Prostate carcinoma metastatic to the cervical lymph nodes: report of two cases and review of the literature

Immunoexpression of CDX2 in metastatic nonintestinal adenocarcinomas: an immunohistochemical pitfall and its pathological implications

Background

CDX2, a homeobox gene is the marker of intestinal differentiation. Its expression may lead to misdiagnosis while evaluating metastasis from unknown primary. In the present narrative, we discuss the clinical, morphological, and immunohistochemical (IHC) findings of metastatic adenocarcinoma of the lymph node that displayed nuclear immunoexpression of CDX2. However, the clinical and radiological picture supported the non-intestinal primary; prostate in one and lung in the other.

Case presentation

A 68-year-old man presented cervical lymph node enlargement. An epithelial tumor with acinar and cribriform pattern was seen that showed expression of CK, CDX2, and PSA in IHC. The patients complained of nonspecific symptoms related to both the gastrointestinal system and the prostate. Serum PSA was diagnostic (> 500 ng/ml). Similarly, core biopsy from mediastinal lymph node from a 51-year-male was received with possible differential of cancer and tuberculosis. Moderately differentiated adenocarcinoma was observed with the expression of EMA, CK 7, CDX2, and TTF1. The expression of both CDX2 and TTF1 was patchy. When the patient was called and all the details were sought the computed tomography (CT) thorax showed a lower chest wall lesion and multiple metastasis. The case was hence signed off as primary from lung on basis of clinical picture.

Conclusion

Such deviants must be reported and recorded. The knowledge of these will make a pathologist cautious and thus avoid misdiagnosis.

Metastatic prostate adenocarcinoma to cervical lymph nodes: an unusual diagnosis on fine-needle aspiration biopsy

INTRODUCTION

Metastatic prostatic adenocarcinoma (PAC) has mostly involved the pelvic lymph nodes; metastases to the cervical lymph nodes are exceedingly rare.

MATERIALS AND METHODS

A retrospective review of cytopathology files (January 1990 to March 2019) identified 13 cases of metastatic PAC to cervical lymph nodes diagnosed using fine-needle aspiration biopsy (FNAB). The clinical and demographic information were collected from the electronic medical records, and the slides were reviewed.

RESULTS

A total of 13 male patients with a mean age at FNAB 69 years (range, 61-86 years); 12 patients had a known history of PAC. In the patient without a history of PAC, the FNAB finding had been misinterpreted as papillary thyroid carcinoma. The interval between the original diagnosis and cervical lymph node metastasis was 98.5 months (range, 1-288 months). Most involved the left side (85%). Most smears had a clean background with few lymphocytes (46%) and numerous cellular clusters in flat sheets and acini (62%) and were composed of polygonal cells (46%) with round-oval shaped nuclei and indistinct cell borders (92%). The cytoplasm was granular (61%) or scanty (46%). The nuclei were uniform, size ≥2 times that of a neutrophil (69%). Prominent nucleoli and anisonucleosis were seen in 54% of cases; cellular pleomorphism was infrequent (30%). Immunostains confirmed the prostate origin in 7 tissue cores.

CONCLUSIONS

Metastatic PAC to the cervical lymph nodes occurs infrequently. If the history is unknown, cases can be misdiagnosed as metastases from cervical neoplasms. The findings indicating metastatic PAC to the cervical lymph nodes on FNAB include involvement of left-sided cervical lymph nodes in elderly male patients and cellular smears composed of uniform polygonal cells, arranged in flat sheets and acini, with granular cytoplasm, indistinct cell borders, and round-oval nuclei with prominent nucleoli.

Incidental cervical lymph node metastasis of papillary thyroid cancer in neck dissection specimens from a tongue squamous cell carcinoma patient: a case report

We report a rare case of lymph node metastasis of papillary thyroid cancer (PTC) incidentally detected in a neck dissection specimen of tongue squamous cell carcinoma (SCC). A 42-year-old Japanese woman was diagnosed with tongue SCC (T1N0M0, Stage I). Partial glossectomy with supraomohyoid neck dissection was performed under general anesthesia, and histopathological examinations revealed primary SCC of the tongue and neck metastasis of PTC in neck dissection specimens. A few months later, total thyroidectomy and left modified radical neck dissection were performed by thyroid surgeons. The histopathological diagnosis was PTC of both the thyroid glands. There was no evidence of tumor recurrence or distant metastasis at the 9-month follow-up.

Left Supraclavicular Lymphadenopathy as the Only Clinical Presentation of Prostate Cancer: A Case Report

Prostate cancer usually metastasis to the regional lymph nodes and can rarely metastases to nonregional supradiaphragmatic lymph nodes. Cervical lymph node metastasis of prostate cancer is extremely rare. However, it should be considered in the differential diagnosis of cervical lymphadenopathy in male patients with adenocarcinoma of unknown primary site. In this report we present a rare case of metastatic prostate adenocarcinoma with left supraclavicular lymphadenopathy as the only clinical presentation with no other evidence of metastasis to the regional lymph nodes or bone metastasis.

Macrophage type 2 differentiation in a patient with laryngeal squamous cell carcinoma and metastatic prostate adenocarcinoma to the cervical lymph nodes

Background

The tumor microenvironment often polarizes infiltrating macrophages towards a type 2, or M2 phenotype, that is characterized by expression of various cysteine-rich, scavenger receptors, including CD163. The primary function of M2 macrophages is to facilitate wound healing. As such, they are capable of providing metabolic support to a growing tumor, neovascularization, as well as protection from cytotoxic T cells. The tumor microenvironment contains a milieu of secreted factors and vesicles, which in certain circumstances can gain access to lymphatic vessels that drain to local lymph nodes.

Case presentation

We report a 59-year-old male with recurrent T4 squamous cell carcinoma (SCC) of the larynx with synchronous prostate adenocarcinoma confined to the prostate and regional pelvic lymph nodes, without metastatic disease. The patient underwent salvage total laryngectomy and bilateral neck dissection with final pathology revealing a recurrent moderately differentiated SCC involving the larynx as well as prostate cancer in draining level 4 cervical lymph nodes bilaterally. CD163 staining was performed on the primary tumor, a negative draining lymph node, and a level four lymph node with a focus of metastatic prostate cancer and compared to benign controls. The negative draining lymph node demonstrated a large CD163 population of cells as did the interface of the focus of prostate cancer and surrounding lymph node. CD163 levels were markedly increased in this patient compared to benign lymph node controls. The macrophage differentiation at the primary tumor in the larynx was strongly CD163 positive supporting an immune permissive environment for tumor growth and metastasis.

Conclusion

We describe a unique case of solitary metastatic prostate cancer to cervical lymph nodes in the setting of a laryngeal cancer. These observations suggest that SCC-derived factors drive a tumor-supportive environment in draining lymph nodes dominated by an overwhelming number of CD163+, M2 macrophages. Lymph nodes that are ‘primed’ by SCC differentiation to M2 phenotype may be at higher risk of harboring metastases.

Unusual Case of Laryngeal Squamous Cell Carcinoma with Cervical Metastasis of a Prostatic Adenocarcinoma: A Case Report

Brain and Head and neck metastases are rare in prostatic carcinoma patients. In this report we present a very uncommon case of the concomitant occurrence of a prostatic adenocarcinoma with neck metastases and an advanced laryngeal squamous cell carcinoma without neck metastases. The presence of cervical lymph node prostate adenocarcinoma metastasis concomitantly with a laryngeal squamous cell carcinoma is at least intriguing and may remind us of a rare event called “collision tumors”. In this case we had the metastatization of 1 carcinoma to the site of the drainage of another carcinoma, but we never found the 2 histological types as close as requested to reach the definition of a collision tumor. This emphasizes the need of histological verification of different sites of recurrence when 2 or more primary cancers are known in a patient, particularly when the treatments of those primary cancers vary widely.

Metastatic prostate adenocarcinoma presenting as a large right supraclavicular and anterior chest wall mass

Left-sided cervical lymphadenopathy as first presentation of metastatic prostate carcinoma is not a novel observation. Here, we discuss a case of metastatic prostate primary carcinoma with an initial presentation of a right supraclavicular mass with extension into the anterior chest wall, which on radiological investigation was suggestive of a sarcomatous tumour; however, was confirmed to be pervasive metastatic prostatic adenocarcinoma. This is the second case in literature, which reports a prostatic primary cancer presenting as a right-sided supraclavicular and anterior chest wall mass.

Prostate cancer metastatic to the cervical lymph nodes

Prostate cancer is the most common cancer in men, often presenting with regional lymph node or bone metastasis and rarely with supradiaphragmatic lymph node involvement. Most metastatic cancers involving the cervical lymph nodes are from cancers of the upper aerodigestive tract. In this report, we describe two cases with cervical lymph node enlargement due to metastatic prostate cancer as the initial clinical presentation: a 43-year-old male, initially misdiagnosed with a tumor of the upper aerodigestive tract and an 87-year-old male with right lobe pneumonia and cervical lymph node enlargement, initially attributed to be an acute inflammatory lymph node reaction. To the best of our knowledge, there are less than 50 cases reported in the literature of adenocarcinoma of prostate metastatic to the cervical lymph nodes and only one case presenting in men younger than 45 years. The authors intend to highlight the importance of digital rectal exam and PSA test in case of persistent left cervical lymph node enlargement, including men younger than 45 years of age.

Pneumothorax as a Presenting Clinical Manifestation of Metastatic Prostate Cancer

Pulmonary metastases are not encountered commonly in patients with prostate cancer. Pulmonary metastases with pneumothorax as a presenting clinical manifestation in newly diagnosed prostate cancer are very rare. Here, we present the case of an 82-year-old patient who was admitted to our center with a chief complaint of worsening dyspnea over the past few days. The chest X-ray and computed tomography (CT) showed left pneumothorax and bilateral lung opacities as well as generalized lymphadenopathy and diffuse bony metastases. After a series of workup including cervical lymph node biopsy with immunohistochemical staining, abdomen CT, serum prostate-specific antigen (PSA), and transrectal ultrasonography (TRUS), he was proved to have prostate cancer with multiple lung, bone and lymph node metastases. This case is reported because of the rarity for a prostate carcinoma presented clinically with an unusual pulmonary manifestation.

Unusual presentations of prostate cancer: A review and case reports

Objective

To report our institutional experience with some rare presentations of prostate cancer, as prostate cancer is a common problem and affects a large group of men during their lifetime, but a few studies report unusual presentations of metastatic prostate cancer.

Methods

All possible clinical and pathological data were collected for six relevant patients with prostate cancer and unusual metastases who were identified at our institution. PubMed was searched for unusual presentations of prostate cancer in the last 20 years (1982–2012) and all relevant publications were assessed. The authors discussed the reports and selected those articles of major clinical significance to include in a review.

Results

We identified 19 reports of major clinical significance and reviewed them. As in the cases from our institution, supraclavicular lymphadenopathy, isolated upper ureteric obstruction and severe obstructing constipation were some of the rare presentations encountered at other institutions, and reported mostly as sporadic case-reports.

Conclusion

Prostate cancer should be always considered in the differential diagnosis of elderly men presenting with supraclavicular lymphadenopathy, hydroureteronephrosis or constipation, even in the presence of a normal digital rectal examination and low serum total prostate-specific antigen (PSA) levels. PSA immunohistochemical staining should be used in doubtful cases.

[Rare locations of metastases from prostate cancer]

The bone tissue is the most frequent site for prostate carcinoma metastasis. Nevertheless many other areas have also been described. Using Pubmed and Cochrane the most exhaustive research possible has been carried out to list these secondary prostate carcinoma lesions.

[Cervical adenopathy presentation of adenocarcinoma of prostate]

The metastases of prostate cancer shows the regional lymphatic dissemination, being the cervical lymphatic metastases to infrequent and little reported in Literature. In the present work we contributed a new observation of this organization. We displayed a clinical case with lateral mass cervical left, abdominal pain and diarrheic. When making biopsy of cervical adenopathy reported adenocarcinoma prostate metastases. Colonoscopy with biopsy was made whose results were carcinoma little differentiated infiltrated necrotic center to rectum. The complementary studies demonstrated bilateral aortic adenopathys without injuries in thorax. Within the diagnosis differential of the cervical adenopathys in neck in adult men it must consider the prostate carcinoma, because in an early diagnosis and adapting treatment it can prolong the survive.

Metastatic prostate cancer presenting as an asymptomatic neck mass

Prostate cancer often metastasizes to the regional lymph nodes, but metastases to distant supradiaphragmatic lymph nodes are uncommon. Rare case reports describe cervical lymph node metastases as the first clinical manifestation of prostate cancer, but only in the setting of widely disseminated disease. We present the unusual case of an 84-y-old male with a known history of prostate cancer and recurrent disease limited to the left supraclavicular lymph nodes.

Expression of the chemokine receptor CCR7 in prostate cancer presenting with generalized lymphadenopathy: report of a case, review of the literature, and analysis of chemokine receptor expression

PURPOSE

Generalized lymphadenopathy is a rare presentation of prostate cancer. We report a case and review reported cases in the literature. Because of the association of chemokine receptor expression with specific metastatic patterns, we tested for expression of chemokine receptors known to mediate migration to lymph nodes.

METHODS

We performed a MEDLINE (National Library of Medicine, Bethesda, MD) database search for case reports during the last 32 years using "prostate cancer," "lymphadenopathy," "metastatic to lymph nodes," and "mimicking lymphoma" as keywords. Expression of the CXCR4 and CCR7 chemokine receptors was assessed by immunohistochemistry. Laser capture microdissection and reverse transcription polymerase chain reaction for CXCR4 were used to exclude nonspecific binding.

RESULTS

Of 153 patients with prostate cancer presenting with lymphadenopathy (LAD) described in the literature, 67 (44%) presented with supraclavicular adenopathy, 29 (19%) retroperitoneal, 22 (14%) mediastinal, 15 (10%) cervical, 9 (6%) inguinal, and 2 (1%) axillary LAD. Only 9 patients presenting with generalized LAD have been previously reported. Monoclonal antibodies to CCR7 showed intense staining in the patient's tumor epithelium. Little or no staining was observed for CXCR4. Reverse transcription polymerase chain reaction for chemokine receptors on ribonucleic acid (RNA) recovered from the patient's sample failed to express messenger RNA for CXCR4 but did express messenger RNA for CCR1, CCR4, and CCR5.

CONCLUSIONS

Prostate cancer may present on rare occasions with generalized adenopathy. Variable expression of chemokine receptors may be associated with organ specific patterns of metastasis. In this case, expression of CCR7 may have accounted for the unusual predilection of this patient's prostate cancer for lymph nodes.