Metastatic prostate cancer initially presenting as chylothorax: A case report

  • Authors:
    • Yu‑Jin Yang
    • Minjung Seo
    • Hee‑Jeong Jeon
    • Jin‑Hee Noh
    • Seol Hoon Park
    • Yunsuk Choi
    • Jae‑Cheol Jo
    • Jin Ho Baek
    • Su‑Jin Koh
    • Hawk Kim
    • Young Joo Min
  • View Affiliations

  • Published online on: March 21, 2016
  • Pages: 1009-1012
Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )
Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )


Chylothorax is caused by disruption or obstruction of the thoracic duct, which results in leakage of chyle in the pleural space. The most common etiologies are malignancy and trauma. Among the causative malignancies, lymphoma is the most common, followed by primary lung cancer, mediastinal tumors, and other metastatic malignancies. Conversely, prostate cancer has rarely been reported as the cause of chylothorax. We herein report a case of metastatic prostate cancer initially presenting as chylothorax, with disappearance of the pleural effusion after the initiation of androgen deprivation therapy. Moreover, we also discuss the various rare manifestations of metastatic prostate cancer, including chylothorax.


Prostate cancer is the most common cancer among men in Western countries. The 5-year survival rate of localized and regional prostate cancer is ~100%, whereas that of metastatic prostate cancer is only 27–28% (1). As serum prostate-specific antigen (PSA) screening has become widespread, the proportion of cases presenting with lymph node involvement or advanced disease has decreased considerably (2). However, ~20% of patients present with metastatic disease. Metastatic prostate cancer usually involves the pelvic lymph nodes, bones, and lungs (2), with bone pain being a common symptom in SUCH patients. However, there are other rare manifestations of metastatic prostate cancer. HereIN, we present a rare case of prostate cancer metastasis initially presenting as chylothorax.

Case report

A 64-year-old Asian man visited the emergency room with dyspnea. The patient's medical history was unremarkable, with the exception of being a current smoker with a 20 pack-year history. Radiographic images, including computed tomography scan of the chest, revealed a left pleural effusion, pericardial effusion, and enlarged lymph nodes in the left supraclavicular/posterior neck/axillary area, right upper paratracheal area, subcarinal area, and bilateral lower paratracheal areas (Fig. 1A and B). Thoracentesis was performed and fluid analysis revealed a chylothorax, in which the triglyceride level was 244 mg/dl (normal range, <50 mg/dl). Whole-body lymphoscintigraphy revealed faint tracer accumulation activity in the medial portion of the left hemithorax, where the pleural effusion was present (Fig. 1C). Considering that the patient had never received thoracic surgery or experienced trauma, malignancy was suspected. Pleural fluid cytology revealed numerous mononuclear leukocytes and some reactive mesothelial cells, but did not show any evidence of malignancy. The serum PSA level was elevated to 194.6 ng/ml (normal range, 0–3 ng/ml).

A prostate biopsy revealed adenocarcinoma of the prostate gland. A bone scan was performed for staging, which revealed multiple bone metastases (Fig. 1D). Therefore, the chylothorax was considered to have resulted from thoracic duct obstruction by enlarged lymph node metastasis from prostate cancer. Androgen deprivation therapy (ADT) was initiated, with simultaneous administration of goserelin and anti-androgen. After 3 months, the amount of pleural effusion had decreased (Fig. 2A) and the serum PSA level decreased from 194.6 to 31.68 ng/ml following ADT. A bone scan performed 8 months after the initiation of ADT revealed that the intensities of multiple bone uptakes had decreased significantly when compared to the initial scan (Fig. 2B). The patient is undergoing regular follow-up at our outpatient clinic for 1 year after diagnosis and has not reported experiencing any further discomfort.


In Korea, among males aged ≥65 years, prostate cancer is the fourth most common type of cancer and its incidence is increasing with advancing age. The crude mortality of prostate cancer is 2.8/10,000 and the 5-year relative survival rate by year of diagnosis from 2007–2011 was 92%, indicating that it is a highly treatable cancer (3).

There is some controversy regarding the efficacy of serum PSA screening. Randomized trials have demonstrated that serum PSA screening reduces metastatic prostate cancer incidence and disease-related mortality (4). However, other STUDIEs have reported that, due to the unnecessary biopsies following false-positive serum PSA results, cancer risk-adapted serum PSA screening is required (5). In the United States, the proportion of patients presenting with metastatic disease decreased from 17% in 1988–1990 to 4% in 1996-1998, while the proportion presenting with stage T1 tumors conversely increased from 14 to 51% (6).

As stated above, metastatic prostate cancer usually involves the pelvic lymph nodes, bones and lungs (2) and it may present as a skin lesion, endobronchial mass, ascites, or renal mass. Table I summarizes some of the rare manifestations of prostate cancer (719). Although our patient was not the first case of metastatic prostate cancer presenting as chylothorax, initial presentation of prostate cancer as chylothorax is quite rare (18,19).

Table I.

Review of cases of rare manifestations from metastatic prostate cancer.

Table I.

Review of cases of rare manifestations from metastatic prostate cancer.

AuthorsPresentationOnset of manifestationAge, yearsTreatmentOutcomeREFS.
Mak et alSkinLate73RadiotherapyPain relief(7)
Garai et alEndobronchial massInitial84Not statedNot stated(8)
Ani et alAscitesInitial57ADTPR(9)
Sakata et alKidneyLate67NephrectomyPR(10)
Ibinaiye et alKidneyInitial55ADTPR(11)
Grenader et alBrainInitial70Radiotherapy + ADTPR(12)
Rahmathulla et alBrainInitial70Surgical resectionPR(13)
Patel et alPituitary glandLate66RadiotherapyPR(14)
Kaswala et alSmall bowelLate42ChemotherapyNot stated(15)
Kusaka et alTestisLate56Radiotherapy + ADTPR(16)
Mortensen et alTestisLate89Bilateral orchiectomyNot stated(17)
Tabba et alChylothoraxLate69ChemotherapyPR(18)
Quinonez et alChylothoraxLate78Bilateral orchiectomy + chemotherapyPR(19)
PRESENT caseChylothoraxInitial64ADTPR

[i] ADT, androgen deprivation therapy; PR, partial response.

Lymphoscintigraphy, which functionally assesses the lymphatic transport and regional lymph nodes, is an easy, non-invasive method for detecting abnormalities in the lymphatic system, including leakages such as chylothorax, chyloperitoneum and chyluria. Positive findings include tracer activity at the site where lymphatic fluid is accumulated, as seen in our case (20,21). ADT is the mainstay of treatment for patients with metastatic prostate cancer. Luteinizing hormone-releasing hormone agonists have become the standard of care in hormonal therapy, as these agents have the potential of reversibility and enable the use of intermittent androgen deprivation (22). Moreover, with ADT, patients avoid the physical and psychological discomfort associated with orchiectomy (23). Intermittent androgen deprivation alternates androgen blockade with treatment cessation, in order to allow hormonal recovery between the treatment cycles, thus potentially improving the tolerability and quality of life. Hence, for older patients, intermittent androgen deprivation may generally be applied (24).

In summary, chylothorax is an uncommon condition. If there is no history of chest/neck injury or surgery, exclusion of malignancy is crucial. Despite its low probability, prostate cancer with mediastinal lymph node metastasis may result in chylothorax. Therefore, when we evaluate the causes of non-traumatic chylothorax, prostate cancer should be considered, and serum PSA screening is recommended to exclude this possibility.



Siegel R, Ma J, Zou Z and Jemal A: Cancer statistics, 2014. CA Cancer J Clin. 64:9–29. 2014. View Article : Google Scholar : PubMed/NCBI


Elkin M and Mueller HP: Metastases from cancer of the prostate; Autopsy and roentgenological findings. Cancer. 7:1246–1248. 1954. View Article : Google Scholar : PubMed/NCBI


Jung KW, Won YJ, Kong HJ, Oh CM, Lee DH and Lee JS: Cancer statistics in Korea: Incidence, mortality, survival and prevalence in 2011. Cancer Res Treat. 46:109–123. 2014. View Article : Google Scholar : PubMed/NCBI


Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, et al: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 360:1320–1328. 2009. View Article : Google Scholar : PubMed/NCBI


Loeb S: Guideline of guidelines: Prostate cancer screening. BJU Int. 114:323–325. 2014.PubMed/NCBI


Crawford ED: Epidemiology of prostate cancer. Urology. 62(6 Suppl 1): 3–12. 2003. View Article : Google Scholar : PubMed/NCBI


Mak G, Chin M, Nahar N and De Souza P: Cutaneous metastasis of prostate carcinoma treated with radiotherapy: A case presentation. BMC Res Notes. 7:5052014. View Article : Google Scholar : PubMed/NCBI


Garai S and Pandey U: Prostate cancer presenting as an endobronchial mass: A case report with literature review. Int J Surg Pathol. 18:554–556. 2010.PubMed/NCBI


Ani I, Costaldi M and Abouassaly R: Metastatic prostate cancer with malignant ascites: A case report and literature review. Can Urol Assoc J. 7:E248–E250. 2013. View Article : Google Scholar : PubMed/NCBI


Sakata R, Iwasaki A, Kobayashi M, Osaka K, Fujikawa A, Tsuchiya F and Ishizuka E: Renal metastasis from prostatic adenocarcinoma: A case report. ACTA UROLOGICA JAPONICA. 57:683–687. 2011.(In Japanese). PubMed/NCBI


Ibinaiye PO, Mbibu H, Shehu SM, David SO and Samaila MO: Renal metastasis from prostate adenocarcinoma: A potential diagnostic pitfall. Ann Afr Med. 11:230–233. 2012. View Article : Google Scholar : PubMed/NCBI


Grenader T, Shavit L, Lossos A, Pizov G and Wygoda M: Brain metastases: A rare initial presentation of prostate cancer. Int Urol Nephrol. 39:537–539. 2007. View Article : Google Scholar : PubMed/NCBI


Rahmathulla G, Prayson RA and Weil RJ: Rare presentation of metastatic prostate adenocarcinoma as a meningioma mimic. J Neurol Surg Rep. 75:e81–e83. 2014. View Article : Google Scholar : PubMed/NCBI


Patel N, Teh BS, Powell S, Lu HH, Amato R and Butler EB: Rare case of metastatic prostate adenocarcinoma to the pituitary. Urology. 62:3522003. View Article : Google Scholar : PubMed/NCBI


Kaswala DH, Patel N, Jadallah S and Wang W: Metastatic prostate cancer to the duodenum: A rare case. J Family Med Prim Care. 3:166–168. 2014. View Article : Google Scholar : PubMed/NCBI


Kusaka A, Koie T, Yamamoto H, Hamano I and Yoneyama T, Hashimoto Y, Ohyama C, Tobisawa Y and Yoneyama T: Testicular metastasis of prostate cancer: A case report. Case Rep Oncol. 7:643–647. 2014. View Article : Google Scholar : PubMed/NCBI


Mortensen MA, Engvad B, Geertsen L, Svolgaard N and Lund L: Metastasis in testis from prostate cancer. Ugeskr Laeger. 176:V101306322014.(In Danish). PubMed/NCBI


Tabba M and Inaty H: A rare case of chylothorax attributed to metastatic prostate carcinoma. J Pulmon Resp Med. S142013.


Quinonez A, Halabe J, Avelar F, Lifshitz A, Moreno J and Berumen AH: Chylothorax due to metastatic prostatic carcinoma. Br J Urol. 63:325–327. 1989. View Article : Google Scholar : PubMed/NCBI


Pui MH and Yueh TC: Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax. J Nucl Med. 39:1292–1296. 1998.PubMed/NCBI


Prevot N, Tiffet O, Avet J Jr, Quak E, Decousus M and Dubois F: Lymphoscintigraphy and SPECT/CT using 99mTc filtered sulphur colloid in chylothorax. Eur J Nucl Med Mol Imaging. 38:17462011. View Article : Google Scholar : PubMed/NCBI


McLeod DG: Hormonal therapy: Historical perspective to future directions. Urology. 61(2 Suppl 1): 3–7. 2003. View Article : Google Scholar : PubMed/NCBI


Seidenfeld J, Samson DJ, Hasselblad V, Aronson N, Albertsen PC, Bennett CL and Wilt TJ: Single-therapy androgen suppression in men with advanced prostate cancer: A systematic review and meta-analysis. Ann Intern Med. 132:566–577. 2000. View Article : Google Scholar : PubMed/NCBI


Abrahamsson PA: Potential benefits of intermittent androgen suppression therapy in the treatment of prostate cancer: A systematic review of the literature. Eur Urol. 57:49–59. 2010. View Article : Google Scholar : PubMed/NCBI

Related Articles

Journal Cover

June 2016
Volume 4 Issue 6

Print ISSN: 2049-9450
Online ISSN:2049-9469

Sign up for eToc alerts

Recommend to Library

Copy and paste a formatted citation
Yang, Y., Seo, M., Jeon, H., Noh, J., Park, S.H., Choi, Y. ... Min, Y.J. (2016). Metastatic prostate cancer initially presenting as chylothorax: A case report. Molecular and Clinical Oncology, 4, 1009-1012.
Yang, Y., Seo, M., Jeon, H., Noh, J., Park, S. H., Choi, Y., Jo, J., Baek, J. H., Koh, S., Kim, H., Min, Y. J."Metastatic prostate cancer initially presenting as chylothorax: A case report". Molecular and Clinical Oncology 4.6 (2016): 1009-1012.
Yang, Y., Seo, M., Jeon, H., Noh, J., Park, S. H., Choi, Y., Jo, J., Baek, J. H., Koh, S., Kim, H., Min, Y. J."Metastatic prostate cancer initially presenting as chylothorax: A case report". Molecular and Clinical Oncology 4, no. 6 (2016): 1009-1012.