Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 2 Issue: 2

Asymptomatic Neck Mass as the Only Presenting Symptom of Advanced Prostate Cancer, a Case Report and Literature Review

Kianoush Sheykholeslami*, Marissa Alcantara, Ajaz Khan and David Laib
OSF Saint Anthony Health System, University of Illinois College of Medicine at Rockford, Department of Surgery, Rockford, IL, USA
Corresponding author : Kianoush Sheykholeslami
OSF Specialty Clinic – Guilford Square, OSF Health System University of Illinois College of Medicine at Rockford, Department of General Surgery, Section of Otolaryngology, Head and Neck Surgery, Department of Biomedical Science, 698 Featherstone Road, Rockford, IL 61107, USA
Tel: (815) 398-3277
E-mail: [email protected]
Received: December 07, 2012 Accepted: April 28, 2013 Published: May 07, 2013
Citation: Sheykholeslami K, Alcantara M, Khan A, Laib D (2013) Asymptomatic Neck Mass as the Only Presenting Symptom of Advanced Prostate Cancer, a Case Report and Literature Review. J Otol Rhinol 2:2. doi:10.4172/2324-8785.1000117

Abstract

Asymptomatic Neck Mass as the Only Presenting Symptom of Advanced Prostate Cancer, a Case Report and Literature Review

Cervical lymphadenopathy is frequently associated with head and neck cancer metastases and is sometimes seen with distant non-regional primary cancers. However, neck masses remain an uncommon presentation of prostate cancer and generally indicate a poor prognosis. In this case, we report asymptomatic neck mass as the only presenting symptom of prostate cancer and survey related cases in the literature.

Keywords: Prostate cancer; Cervical lymphadenopathy; Metastases

Keywords

Prostate cancer; Cervical lymphadenopathy; Metastases

Introduction

Neck masses affect people of all ages and can be a worrisome sign of malignancy to both provider and patient. Any neck mass in an adult should be suspected as malignant until proven otherwise.
Only about 5% of all cancer patients will present with neck masses. Of those, head and neck cancers are the most common primary cancers causing neck masses. The most frequent primary cancers metastasizing to left supraclavicular lymph nodes is from the lung, kidney and breast [1,2]. Prostate cancer rarely metastasizes to the neck which generally indicates a poor prognosis [3-5] but commonly metastasizes to lymph nodes of the pelvis and retroperitoneum, in addition to bones, lungs, bladder and liver [6].
The most common cause of cancer and the 2nd leading cause of cancer death in males is prostate cancer [7]. In this report, we present an unusual case of an elderly male with metastatic prostate cancer confined to the left supraclavicular lymph node as the only presenting symptom.

Case Report

A 65-year-old, previously-healthy male was referred to otolaryngology for a left supraclavicular mass that persisted for 6 weeks. He denied any other constitutional complaints, including fever, chills, recent unintentional weight loss, or difficulty in swallowing or breathing. Physical examination of the patient’s neck revealed a non-tender, semi-mobile left-sided lobulated neck mass approximately 6 cm in diameter. CT scan of the head and neck showed enlarged lymph nodes at the left supraclavicular fossa extending to the lower left internal jugular chain and mildly-enlarged lymph nodes at the upper margin of each pulmonary hilum (Figure 1). Full head and neck clinical exams including flexible nasolaryngoscopy were normal. Percutaneous fine needle aspirate biopsy (FNAB) consisted of a cribriform arrangement of glands lined by atypical epithelial cells having round-oval regular nuclei with occasional small nucleoli interpreted as highly suspicious for adenocarcinoma of prostate origin (Figure 2). Immunohistochemistry staining were equivocal for chromogranin, CK7 and CK20, but were negative for TFT-1 and synaptophysin. Mucicarmine stain was focally weakly positive. PSA staining was positive consistent with a prostate adenocarcinoma (Figure 3). Prostate specific antigen (PSA) level was measured to be 245 ng/ml. Patient denied any urinary complaints but admitted to new onset bone pain. Past medical, surgical, and family histories were negative for diagnosis of prostate cancer or other cancers. Whole body bone scan and CT scan revealed metastatic disease with lymphadenopathy seen in the chest, abdomen and pelvis, and abnormal skeletal uptake throughout the spine, pelvis and thorax (Figure 4). MRI of the spine revealed lytic lesions without cord compression. Definitive diagnosis was made with trans-rectal ultrasound biopsies of the prostate, which showed findings consistent with prostatic adenocarcinoma. Patient was received chemotherapy regimen of bicalutamide (Casodex) and leuprolide (Lupron) followed by zoledronic acid (Zometa) and continued Lupron injections. By the fourth month after initial treatment, the patient’s neck mass completely regressed, PSA dropped to within normal levels (1.1 ng/ ml), and the lower back pain improved. Now after more than two years, the PSA remains within normal range at less than 1 ng/ml and no other mass, lymphadenopathy or symptoms emerged indicating recurrence.
Figure 1: Axial CT slice showing left supraclavicular lymphadenopathy (arrow).
Figure 2: Fine Needle Aspirate Biopsy (FNAB). FNAB of left supraclavicular mass showed monotonous proliferation of cells forming glands, consistent with adenocarcinoma.
Figure 3: PSA staining. Immunohistochemistry positive for PSA consistent with a prostate primary.
Figure 4: Nuclear medicine whole body bone scan taken following IV 27.2 mCi Technetium 99 m labeled MDP. Multiple appendicular joints demonstrate focal increased uptake indicative of osteoarthritis. Metastatic osseous disease documented by multifocal abnormal uptake at, calvarium, sternum, multiple bilateral ribs, multiple thoracic and lumbar vertebral bodies, sacrum and bilateral pelvis.

Discussion

Prostate cancer remains one of the most prevalent cancers in men and one of the most treatable, given early detection. Unusual metastasis may be the only presenting feature of prostate malignancy. In this report, we present a unique case of an asymptomatic neck mass representing advanced prostate adenocarcinoma without other clinical evidence of the disease or prior diagnosis.
Early reviews of post-mortem examination of prostate cancer patients have shown that supraclavicular lymph node metastasis is an extremely rare occurrence in known primary prostate cancer [8-10]. Hessan et al. was the first to report a case of known prostate carcinoma with an isolated neck metastasis [11]. In Carleton et al., reported a patient with left supraclavicular lymphadenopathy as the only symptom of known prostate cancer recurrence with rising PSA [12]. Overall, the incidence of cervical lymph node involvement in patients with known prostate cancer has been reported as 0.4% or less [6]; however, these patients almost uniformly present with signs and symptoms of widespread metastatic disease [13,14].
Very few cases have described metastatic disease confined to the cervical nodes as the first clinical evidence of undiagnosed prostate cancer [5,15-18]. In Hematpour’s retrospective chart review, 4 out of 1,400 patients with prostate adenocarcinoma had clinicallydetectable metastatic disease to the supraclavicular lymph node, a reported rate of 0.28%. Only one of these cases had supraclavicular lymphadenopathy as the presenting symptom of prostate carcinoma [5]. Wang et al. found three patients, including a 42-year-old, who was younger than the recommended PSA screening age, with prostate carcinoma that presented with supraclavicular lymph node enlargement at the initial diagnosis and were subsequently found to have enlarged nodular prostate on digital rectal exam and elevated PSA [16]. Similarly, Chitale et al. reported two cases, and Tunio et al. reported one case, with a neck mass at the presentation [17,18].
Additionally, reports indicate misdiagnosis and incidental findings of metastatic prostate cancer. Yang showed the importance of screening for metastatic prostate cancer in a patient with a persistent left supraclavicular neck mass. The patient, experiencing advanced metastases, was not correctly diagnosed with prostate cancer for over a year [19]. Incidental findings of metastatic prostate cancer have been shown during neck dissections for thyroid cancer, in which the only symptom was enlarged neck masses [20]. Similarly, Sagnak et al. reported a patient, who had a radical prostatectomy, presenting eight months later for multiple left neck swellings diagnosed with papillary thyroid cancer. Testing found metastatic prostate cancer in the neck lymph nodes [21].
Any elderly male patient with cervical lymphadenopathy with unknown primary disease, even in the absence of lower urinary tract symptoms, could have metastatic prostate carcinoma. Initial evaluation should include PSA screening and DRE [16]. FNAB and immunochemistry staining of the lymphadenopathy could lead to the diagnosis of the primary tumor, however definitive diagnosis of prostate cancer in patients with metastatic neck lesions positive for prostate cancer must include serum PSA level and prostate biopsy. CT and PET scans could further evaluate the extent of metastasis and guide treatment. Despite the rarity of prostate carcinoma metastasis to the cervical lymphatic chains, in addition to standard approaches for evaluating unknown malignant mass in the head and neck, a high index of suspicion for metastatic disease to neck remains essential.

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