Morbidity and Mortality: A Case Report of Metastatic Bone Disease

Metastatic prostate cancer and multiple myeloma (MM) usually present with bone lesions, posing a diagnostic challenge in males presenting in late stages. In this case report, an 86-year-old male who had not seen a physician in over 30 years presented with complaints of hip pain and progressive difficulty in walking for three weeks. Outpatient X-ray of the right hip showed multiple lytic bone lesions, raising suspicion of MM. Other laboratory tests revealed elevated serum calcium and elevated prostate-specific antigen (PSA), supporting a diagnosis of prostate cancer. The patient was admitted for further workup. Magnetic resonance imaging (MRI) of the spine showed diffuse metastatic disease throughout the spine as well as pelvis with multilevel central canal and neuro-foraminal narrowing due to degenerative changes. Central canal narrowing at L1-L2 due to tumor involvement could not be ruled out on MRI. Subsequently, urology was consulted and the patient was taken to the operating room for prostate biopsy and possible bilateral orchiectomy. Two intraoperative prostate biopsies were negative for malignancy but patient underwent bilateral orchiectomy due to high clinical suspicion for prostate cancer. Bone lesions in the pelvis were so extensive that orthopedic surgeons recommended complete non-weight bearing as the risk of fracture with weight bearing was thought to be very high. Eventually, laboratory workup for MM came out to be positive. Radiation oncologist recommended radiation therapy; however, at this point, the patient refused further intervention. He opted for palliative care. Consequently, a bone marrow biopsy could not be obtained for a definitive diagnosis of MM. The patient was eventually discharged to a nursing home for hospice care. This case sheds light on the importance of preventative care in routine outpatient setting, which can often screen, identify, and detect malignancies at earlier stages. It also signifies the importance of an interdisciplinary approach and precise knowledge in differentiating and diagnosing such malignancies. In our patient's case, his extensive bone disease precluded his ability to be weight bearing which is an uncommon finding only seen in extensive metastatic bone disease. A definitive diagnosis is warranted to guide appropriate management.