This case report describes a 73-year-old man with prostate cancer that metastasized to a pelvic lymph node. During pathological examination after prostatectomy, it was discovered that this same lymph node was also affected by Hodgkin's lymphoma. Immunohistochemical staining confirmed the presence of both prostate adenocarcinoma and classical Hodgkin's lymphoma in the lymph node. This represents the first reported case of a urological cancer (prostate adenocarcinoma) metastasizing to a lymph node simultaneously involved by Hodgkin's disease. Synchronous occurrence of two or more tumors is rare, but histopathological identification is important for treatment decisions and prognosis.

1. 33
BACKGROUND: Multiple primary tumors in the same
patient are reported to occur in the range of 2–17%.
Histopathological recognition of an unsuspected tumor
is important as it could influence therapeutic decisions
and affect patients’ prognosis, but synchronous con­
comitant malignancies can be a diagnostic challenge
for the pathologist.
CASE: We report a case of prostatic acinar adenocar­
cinoma metastatic to a pelvic lymph node also affected
by Hodgkin disease in a 73-year-old man. After prostatic
biopsies positive for prostatic adenocarcinoma, the pa-
tient underwent a radical prostatectomy with bilateral
pelvic lymphadenectomy. Pathological examination con­
firmed the initial diagnosis, revealing a bilateral high-
grade prostatic adenocarcinoma involving about 70%
of the prostate with extensive extracapsular invasion.
A metastasis of prostatic adenocarcinoma was found
in 1 of the left pelvic lymph nodes; all pelvic lymph
nodes showed an architectural effacement due to a
distinct neoplastic proliferation characterized by large
cells consistent with Reed-Sternberg and Hodgkin cells,
confirmed by immunohistochemistry reactions.
CONCLUSION: This case is, to the best of our knowl-
edge, the first case of a urological neoplasm, namely a
prostatic acinar adenocarcinoma, metastasizing to a
lymph node simultaneously involved by Hodgkin dis-
ease. (Anal Quant Cytopathol Histpathol 2019;41:
33–37)
Keywords: adenocarcinoma, collision metastasis,
Hodgkin lymphoma, lymph node, metastasis, pel­
vic lymph node, prostate, prostate cancer, prostatic
neoplasms, prostatic adenocarcinoma.
Multiple primary tumors in the same patient are
reported to occur in the range of 2–17%. They
Analytical and Quantitative Cytopathology and Histopathology®
0884-6812/19/4101-0033/$18.00/0 © Science Printers and Publishers, Inc.
Analytical and Quantitative Cytopathology and Histopathology®
Metastasis of Prostatic Adenocarcinoma in a
Lymph Node Affected by Hodgkin Lymphoma
A Case Report
Nataniele Piol, M.D., Rita Bianchi, M.D., Francesca Pitto, M.D.,
Marco Mora, M.D., Carlo Terrone, M.D., Valerio G. Vellone, M.D., Ph.D.,
Antonio Lopez-Beltran, M.D., Ph.D., Carlo Toncini, M.D., and Bruno Spina, M.D.
From the Department of Anatomical Pathology, Ospedale Policlinico San Martino, Genoa, and the University of Genoa, Genoa, Italy; the
Uropathology Unit, Ospedale Policlinico San Martino, Genoa, Italy; and the Department of Pathology and Surgery, Faculty of Medicine,
Cordoba, Spain.
Dr. Piol is Consultant Pathologist, Humanitas Research Hospital, Milan, Italy.
Dr. Bianchi is Resident, Department of Anatomical Pathology, Ospedale Policlinico San Martino, and the University of Genoa.
Drs. Pitto, Mora, Toncini, and Spina are Consultant Pathologists, Department of Anatomical Pathology, Ospedale Policlinico San
Martino, and the University of Genoa.
Dr. Terrone is Professor, Uropathology Unit, Ospedale Policlinico San Martino.
Dr. Vellone is Assistant Professor, Department of Anatomical Pathology, Ospedale Policlinico San Martino, and the University of Genoa.
Dr. Lopez-Beltran is Professor, Department of Pathology and Surgery, Faculty of Medicine, Cordoba.
Address correspondence to: Rita Bianchi, M.D., Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Via de
Toni 14, 16132, Genoa, Italy (bianchirita22@gmail.com).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.
C
ASE
R
EPORTS

2. could be synchronous or metachronous based on
timing of diagnosis between the first (index) tu-
mor and the second one. Synchronous occurrence
of 2 or more neoplasms is an unexpected, quite
infrequent occurrence. Concomitant tumors are
synchronous tumors diagnosed at the same time.
They could be in different anatomic sites or they
can sometimes affect the same organ, this being
an uncommon situation upon which an unlucky
pathologist could stumble by chance. Histopatho-
logical recognition of an unsuspected tumor is
obviously important as it could influence thera­
peutical decisions and affect patients’ prognosis.1
Here we report a case of prostatic acinar adeno­
carcinoma metastatic to a pelvic lymph node also
affected by Hodgkin disease.
Case Report
A 73-year-old man was referred to our institution
after a diagnosis of prostatic adenocarcinoma,
Gleason score 10 (5+5) on 3 out of 6 prostatic core
biopsies performed elsewhere.
Radical prostatectomy with bilateral pelvic
lymphadenectomy was performed. Pathological
examination confirmed the initial diagnosis, re-
vealing a bilateral high-grade prostatic adenocar­
cinoma, Gleason score 9 (5+4), involving about
70% of the prostate, with scattered foci of intra­
ductal carcinoma. Extensive extracapsular inva-
sion was identified bilaterally in the posterior
region and in the right anterior quadrant. Margin
of resection, bilateral seminal vesicles, and vasa
deferentia were free of disease.
Ten right pelvic lymph nodes were negative for
metastatic adenocarcinoma, although a metastatis
of prostatic adenocarcinoma was found in 1 out of
23 left pelvic lymph nodes.
Moreover, both right and left pelvic lymph
nodes showed an architectural effacement due to
a distinct neoplastic proliferation. This neoplasm
was characterized by large cells with nuclear en-
largement, prominent nucleoli, and sometimes nu-
clear multilobation consistent with Reed-Sternberg
and Hodgkin cells. Immunohistochemical expres­
sion of CD30, IRF-4/MUM-1, a weak expression
of PAX5, and absence of immunostaining with
CD3, CD20, CD79α, and keratin antibodies con­
firmed the diagnosis of classical Hodgkin disease.
CD15 was not expressed by neoplastic cells.
The above-described metastatic lymph node was
simultaneously affected by Hodgkin disease, too
(Figure 1).
Subsequent CT scan of the chest also revealed
axillary and right subclavian lymphoadenopathies,
and the patient was then treated with ABVD for
Hodgkin disease. After 5 months of follow-up the
patient was alive.
Discussion
Multiple primary tumors in the same patient are
reported to occur in the range of 2–17%. From an
epidemiological perspective they must occur, by
definition, in different anatomic sites and/or must
be of different histomorphologic type.1
Some tumors arise in a background of a cancer
field effect, such as squamous cell carcinomas of
the upper aerodigestive tract, breast carcinomas,
and urothelial carcinomas. These neoplasms are
histologically similar, often occur in the same
anatomic site, and are well known to be multifo­
cal/multicentric with different possible timing of
incidence, but they are usually not considered
multiple primary tumors.2
Multiple primary tumors could be subtyped as
synchronous or metachronous based on timing
of diagnosis between the first (index) tumor and
the second one. No definite consensus on the
definition of the two above terms is yet achieved.
A synchronous tumor is diagnosed <2 months
for Surveillance, Epidemiology, and End Results
(SEER) definition and 6 months for International
Agency for Research on Cancer (IARC) definition
after index tumor diagnosis. Multiple primary
tumors diagnosed beyond those times are consid­
ered metachronous tumors.1
Researchers focused on metachronous neo­
plasms
in order to find risk factors for the development of a
second malignancy: inherited cancer predisposition
syndromes, environmental exposures, unhealthy
life styles, and late effects of chemotherapy drugs
are usually advocated as the most common risk
factors for a second metachronous tumor.1
Even if there are no precise epidemiological
studies aimed to assess the relative frequency of
these two types of tumors, we feel that metach-
ronous neoplasms are far more common than syn­
chronous ones.
Following the above-mentioned definition, the
unusual occurrence of two tumors diagnosed at
the same time falls under the category of syn­
chronous neoplasms. They could affect different
anatomic sites—and in those cases the diagnosis
is usually clinical or radiological and possibly
confirmed by pathologists3—or, even more unusu­
34 Analytical and Quantitative Cytopathology and Histopathology®
Piol et al

3. al, and often clinically unidentified, is the finding
of two concomitant tumors colliding in the same
anatomic site.
From the pathologist’s perspective, synchro­
nous concomitant malignancies can be a diagnos-
tic challenge and require careful interpretation.1
Clinically these cases are challenging because
the oncologist must find a therapy that could treat
both cancer types, and, if that is not possible, has
to decide what disease to treat first, thus assum­
ing the risk of complications for the untreated
malignancy. Addressing these problems, the on-
cologist must consider the potential toxicity and
interactions of concomitant and/or prolonged ex-
posure to different chemotherapeutic drugs.
Two (or more) different concomitant adjacent
neoplasms without intermingled features are usu­
ally referred to as collision tumors. A PubMed
search could reveal a good number of case reports
in which two tumors (usually two carcinomas)
collide, and the discussion of these cases is be-
yond the purpose of this manuscript. Some tu-
mors, for example bladder carcinoma, testicular
germ cell neoplasms, and gynecological carcino-
mas, are known for their propensity of showing
mixed histological features, and these cases are
Volume 41, Number 1/February 2019 35
Metastasis of Prostatic Adenocarcinoma
Figure 1 (A) Macroscopic view of the metastatic lymph node; an alteration of normal structure of parenchyma can also be seen
(hematoxylin-eosin, 20×). (B) Metastasis of prostatic carcinoma, with glandular pattern (hematoxylin-eosin, 100×). (C) Higher
magnification of lymph node parenchyma, with numerous Hodgkin cells (hematoxylin-eosin, 400×). (D) Immunohistochemical reaction
for CD15: intense staining of Hodgkin cells. (E) Immunohistochemical reaction for CD30: intense staining of Hodgkin cells. (F) Double
immunohistochemical reaction for PSA (phosphatase reaction, with red staining) and CD30 (peroxidase reaction, with brown staining):
evidence of metastatic prostatic carcinoma and Hodgkin lymphoma involvement of the same lymph node.

4. considered and classified as carcinomas with vari­
ant histology or mixed neoplasms, but they should
not be diagnosed as collision tumors.4 Collision
metastasis is a rare phenomenon in which me-
tastases of carcinoma from two separate primary
tumors occur in the same lymph node; there are
only a few case reports in the literature describ­
ing this kind of situation, and most of them are
represented by collision of prostatic and urothelial
carcinomas.5
The synchronous concomitant presence of a
hematolymphoid neoplasm and another solid
carcinoma is also possible and described in the
literature.3,6-14
Even if the association of Hodgkin disease with
other solid tumors has been reported, these cases
are rare.15-17 Analogously metastatic malignancy
in a lymph node simultaneously involved by a
hematolymphoid neoplasm is also described, but
rarely is the latter a Hodgkin lymphoma.18-23 So,
even if the association between urological and
hematological neoplasms is not a surprise,24 we
are not aware of reported cases of urological
tumors metastatic to a lymph node also involved
by Hodgkin disease.
Hodgkin disease, or Hodgkin lymphoma (HL),
is a hematological neoplasm usually involving
lymph nodes. It could be subclassified in nodu­
lar lymphocyte predominant Hodgkin lymphoma
(NLPHL) and in classical Hodgkin lymphoma
(cHL). The latter usually occurs in a bimodal
distribution in the 3rd–4th and the 7th decades
of life, and it has a higher male incidence. It is
usually diagnosed in cervical lymph nodes, but
it can also be found in other lymph nodal sites
(mediastinal, axillary, paraaortic); extranodal in-
volvement is rare. Histologically, lymph node
architecture is effaced by the presence of Reed-
Sternberg cells admixed with a variably rich
inflammatory background. Diagnostic Reed-
Sternberg cells have multilobed nuclei with ir-
regular nuclear membrane, pale chromatin, and
prominent nucleoli; they have large, slightly
basophilic cytoplasm. Mononuclear variants are
termed Hodgkin cells. The malignant Hodgkin and
Reed-Sternberg cells in classical subtypes do not
usually express B-cell markers but show expres-
sion of CD30, MUM1, variable expression of CD15,
and a typically weak expression of PAX5.4-25
In our case Hodgkin disease involving pelvic
lymph nodes has typical histological and cytol­
ogical features of a cHL, also supported by im-
munohistochemical expression of CD30, MUM1,
and PAX5, and concurrent nonexpression of B-cell
markers. One of these lymph nodes also harbors
a metastasis from prostatic acinar adenocarcino­
ma, confirmed by immunostainings with PSA and
PSAP.
The case we have reported is, to the best of our
knowledge, the first case of a urological neoplasm,
namely a prostatic acinar adenocarcinoma, which
metastasizes to a lymph node simultaneously in-
volved by Hodgkin disease.
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Metastasis of Prostatic Adenocarcinoma