Generalized lymphadenopathy is a rare manifestation of metastatic prostate cancer. Here, we report the case of a 59-year-old male patient with supraclavicular, mediastinal, hilar, and retroperitoneal and inguinal lymphadenopathy, which suggested the diagnosis of lymphoma. There were no urinary symptoms. A biopsy of the inguinal lymph node was compatible with adenocarcinoma, whose prostatic origin was shown by immunohistochemical staining with PSA. The origin of the primary tumor was confirmed by directed prostate biopsy. We emphasize that a suspicion of prostate cancer in men with adenocarcinoma of undetermined origin is important for an adequate diagnostic and therapeutic approach

Benekli, Mustafa

Buyukberber, Suleyman

Cetin, Bulent

Cetin, Zeynep

Coskun, Ugur

Gonul, Ipek Isık

Sahiner, Ilgin

English

PubMed

Crossref

Hindawi Publishing Corporation
Case Reports in Urology
Volume 2011, Article ID 439732, 3 pages
doi:10.1155/2011/439732
Case Report
Generalized Lymphadenopathy: Unusual Presentation of
Prostate Adenocarcinoma
Bulent Cetin,1, 2 Zeynep Cetin,3 Suleyman Buyukberber,1 Ipek Isık Gonul,4
Ilgin Sahiner,5 Ugur Coskun,1 and Mustafa Benekli1
1Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
2Department of Medical Oncology, Faculty of Medicine, Gazi University, Besevler, 06500 Ankara, Turkey
3Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
4Department of Pathology, Faculty of Medicine, Gazi University, Ankara, Turkey
5Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
Correspondence should be addressed to Bulent Cetin, caretta06@hotmail.com
Received 21 May 2011; Accepted 30 June 2011
Academic Editors: E. Casciani and T. J. Murtola
Copyright © 2011 Bulent Cetin et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Generalized lymphadenopathy is a rare manifestation of metastatic prostate cancer. Here, we report the case of a 59-year-old male
patient with supraclavicular, mediastinal, hilar, and retroperitoneal and inguinal lymphadenopathy, which suggested the diagnosis
of lymphoma. There were no urinary symptoms. A biopsy of the inguinal lymph node was compatible with adenocarcinoma,
whose prostatic origin was shown by immunohistochemical staining with PSA. The origin of the primary tumor was confirmed by
directed prostate biopsy. We emphasize that a suspicion of prostate cancer in men with adenocarcinoma of undetermined origin
is important for an adequate diagnostic and therapeutic approach.
1. Introduction
Prostate cancer is the most common malignancy and the
second most common cause of cancer-related death in men
in the United States. The prognosis of prostate cancer is
mainly determined by the presence or absence of metastases
[1]. Most of the metastases occur in the bone, the other sites
are lung, liver, pleura, and adrenals [2]. Lymphatic metastasis
is rare. So, we present below a prostate cancer with common
lymph node and metastases without symptoms initially. We
present herein a case with rare manifestation of prostatic
carcinoma initially mimicking malignant lymphoma due to
supraclavicular lymphadenopathy and a paraaortic lymph
nodes on F-18-fluorodeoxyglucose-(FDG-) positron emis-
sion tomography (PET/CT).
2. Case Report
A 59-year-old man admitted to a hospital, with left inguinale
swelling. He did not have any complaints. His past medical
history was unremarkable. It was diagnosed as inguinal
hernia and the patient went to surgical operation. After the
surgeon, the swelling was compatible with inguinal hernia.
Three weeks after the surgery, the swelling repeated. Thus
computerized tomography of the abdomen was made. It
showed paraaortic, aortocaval, bilaterale parailiac, and left
inguinale lymph nodes of which the biggest was 13×26mm.
The liver and spleen were not palpable and there was no
other adenopathy. Digital rectal examination was normal.
The rest of the physical exam was unremarkable. Laboratory
evaluation revealed mild normocytic normochromic anemia
with hemoglobin of 12.3 g/dL (range, 13.2 to 17.1). Renal
and hepatic functions were normal. Whereupon a biopsy
of the left inguinale node was taken, it was compatible
with high grade adenocarcinoma of undetermined origin,
investigation of primarily pulmonary or urogenitale systems
was suggested for origin. After it, PET CT showed patholog-
ical increased FDG involvement of the left supraclavicular
(suvmax: 4.5), aorticopulmonary (suvmax: 3.6), paratra-
cheal (suvmax: 4.1), left tracheobronchial (suvmax: 5),
2 Case Reports in Urology
l 405
l 1500(g/mL)
Figure 1: PET CT showed pathological increased FDG involve-
ment of the left supraclavicular (suvmax: 4.5), aorticopulmonary
(suvmax: 3.6), paratracheal (suvmax: 4.1), left tracheobronchial
(suvmax: 5), left hilar (suvmax: 4.95), superior phrenic (suvmax:
5.1), paraaortic-aortocaval (suvmax: 8), common iliac (suvmax:
7.7), left external iliac (suvmax: 9), and left inguinale (suvmax: 7.15)
lymph nodes.
left hilar (suvmax: 4.95), superior phrenic (suvmax: 5.1),
paraaortic aortocaval (suvmax: 8), common iliac (suvmax:
7.7), left external iliac (suvmax: 9) and left inguinale
(suvmax: 7.15) lymph nodes (Figure 1). Then tumoral
markers of the patient was studied. CEA, CA19-9, and
CA15-3 were normal but AFP: 8.3 (0–8), total serum PSA:
119 ng/mL (0–3.9), free PSA: >20.4 ng/mL (0–0.4). This
time, guided prostate core biopsy was made and 12 biopsy
materials were obtained. All of them were involved with
tumoral cells. Histopathological diagnosis was acinar type
adenocarcinoma, gleason grade was 4+5, perineural invasion
(+), and the tumor cells stained strongly positive for prostate
specific antigen, confirming its prostatic origin. Stains for
neuron-specific enolase, synaptophysin, chromogranin, S-
100, pancytokeratin, leukocyte common antigen, and carci-
noembryonic antigen were negative (Figure 2).
Bilateral orchiectomy was made. A bone scan showed
normal uptake of radioactivity in the pelvic bones, thoraco-
lumbar spine, and the ribs. Finally we defined the patient
as prostatic adenocarcinoma with generalized lymph node
metastases and started bicalutamide 50mg, once a day. Total
and free PSA levels and computerized tomography (CT)
of chest, abdomen and pelvis were planned as follow-up
parameter with a three-month interval. Three months later,
his generalized adenopathy had completely regressed and
serum PSA had decreased to normal level (0–4 ng/mL).
3. Discussion
Some carcinomas of the prostate are slowly growing and
may persist for long periods without causing significant
symptoms, whereas others behave aggressively. It is not
known whether tumors can become more malignant with
time. Both early and advanced carcinomas of the prostate
are frequently asymptomatic at the time of diagnosis. Rarely
patients present with signs of urinary retention (palpable
bladder) or neurologic symptoms as a result of epidural
metastases and cord compression. Lymph node metastases
can lead to lower extremity lymphedema. As the axial
skeleton is the most common site of metastases, patients may
present with back pain or pathologic fractures. Our patient
did not have any symptoms at initial presentation.
Lymphatic metastasis of prostate occurs initially to the
obturator nodes followed by perivesical, hypogastric, iliac,
presacral, and para-aortic nodes. Lymphatic spread can best
be assessed by surgical exploration; the frequency with which
it occurs correlates with the size, grade, and the level of
serum PSA. Only about one tenth of tumors with a grade
of less than 5 have lymph node involvement, while more
than 70 percent of tumors with Gleason grade 9 or 10
have coexisting lymphatic invasion at the time of diagnosis.
Lymphatic metastases are present in fewer than 10 percent
of patients in whom the serum PSA level is < 10 ng/mL [3].
Except for bone involvement, distant metastases are relatively
rare at diagnosis and include supraclavicular, mediastinal,
pulmonary, and retroperitoneal metastases, which seldom
are the first evident clinical manifestation of prostate adeno-
carcinoma [4]. In the literature, we found few case reports.
Metastasis to the cervical lymph nodes is seen in about 0.4%
of patients with prostate cancer [5, 6]. In a large series of
mediastinal metastasis, only 1% originated from the prostate
[7].However, our patient’s PET CT scans showed widespread
involvement of the lymph nodes by the tumoral cells. First
of all, we thought lymphoma was suitable for our patient
because superficial and widespread lymphadenopathy is a
symptom of systemic disease such as infection, collagen dis-
ease, and lymphoproliferative disorders, including acute and
chronic lymphocytic leukemia and malignant lymphoma
[8]. But our patient did not have any infectious symptoms
or B symptoms (fever, perspiration, and weight loss) for
malignant lymphoma. The avidity of tumor cells for PSA on
immunohistochemical staining initially raised suspicion for
prostate cancer, which was later confirmed by biopsy of the
prostate.
The prognosis and response to treatment of patients with
lymph node involvement does not seem to diﬀer from that of
other patients with metastatic prostate cancer [9].
In summary, the diagnostic diﬃculty in the present case
was a result of the fact that the patient presented supra-
clavicular, mediastinal, hilar, pulmonary, and retroperitoneal
involvement as the initial manifestation of prostate cancer.
However, the present case suggests that in any male older
than 50 years of age with generalized lymphadenopathy,
prostate carcinoma metastases should also be considered,
especially if urologic symptoms and elevated PSA levels are
also present. A suspicion of prostate cancer in male patients
Case Reports in Urology 3
(a) (b)
Figure 2: (a) Histopathological diagnose was acinar type adenocarcinoma, gleason grade was 4 + 5, perineural invasion (+) (hematoxylin-
eosin, magnification X200). (b) The tumor cells stained strongly positive for prostate-specific antigen and stains for neuron-specific enolase,
synaptophysin, chromogranin, S-100, pancytokeratin, leukocyte common antigen, and carcinoembryonic antigen were negative (immun-
ohistochemical staining X100).
with adenocarcinoma of undetermined origin is important
for an adequate diagnostic and therapeutic approach.
References
[1] L. Bubendorf, A. Scho¨pfer, U. Wagner et al., “Metastatic
patterns of prostate cancer: an autopsy study of 1,589 patients,”
Human Pathology, vol. 31, no. 5, pp. 578–583, 2000.
[2] G. R. Mundy, “Metastasis to bone: causes, consequences and
therapeutic opportunities,” Nature Reviews Cancer, vol. 2, no.
8, pp. 584–593, 2002.
[3] A. I. Sagalowsky and J. D. Wilson, “Hyperplasia and carcinoma
of the prostate,” in Harrison’s Principles of Internal Medicine, pp.
596–602,McGraw-Hill, New York, NY, USA, 14th edition, 1998.
[4] H. Jones and P. P. Anthony, “Metastatic prostatic carcinoma
presenting as left-sided cervical lymphadenopathy: a series of
11 cases,” Histopathology, vol. 21, no. 2, pp. 149–154, 1992.
[5] R. H. Flocks and D. L. Boatman, “Incidence of head and neck
metastases from genito urinary neoplasms,” Laryngoscope, vol.
83, no. 9, pp. 1527–1539, 1973.
[6] H. Saitoh, M. Hida, T. Shimbo, K. Nakamura, J. Yamagata, and
T. Satoh, “Metastatic patterns of prostatic cancer. Correlation
between sites and number of organs involved,” Cancer, vol. 54,
no. 12, pp. 3078–3084, 1984.
[7] L. W. Welsh, J. C. Chinnici, J. J. Welsh, and G. F. Huck Jr.,
“Mediastinoscopy for extrathoracic malignancies,” Annals of
Otology, Rhinology and Laryngology, vol. 91, no. 6, pp. 659–665,
1982.
[8] S. Kosugi, S. Mizumachi, A. Kitajima et al., “Prostate cancer
with supraclavicular lymphadenopathy and bulky abdominal
tumor,” Internal Medicine, vol. 46, no. 14, pp. 1135–1138, 2007.
[9] Y. Furuya, K. Akakura, S. Akimoto, and H. Ito, “Prognosis
of patients with prostate carcinoma presenting as nonregional
lymph node metastases,” Urologia Internationalis, vol. 61, no. 1,
pp. 17–21, 1998.
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Generalized Lymphadenopathy: Unusual Presentation of Prostate Adenocarcinoma

Generalized lymphadenopathy is a rare manifestation of metastatic prostate cancer. Here, we report the case of a 59-year-old male  patient with supraclavicular, mediastinal, hilar, and retroperitoneal and inguinal lymphadenopathy, which suggested the diagnosis of lymphoma. There were no urinary symptoms. A biopsy of the inguinal lymph node was compatible with adenocarcinoma, whose prostatic origin was shown by immunohistochemical staining with PSA. The origin of the primary tumor was confirmed by directed prostate biopsy. We emphasize that a suspicion of prostate cancer in men with adenocarcinoma of undetermined origin is important for an adequate diagnostic and therapeutic approach

Bulent Cetin

Zeynep Cetin

Suleyman Buyukberber

Ipek Isık Gonul

Ilgin Sahiner

Ugur Coskun

Mustafa Benekli

Directory of Open Access Journals

Case Reports in Urology

Huck Jr., “Mediastinoscopy for extrathoracic malignancies,”

Hyperplasia and carcinoma ofthe prostate,”

Incidence of head and neck metastases from genito urinary neoplasms,”

Metastasis to bone: causes, consequences and therapeutic opportunities,”

Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved,”

Metastatic prostatic carcinoma presenting as left-sided cervical lymphadenopathy: a series of 11 cases,”

Prognosis of patients with prostate carcinoma presenting as nonregional lymph node metastases,”

Prostate cancer with supraclavicular lymphadenopathy and bulky abdominal tumor,”

u b e n d o r f ,A .S c h ¨ opfer, U. Wagner et al., “Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients,”

http://doaj.org/search?source=%7B%22query%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22term%22%3A%7B%22id%22%3A%2212a058f02575405aa9c3063a5cbb43c6%22%7D%7D%5D%7D%7D%7D

Generalized Lymphadenopathy: Unusual Presentation of Prostate Adenocarcinoma

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