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Illustrative Case Series
Disseminated Prostate Cancer
By William B. Ershler, MD
A 51-year-old man, a foreman for a local construction business, presented to the emergency department with progressive lower back pain of 2 weeks duration and shortness of breath. Initially mild, the pain had become incapacitating within the prior 48 hours. A two-pack per day cigarette smoker, the patient had no other known medical problems and was on no prescription medications. Physical examination revealed him to be in distress, unable to find a comfortable position, and with mild dyspnea at rest. Blood pressure was 150/88, pulse 93/min, and O2 saturation was 91% on room air. He had a ruddy complexion that was accentuated by non-descript fullness in his neck and prominent neck and chest wall veins. Lung sounds were clear but distant bilaterally, and heart sounds were unremarkable. The abdomen was soft, without mass, tenderness, or organomegaly. Complete blood count showed a white blood count of 9.3 K/uL, platelet count of 450 K/uL, and a hemoglobin concentration of 13.9 g/dL. Chemistries revealed a sodium of 140 mmol/L, potassium 4.0 mmol/L, alkaline phosphatase 483 unit/L, and lactate dehydrogenase of 420 Unit/L [313-618]. An MRI revealed an irregular contour of the T12 and L5 vertebral bodies and an abnormal bone marrow fat-signal diffusely throughout the visualized osseous structures, changes consistent with metastatic tumor. The patient was admitted for pain control and for diagnosis procedures.
Upon achieving pain control, a CT scan of the chest, abdomen, and pelvis revealed mediastinal (paratracheal) lymphadenopathy extending into the neck, enlarged abdominal paraaortic and retroperitonal lymph nodes, and a diffusely enlarged prostate gland with irregular contour. Also demonstrated by CT were extensive and destructive bone lesions. A serum PSA level was 145 ng/mL. Pelvic lymph node biopsy demonstrated well-differentiated adenocarcinoma with a positive staining reaction for PSA and PSAP.
The patient was treated with leuprolide, zoledronic acid, and analgesics. One month later there was remarkable reduction in signs of superior vena cava obstruction and significant reduction in chest adenopathy as detected by chest x-ray.
The patient has disseminated prostate cancer, which, in all likelihood, accounts for all of his current symptoms, including the prominent skeletal pain and shortness of breath. What makes the case unusual is the presentation with what appears to be superior vena cava (SVC) syndrome. Admitting clinicians, considering this presentation, were likely entertaining SVC secondary to either lung carcinoma or lymphoma. The prominent bone involvement and smoking history would favor the former, whereas the extensive lymphadenopathy and perhaps age might have pointed to the latter. Indeed, prostate cancer would have been low on my differential, and it is fortunate that the radiologist called attention to the pelvic CT findings.
Prostate cancer presenting as SVC has been noted in several prior reports,1-8 but certainly it is very uncommon. In one series of 47 patients presenting with malignancy-associated SVC syndrome, Rice and colleagues reported only one case had resulted from prostate cancer metastases.9 The majority (82%) of patients in that series presented with face and neck swelling, such as observed in the current case.
The message from this case is the pursuance of tissue diagnosis. The current patient, despite widespread disease, appeared to promptly respond to androgen ablation (leuprolide) and would not likely have responded to empiric therapy directed at either presumed lung primary or lymphoma.
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9. Rice TW, et al. The superior vena cava syndrome: Clinical characteristics and evolving etiology. Medicine (Baltimore) 2006;85:37-42.