Prostate Cancer with Bone Metastases and PSA of 900

A 82 yo AAM came to the hospital with CC: severe back pain for one week. He was diagnosed with prostate cancer five years ago.

PMH:
DM 2, PUD s/r remote surgery, HTN, prostate cancer with bone mets, (B) orchiectomy

Medications:
Insulin, bisacodyl, senokot, risperdal, sertraline, metoclopramide, Benadryl, docusate, glipizide

Physical examination:
VS 37.3-108-16-125/80
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 do you think is going on?
Progression of bone mets.

What tests would you order?
CBCD, CMP.
MRI of the back.


CMP showed elevated AP and PSA higher than 900. DM2 is uncontrolled (HA1c 17).


Alkaline phosphatase levels during the last two years.


PSA levels during the last two years.


Bone scan from one year ago.


CXR. Surgical scars from previous PUD surgery.


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

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

MRI of thoracic spine with and w/o contrast findings:

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.


MRI of the lumbar with bone mets.

MRI of lumbar spine with and w/o contrast findings:

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?
A fentanyl 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.

Further reading:
P.S.A. Test No Longer Gives Clear Answers. NY Times 6/05
Telling someone they have prostate cancer. NJurology.com/RoboticSurgeryBlog/2006/01

Created: 03/2005
Updated: 08/05/2007