A 78-year-old man comes to the office for the evaluation of persistent, severe, low back pain. The pain does not radiate down to his legs, and is not associated with bladder or bowel disturbances. He has metastatic prostate cancer, which has progressed despite hormonal therapy and chemotherapy. A bone scan done 6 weeks ago revealed the presence of 2 vertebral metastases in the L4 and L5 vertebral bodies. He was started on high-dose narcotic analgesics at that time. He says that the narcotics have "taken the edge" off the pain, but he continues to have severe debilitating pain. Neurological examination of the lower extremities is unremarkable. A repeat bone scan reveals results similar to the previous scan results. Which of the following is the next most appropriate step in controlling this patient's symptoms?

Question

A 78-year-old man comes to the office for the evaluation of persistent, severe, low back pain.  The pain does not radiate down to his legs, and is not associated with bladder or bowel disturbances.  He has metastatic prostate cancer, which has progressed despite hormonal therapy and chemotherapy.  A bone scan done 6 weeks ago revealed the presence of 2 vertebral metastases in the L4 and L5 vertebral bodies.  He was started on high-dose narcotic analgesics at that time.  He says that the narcotics have "taken the edge" off the pain, but he continues to have severe debilitating pain.  Neurological examination of the lower extremities is unremarkable.  A repeat bone scan reveals results similar to the previous scan results.  Which of the following is the next most appropriate step in controlling this patient's symptoms?

Quizplus · Accepted Answer

Explanation: The axial skeleton is the most common site of spread of prostate cancer, which can cause significant pain and functional impairment. The primary goal of treatment in patients with metastatic, hormone-refractory prostate cancer is palliation. Specific aims in the management are adequate pain relief, improvement of the functional status, and prevention of vertebral compression fractures and subsequent spinal cord compression. Focal external beam radiation therapy is the treatment of choice for palliation of pain in patients with metastatic, advanced hormone-refractory prostate cancer. It should be used in patients with a single or few focal bone lesions in which the pain is not adequately controlled with narcotic analgesics. (Choice B) The patient has a history of progressive, metastatic prostate cancer despite hormone therapy. It is unlikely that he will respond adequately to subsequent hormone manipulation. (Choice C) Corticosteroids reduce inflammation by inhibiting prostaglandin synthesis. These drugs are only useful when inflammation or edema surrounding the tumor causes pain secondary to compression or visceral distention. These are also useful in patients with epidural spinal cord compression. (Choice D) Surgery is only indicated in patients with pathological vertebral compression fractures or signs and symptoms of epidural spinal cord compression secondary to the metastases. Educational objective: External beam radiation therapy should be used for pain alleviation in patients with single or few focal bone metastatic lesions due to hormone-refractory prostate cancer.

A 78-Year-Old Man Comes to the Office for the Evaluation