Case 1: Markus (68 years old)

Markus is a 68-year-old former architect with a passion for traveling. Now that he has a lot of free time for traveling, he aims to visit all the World Heritage Sites in the United States.

He presents to his local emergency department with new onset bilateral lower limb weakness over the last 24 hours.

​​​​​Assessment summary:

• Medical history: T3b N0 M0, ISUP grade group 4 [Gleason score 4 + 4] PCa; treated with radical external beam radiation therapy (EBRT) + 2 years of androgen deprivation therapy (ADT) - luteinizing hormone-releasing hormone (LHRH) agonist 5 years ago. Off treatment and lost to follow-up
• Comorbidities:
  • Hypertension controlled with amlodipine
  • Chronic kidney disease managed with ramipril
• Normal cranial and upper limb examination
• Leg power 2/5 bilaterally, with reduced reflexes and reduced anal sphincter tone
• Magnetic resonance imaging (MRI) whole spine: T2 weighted images show osteoblastic metastatic deposits in almost all vertebrae and cord compressing lesions at T3 and T5, T6
• Blood tests: normal except alkaline phosphatase (ALP) 850 IU/l and prostate-specific antigen (PSA) 1,300 ng/ml
• Serum testosterone: 520 ng/dl (18 nmol/l)

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