The Presenting Symptom of Metastatic Prostate Carcinoma: Case of a Large Supraclavicular Mass and Review of Literature

doi:10.4236/ijohns.2013.25043

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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 207-210

http://dx.doi.org/10.4236/ijohns.2013.25043 Published Online September 2013 (http://www.scirp.org/journal/ijohns)

The Presenting Symptom of Metastatic Prostate

Carcinoma: Case of a Large Supraclavicular

Mass and Review of Literature

Cory A. Vaughn1, Kaitlin R. Jaqua1, Ryan K. Meacham2, Fransisco Vieira2

1MD Candidate, University of Tennessee Health Science Cen t e r, Memphis, USA

2Department of Otolaryngology, Head & Neck Surgery, University of Tennessee, Memphis, USA

Email: [email protected]

Received June 23, 2013; revised July 24, 2013; accepted August 9, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Prostate cancer is the most common noncutaneous malignancy of American males and typically presents with genitou-

rinary symptoms, however, head and neck extension is a rare finding. We present a case of a 53-year-old male initially

presenting with a large supraclavicular mass as the only complaint. After an initial non-diagnostic FNA biopsy, PSA

levels, histology and immunohistochemical findings were consistent with metastatic prostatic adenocarcinoma. The

patient was started on anti-hormonal treatment after diagnosis. Due to the increasing reports of such cases, we suggest

PSA levels and appropriate immunohistochemical staining should be obtained on all unknown neck masses.

Keywords: Neck Mass; Prostate; Adenocarcinoma; Metastasis

1. Introduction

Non-tender, mobile masses in the various neck regions

induce a concern for metastatic squamous cell carci-

noma for any otolaryngologist. The presence of a metas-

tatic neoplasm to the neck changes the stage of disease,

thus altering the treatment and prognosis. Adenocarci-

noma uncommonly metastasizes to the neck, thus is often

excluded from initial differential diagno ses. There are in-

creasing numbers of reports documenting adenocarci-

noma dissemination to the head and neck region present-

ing as non-tender, mobile masses relatively small in size.

We describe a case of metastatic prostate adenocarci-

noma with initial presentation as large supraclavicular

lymphadenopathy.

2. Case Report

A 53-year-old African-American male presented with

complaint of a large left neck mass that had been pro-

gressively enlargingfor approximately ten months. The

patient was completely asymptomatic from the mass.

Physical exam revealed a 4 × 7 cm, fluctuant, non-tender,

non-adherent mass in the left supraclaviuclar fossa. The

remainder of the physical exam was unremarkable but

did not include a genital or rectal exam. An ultrasound

revealed a multilobulated left neck mass. The patient was

prescribed Naprosyn and discharged from the Emergency

Department with scheduled follow up to the PCP.

The patient was subsequently lost to fo llow up for four

months. The patient complained of further growth of the

left neck mass and weight loss. The left supraclavicular

mass now measured 8 × 7 cm. Laryngo scopy revealed no

abnormal findings. With concerns of lymphoma, due to

the size of the mass, a fine need aspiration (FNA) was

performed. Cytology and flow cytometry results were

non-diagn ost i c , ho wever rule out lymphoma.

The patient was scheduled for an incisional biopsy re-

vealing low-power eviden ce of prostatic adenocarcinoma

(Figure 1(a)) and histologic evidence of cribriform pat-

tern of cells (Figure 1(b)), prominent solitary nucleoli,

and a uniform population of cells with presence of ve-

sicular chormatin (Figure 1(c)). Immunohistochemical

evaluation of the specimen was positive for CDX2, Ber-

EP4, Vimentin, prostate specific antigen (PSA), and cy-

tokeratin. Histologic and immunohistochemical findings

were diagnostic for metastatic prostatic adenocarcinoma.

At this time a genitourinary exam revealed a normal

phallus and scrotum. On rectal exam, the prostate was

nodular and tender. Initial PSA level was 990. The pa-

tient now had complaints of pain localized to the left

C. A. VAUGHN ET AL.

208

(a) Prostatic adenocarcinoma; metastatic to the neck.

(b) Cribriform pattern.

chromatin, prominent solitary nucleoli, and pale

staining eosinophilic cytoplasmic with indistinct

cyto pl asm ic borde r s.

Figure 1. Incisional biopsy of left supraclavicular neck mass

revealing histological evidence of prostate adenocarcinoma.

(a) low-powered view of incisional biopsy specimen; (b) Me-

dium-powered view of incisional biopsy specimen; (c) High-

powered view of incisional biopsy specimen.

lower back and left leg. CT scan revealed multiple en-

larged pelvic and retroperitoneal lymph nodes (Figure 2).

Bone scan showed multiple lesions througho ut pelvis and

lumbar spine (Figure 3).

The patient was started on a non-steroidal anti-hor-

monal treatment. Four weeks later his PSA was 131 and

Goserelin acetate, a GnRH agonist, therapy was initi-

ated. Clinical follow up 3 months later revealed a PSA of

3.3. Further record of the patients status was unobtain-

able.

Figure 2. Axial and Coronal CT imaging of left neck mass.

Mass measures approximately 6 × 7 cm in dimension as

evidenced by presentation on CT.

Figure 3. Bone scan of patient with evidence of multiple

areas of involvement.

C. A. VAUGHN ET AL. 209

3. Discussion

Since 1984, adenocarcinoma of the prostate has been the

most common noncutaneous neoplasm of American men,

with a lifetime risk of 16.72% [1]. It is well known that

diagnosis of prostate cancer prior to the age of 50 is un-

common, however prostate neoplastic evidence is quite

common in those men 80 years or older. African-Ameri-

can males profoundly have the greatest incidence of pro-

state cancer as well as suffer the largest mortality, 62.3%

[2]. Since the in trodu ction of screening with p ros tate sp e-

cific antigen (PSA) in 1994, a now controversial practice,

the incidence of non-regional spread has declined dra-

matically. Currently, 60% - 75% of newly diagnosed

cases are contained within the prostate organ and are cli-

nically non-palpable [1]. The most common locations of

extra-prostaticdissemination are to the pelvic lymph nodes

and bone, followed by the lungs and liver. It is unusual

for these metastatic lesions to be large, bulky deposits,

rather they tend to form multiple small nodules or be dif-

fusely spread through multiple lymph nodes [1].

The incidence of any genito-urinary malignancy dis-

seminating to the head and neck is rare, especially those

originating from the prostate. At a single institution,

Flocks and Boatman [3] noted that of all metastatic le-

sions in the head and neck 6% were of renal or adrenal

origin respectively and only 1% of prostatic origin. None-

theless, increasing numbers of cases are being reported

detailing supradiaphragmatic lymph node metastatic le-

sions of prostate adenocarcinoma. The lymph nodes that

are most commonly detected include supraclavicular, cer -

vical, axillary, and mediastinal nodes [4].

There are many theories describing the mechanism of

metastasis to the supradiaphragmatic lymph nodes the

gentio-urinary tract. A popular and widely accepted pos-

tulation explains it is the result of homogenous spread

through Batson’s venous plexus allowing communication

of the deep pelvic veins and the thoracic veins via the

internal vertebral venous plexuses [5]. Valsalva maneu-

vers result in a reversal of blood flow into the vertebral

veins from the inferior vena cava [6].

Due to the relative rarity of the extra-prostatic metas-

tasis to the neck, specifically supraclavicu lar lymph nod es,

there have been few multi-patient studies performed and

a limited number of case reports on the subject. Cho et al.

[4] presented 26 patients with prostate cancer metastasis

to supradiaphragmatic lymph nodes, 15 cases involving

the supraclavicular nodes and 58% with abnormal digital

rectal exams. Saeter et al. [7] discuss 35 patients present-

ing with non-regional lymphatic dissemination from a

primary prostate adenocarcinoma, 69% of cases had a

lesion in the left supraclavicular fossa and 75% of cases

had an abnormal digital rectal exam. Butler et al. [8] de-

scribed 19 patients presenting with supraclavicular lym-

phadenopathy who were deemed to have prostate cancer,

42% of cases had a digital rectal exam abnormalities.

Prostate adenocarcinoma spread to other lymph nodes of

the head and neck are even rarer than the reported inci-

dences at the supraclavicular fossa. Flocks and Boatman

reviewed [3] 1500 cases of genitor-urinary neoplasms

which metastasized to the head and neck, 6 cases (0.4%),

prostate in origin, involving the cervical lymph nodes.

This evidence is supported by a similar studies providing

further evidence that emphasizes this rarity [9-15].

Diagnosis of metastatic prostatic cancer via FNA or

excisional biopsy necessitates both microscopy and im-

munohistochemistry. The histological criteria include in-

filtrative small glands or large cribriform glands, absence

of basal cells, nuclear atypia, as well as minor criteria

including, but not limited to, an amphophilic cytoplasm

and nuclear hyperchromasia [16]. Prostate specific anti-

gen has been used for many years as a diagnostic marker

during staining. Prostate acid phosphatase is also a well

known marker used during staining. Immunohistochem-

istry and histochemical stain panels commonly positive

in prostatic carcinoma include PSA, PSAP, Cytokeratin,

as well as Mucin [13]. More recent data suggests that

PSA in conjunction with p501s (prostein), a cytoplasmic

marker expressed in both benign and malignant cells,

provides the greatest immunohistochemical specificity

[17,18].

The prognosis is variable when head and neck metas-

tasis is evident. Hunt et al. [13] reported 14 patients that

underwent combination hormone and radiation therapy, 8

of whom had widespread disease at the time of diagnosis.

After diagnosis, seven patients h ad an average lif espan of

23 months, five averaged 3.6 months (2 of whom had

spinal cord metastasis secondary to vertebral metastasis,

dying within 10 days). Jon es and Anthony pr esented 5 of

11 patients died after findings of head and neck metasta-

sis, averaging 34.4 months of life; the remaining six pa-

tients were alive at the time of diagnosis [14]. McMe-

namin et al. reported two of four patients who were alive

2 years after findings of cervical lymph node metastasis

[15].

4. Conclusion

The presence of a progressively growing neck mass con-

stitutes a wide range of differential diagnoses including

primary and metastatic neoplasia. Metastatic lesions of

the neck are commonly from a squamous cell carcinoma

origin and tend to be small in size. Here we have pre-

sented an unusual case of a metastatic neck mass due to

its primary non-carcinomatous origin and its large size.

This case report adds to the growing evidence suggesting

that non-carcinomatous lesions not be overlooked. Spo-

radic cases and studies for years have been described as

the extraprostatic extension of the neck. In the appropri-

ate population, we sugg est the addition of PSA, PSAP, or

C. A. VAUGHN ET AL.

210

p501s immunohistochemical stains to FNA or excisional

biopies of all neck masses concerning for cancer to pre-

vent delay in diagno sis and to i mprove progn osis th rough

earlier therapy.

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