Obstructive Jaundice From Metastatic Prostate Cancer

Abstract

Introduction: Prostate cancer commonly presents with bone metastases and lymphadenopathy, but development of obstructive jaundice is extremely rare especially without metastases to liver parenchyma. Case Report: A 48-year-old African American male with a recent diagnosis of metastatic prostate cancer presented with elevated liver enzymes and painless jaundice. The patient had metastatic spread to the bone and lungs, and extensive peripancreatic, portacaval, aortocaval, and common iliac lymphadenopathy. He was currently being treated with bicalutamide and lueprolide. Upon presentation, he described 1 week of increasing jaundice without abdominal pain, fever, nausea, or vomiting. He was afebrile. Aside from generalized jaundice and icteric sclera, no hepatomegaly, asterixis, or petechiae were noted on exam. Labs revealed an elevated aspartate transferase (158 units/L), alanine transferase (372 units/L), alkaline phosphatase (515 mU/mL), total bilirubin (8.2 mg/dL) and direct bilirubin (4.5 mg/dL); all of which were normal 2 months prior. The creatinine, blood count, and coagulation studies were normal. HIV test was negative, as were hepatitis serologies. The patient denied alcohol intake and acetaminophen use. Echogram of the liver showed a mass, consistent with lymphadenopathy, that was previously visualized on computed tomography imaging near the portahepatis and now measured 41 x 50 mm. The mass was causing compression of the common bile duct (CBD) with intrahepatic biliary ductal dilation. Magnetic resonance cholangiopancreatography also showed interval development of moderate intrahepatic and extrahepatic biliary duct dilation with the CBD measuring 2 cm and tapering abruptly in a bird beak configuration, also likely secondary to lymphadenopathy near the pancreatic head. The patient underwent endoscopic retrograde cholangiopancreatography during which mid-proximal extrahepatic bile ducts were noted to be dilated to 2 cm, and a 4-cm long, likely malignant biliary stricture was found at the distal CBD. Sphincterotomy was performed and a metallic biliary stent was placed. Histological examination of specimen was consistent with metastatic prostate cancer. The patient’s liver enzymes returned to normal within 5 weeks. Conclusion: Obstructive jaundice in prostate cancer has been documented due to a metastatic mass surrounding the CBD or infiltrating the head of the pancreas. Cyproterone acetate and flutamide, structurally similar to bicalutamide, have also been associated with cholestatic jaundice. After considering other etiologies, clinicians should consider the possibility of biliary obstruction secondary to widespread lymphadenopathy. Palliative stenting greatly improves quality of life.