C. A. VAUGHN ET AL. 209
3. Discussion
Since 1984, adenocarcinoma of the prostate has been the
most common noncutaneous neoplasm of American men,
with a lifetime risk of 16.72% [1]. It is well known that
diagnosis of prostate cancer prior to the age of 50 is un-
common, however prostate neoplastic evidence is quite
common in those men 80 years or older. African-Ameri-
can males profoundly have the greatest incidence of pro-
state cancer as well as suffer the largest mortality, 62.3%
[2]. Since the in trodu ction of screening with p ros tate sp e-
cific antigen (PSA) in 1994, a now controversial practice,
the incidence of non-regional spread has declined dra-
matically. Currently, 60% - 75% of newly diagnosed
cases are contained within the prostate organ and are cli-
nically non-palpable [1]. The most common locations of
extra-prostaticdissemination are to the pelvic lymph nodes
and bone, followed by the lungs and liver. It is unusual
for these metastatic lesions to be large, bulky deposits,
rather they tend to form multiple small nodules or be dif-
fusely spread through multiple lymph nodes [1].
The incidence of any genito-urinary malignancy dis-
seminating to the head and neck is rare, especially those
originating from the prostate. At a single institution,
Flocks and Boatman [3] noted that of all metastatic le-
sions in the head and neck 6% were of renal or adrenal
origin respectively and only 1% of prostatic origin. None-
theless, increasing numbers of cases are being reported
detailing supradiaphragmatic lymph node metastatic le-
sions of prostate adenocarcinoma. The lymph nodes that
are most commonly detected include supraclavicular, cer -
vical, axillary, and mediastinal nodes [4].
There are many theories describing the mechanism of
metastasis to the supradiaphragmatic lymph nodes the
gentio-urinary tract. A popular and widely accepted pos-
tulation explains it is the result of homogenous spread
through Batson’s venous plexus allowing communication
of the deep pelvic veins and the thoracic veins via the
internal vertebral venous plexuses [5]. Valsalva maneu-
vers result in a reversal of blood flow into the vertebral
veins from the inferior vena cava [6].
Due to the relative rarity of the extra-prostatic metas-
tasis to the neck, specifically supraclavicu lar lymph nod es,
there have been few multi-patient studies performed and
a limited number of case reports on the subject. Cho et al.
[4] presented 26 patients with prostate cancer metastasis
to supradiaphragmatic lymph nodes, 15 cases involving
the supraclavicular nodes and 58% with abnormal digital
rectal exams. Saeter et al. [7] discuss 35 patients present-
ing with non-regional lymphatic dissemination from a
primary prostate adenocarcinoma, 69% of cases had a
lesion in the left supraclavicular fossa and 75% of cases
had an abnormal digital rectal exam. Butler et al. [8] de-
scribed 19 patients presenting with supraclavicular lym-
phadenopathy who were deemed to have prostate cancer,
42% of cases had a digital rectal exam abnormalities.
Prostate adenocarcinoma spread to other lymph nodes of
the head and neck are even rarer than the reported inci-
dences at the supraclavicular fossa. Flocks and Boatman
reviewed [3] 1500 cases of genitor-urinary neoplasms
which metastasized to the head and neck, 6 cases (0.4%),
prostate in origin, involving the cervical lymph nodes.
This evidence is supported by a similar studies providing
further evidence that emphasizes this rarity [9-15].
Diagnosis of metastatic prostatic cancer via FNA or
excisional biopsy necessitates both microscopy and im-
munohistochemistry. The histological criteria include in-
filtrative small glands or large cribriform glands, absence
of basal cells, nuclear atypia, as well as minor criteria
including, but not limited to, an amphophilic cytoplasm
and nuclear hyperchromasia [16]. Prostate specific anti-
gen has been used for many years as a diagnostic marker
during staining. Prostate acid phosphatase is also a well
known marker used during staining. Immunohistochem-
istry and histochemical stain panels commonly positive
in prostatic carcinoma include PSA, PSAP, Cytokeratin,
as well as Mucin [13]. More recent data suggests that
PSA in conjunction with p501s (prostein), a cytoplasmic
marker expressed in both benign and malignant cells,
provides the greatest immunohistochemical specificity
[17,18].
The prognosis is variable when head and neck metas-
tasis is evident. Hunt et al. [13] reported 14 patients that
underwent combination hormone and radiation therapy, 8
of whom had widespread disease at the time of diagnosis.
After diagnosis, seven patients h ad an average lif espan of
23 months, five averaged 3.6 months (2 of whom had
spinal cord metastasis secondary to vertebral metastasis,
dying within 10 days). Jon es and Anthony pr esented 5 of
11 patients died after findings of head and neck metasta-
sis, averaging 34.4 months of life; the remaining six pa-
tients were alive at the time of diagnosis [14]. McMe-
namin et al. reported two of four patients who were alive
2 years after findings of cervical lymph node metastasis
[15].
4. Conclusion
The presence of a progressively growing neck mass con-
stitutes a wide range of differential diagnoses including
primary and metastatic neoplasia. Metastatic lesions of
the neck are commonly from a squamous cell carcinoma
origin and tend to be small in size. Here we have pre-
sented an unusual case of a metastatic neck mass due to
its primary non-carcinomatous origin and its large size.
This case report adds to the growing evidence suggesting
that non-carcinomatous lesions not be overlooked. Spo-
radic cases and studies for years have been described as
the extraprostatic extension of the neck. In the appropri-
ate population, we sugg est the addition of PSA, PSAP, or
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