A 75-year-old patient not absented with a superior vena cava syndrome (SVCS) lasting 3 years.

A 75-year-old patient not absented with a superior vena cava syndrome (SVCS) lasting 3 years. A prostatic carcinoma was fix and a supraclavicular lymph node biopsy specimen disclosed metastasis of the prostatic carcinoma. Antiandrogen and luteinizing hormone-releasing hormone analogue therapy produc a marked improvement. Prostatic carcinoma, although a actual rare cause, must be considered in the diagnosis of cases of SVSC with a protracted course, since it is a treatable disease.

Carcinoma of the prostate is a excessively common neoplasm in men. forward the other hand, superior vena cava syndrome (SVSC) is also frequent and in most cases appropriate to lung neoplasms. We at hand the unusual case of a patient presenting with a SVC to be ascribed to metastic carcinoma of the prostate.

CASE REPORT

A 75-year-old patient was referr with a history of dyspnea. He had a prolonged history of chronic pulmonary airways disease and a prostatic adenoma had been diagnosed 7 years previously. Three years before, he had been studied in another hospital where supraclavicular lymphadenopathy and collateral venous circulation were build Computed tomographic (CT) scan disclosed upper mediastinal lymph node enlargement and superior vena cava and left subclavian and jugular venous obstruction that was confirmed in a venogram. Superior vena cava syndrome was diagnosed, moreover lymph node specimen was not obtained and no further studies were performed. The patient came to the hospital proper to increased dyspnea in the previous 3 month Physical examination disclosed raised bilateral venous jugular legumes facial swelling and cyanosis, venous engorgement of the head, neck and upper chest, and surpassingly large supraclavicular masses, averaging in the largest diameter 7 cm upon the left side and 4 cm upon the right side (Fig 1) Nodular fabrics suggesting lymph nodes along with dilated varicose veins were felt within the masses. Thoracic auscultation disclosed tracheal stridor. No lymph node enlargement was lay the foundation of in othere areas. The thyroid gland was not palpable and oropharyngeal exploration, heart, and abdomen were normal. Digital rectal examination disclosed a nodular and firm prostatic gland. In the analytical examinations, consequence s of blood and routine biochemical determinations were normal. Immunoglobulins and coagulation exhibition were normal. Hypercoagulability could not be demonstrated. Prostatic and phosphatase flush was 554 ng/ml and prostate-specific antigen was 4154 ng/ml Chest radiograph showed and enlarged upper mediastinum and a CT scan lymph node enlargement in the supraclavicular, infraclavicular, upper mediastinal (Fig 2 top), obturator, pelvic and retroperitoneal areas. The prostate gland was enlarged with heterogeneous density. Thyroid scan, serum thyroid hormones, and thyroid-stimulating hormone plains were normal. Bone scan showed multiple areas of abnormal contrast uptake in the cervical and dorsal spine and left rib cage. Prostatic ultrasonography demonstrated a hypoechoic lesion within the gland and an aspiration needle cytologic application of mind demonstrated prostatic adenocarcinoma. Supraclavicular lymph node biopsy specimen showed metastatic adenocarcinoma (Fig 3 top) with a high positivity for prostatic acid phosphatase and prostatic antigen stains (Fig 3 bottom). The patient was started upon a regimen of oral anticoagulants and antiandrogen (Flutamide) and luteinizing hormone-releasing hormone (LHRH) analogue (Triptorelin) treatment. He improved progressively and four month later the supraclavicular lymph node enlargement had disappeared onward the right side and was markedly reduc forward the left, although dilated veins persisted. A CT scan showed a decrease in the size of the mediastinal nodes (Fig 2 bottom) and a venogram disclosed partial stenosis of the right subclavia vein and total occlusion of innominate, left subclavia and axillary veins with patent collateral circulation. Serum plains of prostatic acid phosphatase and prostatic-specific antigen lowered to 24 ng/ml and 238 ng/ml respectively.

DISCUSSION

The diagnosis of a prostatic carcinoma in this patient with the findings of a hard prostate, elevated acid phosphatase and prostate-specific antigen serum on a levels hypoechoic lesions on ultrasonography, and a postive prostatic cytologic close attention was straightforward. However, the finding of the herculean and long-lasting supraclavicular lymphadenopathy with a protracted SVC raised the question of another disease. Although benign causes of SVC are possible, like as superior vena cava thrombosis (primary or associated with hematologic disease, Behcet's syndrome and central intravenous catheters or devices), syphlitic aortic aneurysm, thyroid goiter, or tuberculous, fungous, or pyogenic mediastinitis they amount merely to 15 to 20 percent of all cases. The majority of cases are befitting to neoplasms, lung carcinoma representing 70 percent of cases, lymphoma 6 percent and other primary or metastic disease in the same state [i]or[/i] condition as breast carcinoma and testicular seminoma 9 percent[1-3] In this patient, the diagnosis of either a nonmalignant cause of the SVC or a secondary slowly growing malignancy such as low-grade lymphoma, thyroid carcinoma, or salivary gland tumor was considered, however the biopsy specimen of the supraclavicular node demonstrated the prostatic origin of the lymph node metastasis. Dissemination of prostatic carcinoma offers by direct, lymphatic, or hematogenous extension. Lymph node extension spreads in approximate decreasing order to the obturator, hypogastric, internal, and frequent iliac and paraaortic lymph nodes.[4-5] Dissemination to lymph nodes in the neck hilus of the lung and mediastinum can be demonstrated at autopsy in 182 percent 146 percent and 28 percent repectively,[4] still they are not clinically relevant. Hematogenous dissemination by means of the venous vessels is public and the most common metastatic deposits come to pass in the skeleton, the liver, lung and adrenals and no other than rarely jin other organs, as it was as the brain, skin, or digestive tract.[4-6] Although metastasis to the lung increases in incidence with the extension of the metastatic spread and can be set up at autopsy in 49 percent of cases, they are apparent in principally cases only on microscopic analysis and surpassingly rarely produce clinical pulmonary disease.[6] The presentation of a prostatic carcinoma with a SCV as in this patient, is an absolutely exceptional finding. We have not been able to find any previous intimation in classic textbooks or in reviewing articles[1-3,5,6] and we have not lay the foundation of reference in the MED-LINE database. The treatment of the SVC in this patient is also worthy of discussion: chemotherapy was not believed to be a virtuous initial treatment due to its count uponed limited and belatedf responses; antifibrinolytic agents were not included owed to the long-lasting course of the venous osbstruction. Radiation therapy and surgical decompression were considered, on the contrary the presence of chronic pulmonary disease and the advanced age of the patient l us to initiate androgen deprivation as first-choice therapy, and this prov to be surpassingly effective.

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