Clinical cases as Initial Clinical Presentation Case Report O.S. - - PDF document

• nr. 1 / 2017 • vol 16

Romanian Journal of Urology 45

Clinical cases

Cervical Lymph Nodes Metastases from Prostate Cancer as Initial Clinical Presentation – Case Report

O.S. Tataru1, Orsolya Martha1,2, D. Porav1,2, S. Turdean3, O. S. Cotoi3, C. Todea1,2

1Urology Clinic, County Emergency Hospital, Targu Mures, Romania 2 University of Medicine and Pharmacy, Targu Mures, Romania 3 Department of Pathology, University of Medicine and Pharmacy, Targu Mures,

Romania

Correspondence to: Dr. Ciprian Todea-Moga M.D. County Emergency Hospital, Urology Clinic 1 Gheorghe Marinescu st., code 540103, Targu Mures, Romania Tel: +40265215133 E-mail: ciprian.todea@gmail.com

Abstract Introduction and Objectives. In Europe, prostate cancer is the most common malignancy in men, which often me- tastasizes in the regional lymph nodes and bone, with rare supradiaphragmatic lymph node involvement. Materials and Methods. We describe the case of 58-year-old male, initially misdiagnosed with lymphoma, with cervical lymph node enlargement due to metastatic prostate cancer as the initial clinical presentation. The patient complaint of severe weight loss over the past six months, with a left cervicalpalpable mass. The biopsies from the lymph node revealed metastases from an undifgerentiated carcinoma. The computed tomography of the abdomen and pelvis identifjed multiple lymphadenopathies located left paraaortical and paracaval and interaorticocaval, with the largest size of 74 mm, that compress the left ureter, causing left hydronephrosis. The rectal digital exam revealed a indurated and moderate enlarged prostate and the prostatic specifjc antigen was 740 ng/ml.

• Results. Transrectal ultrasonography guided prostate biopsy revealed bilateral adenocarcinoma. The fjnal diagnosis

was prostate adenocarcinoma with left supraclavicular lymph node metastases.

• Conclusions. Prostate cancer spreads primarily to the regional lymph nodes and bones, followed by lung, bladder,

liver, and adrenal gland. Cervical lymph node involvement in prostate cancer is rare. The possibility of a silent prostatic primary cancer should be considered in difgerential diagnosis during investigation of metastases of cervical lymph nodes. Key-words: prostate adenocarcinoma, metastasis, cervical lymph nodes

Romanian Journal of Urology

• nr. 1 / 2017 • vol 16

46

Clinical cases

Introduction and Objectives Prostatic carcinoma is one of the most common malignancies in older men. Some of it’s manifestation compriseurinary dysfunction due to prostatic swelling

• r elevated serum prostate-specifjc antigen 1. Cervical

lymph nodes are a common site of metastasis for head and neck malignancy. Adenocarcinoma of the prostate is known to metastasize to cervical nodes. Such mani- festation should be considered in the difgerential diag- nosis of head and neck malignancies 2. Cervical lymph node metastasis from prostate cancer is an unusual situation with a reported rate of 0.4% to 1% of cases 3. Materials and Methods We describe the case of 58-year-old male, who com- plaint of severe weight loss over the past six months and had a left supraclavicular mass, as the initial clinical presentation, without any storage or voiding symp- toms of urinary bladder. The biopsies from the lymph node revealed metastases from an undifgerentiated carcinoma, with the structure partially replaced by big cells placard with clear cytoplasm and pleiomorphic nuclei with negativ PAS and ALCIAN imunohystochem- ical profjle and CK7, CD45, CD68, S100, SOX10, vimen- tin also negative [Figure 1, 2]. The computed tomography of the thorax, abdo- men and pelvis identifjed multiple lymphadenopathies located left paraaortical and paracaval and interaorti- cocaval, with the largest size of 74 mm, that compress the left ureter, causing left hydronephrosis [Figure 3].

Figure 1. Lymph node with a partially replaced structure by a tumor proliferation with a subcapsular sinusoid starting point (characteristic

• f metastasis)

Figure 2. The tumor proliferation shows a predominantly solid archi- tecture, but also lumen and acinar structures can be identifjed. From a cytological point of view, there is a moderate nuclear pleomorphism, with large nuclei and prominent nucleoli. Figure 3. Left hydronefrosis caused by i ntraabdominal lymphadenopathies Figure 4. Bilateral ureteral stents with paraureteral lymphadenopaty

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Clinical cases

The patient was referred to our urology depart- mentwhere the rectal digital exam revealed a fjrm, fjxed, and globally indurated and moderate enlarged prostate (clinically T4) with the prostatic specifjc anti- gen of 740 ng/ml. Results Transrectal ultrasonography guided prostate biop- sy revealed bilateral adenocarcinoma Gleason 4+5=9 with extraprostatic extension and perineural invasion. In one week time the patient complained of acute re- versible kidney injury secondary to bilateral ureteric

• bstruction and underwent bilateral ureteral stent-

ing [Figure 4] and bilateral orhidectomy. Bicalutamide 50 mg/day was started, followed by an LHRH agonist, and palliative radiotherapyof the prostate and the ab- dominal lymph nodescaused theselymphatic deposits to regress, resulting in a good PSA response after two months (reduced to 33 ng/mL). Discussions Lymph nodes are commonly involved during the course of metastatic prostate cancer, with hypogastric and obturator lymph nodes as the most common sites

• 4. Batson suggested that the supradiaphragmatic ex-

tension of prostate cancer can occur haematogenously via the vertebral venous system, accessible via direct extension from the primary prostate cancer. Supracla- vicular lymph nodes are commonly afgected during the course of metastasis of the head, lungs, neck, thyroid cancer, salivary glands 5. The inci dence of cervical lymph node involvement in patients with prostate cancer has been reported around 0.4%. These patients usually have widespread metastatic disease as much in like our patient. Thoracic and abdominal lymph node involvement, as well as cer- vical lymph node metastasis in cases of prostate cancer, should be primarily treated with androgen ablationand it is considered as a systemic disease 6. Immunohisto- chemical staining for PSA could be helpful in determin- ing a diagnosis of prostate cancer. Some carcinoma of salivary gland origin, female breast carcinoma and lung cancer can be positive for PSA stains 7. In patients with metastatic disease, androgen deprivation therapy, such as bilateral orchiectomy, seems to have a benefjt re- garding quality of life, reduction of disease associated morbidity, and possibly survivalor combined with con- ventional dose radiotherapy. 8 Conclusions The possibility of a non clinical manifesting prostat- ic primary cancer should be considered in difgerential diagnosis during investigation of metastases of cervical lymph nodes. We believe that in men with carcinoma of undetermined origin, a suspicion of prostate cancer is important for accurate diagnosis and therapeutic ap-

• proach. Immunohistochemistry with PSA staining can

confjrm the diagnosis. Androgen blockade associated with radiotherapy can be recommended to raise qual- ity of life and to reduce disease associated morbidity. References

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