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

nr. 1 / 2017 • vol 16 Cervical Lymph Nodes Metastases from Prostate Cancer Clinical cases as Initial Clinical Presentation – Case Report O.S. Tataru 1 , Orsolya Martha 1,2 , D. Porav 1,2 , S. Turdean 3 , O. S. Cotoi 3 , C. Todea 1,2 1 Urology 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 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 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 Romanian Journal of Urology 45

Romanian Journal of Urology nr. 1 / 2017 • vol 16 Clinical cases Introduction and Objectives presentation, without any storage or voiding symp- Prostatic carcinoma is one of the most common toms of urinary bladder. The biopsies from the lymph malignancies in older men. Some of it’s manifestation node revealed metastases from an undifgerentiated compriseurinary dysfunction due to prostatic swelling carcinoma, with the structure partially replaced by big or elevated serum prostate-specifjc antigen 1 . Cervical cells placard with clear cytoplasm and pleiomorphic lymph nodes are a common site of metastasis for head nuclei with negativ PAS and ALCIAN imunohystochem- and neck malignancy. Adenocarcinoma of the prostate ical profjle and CK7, CD45, CD68, S100, SOX10, vimen- is known to metastasize to cervical nodes. Such mani- tin also negative [Figure 1, 2]. festation should be considered in the difgerential diag- nosis of head and neck malignancies 2 . Cervical lymph The computed tomography of the thorax, abdo- node metastasis from prostate cancer is an unusual men and pelvis identifjed multiple lymphadenopathies situation with a reported rate of 0.4% to 1% of cases 3 . located left paraaortical and paracaval and interaorti- cocaval, with the largest size of 74 mm, that compress Materials and Methods the left ureter, causing left hydronephrosis [Figure 3]. 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 Figure 1. Lymph node with a partially replaced structure by a tumor proliferation with a subcapsular sinusoid starting point (characteristic of metastasis) Figure 3. Left hydronefrosis caused by i ntraabdominal lymphadenopathies Figure 4. Bilateral Figure 2. The tumor proliferation shows a predominantly solid archi- ureteral stents with tecture, but also lumen and acinar structures can be identifjed. From a paraureteral cytological point of view, there is a moderate nuclear pleomorphism, lymphadenopaty with large nuclei and prominent nucleoli. 46

nr. 1 / 2017 • vol 16 Clinical cases The patient was referred to our urology depart- Conclusions mentwhere the rectal digital exam revealed a fjrm, The possibility of a non clinical manifesting prostat- fjxed, and globally indurated and moderate enlarged ic primary cancer should be considered in difgerential prostate (clinically T4) with the prostatic specifjc anti- diagnosis during investigation of metastases of cervical gen of 740 ng/ml. lymph nodes. We believe that in men with carcinoma of undetermined origin, a suspicion of prostate cancer is Results important for accurate diagnosis and therapeutic ap- Transrectal ultrasonography guided prostate biop- proach. Immunohistochemistry with PSA staining can sy revealed bilateral adenocarcinoma Gleason 4+5=9 confjrm the diagnosis. Androgen blockade associated with extraprostatic extension and perineural invasion. with radiotherapy can be recommended to raise qual- In one week time the patient complained of acute re- ity of life and to reduce disease associated morbidity. versible kidney injury secondary to bilateral ureteric obstruction and underwent bilateral ureteral stent- ing [Figure 4] and bilateral orhidectomy. Bicalutamide References 50 mg/day was started, followed by an LHRH agonist, 1. Terada, Tadashi. Cervical lymph node metastasis as the fjrst and palliative radiotherapyof the prostate and the ab- and only manifestation of prostatic adenocarcinoma . Human dominal lymph nodescaused theselymphatic deposits Pathology: Case Reports 2.4 (2015): 87-89. to regress, resulting in a good PSA response after two 2. Lin, Yuan-Yung, et al. Neck mass as the fjrst presentation of months (reduced to 33 ng/mL). metastatic prostatic adenocarcinoma. Journal of the Chinese Medical Association 74.12 (2011): 570-573. 3. Davarci, Mürsel, et al. Metastatic prostate adenocarcinoma Discussions presenting as supraclavicular lymphadenopathy: a report of Lymph nodes are commonly involved during the two cases. Wspolczesna Onkol 16 (2012): 53-5. course of metastatic prostate cancer, with hypogastric 4. H, Yoshida K, Uchijima Y, Kobayashi N, Suwata J, Kamata S. and obturator lymph nodes as the most common sites Two difgerent lymph node metastatic patterns of aprostatic 4 . Batson suggested that the supradiaphragmatic ex- cancer. Nat Rev Cancer 1990;65:1843–6. tension of prostate cancer can occur haematogenously 5. Elabbady A, Kotb AF. Unusual presentations of prostate cancer: A review and case reports. Arab Journal of Urology. via the vertebral venous system, accessible via direct 2013;11(1):48-53. doi:10.1016/j.aju.2012.10.002. extension from the primary prostate cancer. Supracla- 6. Carleton, J., P. Van der Riet, and P. Dahm. Metastatic prostate vicular lymph nodes are commonly afgected during the cancer presenting as an asymptomatic neck mass. Prostate course of metastasis of the head, lungs, neck, thyroid cancer and prostatic diseases 8.3 (2005): 293-295. cancer, salivary glands 5 . 7. Lin, Yuan-Yung, et al. Neck mass as the fjrst presentation of metastatic prostatic adenocarcinoma. Journal of the Chinese The inci dence of cervical lymph node involvement Medical Association 74.12 (2011): 570-573. in patients with prostate cancer has been reported 8. Pagliarulo, Vincenzo, et al. Contemporary role of androgen around 0.4%. These patients usually have widespread deprivation therapy for prostate cancer. European urology metastatic disease as much in like our patient. Thoracic 61.1 (2012): 11-25. 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 Romanian Journal of Urology 47