Bony Metastases Research Articles

An observational study of the causes of an isolated elevated alkaline phosphatase level of unclear etiology

BackgroundSerum alkaline phosphatase (ALP) is a commonly obtained laboratory test, but its diagnostic specificity is limited because it is found in multiple tissues. We investigated patients with isolated, elevated, ALP levels without an obvious etiology at presentation to determine the frequency of different causes of an isolated elevated ALP. MethodsThis was a retrospective, cohort study of adults (age >18 years old) from January 1st, 2013, to June 30th, 2020 in both the in- and outpatient setting at the Medical University of South Carolina. 260 patients with an isolated, elevated ALP of unknown etiology (patients with known biliary obstruction, underlying parenchymal liver disease, or pregnancy were excluded) were included. A secondary outcome was mean survival time from the ALP result. ResultsThe most common cause of ALP elevation was due to underlying malignancy (147, 57%), with 61 patients having infiltrative intrahepatic malignancy, 52 patients having bony metastasis, and 34 patients having both hepatic and bone metastasis. Bone disease (75, 29%), unsuspected parenchymal liver disease (18, 7%), non-malignant infiltrative liver disease (7, 2%), and other disorders (13, 5%) accounted for the remainder of the cohort. Notably, 123 of 260 (47%) patients died within an average of 58 months after identification of isolated, elevated ALP. ConclusionsAn isolated, elevated ALP of unclear etiology is associated with several very specific and important disorders, in particular metastatic intrahepatic malignancy - and is uncommonly associated with primary parenchymal liver disease. Providers should be aware of the potential clinical significance of an elevated ALP.

Patterns and Clinicopathological Features of Histologically Proven Metastases in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver malignant neoplasm. Multiple risk factors have been identified for several decades for this overly aggressive tumor. HCC is an overly aggressive malignancy with frequent intrahepatic and extrahepatic metastasis. In our practice, we have observed that HCC has the propensity to metastasize to very unusual sites and can sometimes show variable patterns leading to diagnostic difficulty. In this study of 257 patients, we aim to discuss the unusual sites of HCC metastasis, the various patterns of metastasis, clinicopathological features, and the most common cause of HCC in our population. In the course of our research study, we systematically extracted a comprehensive dataset comprising 257 instances of metastatic HCCs from the hospital database spanning the period from 2016 to February 2022. The assessment of metastatic sites uncovered a wide range of locations, reflecting significant diversity. The most common location was bone, with 135 cases (52.5%). The vertebral column was the most common location among bony metastasis, with 63 cases (24.7%). Morphologically, the most common histological pattern observed was pure trabecular in 192 patients (74.7%). All cases were diagnosed with the help of immunohistochemical stains. Out of 257 cases, 29.18% were diagnosed using glypican-3 and HepPar1, while 26.1% relied solely on HepPar1 positivity. HepPar1 was performed in a total of 240 cases, and positivity was seen in 205 cases (85.5%). In summary, our study represents the most comprehensive investigation of clinicopathological characteristics in metastatic HCC conducted within the past 20 years. It helps understand the histological and immunohistochemical features useful for diagnosis at metastatic sites for tumors with an unknown primary.

Primary mucinous adenocarcinoma intestinal type of the vulva arising at site of prior vulvar Crohn’s disease: A case report and review of the literature

Introduction: Vulvar mucinous adenocarcinoma is a rare subtype that likely arises from atopic gastrointestinal tissue. The evaluation and treatment of this condition often requires a multidisciplinary approach. Case Report: Our patient is a 55-year-old female with a history of Crohn’s disease who initially presented with a painless vulvar mass associated with occasional bleeding. Notably, the mass presented at the site of a prior rectovaginal fistula. A vulvar biopsy was performed with pathology consistent with intestinal type mucinous adenocarcinoma. Further workup was notable for imaging showing retroperitoneal and pelvic metastatic lymphadenopathy, hypermetabolic liver and bony metastases, and pulmonary nodules concerning for metastases. Following discussion at tumor board, the patient was recommended treatment with 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), and bevacizumab. Unfortunately, prior to starting chemotherapy, the patient presented to the emergency department with dizziness and weakness and was found to have brain metastases. She ultimately elected to be discharged home on hospice care. Conclusion: Vulvar mucinous adenocarcinoma is a rare subtype tumor with limited literature on treatment options. For these rare cases, clinicians can consider treatment modalities for colon carcinomas rather than vulvar carcinomas.

Aggressive Synchronous Papillary and Likely Follicular Thyroid Carcinomas in a Patient with Graves’ Disease

We report a case of an uncommonly aggressive presentation of the rare entity of synchronous papillary (PTC) and follicular thyroid carcinomas (FTC) in a 67-year-old woman initially presenting with thyrotoxicosis from Graves’ disease. She was found to have two thyroid nodules with extensive intra-cardiac tumour thrombus, symptomatic left pelvis bony metastasis with pathological fracture, pulmonary metastases and mediastinal lymph node metastases. Further investigations suggested a diagnosis of synchronous papillary and metastatic follicular thyroid cancer. Treatment with radical surgery followed by adjuvant therapeutic radioiodine ablation was proposed, but the patient declined all forms of cancer-specific therapy and was elected solely for a palliative approach to treatment. We discuss the diagnostic considerations in arriving at the diagnosis of synchronous thyroid malignancy – in this case the clear features of PTC and the strong probability of FTC due to invasiveness and metastatic follicular lesions. This case underscores potential limitations of the ACR TI-RADS system, notably with certain ultrasonographic features suggesting malignancy that might not be adequately captured. Notably, the aggressive presentation of DTC in this case may be contributed by the concurrent presence of Graves’ Disease, suggesting heightened vigilance when assessing potential thyroid malignancies in such patients.

Increasing survival for melanoma with bony metastases in the era of novel therapies: A population-based retrospective analysis

Increasing survival for melanoma with bony metastases in the era of novel therapies: A population-based retrospective analysis

Comprehensive diagnostic model of metastasis in prostate cancer: Individual and combined bioscore model of ADC value, Gleason score, and PSA

AbstractProstate cancer (PCa) metastasis significantly influences treatment decisions and prognosis. This study evaluated the individual and combined diagnostic ability of apparent diffusion coefficient (ADC), Gleason score and prostate‐specific antigen (PSA) in detecting metastasis. The study included data from 120 biopsy‐confirmed PCa patients treated from 2019 to 2023. Whole‐body MRI images, incorporating high‐resolution T2 and axial DWI sequences, were evaluated by experienced radiologists. Receiver operating characteristic (ROC) curves and logistic regression models were used to assess the diagnostic performance of ADC, Gleason score, and PSA in detecting metastasis. The prevalence of PCa metastasis was 25.0%, with pelvic lymph node metastasis (16.7%) and bony metastasis (12.5%) being most prevalent. Patients with PCa metastasis had significantly lower ADC values, higher Gleason scores, and higher PSA levels compared to those without metastasis. Individually, an ADC cut‐off of ≤549.00 mm2/s was the best marker for detecting metastasis. The combined bioscore model including PSA, ADC values and Gleason score was the best independent predictor, correlating with a 159‐fold increased likelihood of detecting PCa metastasis. This study demonstrated the prognostic ability of PCa markers in detecting metastasis. ADC was an independent, sensitive, specific, and accurate diagnostic marker. The combined bioscore model of ADC, PSA and Gleason score significantly enhanced the identification of patients with PCa metastasis.

Frequency of Distant Metastasis of Differentiated Thyroid Carcinoma- A Descriptive Analysis

Introduction: The presence of distant metastases is one of the important predictive factors of poor outcomes in patients with thyroid carcinoma. It is rarely observed at early presentation of differentiated thyroid carcinoma (DTC). This study aimed to analyze the frequency of distant metastasis in differentiated carcinoma of the thyroid. Methods: This cross-sectional observational study was conducted at the Department of Otolaryngology, Rajshahi Medical College Hospital, Rajshahi, and Department of Otolaryngology Bangabandhu Sheikh Mujib Medical University (BSMMU), from July 2011 to Jun 2012. A total of 40 patients were selected as study subjects by simple random sampling technique. A descriptive analysis of data was carried out by using a statistical package for social science (SPSS) 22.0 for Windows. Result: In this study, a majority (35, 87.5%) of the patients suffered from papillary carcinoma, followed by (5,12.5%) follicular carcinoma. Considering the distant metastasis, 2 (5.71%) patients had metastasis to the lung among the patients with papillary carcinoma (n=35). 1 patient had lung metastasis and another 1 patient had bony metastasis among the follicular carcinoma patients. In terms of distant metastasis, 50% of the patients had distant metastasis from each papillary and follicular carcinoma. Conclusion: This study concludes that metastasis in differentiated thyroid carcinoma is not uncommon. Distant metastasis is more common in follicular thyroid carcinoma than papillary carcinoma. Lung and bone metastasis are common regarding the site of metastasis.

Langerhans Cell Histiocytosis in the Sphenoid Wing

Langerhans Cell Histiocytosis (LCH) is a rare and broad-spectrum of disease caused by uncontrolled proliferation of pathologic Langerhans cell resulting in localize and systemic organ infiltration. The clinical presentation can be unspecific and varies between individuals depending on the anatomical location and organ involvement. In view of bony infiltration is the most common in LCH, clinicians have to deal with the challenge of diagnosis dilemmas such as Giant Cell Tumour, Ewing’s sarcoma, osteogenic sarcoma, plasmacytoma, osteomyelitis or bony metastasis, particularly from neuroblastoma. Hence, it requires an excellent multidisciplinary team to establish the diagnosis and start targeted treatment early to prevent fatal complications. The treatment modalities include surgery, immunosuppressive therapy, chemotherapy or in combination. Recently, a seven months old boy presented to our centre with one-week duration of left cheek swelling and left eye proptosis. After detailed clinical evaluation together with imaging and biopsy, the lesion over the bilateral sphenoid and left zygoma were concluded to be Langerhans Cell Histiocytosis (LCH).

E013 Looking back at back pain: how well do our referrals measure up to available criteria?

Abstract Background/Aims According to the Global Burden of Disease Study 2021, low back pain remains the leading cause of years lived with disability (YLDs) globally affecting about 619 million people as of 2020. Inflammatory back pain affects fewer patients but remains an important referral indication. A previous audit from the early back pain clinic of cases seen between 2015-16 at the Royal National Hospital for Rheumatic Diseases, Bath, identified an axial spondyloarthritis (AxSpA) diagnosis in 21% of patients of whom, two thirds were HLAB27 positive. This follow-up audit aimed to evaluate for interval change in axSpA prevalence and assess the referrals against NICE and ASAS criteria respectively. While the NICE referral guidance is largely clinical, ASAS incorporates extra musculoskeletal manifestations and investigations. Methods We reviewed 100 of the 271 early back pain clinic referrals received between July 2022-23. The completed referral proforma was evaluated against the NICE and ASAS criteria respectively. Electronic medical records and clinic letters of patients were also reviewed including demographics, baseline investigations and imaging. Results The patients were 54% male with an average age of 38.7 ± 13.7years. An axSpA diagnosis was made in 19 patients (19%) of which 12 were HLAB27 positive (63.1%). The median symptom duration was 24 months (6-72) with an appointment delay of 128 days (36-182). Discharge rate was 35% after the first appointment. Overall, 62% of referrals satisfied NICE criteria compared to 71% for ASAS. This was after excluding 21 referrals which did not satisfy the ASAS entry criterion of symptoms > 3months in patients <45 years. Among our cohort, sensitivities were 68.4% for NICE and 73.7% for ASAS while specificities were 39.5% for NICE and 29.6% for ASAS. Three patients all above 45 years with a normal CRP met neither criteria, but were diagnosed with axSpA after MRI while one patient who satisfied both criteria turned out to have lung cancer with bony metastases. Conclusion There has been minimal interval change in AxSpA prevalence from our referrals between 2015-23. The ASAS criteria was easier to satisfy and can serve as an alternative referral indication for patients who do not meet NICE criteria. Both criteria are still very useful in terms of ensuring the quality of referrals received. Improvements in the referral pathway are being planned to reduce primary and secondary care delays thus enhancing earlier diagnosis and treatment. Disclosure A. Akpabio: None. M. Camillieri: None. T. Williams: None. R. Sengupta: None.

Myxofibrosarcoma of the Chest Wall Detected on 99mTc-MDP Whole-Body Bone Scan.

Myxofibrosarcoma is a type of soft tissue sarcoma, predominantly characterized by a high propensity for local recurrence, albeit demonstrating a relatively diminished risk for distant metastasis. Its prevalence is notably higher in elderly patients. Here, we present a case of a 73-year-old woman diagnosed with Myxofibrosarcoma. She was subjected to a whole-body bone scan using 99mTc-methylene diphosphonate (MDP) to survey potential bony metastasis. It revealed marked MDP accumulation with peripheral soft tissue uptake in the right lateral chest region of this patient. This imaging phenotype could potentially be attributed to the augmented vascularity within the tumor, a finding that was prominently displayed in this particular case.

Renal primitive neuroectodermal tumor in an adolescent: a case report and review of literature

Renal primitive neuroectodermal tumor is a highly malignant neoplasm that commonly affects young adults and infrequently presented in children and adolescents. We report a case of a 14-year-old female child who presented with abdominal mass. PET-CT showed an FDG avid cystic lesion in the inter and lower polar regions of the right kidney, extending into the right renal fat and renal vein, with multiple FDG avid lesions in the axial and appendicular skeleton, suggesting renal mass with bony metastases. Biopsy confirmed the diagnosis of primitive neuroectodermal tumor of the kidney. The patient completed six cycles of chemotherapy with partial response and subsequently the patient defaulted and lost to follow-up. To emphasize the critical significance of renal PNET in the differential diagnosis of renal tumors in children.

Staging Investigations in Early-Stage Breast Cancer Patients: Are Clinically Significant and Rational?

Introduction: Multiple studies have demonstrated that the yield of imaging for distant metastatic disease is low in patients with early-stage breast cancer without signs and symptoms of metastatic disease. So, a study was carried out to assess the clinical significance and usefulness of staging investigations in newly diagnosed early-stage breast cancer patients. Materials and method: A retrospective review of medical records of 171 patients with early-stage (stage I & II) breast cancer referred to the Tumor Board & Radiation Oncology department of NICRH and one private hospital after having surgery & adjuvant chemotherapy during the two-year period (January 2019-December 2020), were performed. The staging investigations the patients underwent perioperatively and the value of those in detecting metastasis were evaluated. Result: All patients had chest radiography and routine blood tests performed preoperatively. Postoperative chest radiography evaluation in various frequencies were done in 156 (91.22%) patients. CT scans of the chest were performed in 13 patients (7.6%). One patient (0.64%), who had complained of cough was diagnosed with pulmonary metastasis after evaluation. An ultrasonogram (USG) of the whole abdomen was done preoperatively in 135 patients (78.9%) & postoperatively and subsequently in 162 patients (94.7%) in various frequencies and CT scans of the abdomen were done in 7 patients (4.1%). No metastasis was detected by USG or CT scan of the abdomen. Bone scan was done in 53 patients (31%). Four patients (4/53) were diagnosed with bony metastases out of which 2 had symptoms of bone pain. Routine bone scan can picked up 2(3.7%) bone metastases in asymptomatic patients. Conclusion: Staging investigations for distant metastases in newly diagnosed early-stage breast cancer patients in the absence of signs and symptoms of metastatic disease have low yield, not evidence-based, not cost-effective and thus not recommended. J Bangladesh Coll Phys Surg 2024; 42: 38-42

Bone metastasis manifested 52 years after resection of an apparently benign paraganglioma: A case report

Paraganglioma is derived from the paraganglia tissue in the neck, along the sympathetic trunk, and in the pelvis. Paraganglioma has malignant potential and can metastasize to remote organs such as the liver, lungs, and bones. Most metachronous metastases occur within several years after the initial diagnosis of paraganglioma. Here, we report the case of a 71-year-old male patient who developed bony metastasis 52 years after the resection of a large paraganglioma at the aortic bifurcation. The biopsy-proven paraganglioma metastasis to the lesser trochanter of left femur presented as an avulsion fracture. His normetanephrine level was elevated. DOTATATE PET (positron emission tomography) did not find any other metastatic lesions. The bony metastasis was treated with radiation therapy. We believe that the patient had one of the longest gaps ever reported, 52 years, between the initial diagnosis and metastasis of paraganglioma. This case highlights the importance of long-term surveillance of patients with paraganglioma for metastasis.

Exploring the Prognostic Value of CS15-3 Tumor Marker in Breast Cancer Recurrence.

The most prevalent tumor marker for breast cancer is CS15-3. This marker's elevated serum levels have been proven to predict a patient's risk of developing the condition again. The purpose of this study was to ascertain the sensitivity of blood CS15-3 levels in the identification of breast cancer recurrence. A prospective cohort follow-up analytical study was conducted at Basra Oncology Center from early 2016 to the end of 2022. The study included 178 females aged ≥18 years with histologically confirmed invasive ductal breast cancer. CS15-3 had been evaluated for all included cases on two occasions: the first, at the time of diagnosis or remission, and the second, at the time of progression. The tumor marker (CS15-3) was evaluated using a Cobas e411 analyzer (Roche Diagnostics International Ltd). The mean age showed no significant difference between the groups (P=0.581). The duration of progression was higher among those with the luminal group (40.60± 42.08). Those with bony and liver metastasis were mostly among luminal (50.0%) and HER 2+ (52.4%) groups respectively. At the time of diagnosis CS15-3 tumor marker showed no significant difference between the three groups, while at the time of progression, the luminal group showed higher means (120.74± 95.07) compared to others with a significant mean difference of (-99.84± 94.43). Age, disease stages, and co-morbidity have no significant influence on the distribution between groups of luminal. The duration of progression was higher among those in the luminal group. Osseous and hepatic secondaries are mostly among luminal and hormonal receptors positive. Initially, at the time of diagnosis CS15-3 marker expressed no significant difference between the groups, whereas at the time of progression, the luminal group expressed a higher means of level of the CS15-3 marker.

Chapter 8: Management of Radioiodine Refractory Thyroid Cancer

ABSTRACT A small subset of patients with differentiated thyroid cancers (DTCs), over the course of their natural disease progression, undergo dedifferentiation which leads to altered tumor biology and an inability to concentrate and respond to radioactive iodine (RAI), despite being able to functionally produce and release thyroglobulin. They broadly consist of two groups – (a) thyroglobulin-elevated negative iodine scintigraphy and (b) radioiodine refractory DTC. This review deals with their definitions, presentation, and overall management principles, highlighting the key points of their treatment philosophy. Whole-body 18F positron emission tomography-computed tomography is the investigation of choice since majority of these become fludeoxyglucose avid once they lose their iodine avidity. Asymptomatic patients with low disease burden may be observed. Surgical ablation, for symptomatic patients with accessible disease is the prime treatment modality. For those deemed inoperable with high tumor burden and increasing symptomatology are best treated with multikinase inhibitors. External beam Radiation may be a choice for painful bony metastasis, while those refractory to multikinase inhibitors may be offered newer forms of localized therapy such as radiofrequency ablation, newer isotope therapy, and transarterial chemoembolization.

Ewing’s Sarcoma of the Mandible with Extensive Bony Metastasis in a Young Male: A Case Report

Ewing’s Sarcoma Family of Tumours (ESFTs) comprises locally aggressive, undifferentiated small round blue-cell tumours of neuroectodermal origin, predominantly seen in adolescents. These tumours arise from non random chromosomal translocations involving the Ewing’s Sarcoma (EWS) gene. ESFTs in the mandible are uncommon. A 14-year-old male patient presented with a painless swelling in the right jaw. Plain radiographs, ultrasonography, contrast-enhanced Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) revealed a large, partially well-defined, highly vascular soft tissue mass in the right mandibular region. It measured approximately 80×82×75 mm (anteroposterior x transverse x craniocaudal), with both solid and cystic components. The mass was destroying the underlying right temporomandibular joint, head, ramus and posterior body of the right hemimandible, including extensive sunray-type bony spiculations. There were multiple lytic lesions in the skull and facial bones, as well as, altered marrow signal intensity in the calvarium, bilateral humeri and clavicles, and cervical and thoracic vertebrae, indicating a locally aggressive tumour with extensive metastasis into the bones and marrow. The diagnosis was confirmed by histopathology, which showed fibrocollagenous tissue infiltrated by sheets of small round cells with scanty eosinophilic cytoplasm and prominent nuclei. Management typically involves a combination of chemotherapy, radiation and surgery. However, metastatic Ewing’s Sarcoma has a poor prognosis.

Uncharted Pathways: A Rare Case of Bony and Soft Tissue Metastasis from Cervical Carcinoma

Background: The most frequent tumors of the spine are metastases. However, we present a particular case characterized by an atypical primary origin resulting in secondary lesions in both the spinal column and adjacent soft tissues - specifically, squamous cell carcinoma of the cervix.

Adenosquamous carcinoma of prostate: An entity out of the ordinary

Adenosquamous carcinoma (ASC) of the prostate is an extremely rare, aggressive histological subtype of prostate cancer. We report one such case here of a 73-year-old man with prostatic malignancy with a combination of squamous and glandular components. Immunohistochemistry with p40, AMACR and HMWCK corroborated the diagnosis of ASC. The squamous component being refractory, is better amenable to aggressive surgery, highlighting the importance of recognising this entity. Bony metastasis was not seen in this patient. Serum PSA was near normal.

Solitary versus multiple bone metastases in the appendicular skeleton.

We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton. We conducted a retrospective study on a population-based cohort of all adult patients treated surgically for bony metastases of the appendicular skeleton between January 2014 and December 2019. We excluded patients in whom the status of bone metastases and resection margin was unknown. Patients were followed until the end of the study or to their death. We had no loss to follow-up. We used Kaplan-Meier analysis (with log-rank test) to evaluate patient survival. We identified 506 operations in 459 patients. A total of 120 operations (in 116 patients) were for solitary metastases and 386 (in 345 patients) for multiple metastases. Of the 120 operations, 70 (in 69 patients) had no/an unknown status of visceral metastases (solitary group) and 50 (in 49 patients) had visceral metastases. In the solitary group, 45 operations (in 44 patients) were R0 (resections for cure or complete remission) and 25 (in 25 patients) were R1/R2 (resections leaving microscopic or macroscopic tumour, respectively). The most common types of cancer in the solitary group were kidney (n = 27), lung (n = 25), and breast (n = 20). The one-year patient survival was 47% (95% confidence interval (CI) 38 to 57) for the solitary bony metastases and 34% (95% CI 29 to 39) for multiple bone metastases (p < 0.001). The one-year patient survival was 64% (95% CI 52 to 75) for solitary bony metastases without/with unknown visceral metastases and 23% (95% CI 11 to 36) for solitary bony metastases with visceral metastases (p < 0.001). The one-year patient survival was 75% (95% CI 62 to 89) for a solitary bony metastasis after R0 surgery and 42% (95% CI 22 to 61) for a solitary bony metastasis with R1/R2 surgery (p < 0.001). Our study suggests that the surgical treatment of patients with a solitary bony metastasis to the appendicular skeleton results in better survival than for patients with multiple bony metastases. Furthermore, aggressive treatment of a solitary bony metastasis with R0 surgery may improve patient survival.

Pure Foamy Gland Carcinoma of Prostate - A Series of Rare Cases

Foamy gland carcinoma (FGC) is a distinct histological variant of prostatic acinar adenocarcinomas. It was first described by Epstein and Nelson in 1996. It is characterized by abundant xanthomatous cytoplasm, pyknotic nuclei, and intermediate Gleason grade. However, FGC with a high Gleason grade exists. FGC is found admixed with conventional acinar adenocarcinoma in 17 to 22% of needle biopsies and 13 to 22% of radical prostatectomy specimens and only rarely found in pure form. We report six cases of pure foamy gland carcinoma of prostate. The mean age in our study was 62.83 years and 5 out of the 6 cases presented with an elevated serum PSA level. Histopathological examination of our cases showed tumor cells with abundant foamy cytoplasm and low nucleo-cytoplasmic ratio. This deceptively benign-looking morphology can mimic nonneoplastic prostatic glands, Cowper’s gland, mucinous metaplasia, and xanthomatous prostatitis and hence often pose diagnostic challenges, especially in core needle biopsies. PNI was detected in two of our cases. PSA and AMACR staining was positive in all our cases (100%). p63 Staining was negative in all four cases where it was performed. Three, two, and one of our cases had a Gleason score of 7, 8, and 6 respectively. The prognosis depends on the Gleason score and the presence or absence of PNI or extraprostatic extension. Three of the cases presented with bony metastasis. We report this case series in view of the rarity and also to raise awareness of this entity which is often missed on small biopsies. Keywords: Foamy gland carcinoma, Gleason score, Prostate