Letter to the Editor
Non-obstructive jaundice as a paraneoplastic syndrome of prostate carcinoma
Ictericia no obstructiva como síndrome paraneoplásico del carcinoma de próstata
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Uptake compatible with multiple retroperitoneal and cervical lymphadenopathy was observed. (B) Bone scintigraphy. A generalized increase in skeletal uptake is observed, mainly in the axial and proximal ends of the humerus and femurs, with an absence of activity in the kidneys and soft tissues ("superscan" pattern), indicative of generalized metastatic bone involvement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paraneoplastic intrahepatic cholestasis is a rare phenomenon classically associated with renal cell carcinoma. Cases have been described in association with other tumours, such as prostate cancer (PCa).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report the case of a patient with liver failure secondary to paraneoplastic intrahepatic cholestasis as the initial form of metastatic PCa.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an 84-year-old male with a history of atrial fibrillation, dyslipidaemia, and arterial hypertension on regular treatment with acenocoumarol, bisoprolol, simvastatin, and irbesartan. The patient was hospitalised for jaundice, acholia and choluria occurring within the previous 3 days. No other symptoms by organs or systems were observed. Laboratory analysis highlighted an AST of 60 U/l (normal range [nr]: 15–37), ALT 69 U/l (nr: 16–63) and GGT of 368 U/l (nr: 10–50); alkaline phosphatase 1. 747 U/l (nr: 38–126) and total bilirubin of 17.8 mg/dl (nr: 0.1–1.2) with direct of 12 mg/dl (nr: 0−0.3) and a prothrombin time of 17 s (nr: 11–13.5). Serological screening for hepatotropic viruses and the autoimmunity study were negative. Ultrasound showed no significant findings, except for the presence of retroperitoneal lymph nodes. A nuclear magnetic resonance cholangiography found that the liver, pancreas, pancreatic duct, and bile duct were normal, with no evidence of lithiasis or areas of stricture. Positron emission tomography combined with computed tomography (PET-CT) revealed multiple retroperitoneal and cervical lymphadenopathies (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The right paratracheal clusters suspected on PET-CT were biopsied and the anatomical pathology findings were compatible with metastatic carcinoma.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Given the suspicion of metastasis, tumour markers were requested, among which a PSA of >1,000 stood out. The work-up was completed by prostate biopsy and bone scintigraphy, which revealed PCa with Gleason 4 + 5 and generalised metastatic bone involvement, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Upon learning of the diagnosis, combined androgen deprivation therapy was started, with 45 μg of leuprolide acetate subcutaneously and 50 mg of bicalutamide orally once a day for 2 weeks. Conjugated bilirubin and liver function abnormalities stabilised at 10 days post-treatment and were completely normal at 11 months. The patient is maintained on six-monthly leuprolide treatment and remains asymptomatic in terms of his cancer. His informed consent was obtained for this report.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The occurrence of cholestasis in the context of prostate cancer can be triggered by different causes: external compression of a metastatic focus, generalised hepatic infiltration or, in rare cases such as this one, it may occur as a reversible cholestasis in the absence of bile duct obstruction.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In our diagnostic algorithm, we rule out the possibility of external compression or mechanical obstruction of the bile duct using imaging techniques (ultrasound, PET-CT, magnetic resonance cholangiography). In addition, we excluded causes of intrahepatic cholestasis (drug toxicity, infectious hepatitis, autoimmune hepatitis, or liver storage diseases) through laboratory tests and a thorough history-taking.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A paraneoplastic syndrome is a set of systemic symptoms and signs secondary to the malignancy of a tumour that are not a direct consequence of tumour extension or metastasis and that are reversible with antitumor treatment. Paraneoplastic intrahepatic cholestasis, also known as Stauffer's syndrome, is associated with RCC. Its diagnosis is by exclusion, and it is estimated that it affects 3–6% of these patients,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> although it has been described in association with other tumours, such as PCa, Hodgkin's disease or thyroid cancer, among others.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This phenomenon has been related to the increase in interleukin-6, which could act as an inhibitor of hepatocellular bile secretion. Paraneoplastic cholestasis in PCa is an extremely rare entity; in general, it is usually observed in advanced stages of the disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Although the prognosis is not yet well known, in our case the response to treatment was excellent, with resolution of liver failure after treatment of the primary tumour.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is important to consider the diagnosis of paraneoplastic syndrome in patients with jaundice when other causes have been ruled out; its suspicion will allow us to make an early diagnosis and start treatment in the early stages of the disease. Paraneoplastic cholestasis is a rare and underrecognized manifestation of PCa. Our case was safely treated with a combination of leuprolide and bicalutamide, with excellent results.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín Enguix D, Alarcón Blanco PA, Lacorzana J. Ictericia no obstructiva como síndrome paraneoplásico del carcinoma de próstata. Med Clin (Barc). 2022;158:294–295.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1675 "Ancho" => 2508 "Tamanyo" => 271918 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Positron emission tomography combined with computerized tomography (PET-CT). Uptake compatible with multiple retroperitoneal and cervical lymphadenopathy was observed. (B) Bone scintigraphy. A generalized increase in skeletal uptake is observed, mainly in the axial and proximal ends of the humerus and femurs, with an absence of activity in the kidneys and soft tissues ("superscan" pattern), indicative of generalized metastatic bone involvement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stauffer syndrome: a comprehensive review of the icteric variant of the syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. Sharma" 1 => "U. Darr" 2 => "A. Darr" 3 => "G. 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Maurício" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urolonc.2018.01.019" "Revista" => array:6 [ "tituloSerie" => "Urol Oncol" "fecha" => "2018" "volumen" => "36" "paginaInicial" => "321" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29657090" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015800000006/v1_202204240523/S238702062200095X/v1_202204240523/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015800000006/v1_202204240523/S238702062200095X/v1_202204240523/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062200095X?idApp=UINPBA00004N" ]
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