Case Report: Prostate adenocarcinoma presented with inguinal lymph node metastasis

Introduction

Prostate cancer is a common cancer among older men that frequently spreads to regional lymph nodes and, in rare cases, bone. The inguinal region is rarely involved in the lymphatic dissemination of prostate cancer. Prostatic adenocarcinoma is an asymptomatic disorder and can be a silent killer. The common mode of presentation in symptomatic disease is in the form of obstructive uropathy. It is the leading cause of death in male cancer patients.¹ Around one-half of these cancer patients have metastatic disease at presentation. Bone and lymph nodes are the most common targets of cancer cells. However, spreading to inguinal lymph nodes without pelvic lymphadenopathy or other metastases is rare. This cancer adopts root of spread from the obturator lymph nodes, sacral both pre and lateral, internal and external iliac, and lastly the inguinal lymph node.² We report a rare metastatic prostate adenocarcinoma only to the inguinal lymph nodes without involvement of other nearby reginal nodes.

Providing more information on the symptoms and diagnosis of metastatic prostate adenocarcinoma could be helpful to readers who are interested in learning more about the disease. This could include details on identifying the signs of metastasis and what tests are typically used to confirm a diagnosis. Additionally, the article could benefit from additional information on treatment options for metastatic prostate adenocarcinoma. This would be especially useful for readers who may be dealing with the disease themselves, like physicians and surgeons.

Case report

A 62-year-old of male gender having Indo Aryan ethinicity. He was farmer by occupation, came to Acharya Vinobha Bhave Rural Hospital, Sawangi, with the chief complaint of swelling in the left inguinal region, which had been from two months. The swelling was initially minor and progressively grew larger; no pain was associated. The patient has a past medical case of prostate carcinoma for which he underwent Transurethral resection of the prostate (TURP) with orchidectomy 2 years ago, received two cycles of chemotherapy with docetaxel, and ten sessions of radiotherapy. There is no positive family history means no any other family member were affected by similar disease like prostate. Personal history revealed complaints of constipation, burning micturition, and weight loss. He lost 8 kg in the previous month.

He was well-oriented to time, place, and person. On general examination, including all the components like sex, age, temperature, pulse, respiration, cyanosis, clubbing, pallar, blood pressure, icterus, development and habitus, state of nutrition, consciousness, facial features and expression, position (decubitous), skin, eyes, jugular venous pressure, limb oedema and lymph nodes etc. It was normal except of inguinal lymphadenopathy. Per abdominal examination was done thoroughly following all four basic steps including inspection, palpation, percussion, and auscultation. The bowel sounds were normal. Auscultation was done with bell of stethoscope in supine posture in calm and quite place. No undue pressure on stethoscope was was given. Bowel sounds were heard for 5minutes in all four quadrants. Auscultation was done immediately after inspection before palpation or percussion as it can stimulate the peristalsis. They were heard in all four quadrants. On palpation found to have mild hepatomegaly. There was no tenderness. There was no evidence of guarding, rigidity, or distension of the abdomen.

On digital rectal examination, there were no external skin tags or hemorrhoids, normal anal tone, and normal anal mucosa. There was grade 3 prostomegaly, a gloved finger stained with stool. The inguinal region assessment showed a firm, non-tender swelling of approx. 3*2cm on left inguinal region. The skin over the swelling appeared to be normal. Other systemic examination was normal. He underwent further investigations.

A prostate-specific antigen (PSA) was elevated. The patient underwent an enhanced computed tomography (C.T.) scan of the abdomen and pelvis. Enlarged left inguinal lymph nodes with a maximum diameter of 3 cm were discovered on a C.T. scan of the abdomen.

Along with it, U.S.G. abdomen and pelvis were performed, both revealed an enlarged, irregular, and heterogeneous prostate. The bladder showed cystitis with severe bladder wall thickening at the bladder neck. There were multiple hepatic metastases. The lobulated hypoechoic mass lesion in the left inguinal canal suggestive of metastatic lymph nodal mass (see Figure 1).

Figure 1. C.T. Scan image shows a swollen left inguinal lymph node with a maximum diameter of 3 cm.

Tranrectal ultrasound guided fine needle aspiration cytology was performed to reconfirm the diagnosis (see Figure 2A). After obtaining physician fitness under general anesthesia, the patient underwent an excision biopsy of the left inguinal lymph node. Incision taken parallel to and 1.25 cm above medial half of left inguinal ligament. Incision deepened. Lymph node visualized. Separated and freed from all sides. Lymph node mass delivered out. Mop count and instrument count checked. Haemostasis achieved. Incision closed in layers. Skin sutured using ethilon. The procedure is uneventful. Histopathological examination confirms the diagnosis of adenocarcinoma metastasis from adenocarcinoma a (see Figure 2B).

Figure 2. A. (left) Histopathological examination reveals adenocarcinoma with considerable differentiation (Gleason score 3 + 4 = 7) (H&E staining, 200). B. (right) The biopsy of the enlarged inguinal lymph node (right) reveals metastatic deposits of adenocarcinoma. The cytoplasm of the tumor cell displays vascular degeneration (H&E staining, 200).

Discussion

Despite all advances in understanding the treatment of prostatic cancer, around two and a half lakhs of persons succumb to death every year worldwide. Patients having distant metastasis suggest a poor prognosis with a median survival of up to 2 and half years with considerable inter-patient variations; few may have a short life, and others may survive up to 10 years with hormonal therapy. The cause of this diversity is unknown.

Rosa M. et al. report a case of aggressive prostate cancer in a middle-aged man. He initially had nonspecific symptoms like nausea, vomiting, and inguinal lymphadenopathy for a month. A fine needle aspiration biopsy (F.N.A.B.) and immunohistochemical tests confirm the diagnosis. Inguinal lymphadenopathy was similar to the present case.¹

Komeya M et al. reported a case of a middle-aged male with urinary symptoms. During the patient's examination, a nodule was found in the left lobe of the prostate. Further testing revealed that the patient had adenocarcinoma. However, a C.T. scan, magnetic resonance imaging, and bone scan showed no metastasis. The patient received two months of neoadjuvant hormonal therapy (leuproreline and bicalutamide) before undergoing retropubic radical prostatectomy and obturator lymph node dissection. Pathological findings showed that the patient had a moderately differentiated adenocarcinoma. It's important to note that this case was not similar to the present case, as the patient also had inguinal lymphadenopathy and involvement of obturator lymph nodes. Treatment options, their effectiveness, and potential risks and side effects should be discussed with a medical professional.²

Doreswamy K et al. reported that based on the patient's medical history and diagnostic tests, it has been determined that he has prostatic cancer that has spread to the bladder base, seminal vesicles, and vertebral region. The transrectal ultrasound biopsy has confirmed the presence of adenocarcinoma, and the inguinal lymph node biopsy has shown that the cancer has metastasized. The patient has been informed of his diagnosis and is currently undergoing treatment to manage his condition. He needs to continue to receive regular medical care and followup appointments to monitor his progress and address any symptoms that may arise.³

Kirpana K. et al. had a similar case of a 65-year-old patient with carcinoma prostate with inguinal lymphadenopathy. As P.S.A. levels were increased, the diagnosis was confirmed with a prostatic biopsy. He underwent an inguinal lymph node Biopsy to confirm the diagnosis of metastasis. Hormonal treatment was advised with a good prognosis of up to ten years of the latest followup without distant metastasis.

One of the peculiarities of this case report was its presentation as an enlarged lymphadenopathy, as very few were reported in the literature.^1–4 One possible explanation might be abnormal or aberrant lymphatic drainage of the prostate to the inguinal lymph node.

Conclusion

Although inguinal metastasis is uncommon in the early stages, the physician must always rule it out. Its existence will significantly affect treatment and management, including hormone therapy with or without locoregional radiation.