Prostate Cancer with Bone Metastases and PSA of 900 ng/ml

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

An 82-year-old African American male (AAM) was admitted to the hospital with a chief complaint (CC) of severe back pain for one week. He was diagnosed with prostate cancer five years ago.

Past medical history (PMH)

Diabetes type 2 (DM 2), peptic ulcer disease (PUD) s/p remote surgery, hypertension (HTN), prostate cancer with bone metastases, bilateral (B) orchiectomy, depression, constipation.

Medications

Insulin, bisacodyl, Senokot (senna), risperidone (Risperdal), sertraline (Zoloft), metoclopramide, Benadryl (diphenhydramine), docusate, glipizide.

Physical examination

VS 37.3-108-16-125/80 mm Hg.
CVS: Clear S1S2.
Chest: CTA (B).
Abd: Soft, NT, ND, +BS.
Back: Limited ROM, no local tenderness.
Rectal exam: decreased sphincter tone, no blood. The prostate is enlarged and hard to palpation.
Neurogical examination: nonfocal.

What is the most likely reason of his back pain?

Progression of bone mets.

What laboratory tests would you suggest?

CBCD, CMP.
MRI of the back.


CMP showed elevated alkaline phosphatase (AP) and PSA higher than 900 ng/ml. DM2 is uncontrolled (HA1c 17) (click to enlarge the images).


Alkaline phosphatase levels during the last two years (click to enlarge the images).


PSA levels during the last two years (click to enlarge the images).


Bone scan from one year ago (click to enlarge the images).


The CXR shows surgical scars from previous PUD surgery (click to enlarge the images).


Thoracic vertebra with osteoblastic mets (left); a close-up (middle); MRI of the thoracic spine (right) (click to enlarge the images).

The MRI of the spine showed extensive bony metastatic disease in the lumbar spine as well as varying degrees of canal stenosis, most severe at level L3-L4. Foraminal stenosis was also noted at multiple levels.

Report of MRI of thoracic spine with and without contrast:

Comparison is made with the previous exam from one year ago.

Sagital images demonstrate extensive heterogeneity of marrow signal throughout the thoracic spine, which would be consistent with multiple bony metastases. There is extensive abnormality of marrow signal involving the T10 vertebral body. There are less extensive lesions involving T9 and T11, also noted on the previous exam. Further lesions are noted more superiorly in the thoracic spine at this time, being most pronounced at the T2 and T4 levels, but also seen at several additional levels. No gross thoracic compression fracture is identified. The spinal cord does not appear abnormally widened. No cord compression is seen. No focal cord enhancement is identified. There are multiple enhancing vertebral lesions. If clinically indicated, post myelographic CT might permit better definition of the thoracic cord and spinal canal.

Impression:

1. Extensive bony metastatic disease throughout the thoracic spine, appearing more widespread than on the previous study; similar appearance noted that T9, T10 and T11 levels.
2. No abnormal widening of the thoracic cord and no focal cord enhancement identified.
4. Bony canal stenosis suspected at the T10 level, relating to posterior element disease; no cord compression identified


MRI of the lumbar spine shows extensive metastatic disease (click to enlarge the images).


MRI of the lumbar with bone metastases (click to enlarge the images).

Report of MRI of lumbar spine with and without contrast:

There is severe degenerative narrowing of the L5-S1 disc interspace, with associated degenerative endplate changes, particularly involving L5. There is diffusely diminished signal with some heterogeneity involving the L4 vertebral body, suggesting diffuse marrow infiltrating pathology. More focal lesions are noted in the remaining vertebral bodies, with a focal rounded lesion overlying the superior L2 vertebral body, of diminished T1 and increased T2 signal, where enhancement is also noted. These findings suggest diffuse bony metastatic disease in the lumbar spine. Further focal lesions overlying the visualized sacrum bilaterally, with further involvement of the iliac bones suspected posterior medially, again suggesting the bony metastatic disease. No compression of the conus is seen. At L3-4 there is severe canal stenosis, in association with posterior element hypertrophy and relatively short pedicles.

Impression:

1. Extensive bony metastatic disease in the lumbar spine, as described above; concern for mild increase in AP diameter of the L4 vertebral body.
2. Varying degrees of canal stenosis, as described above, being most severe at the L3-4 disc level.
3. Foraminal stenosis also noted at multiple levels, most severe at the lower three lumbar disc levels.
4. Further metastatic lesions in the visualized sacrum and iliac bones. These findings might be better evaluated globally by bone scan.

What happened?

Duragesic (Fentanyl Transdermal) patch was started and the pain decreased to 1/10. The patient felt much better, an oncology consult was called and he was discharged to a transitional care unit. He refused treatment for prostate cancer.

Final diagnosis

Prostate cancer with extensive bony metastases to the thoracic and lumbar spine.

Related reading

P.S.A. Test No Longer Gives Clear Answers. NY Times, 6/2005.
Telling someone they have prostate cancer. NJurology.com/RoboticSurgeryBlog, 2006.

Published: 03/12/2005
Updated: 12/09/2009

10 comments:

  1. How does prostate cancer metastasise to the lumbar spine i.e. through what route?

    ReplyDelete
    Replies
    1. Typically prostate metastases find their way in the spine through to venous route. this spread is thought to be helped by increased venous preassure during defecation and coughing etc.

      Delete
  2. "How does prostate cancer metastasise to the lumbar spine i.e. through what route?"

    I would assume it is blood. See the reference below:

    Advanced prostate cancer results from any combination of lymphatic, blood, or contiguous local spread.

    http://emedicine.medscape.com/article/454114-overview

    ReplyDelete
  3. This patient is not fit for any active oncological treatment,he just needs analgesics,bisphosphonates,to keep blood sugar and hypertension in contral,adequate hydration,monitor calcium,blood and renal counts.

    ReplyDelete
  4. As this patient is not agreeing for any treatment for Ca Prostate (of course only Orchidectomy with antiandrogen medication might help however if this is hormone refractory case Metastron therapy may be better useful to relieve pain(the Metastron will offer longer painfree life without giving undue side effect and associated with other pain killers)
    Thanks from Dr M Chowhan

    ReplyDelete
  5. Wondering if there is any research on tonsil cancer that was treated "successfully" with radiation and in one year metastasized to the spine and vertebra?

    ReplyDelete
  6. The spread of cancer (treated or untreated) is often unpredictable. All "successful treatment" conclusions come with preconditions, unfortunately.

    ReplyDelete
  7. Surely the next best course of management would be to use dexamethasone to better control his disease, as pain releif and generally give him a boost. While this man has got diabetes which could be exacerbated this could be monitored and controlled better.

    ReplyDelete
  8. Why dexamethasone? Also, there is no such thing as "surely"...

    ReplyDelete
  9. RE: Also, there is no such thing as "surely"...

    Surely | Define Surely at Dictionary.com
    dictionary.reference.com/browse/surely
    undoubtedly, assuredly, or certainly: The results are surely encouraging. 3. (in emphatic utterances that are not necessarily sustained by fact) assuredly: Surely ...

    ReplyDelete