J Oral Maxillofac Surg59:571-573, 2001

Metastatic Prostatic Carcinoma Presentingas Cervical Lymphadenopathy

Stuart Clark, FDSRCS Ed, FRCS Ed,* Robert J. Sanderson, FRCS,†

and Katherine M. McLaren, BSc (Hons) FRCP Ed, FRCS Ed FRCPath‡

Cervical lympadenopathy is a common presenta-tion in patients seen by the oral and maxillofacialsurgeon. In addition to a full medical examination,fine-needle aspiration cytology is a valuable inves-tigation in assessment of this condition. If meta-static carcinoma is diagnosed, the search for theprimary site involves panendoscopy, biopsy, andcomputed tomography.1 If no primary site is iden-tified, a neck dissection can still be effective treat-ment.2

Prostatic carcinoma is common in the elderly andcan metastasize to the neck.3 A case is presented toremind clinicians of this possibility.

Report of Case

A 67-year-old, nonsmoking, retired man was referred forconsultation regarding left cervical lymphadenopathy of2-months duration. He was known to suffer from chronicobstructive pulmonary disease (COPD), and he had a 9-yearhistory of primary detrusor instability. He had received noactive treatment for these conditions.

Examination revealed 3 firm cervical lymph nodes, one atlevel II and the others at level V. The systems examinationwas normal, with no other palpable lymphadenopathy orhepatosplenomegaly. A rectal examination was not per-formed.

A chest radiograph showed changes compatible withCOPD, but his hematology and biochemistry tests werenormal. Fine-needle aspiration cytology of one node re-vealed findings consistent with metastatic large cell carci-noma, which was further interpreted as possibly of squa-mous nature (Fig 1). Computed tomography of the neck andmediastinum showed no other abnormalities.

The patient was referred for a head and neck consul-tation and underwent fiber optic examination of thelarynx, oropharynx, and postnasal space; all of whichwere normal. Panendoscopy, left tonsillectomy, multiplepharyngeal biopsies, and computed tomography of hischest were then completed; all of which were also nor-mal. Subsequently, a left modified radical neck dissectionwas completed, following which he made a good recov-ery. Microscopic analysis of the specimen revealed thelymphadenopathy to be caused by metastatic prostaticadenocarcinoma (Fig 2). The prostate specific antigen(PSA) was measured at 66. He was referred to a urologic

*Registrar, Department of Oral and Facial Surgery, Sunderland

Royal Hospital, Sunderland, England.

†Consultant, Ear, Nose and Throat Department, City Hospital,

Edinburgh, Scotland.

‡Consultant, Department of Pathology, University of Edinburgh,

Medical School, Edinburgh, Scotland.

Address correspondence and reprint requests to Dr Clark: De-

partment of Oral and Facial Surgery, Sunderland Royal Hospital,

Kayll Road, Sunderland, England SR4 7TP.

© 2001 American Association of Oral and Maxillofacial Surgeons

0278-2391/01/5905-0017$35.00/0

doi:10.1053/joms.2001.22692

CLARK, SANDERSON, AND McLAREN 571

oncologist who diagnosed the prostate as the primary siteand commenced treatment of it.

DiscussionExcluding thyroid disease, 90% of cervical masses

after the fifth decade of life have a metastatic cancer-ous origin.4 The higher the level at which the cervical

lymph gland is found, the more likely there is a headand neck primary site.5

Current practice in assessment of cervical lymphade-nopathy presumed to be metastatic in nature involves acareful history, clinical examination, and search for aprimary site, including panendoscopy with random bi-opsies, particularly of the postnasal space, tonsil, and

FIGURE 1. Photomicrograph offine-needle aspiration biopsyshowing lymphocytes and areasof necrosis, along with multiplemalignant cells. (Hematoxylinand eosin stain, original magnifi-cation �40.)

FIGURE 2. Photomicrographfrom left cervical lymph nodefrom neck dissection showing typ-ical appearance of prostatic ad-enocarcinoma. (prostatic acidphosphatase stain, original mag-nification �20.)

572 METASTATIC PROSTATIC CARCINOMA

base of the tongue. Computed tomography of the head,neck, and chest is also advocated.1

Fine-needle aspiration cytology is recommended tomake the diagnosis, because it has high sensitivity andspecificity1,6 and can be easily performed in the outpa-tient clinic. It also avoids the increased incidence oflocal complications of surgical lymph node biopsy7 andthe possibility of seeding, which may occur with widercone needle biopsies (Tru-Cut; Baxter, Deerfield, IL).8

However, if doubt remains about the origin of the tu-mor, lymph node biopsy and frozen section analysis viaan incision that would then allow progress to a neckdissection is appropriate.

In this case, the cytology showed large cell carci-noma, which should have alerted the clinicians to thepossibility of the tumor arising from a germ cell orprostatic origin. Serum assay of PSA is a simple inves-tigation and, if undertaken preoperatively, could havehelped prevent this patient from receiving unneces-sary surgery to the neck. Wang et al2 suggest thatcontrol of resectable metastatic cervical squamouscell carcinoma from an undiagnosed primary site ismore effective with combination surgery and radio-therapy in patients with advanced disease. Control ofmetastatic squamous cell carcinoma with lower stageneck disease has comparable results with radiother-apy or surgery alone.2

Prostate carcinoma is the second most commontumor in white males,9 is well known to spread viathe lymphatics, and may occasionally present withdistant metastatic disease. Although it commonly me-tastasizes to bone, it may also involve soft tissue.10

It has been shown that left cervical lymphadenopathyarising from a prostate tumor is a rare occurrence that isoften overlooked and that it can be the presenting sign inthe absence of urinary obstruction.11 This patient wasknown to have a poor urinary stream and once nightlynocturia; although these symptoms were thought to becompatible with his age and detrusor instability. Right-sided metastatic cervical lymphadenopathy from the pros-tate has been reported in only 2 cases; one with simulta-neous left cervical lymphadenopathy.10

Extensive investigations should be limited in patientswith metastatic adenocarcinoma of unknown origin be-cause they have a low yield and are unlikely to improveoutcome or to alter management.12 At postmortem, themost common primary site is the pancreas.13

Patients with prostate carcinoma metastatic to non-regional lymph nodes have a statistically similar re-sponse to treatment as patients with only skeletalmetastases,14 and have a more favorable prognosis ifthe Gleason histology score is low.15 Thus, everyeffort should be made to exclude tumors of the pros-tate and germ cells if the cytology of cervical lymphnode suggests large cell carcinoma. PSA assay shouldbe part of the screening for cervical lymphadenopa-thy with an undiagnosed primary site.

Acknowledgment

The authors wish to thank the pathology department of VictoriaHospital, Kirkcaldy for assistance in this publication.

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