Introduction:
Prostate cancer is the second most common cause of cancer and the fourth most common cause of mortality due to cancer among males worldwide [1]. Advanced-stage prostate cancer is known to metastasize to many locations; pulmonary, hepatic, and pleural sites are among the most frequently observed [2]. Most commonly, however, prostate cancer spreads to bone, occurring in up to 29.2% of all diagnosed prostate cancers, and in 88.74 % of metastatic tumours [3,4]. Bone metastases are typically located in the spine but more rarely can be found in the long bones, ribs, or skull [2].
Atypical osteolytic metastases may also be observed but are much rarer. Descriptions of such osteolytic prostatic metastases are consequently sparse, with only a few examples of reported cases in the literature As such, lytic-appearing osseous lesions in the setting of suspected metastatic prostate cancer may confound an otherwise straightforward imaging diagnosis.
Purpose:
This a case of a patient with learning disability with confirmed osteolytic metastases in the right femur from a primary prostate adenocarcinoma. Highlighting the importance of histopathology to confirm diagnosis of unfamiliar metasets presentation. Showing the importance of extra vigilance while treating patients with learning disabilities.
Case presentation:
84-year-old care home resident gentleman, with history of learning disability and poor communication, presented to ED as unable to bare weight following a fall. He was found to have right neck of femur. Hip replacement done and the head of femur sent for histopathology analysis given the history of enlarged prostate and long-term urinary catheter for the last 4 months. However, no lesions were identified, and the patient was discharged back to the care home.
About 17 months later, patient sustained another fall and was brought to hospital with signs of left hip fracture. It was noted that no investigations were done for the enlarged prostate since the original presentation.
Investigations:
XR confirmed the diagnosis of left femur fracture and multiple sclerotic lesions were noticed (fig1)
CT was done (Fig 2) that confirmed sclerotic and lytic lesions. Bone fixation was done, and reaming was sent for histopathological analysis.
Given the lytic lesions, skeletal survey and multiple myeloma screen was done which came back negative.
PSA test was done at this time, and levels were found to be 1123.
Histopathology report was as follows:
Sections show bony fragments infiltrated by highly pleomorphic nest of tumour cells with vesicular nuclei, increase N/C ratio and prominent nucleoli. These tumour cells are positive for MNF116, NKX3.1 and PSA in keeping with metastatic prostatic adenocarcinoma.
Further imaging and staging of prostate cancer were done that confirmed vertebral (Fig 3) and hip bony metastases.
Patient was referred to urology and spine team for further assessment and formulation of a management plan.
Discussion:
Osteoblastic (5) bone metastases are common complication in prostate cancer (6) however lytic bone lesions are rare presentation. Bone lesions, even if lytic, should warrant investigation for cancer prostate with bone metastasis. Histopathological analysis is essential for diagnosis in these scenarios.
This case can also highlight concerns regarding the quality of care provided to patients with learning disabilities, a persistent issue within healthcare systems. Learning disabilities continue to be a significant risk factor contributing to health inequalities (7). Could a better follow up to the enlarged prostate would have discovered the cancer early (8)? Would the patient have had the ability to express bony pain prompted earlier presentation altering the course of diagnosis and management?
References:
1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019;144(8):1941–1953. doi: 10.1002/ijc.31937. [DOI] [PubMed] [Google Scholar]
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6. Hernandez RK, Wade SW, Reich A, Liede A, Lyman GH. Incidence of bone metastases in patients with solid tumors: analysis of oncology electronic medical records in the United States. BMC Cancer. 2018;18(1):44. doi:10.1186/s12885-017-3922-0.
7. Louch G, Albutt A, Harlow-Trigg J, Moore S, Smyth K, Ramsey L, O’Hara JK. Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review. BMJ Open. 2021 May 19;11(5):e047102. doi:10.1136/bmjopen-2020-047102. PMID: 34011599; PMCID: PMC8137174.
8. Bengtsen MB, Farkas DK, Borre M, Sørensen HT, Nørgaard M. Acute urinary retention and risk of cancer: population based Danish cohort study. BMJ. 2021;375:n2305. doi:10.1136/bmj.n2305.
Biography:
Fatma Mohammed Gouda Essayed Shahin, MBBCH With honors from Benha University, Faculty of medicine, Egypt, currently part of lewisham & Greenwich NHS trust organization , published 3 pubmed cited research.
Presenting author details:
Full Name: Fatma Mohammed Gouda Elsayed Shahin
Category: (Oral/Poster Presentation/Workshop): Poster
Track name:
Research interest:
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