Cervical spinal cord compression as an initial presentation of - PDF document

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/235726392 Cervical spinal cord compression as an initial presentation of prostate cancer: a case report Article in International Journal of Students' Research · February 2013 DOI: 10.4103/2230-7095.113488 CITATIONS READS 0 463 5 authors , including: Sachin Agnihotri Sachin kumar Amruthlal jain South Ural State University Icahn School of Medicine at Mount Sinai 40 PUBLICATIONS 420 CITATIONS 41 PUBLICATIONS 71 CITATIONS SEE PROFILE SEE PROFILE Yousif Ismail Providence Hospital 4 PUBLICATIONS 29 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Call for Book Chapter: Computational Intelligence for Managing Pandemics View project Mild anemia as a possible cause of false positive stress echocardiography in Non-obstructive coronary artery disease: A pathophysiologic hypothesis View project All content following this page was uploaded by Sachin kumar Amruthlal jain on 20 May 2014. The user has requested enhancement of the downloaded file.

Int nterna rnationa nal Journ rnal of f StudentS’ ReSeaRch Volume 2 Issue 1 Year 2012 www.ijsronline.com CASE REPORT Cervical spinal cord compression as an initial presentation of prostate cancer: a case report Sachin Kumar Amruthlal Jain, Kashyap Patel, Yousif Ismail, Michael Williams ABSTRACT Prostate cancer is notorious for its atypical presentation. However, spread to the cervical spine is uncommon. We herein describe the findings in a 57-year-old African American gentleman, who presented with neck pain and right-sided weakness. Examination revealed neck tenderness with numbness in the distribution of C6 region on right side. An MRI of the neck imaged a 3.4cm extradural soft tissue mass in the C6 region extending into the spinal-canal, causing spinal cord compression. At this point, differential diagnosis included: metastatic cancer vs. chronic granulomatous vs. primary CNS lesion. Management included high dose intravenous steroids and mass resection with cervical-spine fusion. The prostate specific antigen (PSA) was 1815 ng/mL (normal less than 4 ng/mL) with a repeat value of 1666 ng/mL, and the pathology findings confirmed the mass to be metastatic prostate carcinoma. This case illustrates an unusual presentation of metastatic prostate cancer, lytic in nature, presenting as cord compression, and sparing the bone and lymph nodes in the cervical region. Metastatic lesions of prostate cancer to the bone are most often blastic rather than lytic in nature [11]. Cervical involvement is seen in only 5% of cases. Regardless of this atypical presentation, early diagnosis of cord compression is of utmost importance because neurologic status upon presentation has important prognostic value. It is important to consider prostate cancer metastasis in any compressive neuropathy, or findings of an atypical mass affecting the cervical spine. Key Words : Prostate carcinoma, extradural metastasis, cervical mass, PSA screening Introduction known family history of cancer. It is estimated that approximately 1 out of 6 Caucasian and 1 ER workup included an electrocardiogram (EKG) which out of 5 African American males in the United States showed a normal sinus rhythm with no notable abnormality. eventually develop prostate cancer at some point in their His chest pain was thought unlikely to be of a coronary lives [1]. Despite advances in diagnostic modalities such as origin. The patient was discharged on naproxen for neck the advent of the prostate specific antigen (PSA) test, the pain. finding of metastatic carcinoma on previously undiagnosed patients still remains high. Depending on their age, this can One month later, the patient returned with the same pain in be seen in up to 17% of patients [2,3]. We present a case of his neck and back. The intensity was now graded as 10/10, cervical spinal cord compression due to metastasis of a and was accompanied by paresis of the right upper and lower previously undiagnosed prostate carcinoma. The extremities. He reported difficulty in walking, and being presentation, however, was uncommon in that the tumor clumsy with his right arm. involved a less frequently affected region of the spinal cord, and that it spared the bone. He was afebrile with a blood pressure of 170/100. All other vital signs were stable. On examination, he was alert and Case Presentation oriented. Cranial nerves II-XII were intact. There was mild right-sided paraspinal tenderness over the lower neck. A 57-year-old African American male, initially presented to Sensation in his right thumb and index finger (C6 the emergency room (ER) with complaint of right sided dermatomal distribution) was decreased, with some chest pain, which occurred on the prior day and had lasted numbness and tingling. His motor strength was graded 4/5 in for about 10 – 20 minutes. The patient also complained of the right upper and lower extremities. The right upper back and neck pain for the past several months. The brachioradialis, biceps, and patellar reflexes were 3/4 (hyper neck pain was exacerbated by motion and radiated into the reflexive). No abnormalities were observed on the left side. right arm. He denied any numbness, tingling, or weakness. Cerebellar function was normal bilaterally. Gait was affected The pain responded moderately to ibuprofen. due to weakness of the right leg. The remaining exam was unremarkable for any abnormality. An MRI of the neck demonstrated a 3.4 cm extradural soft tissue mass in the C5 – His past medical history was significant for a gunshot injury to the head 20 years ago, which had not required surgery. He C6 region, extending into the spinal canal and causing cord had no other relevant medical or surgical history and no compression (Figure 1). He was administered high dose intravenous steroids, and the Department of Internal Medicine, Providence Hospital and hypertensive urgency was managed with intravenous Medical Centers, Southfield, Michigan, USA labetalol. The patient then underwent emergent laminectomy Corresponding Author with a spinal fusion and excision of the mass. Sachin Kumar Amruthlal Jain, Email: doctorsachin@gmail.com Jain et. al. Int J Stud Res 2012;2(1):28-31 28

Int nterna rnationa nal Journ rnal of f StudentS’ ReSeaRch Volume 2 Issue 1 Year 2012 www.ijsronline.com CASE REPORT Figure 1 Magnetic Resonance Imaging (MRI) of the Neck showing an extradural soft tissue mass extending in to spinal canal . Our differential diagnosis for this soft tissue mass included a chronic granulomatous lesion, a primary CNS tumor or metastatic cancer. A bone scan showed increased uptake in the C5-C6 region, (Figure 2), and computerized tomography (CT scan) of the chest, abdomen and pelvis was unremarkable, with no evidence of other lesions. Dermatologic exam did not reveal any visible skin lesions. Serum marker tests were ordered to check for common malignancies. At this time, we suspected the tumor to be metastatic lung or gastrointestinal cancer. Prostate cancer was amongst the differential, but was thought to be unlikely as the tumor was located in the cervical spine, and spared the bony and lymphatic tissue. However, the PSA levels were found to be elevated at 1815 ng/mL (normal < 4ng/mL). A repeat test reported the level at 1666 ng/mL. The pathology report Figure 2 Bone scan showing normal uptake, other than confirmed that the mass was metastatic prostate carcinoma increased uptake in cervical region. (Gray arrow showing (Figure 3 and 4). cervical uptake) Figure 3 Hematoxylin and Eosin stain of the biopsied tissue Figure 4 Immunohistochemistry stain of the biopsied tissue show neoplastic glands with nuclear enlargement, showing positivity to prostate specific antigen. prominent nucleoli, mitotic figures and amorphous eosinophilic secretions diagnostic of adenocarcinoma. Jain et. al. Int J Stud Res 2012;2(1):28-31 29