A rare case of prostate cancer spreading to the anterior urethra has been reported in a 64-year-old man whose prostate-specific antigen (PSA) levels showed only minimal change. Doctors say this unusual pattern underscores the limits of relying on PSA alone and highlights the need for close clinical monitoring even years after treatment.
The patient first showed signs of trouble in May 2024, when he reported visible blood in his urine. A flexible cystoscopy two months later revealed two abnormal growths: a 1.5-centimeter polyp in the anterior urethra and a second small villous lesion near the bladder neck.
His medical history included high-risk prostate adenocarcinoma diagnosed in 2017 after a transurethral resection of the prostate (TURP). He then received radical radiotherapy and two years of hormonal therapy. His PSA levels remained stable for years, and imaging at that time showed no spread of disease.
Both urethral lesions were surgically removed. Laboratory analysis showed that the prostatic urethral lesion was a benign nephrogenic metaplasia, while the anterior urethral lesion was confirmed as metastatic prostate adenocarcinoma with a Gleason score of 4+4. Because of this new metastatic site, a multidisciplinary team recommended restarting hormonal therapy. The patient is now under regular follow-up, including PSA monitoring and repeated cystoscopy. His most recent scans show no new disease.
A Rare and Easily Missed Recurrence
Tumors in the urethra—whether primary or metastatic—are extremely uncommon. Prostate cancer most often spreads to the bones, lymph nodes, lungs, and liver, making urethral involvement particularly unusual. When urethral metastasis does occur, blood in the urine is usually the first sign.
One major challenge is that PSA levels may not rise when cancer returns in the urethra. Several previous reports have shown similar cases in which recurrence happened despite very low or even undetectable PSA levels. Doctors believe this may be linked to poorly differentiated tumor cells that produce little PSA. This case again shows that PSA stability cannot rule out recurrence, especially in patients with new urinary symptoms.
Diagnosis and Treatment
The diagnosis of urethral metastasis depends on endoscopic examination, biopsy, and imaging. In this case, immunohistochemistry confirmed the lesion’s prostatic origin through positive PSA and NKX3.1 staining. Advanced imaging such as PSMA PET/CT ruled out widespread disease.
There is no standard treatment because the condition is so rare. Small, isolated lesions may be removed endoscopically, while more extensive disease sometimes requires major reconstructive surgery. Hormonal therapy remains a cornerstone for systemic control. In this patient, local removal followed by renewed androgen deprivation therapy was considered the safest approach.
Conclusion
While outcomes vary widely, this case stresses the importance of long-term vigilance. Urethral metastasis can emerge years after successful treatment and may not correspond with PSA levels. Experts advise that any new urinary symptoms in a prostate cancer survivor should prompt endoscopic evaluation, even when PSA results appear reassuring.
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