Prostatic cancer is the third most commonly diagnosed malignancy in males after lung and colorectal cancer with 1,414,259 new cases registered by WHO in 2020. And it is one of the death-leading malignancies worldwide [1].

The risk of developing the disease is linked to factors such as age, race, and family history, with the highest incidence being in the elderly (over 55 years). The incidence and mortality rates are higher among African Americans than Caucasians [2].

The symptoms of advanced prostatic cancer are variable and sometimes not recognized which may lead to delayed diagnosis hematogenous spread frequently affects the bone but can occur in the lungs, liver, pleura, and adrenals. Metastasis to lymph nodes is commonly seen in the pelvic and abdominal groups [3].

The left supraclavicular or Virchow lymph node enlargement is classically linked to carcinoma of the stomach. Other causes include thoracic, abdominopelvic malignancy, lymphoma, tuberculosis, and hydatid disease [4]. Furthermore, the causes of axillary lymphadenopathy include metastatic breast carcinoma, melanoma [5] lymphoma leukemia, and various infections [6].

The combination of supraclavicular and left axillary lymph nodes in a patient may suggest carcinoma of the stomach or other abdominal malignancies [7].

Here we present an unusual presentation of prostatic adenocarcinoma with axillary and supraclavicular mass as the main presentation. This work has been reported in conformity with the SCARE 2020 criteria [8].

An 82-year-old male presented with complains of left axillary and left side neck swellings for a period of 5 months duration. The patient noticed painless small swellings like the size of a bean mainly in the left axillary area and left side of the neck. They were painless and gradually increased in size with normal overlying skin. There were no swellings in other sites of the body. The patient denied any symptoms of fever, loss of weight or loss of appetite. He was complaining of burning micturition, but there was mild dysurea with no symptoms of obstruction or hematurea. His systemic review was unremarkable and he denied any GI complaints.

His systemic examination revealed a left supraclavicular lymph node and a left axillary lymph node. No neck mass or cervical LN involvement. His chest and abdominal examination were normal. The axillary lymph node was about 4 cm, hard, but mobile.

His labs were normal CBC: HB 11.7 g/dl, TWB CS 4.9 × 10³/µl, PLT 270 × 10³/µl, RFT: urea: 32 mg/dl, creatinine: 0.9 mg/dl, Na: 141, K: 3.5. Urine general: no hematuria.

Cervical and axillary ultrasonography showed suspiciously enlarged lymph nodes (Figure 1). Fine needle aspiration cytology was inconclusive. As a result decisional biopsy was done and showed metastatic adenocarcinoma (Figure 2(A) and Figure 2(B)).

The treating team’s main suspicion was GI malignancy, hence, the patient was referred to the gastroenterology department where upper and lower GI endoscopies were done to exclude gastrointestinal malignancy and they revealed no pathology. Four days later, he presented with signs and symptoms of massive pneumoperitoneum and peritonitis. Therefore, colonic perforation was suspected (Figure 3). His rectum was empty and the prostate was mildly enlarged with hard palpable nodules bilaterally and obliterated median sulcus.

Exploratory laparotomy was performed and revealed moderate intraperitoneal pus collection and sigmoid perforation for which a colostomy was made. The rest of the abdomen was unremarkable apart from enlarged pelvic and para-aortic lymph nodes. A biopsy was taken from the iliac nodes and sent for histopathology. The PSA at that time was 449 ng/ml.

The histopathology of the pelvic lymph nodes resulted in metastatic adenocarcinoma of the prostate (Figure 4). Tru-cut biopsy from the prostate confirmed the diagnosis with a Gleason score of (3 + 4 = 7/10) (Figure 5). Then the patient was offered surgical castration, and a reversal of colostomy was done after he became fit again. Currently, the patient has no symptoms and his last PSA was 0.01ng/ml.

Staging CT chest and abdomen showed Significant enlarged LNs involving most of the abdominal groups and side pelvic wall with the largest on aortocaval (4.7 × 2.7 cm), no lung or mediastinal metastasis was detected (Figures 6-8).

The prostatic cancer burden is increasing in Sudan [9] [10]. Three decades ago, prostate cancer ranked tenth among all men’s cancers diagnosed at the Sudan Cancer Registry in 1978, less frequent than skin cancers and non-Hodgkin lymphoma [10]. However, it is now the most common cancer in Sudanese males. It ranked second among all cancers in both sexes after breast in 2012 [11].

Risk factor for prostate cancer includes older men and non-Hispanic Black men. About 6 cases in 10 are diagnosed in men who are 65 or older, and it is rare in men under 40. The average age of men at diagnosis is about 66 [12].

The most common presentation of Prostatic Cancer in the pre-PSA era was urinary complaints or retention, back pain, and hematuria. Currently, with PSA screening, most prostate cancers are diagnosed at an asymptomatic stage. When symptoms do occur, diseases other than prostate cancer may be the cause. For example, urinary frequency, urinary urgency, and decreased urine stream often

result from benign prostatic hyperplasia [13]. Our patient was having minimal urinary tract symptoms and only presented to seek medical care after he noticed an axillary mass. This pattern of presentation is very rare and only seldom physicians include prostate cancer in their list of differential diagnosis [14]. Our patient is a male patient so exclusion of breast cancer is very easy based on clinical examination. Next head and neck malignancy was ruled out because no clinical abnormality was present. Hematological malignancy was unlikely based on his CBC and peripheral blood picture. When we received the result of lymph node histopathology which was showing metastatic adenocarcinoma, we diverted our attention to the GI cause (esophagi gastric/pancreatic/colonic origin). Prostatic cancer was not entertained as a differential diagnoses until DRE and exploratory laparotomy was done for the sigmoid perforation.

Metastatic prostate cancer has a recognizable pattern of spread, most often to regional lymph nodes and the bones. Pelvic and abdominal retroperitoneal lymph nodes typically occur in the obturator and internal iliac nodes. Any lymphadenopathy occurring outside the abdomen and pelvis is considered atypical [15]. In one study, the most frequent sites of atypical metastases were the lungs and pleura, liver, supradiaphragmatic lymph nodes, and adrenal glands [16].

Reports describing atypical metastatic sites such as single or generalized lymphadenopathy with the absence of other symptoms of the disease have been documented [17]. But axillary lymph node metastasis was extremely rare and only mentioned in literature as a case report [14] [16] [18]. Other described supraclavicular and mediastinal lymphadenopathy which caused confusion with bronchial carcinoma [19].

Theories behind spread to the left supraclavicular lymph node include spread via Batson’s venous plexus. Another theory is that these nodes are located close to the entry of the thoracic duct into the subclavian vein predisposing to retrograde metastasis. Further studies in this regard are necessary to elucidate the exact way of such involvement [20].

Detection of lymph node metastasis is of major prognostic significance for many cancers. This observation also holds true for prostate cancer where patients with lymph node metastases exhibit a poor prognosis with significantly decreased disease-specific and biochemical recurrence-free survival rates [21].

Our patient fell in grade group 2 according to the 2014 International Society of Urological Pathology (ISUP) Consensus Conference [22]. However, the presence of a left axillary lymph node places him on stage IV as it is regarded as a distant metastasis [23]. A review of the literature has shown that the survival and treatment should be approached with the same protocols used in the patient that initially presented with bony or visceral metastasis. Therefore, surgical castration was offered to him.

Atypical presentation in prostatic adenocarcinoma can include left axillary mass. Suspicion of prostate cancer should be included in all elderly patients present with signs suggestive of malignancy. Early PSA measurement could have spared our patients from unnecessary endoscopes.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review if requested.

The authors declare no conflicts of interest regarding the publication of this paper.

Ibrahim, M.I., Hamadelnil, A.E., Mohamed, M., Abdelrhman, R.O., Mahmmoud, T.A., Elnour, A.M., Yagoub, H., Alagab, L.M. and Hamad, A.G. (2022) Atypical Presentation of Prostatic Cancer with Left Axillary and Supraclavicular Lymphadenopathy. Open Journal of Urology, 12, 228-236. https://doi.org/10.4236/oju.2022.124022