Lymphangitic Pulmonary Metastases in Castrate-Resistant Prostate Adenocarcinoma

Abstract

A 63-year-old man with castrate-resistant metastatic prostate adenocarcinoma with known osseous and pelvic nodal involvement presented with progressive dyspnea for one week. Complete cardiopulmonary evaluation revealed a restrictive lung defect that could not be attributed to any of his previous therapies. On presentation, physical examination revealed coarse breath sounds diffusely with hypoxemia. Computed tomography of the chest showed severe bilateral airspace opacities and ground-glass appearance most consistent with interstitial pneumonitis. The patient was intubated due to progressive hypoxemia and worsening respiratory status despite empiric antibiotics and high dose steroids. Subsequent emergent bronchoscopy with transbronchial biopsies revealed atypical intralymphatic cells that stained positively for prostate-specific antigen and prostatic-specific acid phosphatase, confirming the diagnosis of intralymphatic pulmonary metastasis from prostate adenocarcinoma. Lymphangitic pulmonary metastasis from prostate adenocarcinoma is exceedingly rare, with few reported cases that are biopsy-proven. Herein, we describe a rare case of biopsy-proven lymphangitic pulmonary metastasis in the setting of castrate-resistant prostate adenocarcinoma and provide a comprehensive literature review.

Atypical pulmonary metastasis of prostate adenocarcinoma: a rare phenomenon

“…Clinically, the disease can present with progressive dyspnoea without any inciting event. Imaging studies of the lymphangitic spread can characteristically show multiple linear densities forming a reticular pattern with a thickened bronchovascular bundle [ 1 ] . Another radiographic pattern includes the characteristic ‘tree in bud’ appearance with bronchial luminal impaction in the peripheral branching airway.…”

“…Pulmonary metastasis is relatively uncommon. Lymphangitic pulmonary involvement in patients with prostate adenocarcinoma is extremely rare and occurs in less than 0.2% of the patient population [ 1 ] . Androgen deprivation (hormone) therapy is the backbone of management of prostate cancer metastasis; this case involves a diffuse nodular metastasis with malignant pleural effusion while the patient is on this therapy.…”

Initial diagnosis and successful treatment of pulmonary tumor embolism manifesting as the first clinical sign of prostatic adenocarcinoma

“…Although the lungs are the common site of metastasis, PTE, and PLC are exceptionally rare, and either pattern is rarely the first clinical sign of prostate cancer [ 3 , [9] , [10] , [11] , [12] ].…”

“…Because PLC often coincides with either microscopic PTE or PTTM [ [2] , [3] , [4] , [5] , 7 , 11 ], the presence of characteristic CT findings of PLC (smooth, nodular or irregular thickening of interlobular septa and/or bronchial wall and associated intrathoracic lymphadenopathy [ 12 , 13 ]) in addition to dilated beaded peripheral pulmonary arteries and perfusion defects can serve as a clue for diagnosing microscopic PTE or PTTM, akin to the present case.…”