Metastatic carcinoma of the prostate presenting as a superior vena cava syndrome

Internal jugular venous thrombosis due to Trousseau's syndrome as the presenting feature of metastatic prostate carcinoma: a case report

Background

Internal jugular vein thrombosis is a rare vascular event with a potentially fatal outcome. Of the known etiologies, internal malignancies, either known or occult, are well described. Even though malignancies are known to present with internal jugular vein thrombosis, it rarely occurs due to prostate carcinoma. Many cases of jugular vein and superior vena cava thrombosis secondary to malignancies are due to metastatic compression of veins. Recurrent and unusual vascular thrombosis due to hypercoagulability associated with malignancies is also known as Trousseau’s syndrome. Here we report a rare case of a patient with internal jugular vein thrombosis as a presenting feature of metastatic prostate carcinoma, which is a case of Trousseau’s syndrome.

Case presentation

A 75-year-old Sri Lankan man with hypertension, hyperlipidemia, and past history of spontaneous intracranial hemorrhage presented with a short history of painless swelling in his left supraclavicular fossa. An examination revealed the swelling was due to a thickened left external jugular vein. A duplex ultrasound scan revealed left-sided internal jugular, external jugular, and brachiocephalic venous thrombosis. Surveillance into underlying malignancies showed an irregular, hard prostate gland suspicious of prostate carcinoma, which was proven with histology, and biochemically. A computed tomography scan found extensive vertebral, pelvic bone, intra-abdominal lymph node metastasis, and a single right-sided lower lung metastatic lesion, with no direct involvement of the jugular vein.

Conclusions

Spontaneous thrombosis of the internal jugular vein due to Trousseau’s syndrome is rare and unusual. Clinicians should promptly investigate for malignancies as it can be the first presentation of underlying occult malignancies. Although prostate carcinomas are rare to present with internal jugular vein thrombosis, this case illustrates the importance of having a high degree of suspicion in the appropriate clinical setting.

Superior vena cava syndrome as a presentation of metastatic prostate cancer

Superior vena cava (SVC) syndrome is an uncommon complication of malignant disease caused by the obstruction of venous blood flow in the SVC. When present, a diagnosis of lung cancer or lymphoma will be made in approximately 95% of cases. Although other malignant diseases are occasionally associated with SVC, its occurrence in patients with prostate cancer is rare. We present a case of a patient presenting with SVC obstruction who was subsequently diagnosed with prostate adenocarcinoma. The patient has been successfully treated with GnRH agonist. This case reflects the importance of a full clinical assessment and pathological confirmation of suspected tumour prior to treatment.

Superior vena cava syndrome caused by an intravascular thrombosis due to underlying prostate carcinoma

Superior vena cava (SVC) syndrome is usually caused by malignant tumors or their lymph node metastases oppressing a SVC. However, we encountered a case of SVC syndrome that was caused by a thrombus in the SVC, which we considered as a manifestation of Trousseau's syndrome triggered by underlying prostate cancer. A 60-year-old man patient complained of facial swelling. Physical examinations suggested SVC syndrome; enhanced CT and MRI demonstrated the presence of thrombus in the SVC accompanied by multiple mediastinal and axillary lymph node swelling. Histological examination of both percutaneous transluminally aspirated thrombus via a catheter through jugular vein and the axillary lymph nodes included metastatic prostate cancer. Although the ultrasonic and MR images were not compatible with the prostate cancer, needle biopsies from the prostate established the diagnosis. The SVC syndrome as an initial manifestation of underlying unknown malignancy and also due to intravascular thrombosis caused by cancer metastasis to the vascular wall is extremely uncommon.

Superior vena cava obstruction due to prostate carcinoma

Superior vena cava obstruction (SVCO) is considered an oncologic emergency commonly associated with lung carcinoma. The case presented here is that of a 48-year-old man presenting with SVCO, which was diagnosed as metastatic prostate carcinoma localized to the chest. He was treated with goserelin and aggressive radiotherapy with a drop in his prostate-specific antigen levels and symptomatic relief that lasted approximately 12 months. SVCO recurred locally in the chest and the patient died 24 months after diagnosis. This represents a rare presentation of prostate carcinoma and underlines the necessity for tissue diagnosis before local radiotherapy.

Fine-needle aspiration of supraclavicular lymph nodes

Malignancies from many primary sites may metastasize to supraclavicular lymph nodes (SCLN). We reviewed 100 fine-needle aspirations (FNAs) of SCLNs. There were three major types of malignancy detected by this method: adenocarcinoma (n = 40), squamous cell carcinoma (n = 14), and other malignancies (n = 29). Adenocarcinomas and other malignancies from all sites tended to metastasize to the left SCLN. Squamous cell carcinomas from all sites, however, tended to appear on the right side. For 61 patients, a previous diagnosis of malignancy had been made within 1 yr of the clinical appearance of the abnormal SCLN. For 20 patients, the primary diagnosis antedated SCLN metastasis by more than 1 yr, particularly patients with adenocarcinoma of the breast, prostate, or thyroid papillary carcinoma.