Simon (68 years old)

Simon, a 68-year-old retired high school teacher, has a history of prostate cancer. While walking to the supermarket, he lost strength in his legs and felt. Someone called the ambulance and they took him to the 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 (luteinising hormone-releasing hormone agonist) 5 years ago. Off treatment and lost to follow-up
  • Hypertension controlled with amlodipine
  • Chronic kidney disease managed with ramipril
  • Myocardial infarction 18 months ago and is on clopidogrel and simvastatin
• 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.