Metastatic prostate cancer presenting as an asymptomatic neck mass

Abstract

Prostate cancer often metastasizes to the regional lymph nodes, but metastases to distant supradiaphragmatic lymph nodes are uncommon. Rare case reports describe cervical lymph node metastases as the first clinical manifestation of prostate cancer, but only in the setting of widely disseminated disease. We present the unusual case of an 84-y-old male with a known history of prostate cancer and recurrent disease limited to the left supraclavicular lymph nodes.

Introduction

While lymph nodes are the single most common metastatic site for carcinoma of the prostate, the lymph nodes that are most frequently involved are those of the pelvis and retroperitoneum.1 Although left supraclavicular nodes have been reported as a site of nonregional, extraskeletal metastases, they are an uncommon presentation of prostate cancer.2, 3

We present the unusual case of an elderly male with metastatic prostate cancer confined to the left supraclavicular lymph nodes. The majority of cancers metastatic to the cervical lymph nodes are derived from primary malignancies in the mucosal surfaces of the upper aerodigestive tract. Tumors in the head and neck from nonmucosal sources such as skin, salivary glands, and thyroid are the second most common source of cervical node metastases.4 The higher the level of nodal involvement, the more likely the primary is from the head and neck.5 Other distant primaries rarely metastasize to the neck, but the most frequently encountered are from the lung, kidney, and breast.4 To initiate appropriate treatment of metastatic prostate cancer, a histological diagnosis must be established.6

Case report

An 84-y-old male was referred to otolaryngology for a left supraclavicular mass. The patient reported increasing swelling on the left side of his neck for approximately 2 months. He denied any other subjective complaints, including difficulty in swallowing or breathing. Physical examination of the patient's neck revealed a nontender left-sided neck mass approximately 4 cm in diameter. Subsequent computerized tomography (CT) scan of the head and neck showed a 4.2 cm, solid left supraclavicular mass with extension from the clavicles to the true vocal cords (Figure 1). A percutaneous fine needle aspirate (FNA) was performed and interpreted as highly suspicious for malignancy (Figure 2a).

Figure 1
figure1

Dedicated CT scan of the head and neck with intravenous contrast demonstrating a 4.2 cm left supraclavicular mass posterior to the sternocleidomastoid muscle and lateral to the carotid sheath (panel a). In addition, enlarged lymph nodes in the lower posterior triangle were noted (panel b).

Figure 2
figure2

Fine needle aspirate of the neck mass (panel a) demonstrating a cluster of malignant appearing cells (H&E, × 20). Final pathology of open biopsy (panel b) revealing moderately well differentiated adenocarcinoma of the prostate (H&E, × 20). Prostatic primary was further confirmed by immunohistochemistry for PSA (not shown).

The patient's past medical and surgical history were notable for a diagnosis of prostate cancer 15 years ago, treated with radical retropubic prostatectomy and bilateral pelvic lymph node dissection. The pathology specimen revealed a Gleason score of 2+2, with organ-confined prostate cancer. He was first noted to have evidence of recurrent disease approximately 10 months prior, when a prostate-specific antigen (PSA) level of 13.4 ng/ml was detected. Within only 8 months, the patient's PSA level increased to 55.5 ng/ml. Diagnostic work-up included a negative bone scan as well as an unremarkable CT scan of the abdomen and pelvis. In the absence of documented metastatic disease, but a rising PSA, he was initiated on total androgen ablation with leuprolide (Lupron) and bicalutamide (Casodex).

The patient was taken to the operating room for open biopsy of the left neck mass, laryngoscopy with biopsies, bronchoscopy, and esophagoscopy. Biopsy of the left supraclavicular mass showed a moderately differentiated adenocarcinoma consistent with prostatic origin (Figure 2b). PSA immunohistochemistry was positive. The biopsies performed during direct laryngoscopy were negative for malignancy. Additional diagnostic work-up included a repeat bone scan and CT scan of the chest, abdomen and pelvis, which once again did not demonstrate evidence of other metastases or recurrent disease.

Following tissue diagnosis, the patient's PSA continued to rise, indicating the development of hormone-refractory disease. Additional treatment measures such as secondary hormonal manipulation, systemic chemotherapy, and radiation for local palliation were discussed with the patient who declined further treatment.

Discussion

This case is unique because it presents only the second reported case of prostate cancer metastatic to the neck in the absence of other clinical or radiographic evidence of disease. The incidence of cervical lymph node involvement in patients with prostate cancer has been reported as 0.4% or less; however, these patients almost uniformly present with widespread metastatic disease.1, 4, 7, 8 Hesson et al9 report one case of prostate carcinoma with an isolated neck metastasis. Several other case reports describe cervical node metastases as the presenting finding for disseminated cancer of the prostate, but none describes metastatic disease confined to the cervical nodes as first clinical evidence of recurrent prostate cancer.

Two of the papers describing prostate cancer presenting with cervical metastases address other interesting clinical features related to disease detection. In a retrospective study of patients undergoing diagnostic biopsy, Cho and Epstein2 found that 35% of patients had no evidence of bony metastases, 24% had normal serum acid phosphatase levels, and 42% had no prostatic abnormalities on digital rectal exam. Jones and Anthony6 found that PSA or prostate specific acid phosphatase levels were elevated in only five of nine patients with cervical metastases. The possibility that not all patients may have elevated biochemical markers for prostate cancer emphasizes the importance of an appropriate tissue diagnosis. While the patient in this case report had an elevated PSA, his left neck mass was the only other evidence of recurrent disease. The ultimate diagnosis was established by immunohistochemistry with PSA staining on tissue obtained by open surgical biopsy.

An isolated neck metastasis raises issues regarding treatment. While neck dissection has an established role in the treatment of some of the loco-regional malignancies that spread to the cervical lymph nodes, experience with prostate cancer lymph node metastasis to other sites suggests that surgical intervention is of little utility. Cervical lymph node metastasis should be treated as systemic disease and primarily treated with androgen ablation. A potential role for radiation lies in the palliation of local symptoms relating to venous obstruction and/or neural compression.

Finally, this elderly patient experienced a late recurrence of his prostate cancer detected by a rising PSA. This case report illustrates both the need for continued long-term surveillance of patients who have undergone local prostate cancer treatment with curative intent, as well the potential morbidity and mortality of recurrent disease, even in the elderly. The presence of supraclavicular lymphadenopathy emphasizes the importance of a thorough physical examination in every urologic patient, in particular those with a history of malignancy.

Editorial comment

This is the first in a new series for Prostate Cancer and Prostatic Diseases in which we will feature an interesting case regarding the prostate. This case comes from Dr Dahm and colleagues from Duke University and the Duke Prostate Center. Readers are asked to contact Dr Judd Moul, co-editor, if they have an interesting case for consideration.

This is a highly unusual case of biochemical recurrence that was associated with isolated supraclavicular lymph node metastases. This patient had a very rapid PSA doubling time (PSA-DT) at less than 3 months, which was recently shown by D’Amico et al to be a direct surrogate of prostate cancer death.10 Even though no one would argue against hormonal therapy in this setting, it is unclear if it results in longer survival. Moul et al11 recently reported that men with a biochemical recurrence and a PSA-DT <1 y had delayed clinical metastases (positive bone scans primarily) if they received hormonal therapy before the PSA reached 10.0 ng/ml. However, it is only speculative if the hormonal therapy had been started earlier (say at the PSA of 13.4 ng/ml) of whether the cervical adenopathy would have been delayed or averted.

It will be interesting to see the response duration of hormonal therapy in this setting of soft-tissue-only metastases. Some clinicians feel that soft-tissue disease has a more durable response to hormonal therapy. The nature of this soft-tissue, nonbone metastases pattern at spread is undoubtedly due to the molecular profile of the patient's cancer. Future genomic profiling will hopefully shed more light on this less common pattern of prostate cancer presentation.JWM

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Correspondence to P Dahm.

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Funding: Departmental

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Carleton, J., van der Riet, P. & Dahm, P. Metastatic prostate cancer presenting as an asymptomatic neck mass. Prostate Cancer Prostatic Dis 8, 293–295 (2005). https://doi.org/10.1038/sj.pcan.4500805

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Keywords

  • prostatic neoplasms
  • lymphatic metastasis

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