Cancer of the Prostate Presenting With Diffuse Osteolytic Metastatic Bone Lesions

A Case Report

Innocent Lule Segamwenge; Nuru Kaddu Mgori; Safia AbdallahYussuf; Celia Nantume Mukulu; Philip Nakangombe; Paul Kioko Ngalyuka; Fred Kidaaga


J Med Case Reports. 2012;6(425) 

In This Article

Case Presentation

A 65-year-old Namibian man was referred to our hospital by a district hospital for evaluation of anemia, thrombocytopenia and back pain. The patient had been in his usual state of health until seven months prior to admission when he started experiencing low back pain. The pain was initially mild but gradually increased in intensity to severe pain by the time of admission. The pain was radiating to the patient's lower limbs; it worsened with routine activities like walking, and was relieved by rest. There was no associated trauma to the back. In addition, the patient complained of exertional dyspnea, fatigue and palpitations four months prior to admission.

A review of his other systems revealed complaints of weight loss, fevers and general malaise. He also complained of straining while passing urine and frequency of micturition and dysuria. He had neither symptoms of cough, difficulty in breathing nor symptoms related to the gastrointestinal tract. His past medical and surgical history were unremarkable. The patient did not consume alcohol or smoke cigarettes.

On examination the patient had moderate pallor and mild wasting. The right shoulder joint was swollen and tender with limited range of movement (Figure 1). He had tenderness to percussion over the thoracic and lumbar spines with no swelling or deformity noted. On digital rectal examination he had asymmetrical enlargement of the prostate which felt nodular and hard with diffuse firmness in some parts. Other examination findings were normal.

Figure 1.

Swollen right shoulder joint.

The patient had a normocytic normochromic anemia of 5.4g/dL and thrombocytopenia of 42,000/μL. The absolute reticulocyte count was 101,500 cells/μL and a reticulocyte index of 1.1. The peripheral blood smear showed anisocytosis, polychromasia, nucleated red cells, no rouleaux formation and the platelet morphology was normal. Other blood tests showed hypercalcemia of 2.9mmol/L, raised alkaline phosphatase (ALP) of 509IU/L and lactate dehydrogenase (LDH) of 547IU/L. The renal function tests and liver function tests were normal. The serum protein electrophoresis showed no M-protein band and the urine was negative for Bence Jones proteins.

The urine analysis showed mild proteinuria of 30mg/dL with microscopic hematuria and the urine culture grew Escherichia coli sensitive to cefuroxime. The prostate-specific antigen (PSA) was greater than 100ng/mL.

X-rays of the patient's right shoulder joint showed osteolytic bone lesions on his humerus (Figure 2). Similar lesions were seen on computed tomography scans of his lumbar spine, femur and pelvic bones (Figures 3, 4, 5 and 6). The lateral skull X-ray was normal.

Figure 2.

Lytic lesions (arrows) involving the humerus.

Figure 3.

Computed tomography scan showing lytic lesions involving the entire spine.

Figure 4.

Thoracic vertebrae with lytic lesions.

Figure 5.

Sacral and pelvic bones with lytic lesions.

Figure 6.

Computed tomography scan showing lytic lesions involving the femur and pelvic bones.

A biopsy of the prostate was done and the subsequent histology confirmed infiltrating adenocarcinoma of the prostate with a Gleason score of 9.

A bone marrow trephine showed a diffuse infiltrate of metastatic adenocarcinoma which stained positive to PSA immunohistostain confirming the prostatic origin of the metastases.

The patient received a blood transfusion and his hemoglobin level was raised to 10g/dL. The urinary tract infection was treated with a seven-day course of cefuroxime. He was given adequate pain relief with 100mg of oral tramadol per eight hours. The patient declined to have bilateral orchidectomy the only form of androgen deprivation therapy available in the Namibian free health scheme. He continues to receive palliative care.