A B S T R A C T

Metastatic Prostate AdenocarcinomaPresenting with Bilateral Inguinal Adenopathy

Key words Prostate adenocarcinoma, Metastatic inguinal lymphadenopathy, Rare sites.

Mutahir A Tunio, Altaf Hashmi, Syed Shoaib Raza

INTRODUCTION:Prostate adenocarcinoma accounts for approximately3.4% of all the cancers and ranks 8th in Pakistanimales,1 of whom 70% of patients are diagnosed asadvanced metastatic stages.2 Such cases mostlypresent with the bone pain, iliac and para-aorticlymphadenopathy, prostatism and urinary retention.3,4

The pr imary lymphat ic spread of prostateadenocarcinoma most often involves the iliac (externaland internal), obturator, pre-sacral and hypogastricnodes, followed by para-aortic lymph nodes.5 Theinguinal lymphadenopathy is very rare manifestationduring any stage of prostate adenocarcinoma,especially in absence of pelvic lymphadenopathy orother site of metastases.6

Here - i n we p resen t a case o f p ros ta tea d e n o c a r c i n o m a w i t h b i l a t e r a l i n g u i n a llymphadenopathy during init ial presentation.

CASE REPORT:A 66-years-old male presented in the Oncology clinicwith bilateral inguinal swelling for the last 2 months.He also had frequency of urine for 3 months.Physical examination revealed enlarged, hard inguinallymph nodes of varying size from 2x2 cm to 4 x4 cmon both sides (Fig-I). No other palpable lymph-adenopathy or visceromegaly was observed. Digitalrectal examination (DRE) showed large prostate withstony hard consistency.

Correspondence:Dr. Mutahir A TunioRadiation Oncology DepartmentSindh Institute of Urology & Transplantation (SIUT),KarachiE mail: drmutahirtonio@hotmail.com

Baseline investigation including full blood count,urea, electrolytes, liver function tests and chest x-ray were normal. Computed tomography (CT) ofneck, chest, abdomen and pelvis showed bilateralinguinal and para-aortic lymphadenopathy in absenceof pelvic adenopathy and large prostate involvingseminal vesicles (Fig-II).

Metastatic prostate adenocarcinoma generally manifests either as painful bone metastasesoften in axial skeleton or as bulky iliac and para-aortic lymphadenopathy. The inguinallymphadenopathy is very rare. Here-in we present an unusual case of metastatic prostateadenocarcinoma with bilateral inguinal adenopathy.

CASE REPORT

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Fig-I: Physical examination showing enlarged,hard inguinal lymph nodes of varying sizefrom 2x 2 cm to 4 x 4 cm on both sides.

Fig-II: Computed tomography (CT) neck,chest, abdomen and pelvis showed bilateralinguinal and para-aortic lymphadenopathy inabsence of pelvic adenopathy and largeprostate invo lv ing seminal ves ic les.

A fine needle cytology of inguinal lymph noderevealed metastatic moderately differentiatedadenocarc inoma (F ig- I I I ) . Serum markerscarcinoembryonic antigen (CEA), alpha feto-protein(AFP) and beta human chorionic gonadotrophinwere normal. Serum prostate specific antigen (PSA)was 108 ng/ml. Patient underwent trans-rectalultrasound guided biopsy of prostate which showedprostate adenocarcinoma (Gleason score 3+4=7).Bone scan was done which showed increased uptakein 12 th thoracic vertebra. He was staged asT3bN2M1a. Patient was started on androgendeprivation therapy {oral bicalutamide 50 mg for aweek and monthly subcutaneous leutinizing releasinghormone (LHRH) analogues}. The inguinal lymphnodes were irradiated for pain relief with 12 MeVelectrons with radiation dose 3000 cGy in tenfractions over two weeks.Three months later, theserum PSA returned within normal limits and followup CT scan showed regression of nodal disease.Pat ient is current ly on regular fo l low-up.

DISCUSSION:The prostate adenocarcinoma is predominantly adisease of older men above 50 years of age. It mostoften metastasize to regional lymph nodes (iliac andob tu ra to r ) and bones by l ympha t i c andhematogenous spread. Metastases to inguinal lymphnodes is very rare and only few related case reportshave been published in medical literature.5,6,7 Thepossible explanation of the dissemination mechanismof prostate adenocarcinoma to inguinal lymph nodesis three-fold; (I) retrograde lymphatic spread in thepresence of para-aortic lymph nodes (II) prostatecancer cells could reach the inguinal canal via thespermatic cord and (III) ectopic prostate tissueoutside the genital-urinary system.8

Inguinal lymph nodes do not lie in the lymphaticdrainage pathway of the prostate; therefore, inguinallymphadenopathy is an unlikely early manifestation

of metastatic prostate adenocarcinoma and isindicator of very advanced stage and dismalprognosis.9 The treatment in our patient was thestandard hormonal therapy in form of LHRHanalogues and palliative radiotherapy for painfulinguinal lymphadenopathy. Following the treatment,there was remarkable decline in the PSA value anddisease regression was seen.

In differential diagnosis of metastatic inguinal nodesapart from scrotal, vaginal, anal canal and cervicalcancers, prostate adenocarcinoma also must bekept in mind by physicians. We emphasize that perabdomen examination, digital rectal examination(DRE) and serum PSA shall be performed to ruleout primary of unknown origin in case of persistentinguinal lymphadenopathy. Prompt diagnosis andtreatment may affect outcome.

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1. Bhurgri Y, Kayani N, Pervez S, Ahmed R,Tahir I, Afif M, et al. Incidence and trends ofprostate cancer in Karachi South, 1995-2002. Asian Pac J Cancer Prev 2009;10:45-8.

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3 Sagnak L, Topaloglu H, Gucuk O, Han U,Ersoy H. Skip metastase on the left necklymph nodes of the prostatic adenocarcinomawith neuroendocrine differentiation andaccompanying thyroid micropapi l larycarcinoma. Pathol Oncol Res 2008;14:493-5

4 Oyan B, Engin H, Yalcin S. Generalizedlymphadenopathy: a rare presentation ofdisseminated prostate cancer. Med Oncol2002; 19:177-9.

5 Huang E, Teh BS, Mody DR, Carpenter LS,But ler EB. Prostate adenocarcinomapresenting with inguinal lymphadenopathy.Urology 2003; 61:463.

6. Slavis SA, Golji H, Miller JB. Carcinoma ofthe prostate present ing as inguinaladenopathy. Cleve Clin J Med 1990; 57:97.

7 Rosa M, Chopra HK, Sahoo S. Fine needleaspiration biopsy diagnosis of metastatic

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Metastatic Prostate Adenocarcinoma Presenting with Bilateral Inguinal Adenopathy

Fig-III: A fine needle biopsy of inguinallymph node revealed metastatic poorlyd i f f e r e n t i a t e d a d e n o c a r c i n o m a

Mutahir A Tunio, Altaf Hashmi, Syed Shoaib Raza

prostate carcinoma to inguinal lymph node.D iagn Cy topa tho l 2007 ; 35 :565-7 .

8 Ito H, Fuse H, Hirano S, Masuda S. Ectopicprostatic tissue outside the urinary tract: acase report. Int J Urol 1998; 5:391-2.

9 Attila T, Ricketts-Loriaux R, Sauer DA, FaigelDO. Celiac and perigastric lymph nodemetastasis of prostate cancer diagnosedwith endoscopic ultrasound-guided fine-needle aspiration. Can J Gastroenterol 2009;23:479-80.

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