Visual loss as the initial manifestation of an ignored disseminated prostate cancer: A case report

Abstract

Purpose: To present a rare case of advanced disseminated prostate cancer with bilateral visual loss as the initial manifestation of the disease.

Observations: A 55-year-old man referring progressive visual blurring for the last 6 months and painless severe bilateral visual loss in the last 7 days prior to our consultation, associated with a bilateral optic disc swelling and leptomeningeal metastases from a previously ignored prostate carcinoma is presented. Rapid improvement of visual acuity and involution of leptomeningeal metastasis was observed after initiation of the specific oncologic treatment.

Conclusions and importance: Bilateral visual loss may be the initial manifestation of leptomeningeal carcinomatosis from an ignored prostate cancer. Prompt diagnosis is crucial in order to improve the quality of life of a critically ill patient with a disseminated prostate cancer.

Keywords: Choroidal metastases; Meningeal metastasis; Optic neuropathy; Papilledema; Prostate cancer; Visual loss.

Fig. 1

Color fundus images of the right eye (A) and left eye (B), showing a marked bilateral papilledema, with optic disc's margins completely faded, obscuration of all vessels of the disc, slight venous dilatation, epi and juxta-papillary exudates and peripapillary superficial retinal hemorrhages. C: color fundus image of the temporal mid periphery of the right eye, showing a slightly prominent, gray-yellowish ovoid lesion with ill-defined edges (black arrows). D, E, and F: post systemic chemotherapy treatment; color fundus images of right (D) and left eye (E), showing bilateral complete resolution of optic disc swelling and retinal hemorrhages 18 months after initial visit; note the bilateral residual choroidal folds. F: color fundus image of the temporal mid-periphery of the right eye showing flattening and attenuation of the lesion described in Fig. 1C (black arrows) 18 months after initial visit. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

B-ultrasound scan of the right eye at initial examination showing a choroidal dome-shaped protruding lesion with heterogeneous internal reflectivity.

Fig. 3

A: sagittal T1-weighted gadolinium-enhanced brain magnetic resonance imaging (MRI) showing diffuse and nodular pachymeningeal metastatic thickening with peripheral gadolinium enhancement (arrowheads). B: horizontal T1-weighted brain MRI showing close relationship of both optic nerves with pachymeningeal metastatic involvement (arrowheads). C: sagittal T1-weighted gadolinium-enhanced brain MRI showing resolution of the diffuse and nodular pachymeningeal thickening described in Fig. 3A after initiation of specific oncologic treatment. D: horizontal T2-flair brain MRI showing good definition of both optic nerves after treatment. E: initial computed tomography scan of the thorax, abdomen and pelvis showing axial skeleton involvement; arrow pointing at one osteolytic lesion.

Fig. 4

Needle biopsy of the prostate gland (hematoxylin-eosin stain). A (low magnification) and B (high magnification) right lobe biopsy: moderate to poorly differentiated infiltrating adenocarcinoma (arrows); Gleason classification: 8 (5 + 3); International Society of Urological Pathology (ISUP) group classification: 4. C (low magnification) and D (high magnification): left lobe biopsy: well to moderately differentiated adenocarcinoma (arrow); Gleason classification: 6 (3 + 3). ISUP group classification: 1; also, it can be observed perineural infiltration in the right lobe (N:nerve).