Case description:
We present the case of a 70-year-old Hispanic male who presented to the
urgent care clinic with left lower quadrant abdominal pain, nausea,
headache, myalgia, and severe constipation. He had just received his
fourth COVID booster vaccine the day prior and stated to have been
asymptomatic prior to receiving the immunization. An abdominal x-ray
showed no obvious bowel obstruction or extravasation of air; hence the
patient was reassured to be experiencing the expected side effects of
the vaccine and was sent home. He returned to the emergency room two
days later complaining of a right-sided neck swelling that had been
increasing in size since the day of his vaccination. A CT soft tissue
neck with contrast (Figure 1,2) showed bilateral posterior
triangle/supraclavicular adenopathy, most extensive on the right with a
large nodal mass measuring up to 4.7 x 2.4 x 3.2 cm with surrounding
inflammatory changes. There was also bulky mediastinal adenopathy with
the largest node being a right suprahilar lymph node measuring up to 5
cm in maximal diameter. A contrast CT scan of the chest, abdomen, and
pelvis (Figure 3) showed a mass interposed between the superior vena
cava and the right side of the ascending aorta measuring 42 x 59 x 45
mm, a portion interposed between the ascending and descending aorta
displacing the trachea to the left side, enlarged level 5, and
subcarinal level 7 lymphadenopathy, distal mediastinal tumor above the
diaphragm with extension of the retroperitoneal tumor inferiorly along
the aorta into the pelvis causing hydronephrosis and hydroureter of the
left kidney. The tumor surrounded the inferior mesenteric artery and
extended into the pelvis and into the mesentery in the presacral space.
Pelvic tumor was also seen in the mesentery surrounding the sigmoid
colon and in the sub-peritoneal space adjacent to the enlarged prostate
likely contributing to his constipation. Radiologically, the patient’s
findings were highly suspicious for a lymphoproliferative disorder, and
the hematology/oncology team was consulted for the same. However, on
examining the ultrasound-guided biopsy results of the enlarged right
supraclavicular node, the histopathology was consistent with that of
prostate acinar adenocarcinoma (Figure 4). The negative staining pattern
for CK7 and CK20 with patchy weak PSA antigen staining and positive
prostate marker immunohistochemistry stain for NKX3A further supported
the diagnosis. Prostate specific antigen (PSA) level was then checked
which measured 121.3 ng/mL (reference range 0.1 to 4.0 ng/mL). The
patient denied prior screening for prostate cancer or prior urinary
symptoms apart from left flank/lower abdominal pain which began after
receiving the COVID vaccine. A bone scan was performed, which suggested
very early metastatic disease in the manubrium, inferior tip of right
scapula, inferior aspect of right iliac wing, and T11 vertebral body. A
subsequent prostate biopsy confirmed prostate adenocarcinoma with a
Gleason score of 8 (4+4). He underwent left ureteral stent placement and
was started on bicalutamide for four weeks prior to discharge from the
hospital. After establishing in the outpatient oncology clinic, he was
transitioned to gonadotropin releasing hormone analogue (leuprolide)
injections every 3 months and oral androgen receptor signaling inhibitor
(abiraterone with prednisone daily). PSA level declined to 1.3 ng/mL
after 3 months of therapy, and repeat imaging showed marked improvement
in the size of his mediastinal, retroperitoneal, and pelvic
lymphadenopathy.
Discussion:
In the United States, prostate cancer is the most diagnosed male
malignancy and one of the leading causes of cancer-related death.
Approximately 12.9% of all men with be diagnosed with prostate cancer
in their lifetime. At the time of diagnosis, 82% of prostate cancers
are confined to the prostate and regional lymph nodes and have a 100%
5-year survival rate. However, 8% of cases have already metastasized at
the time of diagnosis and confer a 34.1% 5-year survival rate [2].
The most common sites of distant spread include bones (84%), distant
lymph nodes (10.6%), liver (10.2%), and thorax (9.1%) [3].
Metastasis to cervical lymph nodes is rare, though becoming increasingly
reported in recent literature.
Prostate cancer most commonly spreads to regional lymph nodes, pelvic
organs via direct invasion, or to the axial skeleton. It uncommonly
metastasizes to cervical lymph nodes. Patients usually present with
urological symptoms before metastases become extensive. However, our
patient presented to the hospital initially due to his enlarging right
supraclavicular mass aggravated by a COVID booster vaccine. Generalized
lymphadenopathy has been described following COVID vaccination, though
most often confined to the axillary region. Imaging is not routinely
recommended until 6 weeks post-vaccination [4]. It is likely that
our patient had pre-existing lymphadenopathy that he noticed only
following immunization. To the best of our knowledge, this is the first
case reported of a COVID vaccine booster uncovering lymphadenopathy
leading to the diagnosis of metastatic prostate cancer. In a recent
literature review, Liu et al note that 58 cases have been reported where
cervical lymphadenopathy is the initial presentation of metastatic
prostate cancer. It is interesting to note that only 7 of the 58
patients presented with right-sided supraclavicular lymphadenopathy
since more commonly, retrograde lymphatic spread via the left jugular
trunk leads to the left-sided cervical lymph nodes [5]. Though we
obtained biopsies only from the right supraclavicular node and prostate,
the distribution of other enlarged lymph nodes and their decrease in
size following androgen deprivation therapy, together with decline in
PSA from 121ng/ml to 1.3 ng/ml favors the assumption that the
generalized lymphadenopathy was secondary to metastatic spread and not
any other secondary or additional diagnosis.