Metastatic prostate adenocarcinoma with occult bone metastases

Case contributed by Dr Michael P Hartung


Back and flank pain.

Patient Data

Age: 45 years
Gender: Male

Mild retroperitoneal adenopathy. More pronounced adenopathy in the right common iliac and pelvic sidewall. No other acute findings.

Very subtle small, round sclerotic lesion in the left femoral neck. No sclerotic or lytic metastases identified elsewhere.

Numerous T1 hypointense, mildly T2 hyperintense, and hyperenhancing lesions throughout the lumbar vertebral bodies and posterior elements. Smooth, diffuse leptomeningeal enhancement.

Case Discussion

What makes this a particularly interesting case is the patient's atypical presentation and unexpected findings on a renal stone CT. It is worth asking yourself how you might interpret the non-contrast CT of the abdomen and pelvis alone, and what recommendations would make.

Pelvic and retroperitoneal adenopathy in a male is concerning for prostate cancer, however, he is relatively young (45 years old). Alternatively, lymphoma, bladder, and testicular cancers are other considerations. No easy target for lymph node biopsy can be identified. A particularly careful reader of the CT might notice a single round, sclerotic lesion in the left femur, which could direct further evaluation.

The patient had severe back pain and underwent MRI with contrast after the CT, which showed extensive osseous metastatic disease. The leptomeningeal enhancement is worrisome for the spread of a tumor, and actually steered the interpretation toward lymphomatous leptomeningitis. However, vertebral body biopsy was performed, yielding adenocarcinoma, and the PSA was 40, confirming prostate adenocarcinoma primary.

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Case information

rID: 59565
Published: 14th Apr 2018
Last edited: 8th Mar 2019
Inclusion in quiz mode: Included

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