascites.

δ Nonmalignant cytology, non-chylous.

Literature review

We reviewed the literature including cases and postmortem studies of patients with “prostate cancer” AND “malignant ascites” through a PubMed (RRID:SCR_004846) search (human; all languages; 1968–2022; last search 10 May 2022). We performed a manual retrieval of bibliographical information of resulting papers to identify additional literature and collect information regarding age, clinical features, metastatic sites, treatments, outcomes, survival, and cause of death.

Case report

A 78-year-old retired Caucasian male patient with diabetes, hypertension, peripheral vascular disease, and stage IV chronic kidney disease due to obstructive uropathy was initially diagnosed with intermediate risk, T2b N0 M0, clinical stage II prostatic adenocarcinoma at another facility where he completed definitive radiotherapy in 2008. He had a 90 pack/year smoking history, which he quit in 1992. Family history was notable for prostate cancer in his paternal uncle. In 2018, a computed tomography (CT) scan of his abdomen revealed bilateral hydronephrosis and right-sided bladder wall thickening. He was found to have PSA elevated to 45 ng/ml and was initiated on combined androgen blockade with intramuscular leuprolide (22.5 mg every three months) and oral bicalutamide (50 mg daily). Cystoscopy at that time was only notable for radiation cystitis.

In March 2019, after being transferred to Scripps Clinic, he was found to have a solitary right upper lobe pulmonary lesion on positron emission tomography (PET)/CT. He completed stereotactic body radiation therapy (SBRT) in June 2019, at which time his PSA level was 38.2 ng/ml. A follow up surveillance PET/CT was without evidence of active metastatic disease.

The patient was admitted to Scripps Green Hospital with severe abdominal distension and shortness of breath on 12 April 2020. Physical exam was notable for palpable fluid wave and shifting dullness consistent with new onset ascites. A therapeutic and diagnostic paracentesis yielded 3L of serosanguinous fluid with 79,000 red blood cells, albumin 1.8 g/dL, protein 3.4 g/dL, glucose 154 mg/dL, lactate dehydrogenase (LDH) 1,004 units/L, pH 7.5, polymorphonuclear cell count 184 cells/mm³, and negative gram stain, ruling out spontaneous bacterial peritonitis (SBP). Serum albumin was 2.7 g/dL with a serum albumin ascites gradient (SAAG) <1, consistent with an exudative process. Ascitic fluid cytopathology revealed metastatic prostatic adenocarcinoma with immunohistochemistry (IHC) positive for prostatic markers homeobox protein Nkx-3.1 (NKX3.1), ETS transcription factor ERG (ERG) and PSA (Figure 1 and Figure 2). Gastrointestinal IHC was negative for CDH17. PSA levels were elevated at 446.60 ng/mL. CT abdomen and pelvis without IV contrast demonstrated severe peritoneal thickening, nodular omental infiltration, ascites, mildly nodular bladder wall thickening, scattered sclerotic osseous foci, and new vertebral osseous metastasis at T12 with interval development of 7.1 × 6.3 cm right cardiophrenic angle tumor (Figure 3). He had stable scattered small nonspecific abdominal mesenteric and retroperitoneal lymph nodes. He required paracentesis every 24-48 hours due to rapid reaccumulation of ascites.

Figure 1. Cytology images of ascitic fluid.

Cytology of ascitic fluid demonstrating highly atypical epithelial cells with somewhat vacuolated cytoplasm, pleomorphic nuclei, and mitotic figures in a background of necrosis and acute inflammation on H&E stain (left) with immunohistochemistry demonstrating positive PSA (right) staining (400×). PSA, prostate specific antigen.

Figure 2. Immunohistochemistry of ascitic fluid demonstrating positive NKX3.1 (left) and ERG (right) staining (400×).

Figure 3. Patient imaging.

(A) CT abdomen and pelvis without IV contrast showing severe peritoneal thickening with nodular omental deposits (arrows). (B) Heterogeneity of bone density with scattered sclerotic foci and ill-defined sclerotic lesion of T12 vertebral body (arrow). (C) Bulky soft tissue tumor at the right cardiophrenic angle measuring approximately 7.1 × 6.3 cm transversely (circle) with ascites (arrow). (D) Asymmetric and mildly nodular right greater than left bladder wall thickening (arrows). CT, computed tomography.

He was initiated on intravenous docetaxel 75 mg/m² every 21 days per the androgen ablation therapy vs. combined chemo-hormonal therapy trial for metastatic prostate cancer (CHAARTED) trial.⁶ Five days later, he developed worsening renal insufficiency secondary to known bilateral hydronephrosis and nephrostomy tubes were placed. Further laboratory workup showed an elevated uric acid (20.6 ng/dL), potassium (5.8 nmol/L), and phosphorus (12.1mg/dL), consistent with tumor lysis syndrome (TLS). He received three hemodialysis sessions with improvement in renal function and was transferred to a skilled nursing facility. He had intermittent improvement in his ascites and did not require therapeutic paracentesis for one month. Cycle two of docetaxel was reduced to 37.5 mg/m² due to renal insufficiency and fatigue with cycle one. Serum PSA decreased from 446.60 ng/mL to 43.79 ng/ml after two cycles. Unfortunately, he was readmitted on 3 July 2020 for rapidly reaccumulating ascites and encephalopathy, he was then subsequently found to have Escherichia coli bacteremia with acute kidney injury. He eventually expired from obstructive shock due to massive saddle pulmonary embolism during this admission.

Results

Based on our literature review, we describe the 32^nd case of prostate cancer with peritoneal metastasis and ascites, and only the 29^th case with malignant ascites (Table 1). Of these cases, only four others had hemorrhagic ascites. Six cases (18.8%) were associated with ascites with negative cytology and two of these patients had chylous ascites.⁷^–¹² A total of 10 patients (31.2%) achieved documented disease remission with two patients surviving for at least six weeks and five surviving for ≥ six months, four of whom survived at least 10 months in remission.¹⁰^,¹²^–¹⁴ Survival was not reported in four cases. A diagnosis of malignant ascites in two of these cases was made purely based on ascitic PSA elevated above serum PSA levels despite negative cytology.¹²^,¹⁵ Elevated ascitic PSA in one case prompted clinicians to repeat a paracentesis, which eventually yielded malignant cytology.¹⁶ Time from initial diagnosis of cancer to development of ascites typically ranged from 1-16 years. Ascites occurred one week after aborted prostatectomy in one case, though imaging suggested peritoneal deposits before this.¹⁷ There was a documented response of ascites in 14 cases (43.8%), remaining stable in two (6.3%), diminishing in five (14.3%), and resolving in six (18.8%) with remission. Ascites diminished at least transiently in two cases of disease progression, including our own. Responses after development of ascites were elicited by surgical or chemical castration in six cases (18.8%), cytotoxic therapy in four cases (12.4%), and combined therapy in five cases. Ascites was the initial presentation of disease in nine cases (28.1%), occurred late in 20 (62.5%), was not reported in two, and occurred one week after aborted prostatectomy in one case (Table 2). The median age at which ascites presented was 70 years old.

Table 2. Features of ascites in patients with prostatic peritoneal carcinomatosis.

			Number of cases
Ascites characteristics (if atypical)	Negative cytology
		Chylous	2
		Non-chylous	3
		Non-chylous, elevated PSA	2
	Positive cytology	Hemorrhagic	5
Ascites response to treatment*	If remission achieved	Stable	2
		Diminished	5
		Resolved	6
		Not reported
	If disease progressed		2^§
	Response not reported		1
		Total	17
Therapy used to elicit response*	Castration		6
	Cytotoxic		4
	Combined		5
		Total	15
Time at which ascites presented from initial diagnosis	Initial presentation		9
	Early (<1 year)		1
	Late (≥1 year)		20
	Not reported		2
		Total	32

* If ascites remained stable, diminished, or resolved.

§ Initially diminished but recurred.

Discussion

In a large population-based analysis by Gandaglia et al., the most common sites of metastasis in prostate cancer were bone (84%), distant lymph nodes (10.6%), liver (10.2%), thorax (9.1%), brain (3.1%) and digestive tract (2.7%).⁵ Peritoneal and omental metastasis are exceedingly rare with associated ascites being even less common. In determining the pathophysiology of malignant dissemination, Paget first described the “seed and soil” hypothesis, in which cancer cells (seeds) migrate to secondary sites (soil) based on local factors contributing to the proclivity of cell migration.¹⁸ Mechanisms of metastasis in prostate cancer have been studied in most detail in osseous disease and describe interactions between chemokines like C-X-C motif chemokine 12 (CXCL12) in bone and chemokine receptors type four and seven (CXCR4, CXCR7) in migration of tumor cells. Other receptors such as annexin II, integrin αvβ3, and receptor-ligand pairs like Notch-Jagged have also been implicated in osseous metastasis.¹⁹ While the chylous and transudative nature of fluid in three of these cases suggests ascites was due to lymphangitic carcinomatosis or obstruction, exudative fluid with detectable malignant cells in most other cases suggests lymphangitic carcinomatosis or invasion of the mesothelial peritoneal lining.⁸^–⁹^,¹⁶ It has also been hypothesized that robotic-assisted resections have led to port-site metastasis, though not always with concurrent malignant ascites.²⁰^,²¹

In addition to the rarity of our patient’s metastatic spread, we also describe the first documented case of TLS in a patient with prostate cancer with peritoneal carcinomatosis and malignant ascites. TLS is extremely rare in solid tumors, particularly prostate cancer, with only 11 cases reported as of January 2020.²²^,²³ A total of 10 of these cases notably had widespread metastatic disease, typically with extensive bone and liver involvement, though our patient had only a single known vertebral metastasis with few other small, scattered foci of osseous involvement without liver involvement.

Baeksgaard and Sorenson note that the mortality rate of TLS in solid tumor malignancies is significantly higher than in hematological malignancies, further highlighting the importance of early clinical recognition or potential prophylaxis for TLS in patients with metastatic prostate cancer.²⁴

Strengths of our paper include construction of the first comprehensive table of cases of prostate cancer and malignant ascites as well as the characteristics of such cases gained from literature review in all languages (Tables 1 and 2). Furthermore, we describe one of the few known cases of TLS in a patient with prostate cancer. Our conclusions are limited by the inability to make causal inferences regarding the pathogenesis of ascites in all cases, given the retrospective nature of our review.

Conclusions

Our case and review of the literature suggest that (1) the occurrence of ascites in patients with prostate cancer is typically associated with a worse prognosis than non-ascitic variants. (2) More common etiologies of ascites, including other primary malignancy must be evaluated for. (3) Ascitic fluid PSA measurement may aid in the diagnosis of malignant ascites in cases with negative fluid cytology and diagnostic uncertainty. (4) Carefully selected patients with advanced disease may achieve palliative benefit from combined hormonal and cytotoxic therapies. (5) Awareness of the occurrence of TLS in patients treated for prostate cancer or with ascites may help raise clinical suspicion and identify patients in whom prophylaxis would be beneficial.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the daughter of the patient.

Acknowledgements

We would like to acknowledge and thank Dr. Tridu Huynh for his aid in translating portions of three French papers.

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¹ Department of Internal Medicine, Scripps Clinic, La Jolla, California, 92037, USA
² Department of Hematology-Oncology, Scripps Clinic, La Jolla, California, 92037, USA
³ Department of Pathology, Scripps Clinic, La Jolla, California, 92037, USA

Aparajit Ram Venkateswaran
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Safa F. Elzein
Roles: Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Emilio D. Sulpizio
Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing

Bernard Chang
Roles: Data Curation

Michael P. Kosty
Roles: Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

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Published: 18 Aug 2022, 11:957

https://doi.org/10.12688/f1000research.121639.1

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© 2022 Venkateswaran AR et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Venkateswaran AR, Elzein SF, Sulpizio ED et al. Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome [version 1; peer review: 1 approved with reservations]. F1000Research 2022, 11:957 (https://doi.org/10.12688/f1000research.121639.1)

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Reviewer Report 06 Oct 2023

Tomislav Omrčen, University Hospital Split, Split, Croatia

Approved with Reservations

https://doi.org/10.5256/f1000research.133526.r208067

The authors present a case report including patient with a rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome. They also reviewed literature with patients with prostate cancer and ascites. The introduction, case ... Continue reading

The authors present a case report including patient with a rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome. They also reviewed literature with patients with prostate cancer and ascites. The introduction, case report, results, discussion, references, tables and figures are all appropriate and well described. This case report will be of interest to oncologists and help guide patient selection for approach and treatment for this rare population with prostate cancer. I think this paper should be published.

I think that in the Conclusion section it should be added as a sixth suggestion to the readers that this rare form of presentation of advanced prostate cancer requires additional genomic/molecular analysis of the available tumor tissue (peritoneum) or cytobloc or liquid biopsy in order to obtain additional important information about the genomic alterations that occur in such form of prostate cancer, which would be relevant for the prognosis of the disease and a possible personalized treatment approach.

Is the background of the case’s history and progression described in sufficient detail?

Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes
Is the case presented with sufficient detail to be useful for other practitioners?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Urological oncology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report

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06 Oct 2023 | for Version 1

Tomislav Omrčen, University Hospital Split, Split, Croatia

4 Views Cite this report Responses(0)

Approved With Reservations

The authors present a case report including patient with a rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome. They also reviewed literature with patients with prostate cancer and ascites. The introduction, case report, results, discussion, references, tables and figures are all appropriate and well described. This case report will be of interest to oncologists and help guide patient selection for approach and treatment for this rare population with prostate cancer. I think this paper should be published.

I think that in the Conclusion section it should be added as a sixth suggestion to the readers that this rare form of presentation of advanced prostate cancer requires additional genomic/molecular analysis of the available tumor tissue (peritoneum) or cytobloc or liquid biopsy in order to obtain additional important information about the genomic alterations that occur in such form of prostate cancer, which would be relevant for the prognosis of the disease and a possible personalized treatment approach.

Is the background of the case’s history and progression described in sufficient detail?

Yes
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes
Is the case presented with sufficient detail to be useful for other practitioners?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Urological oncology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome

Abstract

Keywords

Introduction

Table 1. Cases of prostate cancer with ascites.

Literature review

Case report

Figure 1. Cytology images of ascitic fluid.

Figure 2. Immunohistochemistry of ascitic fluid demonstrating positive NKX3.1 (left) and ERG (right) staining (400×).

Figure 3. Patient imaging.

Results

Table 2. Features of ascites in patients with prostatic peritoneal carcinomatosis.

Discussion

Conclusions

Data availability

Underlying data

Consent

Acknowledgements

References

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