Presentation
Chronic lower back pain. Flare up last 6 weeks
Patient Data
Diffuse bone marrow low T1 signal, darker than skeletal muscle, throughout the lumbar spine and patchy through the sacrum. Bone marrow T2 signal is also abnormally low although mildly heterogeneous. Patchy mixed high and low T2 signal on the fat saturated sequence. Paraspinal soft tissues demonstrate no gross abnormality. In particular, no soft tissue mass. Limited visualization of the abdominopelvic viscera demonstrates no gross abnormality. Prominent para-aortic nodes although <10 mm in short axis diameter.
Pathology
MACROSCOPY
Bone BX ileum bone: four tan/brown friable tissue cores 5, 6, 4, 11 mm. Also submitted with 6 friable fragments 1-3 mm.
MICROSCOPY
Sections show fragmented bone including some marrow space component, with focal normal hematopoietic tissue visible. There are clusters of partly crushed atypical epithelial cells identified, highlighted with cytokeratin AE 1/AE 3 immunohistochemistry. These tumor cells coexpress PSA (cytoplasmic)and show strong nuclear staining with NKX3.
CONCLUSION
Bone biopsy ileum: Scant tumor tissue, showing features consistent with metastatic prostatic acinar adenocarcinoma.
Case Discussion
This patient went on to clinical and laboratory work-up, which demonstrated a high PSA. Subsequent PSMA PET-CT showed extensive skeletal uptake with a few nodes but no prostate uptake. In this context, a bone biopsy was performed which confirmed prostate cancer metastases.
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