SLIDE 4 Int nterna rnationa nal Journ rnal of f StudentS’ ReSeaRch
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CASE REPORT
Jain et. al. Int J Stud Res 2012;2(1):28-31 The patient’s symptoms improved dramatically after laminectomy and spinal fusion. He was started on leuprolide (GnRH agonist), bicalutamide (androgen antagonist), and palliative radiation therapy. The patient was followed up in clinic one time only after 2 weeks. He improved significantly without any residual paralysis. He is being followed in the Department of Oncology. Discussion Spinal cord compression occurs in 5% to 10% of cancer patients [4]. In prostate cancer, bone involvement is common and present in 90% of metastatic cases [5]. Bubendorf et al. examined 1,589 autopsies of prostate cancer. They found the spine was most commonly involved in cases with smaller
- tumors. Lungs, on the other hand, were most commonly
involved with larger tumors. They suggested the possibility that spinal metastases precede lung and liver metastases in prostate cancer as a general sequence of progression. Accordingly, there is a high incidence of spinal cord compression in metastatic prostate cancer. Approximately 12% to 19% of newly diagnosed patients present with cord
- compression. [6,7]. A valveless network of veins called
Batson's venous plexus which connects the prostate to the vertebral venous plexus may be responsible for this high rate
- f vertebral metastases in prostate cancers. It is theorized
that this network of valveless veins allows bidirectional flow
- f blood to help regulate intracranial pressure, but becomes a
route of spread for metastatic cells in prostate cancer [8]. When prostate cancer metastasizes and causes spinal cord compression, the most common symptom is back pain (or neck pain if the tumor is located in a cervical vertebra) [9]. As in the case of our patient’s first ER visit, there may not be any initial neurologic complication other than pain. In four retrospective studies reported by Osborn et al, pain was experienced by more than three quarters of all patients [9]. However, weakness was not seen in up to half of the patients in one of these studies. Sensory loss was variable; present in 23% to 68% of cases. Rodichok et al found that 36% of patients with various cancers, who had back pain in the setting of an otherwise normal neurologic exam, actually had myelographic evidence of epidural metastases [10]. This case serves as an important reminder that the absence of neurologic deficits does not rule out spinal cord compression. When present, findings on the neurologic exam vary depending on the level of the spinal cord involved. There is a decreasing rate of metastasis from lumbar to cervical vertebrae [5]. Only about 5 – 15% of metastases involve the cervical spine [9]. Lesions responsible for neurologic deficits will most likely be below T1 if the patient presents with paraparesis or paraplegia, and above C5 if quadriparesis or
- quadriplegia. Deep tendon reflexes (DTR’s) may be reduced
at the level of the lesion, and increased at myotomes below the level [9]. Abnormal DTR’s, radicular pain, and distribution of sensory or motor loss all help to localize the lesion. Plain X-ray films can be useful in diagnosing spinal cord
- compression. Rodichok reported an overall accuracy of 80%
in determining the presence or absence of cord compression by X-rays alone [10]. These patients with back pain in the absence of neurologic deficits were ultimately diagnosed as having cord compression by myelography. All of these patients had abnormalities identified on plain X-rays. A general conclusion from this might be that any cancer patient with back pain should, at the least, be screened for spinal metastases with a plain radiograph. Further investigation may include more definitive studies such as magnetic resonance imaging (MRI), which is the study of choice, or a myelogram. Most cases of metastatic prostate carcinoma have multiple lesions affecting the spinal cord. Our patient’s presentation with a solitary lesion is unusual. It is imperative to follow through with complete spinal imaging studies to rule out
In a case like ours, prompt diagnosis is necessary for the recovery of neurologic function. Intravenous dexamethasone, hormonal therapy, appropriate surgery, and radiation therapy are the mainstay of management of such a case. Conclusion In some cases, back pain may be the initial presentation of prostate cancer that has metastasized to the spine. This pain usually precedes onset of serious neurologic deficits, which
- ccur as compression of the spinal cord worsens. Our patient
initially presented in this interim period between the onset of back pain and the onset of neurologic deficits. We did not suspect cord compression on his first visit, but this was ultimately diagnosed with an MRI scan when he returned with hemiparesis. With prompt surgery and medical treatment, the patient has remained ambulatory and free of major neurologic complications for the past four years. Our literature review indicates that a plain x-ray of the spine may help identify similar patients with cord compression before they develop neurologic deficits, as prompt diagnosis is vital in prevention of permanent neurologic deficits. References
1. American Cancer Society. Cancer facts & figures 2010. Atlanta: American Cancer Society [Internet] 2010 [cited 2011 November 14] Available from http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/ documents/document/acspc-026238.pdf. 2. Scosyrev E, Messing EM, Mohile S, Golijanin D, Wu G. Prostate cancer in the elderly: Frequency of advanced disease at presentation and disease-specific mortality. Cancer 2011. doi: 10.1002/cncr.26392. 3. Terris M, Qureshi S, Rhee A. Metastatic and Advanced Prostate
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http://emedicine.medscape.com/article/454114-overview 4. Mehta MP, Chang S. Guha A, Newton HB, Vogelbaum MA. Principles and practice of neuro-oncology: a multidisciplinary
- approach. New York. Demos Medical; 2011. Chapter 101, Metastatic
disease; p.902-922. 5. Bubendorf L, Schöpfer A, Wagner U, et al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol 2000;31(5):578-83. 6. Kuban DA, el-Mahdi AM, Sigfred SV, Schellhammer PF, Babb TJ. Characteristics of spinal cord compression in adenocarcinoma of
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7. Smith EM, Hampel N, Ruff RL, Bodner DR, Resnick MI. Spinal cord compression secondary to prostate carcinoma: treatment and
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