AJR 2002; 179:1477-1479
© American Roentgen Ray Society
Giant Multilocular Cystadenoma of the Prostate
David Rusch1,
Alireza Moinzadeh2,
Karim Hamawy2 and
Carl Larsen1
1 Department of Radiology, Lahey Clinic, 41 Mall Rd., Burlington, MA
01805.
2 Department of Urology, Lahey Clinic, Burlington, MA 01805.
Received March 25, 2002;
accepted after revision May 23, 2002.
Address correspondence to D. Rusch.
Introduction
Giant multilocular prostatic cystadenoma is a rare pathologically benign
entity [1]. Patients typically
present with urinary obstructive symptoms because of the large size of the
lesion. Imaging modalities can depict the cystic, septated structure of the
mass and show its relationship to adjacent organs. Therefore, imaging provides
useful information for planning complete surgical excision, a curative
procedure that can provide the pathologic diagnosis as well. We report two
cases of giant multilocular prostatic cystadenoma—one, an initial
presentation and the other, a recurrence.
Case Reports
A healthy 30-year-old man presented after three episodes of urinary
retention and a 2-month history of worsening lower urinary tract symptoms. The
patient complained of frequency, urgency, and inability to completely empty
his bladder. He reported no episodes of fevers, chills, or dysuria. The
patient's primary care physician had previously treated him for a presumed
urinary tract infection with antibiotics and had also prescribed an
-blocker. Findings at physical examination were normal except for an
extremely enlarged prostate gland with multiple lobulations discovered during
the digital rectal examination. Values from the routine laboratory tests were
all normal. The prostate-specific antigen level was 2.0 ng/mL. A urinalysis
revealed an RBC of 2-5 x 106 µL per high-power field.
Results of the urine culture were negative. The postvoid residual volume was
elevated at 342 mL.
A contrast-enhanced CT scan showed an approximately 15-cm cystic mass in
the pelvis that appeared to be originating from the prostate, displacing the
bladder anteriorly and the sigmoid colon laterally. The mass had multiple
septations with some soft-tissue components
(Fig. 1A). Endorectal
sonography confirmed the presence of a large multilocular cyst arising from
the prostate (Fig. 1B).
Aspiration yielded 300 mL of hemorrhagic fluid. Cytologic examination of the
fluid showed only RBCs and histiocytes with no malignant cells. Biopsy of the
prostate revealed benign prostatic tissue with cystic dilatation of glands and
no evidence of malignancy.
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Fig. 1A. —30-year-old man with urinary retention. CT scan shows large
complex cystic mass in expected location of prostate gland. Mass displaces
bladder (arrowhead) anteriorly and sigmoid colon (arrow)
laterally.
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Fig. 1B. —30-year-old man with urinary retention. Endorectal sonogram
reveals multiseptated cystic mass (arrow) arising from normal
prostatic tissue. Bladder (arrowhead) can be seen anteriorly.
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During exploration through a midline peritoneal incision, surgeons located
and removed a mass with a thin fibrous capsule, leaving intact the
normal-appearing portion of the prostate, seminal vesical, and vas deferens
(Fig. 1C). Histologic
examination of the specimen revealed glands and cysts lined by cuboidal and
low-columnar epithelial cells with basally located nuclei. The pathologic
findings were consistent with giant multilocular prostatic cystadenoma. At
follow-up 18 months later, the patient remained free of lower urinary tract
symptoms.
Our second case involves a 41-year-old man who had undergone an incomplete
excision of a giant multilocular prostatic cystadenoma 1 year earlier at
another institution (Fig. 2A).
He presented to our hospital with acute urinary retention. CT and MR imaging
showed an approximately 15-cm multiseptated cystic mass in the pelvis (Figs.
2B and
2C). The patient underwent
surgical excision of the mass and required a urinary diversion. Pathologic
examination confirmed the mass was a benign prostatic cystadenoma.
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Fig. 2A. —41-year-old man with acute urinary retention. CT scan shows
large multiloculated cystic mass arising from prostate gland, which is
displaced to right side. Bladder (arrow) is filled with contrast
material, and Foley catheter (arrowhead) is seen in prostatic
urethra.
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Fig. 2B. —41-year-old man with acute urinary retention. CT scan
obtained 1 year after surgical resection of mass shows recurrence of loculated
cysts in lower pelvis. Foley catheter (arrow) was placed to alleviate
urinary obstruction.
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Fig. 2C. —41-year-old man with acute urinary retention. Sagittal
T2-weighted MR image obtained at same time as B reveals recurrent large
multiloculated cystic mass that displaces bladder (arrow)
anteriorly.
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Discussion
Giant multilocular prostatic cystadenoma is a rare clinical entity, with
only 11 cases previously reported
[1,2,3,4,5,6].
This benign tumor is characterized histologically by glands and cysts lined
with cuboidal epithelium in a hypo-cellular fibrous stroma. Positive
immunohistochemical staining of the epithelial cells for prostate-specific
antigen confirms the prostatic origin of the lesion. Grossly, the lesion can
attain massive proportions, but it does not invade adjacent structures
[1]. Because of the large size
of the mass, the clinical presentation of a patient with giant multilocular
prostatic cystadenoma typically includes obstructive urinary symptoms and a
palpable abdominal mass, as was seen in our first patient.
Multiple entities can produce cysts in the prostate
[7]. Some of these lesions have
characteristic features that can aid one in differentiating them from giant
multilocular cystadenoma. Cystic degeneration in benign prostatic hyper-plasia
and retention cysts typically are small and, hence, are usually asymptomatic
and discovered incidentally on endorectal sonography. Müllerian duct
cysts and prostatic utricle cysts are identifiable because of their midline
location. Cavitary prostatitis and prostatic abscesses usually occur in
patients with clinical signs and symptoms of infection.
On the other hand, giant multilocular cystadenoma can resemble less common
lesions such as a parasitic cyst, phyllodes variant of atypical prostatic
hyperplasia, and cystic carcinoma. In addition, although giant multilocular
cystadenoma typically arises in the prostate, it has been reported to occur in
sites that are completely separate from the gland
[1]. For this reason, giant
multilocular cystadenoma should be included in the broader differential
diagnosis of cystic retrovesical and retroperitoneal masses in men (i. e.,
lymphangioma, teratoma, cystic sarcoma, and multilocular peritoneal inclusion
cyst). However, a key point to remember is that radiographic evidence of local
invasion essentially excludes the possibility of giant multilocular prostatic
cystadenoma.
Despite its benign nature, giant multilocular cystadenoma of the prostate
can regenerate and produce recurrent symptoms after an incomplete resection.
This was the case in the second patient we presented, and Maluf et al.
[1] reported the case of a
38-year-old man who developed a recurrence 16 months after the initial
operation. Therefore, the treatment of choice for giant multilocular prostatic
cystadenoma is complete surgical excision, which provides a pathologically
confirmed diagnosis as well as a cure.
Acknowledgments
We thank St. Mary's Regional Medical Center, Lewiston, ME, for providing
images for this article.
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Introduction
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