Jim (68 years old)

Jim is 68 years old and has a history of prostate cancer. He is very stubborn and claimed he was doing fine, but his wife noticed something was wrong and could finally convince him to go to the local emergency department.

• Symptoms: new onset bilateral lower limb weakness over the last 24 hours
• Medical history:
  • T3bN0M0
  • Prostate biopsy: ISUP grade 4 (Gleason score 4+4)
  • Treated with radical EBRT + 2 years of ADT (LHRH agonist) 5 years ago. Off treatment and lost to follow-up
  • Hypertension controlled with amlodipine
  • Chronic kidney disease managed with ramipril
• Physical examination: normal cranial and upper limb examination, but leg power 2/5 bilaterally, with reduced reflexes and reduced anal sphincter tone
• Blood tests: anaemia, ALP 850 IU/l and PSA 1,300 ng/ml
• Serum testosterone: 520 ng/dl (18 nmol/l)
• MRI whole spine: T2 weighted images show osteoblastic metastatic deposits in almost all vertebrae and cord compressing lesions at T3, T5 and T6

Neurosurgical opinion is sought, but no operative strategy is thought possible given the disease extent and comorbidities. Dexamethasone is started and the patient receives RT to the compressive spinal cord lesions. Combination systemic therapy is planned.