Download Cervical lymph node enlargement on the right side as the initial

CERVICAL LYMPH NODE ENLARGEMENT ON THE RIGHT SIDE AS THE INITIAL MANIFESTATION OF METASTATIC PROSTATE CANCER
international section
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Arch. Esp. Urol., 56, 7 (859-861), 2003
Cervical lymph node enlargement on the right side as the initial manifestation of
metastatic prostate cancer.
ABDURRAHMAN ÖZGÜR, YALÇIN ILKER, LEVENT N. TÜRKERI.
Marmara University School of Medicine Department of Urology.
Summary.- OBJECTIVES: Cervical lymph node
enlargement (LAP) due to metastatic spread is an
uncommon manifestation of prostatic adenocarcinoma. In
case of non-regional lymphatic spread, left supraclavicular
region was found to be the most common site (1,2,3)
whereas right sided metastatic lymph node involvement
has been extremely uncommon.
METHODS: We here in describe a case of a 75 year-old
man who had an enlarged cervical lymph node for a year
which subsequently proved to be involved by metastatic
adenocarcinoma of the prostate.
CONCLUSIONS: Although, prostate cancer rarely
metastasize to the cervical lymph node chain it should
always be considered in the differential diagnosis of
metastatic lymph node enlargement in the cervical area of
elderly men.
Keywords: Prostatic neoplasms. Lymph node
metastasis.
Resumen.- OBJETIVOS: La adenopatía cervical secundaria a diseminación metastásica es una manifestación poco frecuente del adenocarcinoma prostático. En
los casos de diseminación linfática extraregional, la
región supraclavicular izquierda es la localización más
frecuente (1, 2,3) mientras que las adenopatías derechas
han sido extremadamente raras.
MÉTODOS Y RESULTADOS: Describimos el caso de
un varón de 75 años que presentaba una adenopatía
cervical de un año de evolución que se demostraría
posteriormente que era secundaria a una metástasis de
adenocarcinoma prostático.
CONCLUSIONES: Aunque el cáncer de próstata rara
vez metastatiza en la cadena linfática cervical, debería
siempre considerarse en el diagnóstico diferencial de los
casos de adenopatías metastáticas del área cervical en
ancianos.
Palabras clave: Neoplasias prostáticas. Metástasis
linfáticas.
INTRODUCTION
Address correspondence to:
Levent N. Türkeri, M.D.
Marmara University School of Medicine
Turkey
E-mail: [email protected]
Accepted for publication January 20, 2003.
Prostate cancer is the most common cancer diagnosed
in men. Bone is the most common metastatic site in this
tumor and the presence of soft tissue or visceral
metastases is uncommon. In case of non-regional
lymphatic spread, left supraclavicular region was found
to be the most common site (1, 2, 3) whereas right sided
metastatic lymph node involvement has been extremely
uncommon.
860
ABDURRAHMAN ÖZGÜR, YALÇIN ILKER AND LEVENT N. TÜRKERI
DISCUSSION
Fig. 1.
CASE REPORT
A 75 year old man presented with a right-sided
cervical mass with a duration of one year and cervical
needle biopsy revealed metastatic adenocarcinoma in
August 2000.
In January 2001 he had lumbar and right flank pain.
Abdominal ultrasound examination at that time revealed
grade 4 hydronephrosis on the right side, para-aortic
lymph node enlargement (LAP) measuring 16x8 mm
and prostatic indentation to the bladder. Consequently,
he was referred to a urologist and his serum PSA level
wasmeasured1399ng/ml.Transrectalultrasoundguided
biopsy of the prostate revealed adenocarcinoma of the
prostate with a Gleason score of 8 (4+4) and perineural
invasion was observed. Bone scintigraphy revealed
multiple metastases and a non visualized right kidney.
Subsequently, maximal androgen blockade therapy
with an LHRH agonist and Bicalutamide was initiated.
Seven months after the therapy the PSA level decreased
to 53.4 ng/ml, without any significant change in the
cervical LAP which was measuring 6.5x7.5 cm. In
November2001,thepatient’scervicalLAPwasenlarged
to 8x8.5 cm (Figure-1, 2), and his PSA level was > 400
ng/ml. At this point bicalutamide was discontinued and
Estracyt + Mitoxantrone + Vinorelbine chemotherapy
was initiated. At one month follow up of this therapy
PSA level was down to 253 ng/ml and the size of the
cervical LAP was decreased to 8x7 cm.
Prostate cancer is the most common cancer diagnosed
in men. Through the use of digital rectal examination,
prostate specific antigen (PSA) and biopsy it is now
possible to diagnose prostate cancer at an earlier stage.
The most common metastatic site of prostate cancer is
bone. Rarely, metastases are found in non-regional
supradiaphragmatic lymph nodes, most commonly the
leftsupraclaviculargroup,whereasrightsidedmetastatic
lymph node involvement has been extremely uncommon
(1, 2, 3).
Most metastatic cancers to the cervical lymph nodes
are from primary head and neck cancers involving the
mucosal surfaces of the upper aero digestive tract (4).
Our patient presented with a right sided cervical LAP
which is an uncommon metastatic site for prostate
cancer. Initial hormonal therapy with LHRH agonist
andbicalutamidewasselectedasthetreatment.However,
the response to maximal androgen blockade therapy
was incomplete and of a short duration. As a second line
therapy combination chemotherapy was started. Which
resulted in a reduction of both serum PSA level to 253
ng/ml and the size of the metastatic lesion to 8x7 cm.
Although, current literature indicates that the location
or number of soft tissue metastases did not influence the
response rate and survival of these patients is reported
to be no different from those with skeletal metastases
alone (2), our patient had a poor clinical response to
Fig. 2.
CERVICAL LYMPH NODE ENLARGEMENT ON THE RIGHT SIDE AS THE INITIAL MANIFESTATION OF METASTATIC PROSTATE CANCER
hormonal therapy.
Therefore, if the initial response to hormonal therapy
is limited, it appears to be useful to continue treatment
in combination with chemotherapeutic agents until more
effective new treatment modalities are developed.
REFERENCES AND RECOMMENDED
READING (*of special interest, **of
outstanding interest)
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2001.
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prostatewithsofttissueornon-regionallymphaticmetastases
at the time of diagnosis: a review of 47 cases." Br. J. Urol.,
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1987.
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"Prostate carcinoma metastatic to the cervical lymph nodes:
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