A 77-year-old man is brought to the emergency department due to acute-onset chest pain, shortness of breath, and syncope. Medical history is significant for coronary artery disease, which was treated with right coronary artery stenting 5 years ago. The patient develops cardiac arrest and resuscitation is unsuccessful. Autopsy shows a large bilateral pulmonary embolism occluding the pulmonary trunk. Further history obtained from the patient's wife indicates that he has had constant back pain over the past few months. Autopsy of the vertebrae is shown in the image below: Histologic examination of the bone lesions in this patient would most likely show which of the following?

Question

A 77-year-old man is brought to the emergency department due to acute-onset chest pain, shortness of breath, and syncope.  Medical history is significant for coronary artery disease, which was treated with right coronary artery stenting 5 years ago.  The patient develops cardiac arrest and resuscitation is unsuccessful.  Autopsy shows a large bilateral pulmonary embolism occluding the pulmonary trunk.  Further history obtained from the patient's wife indicates that he has had constant back pain over the past few months.  Autopsy of the vertebrae is shown in the image below:  Histologic examination of the bone lesions in this patient would most likely show which of the following?

Quizplus · Accepted Answer

11ec160b_39a2_944c_9249_19f6ed8f6dc1_MD0001_00 This patient's vertebral body bony lesions raise strong suspicion for osteoblastic metastases due to prostate adenocarcinoma; his massive pulmonary embolism was likely precipitated by an underlying hypercoagulable state of malignancy. Prostate cancer is the most common non-skin cancer in men, and risk is strongly linked to advancing age. Because most cases develop in the periphery of the prostate gland, urinary symptoms are uncommon until late in the disease course; therefore, the diagnosis is usually prompted by elevated prostate-specific antigen level, abnormal digital rectal examination, or symptoms related to advanced disease (eg, bone pain). Prostate cancer preferentially metastasizes to bone due to specific adhesion molecules (eg, CXCR4) and receptor ligands (eg, RANK) on the cancer cell surface that adhere to pericytes and bone marrow stromal cells. After it establishes a nidus, the tumor secretes osteoblast differentiation factors (eg, endothelin 1, insulin-like growth factors, platelet-derived growth factors, bone morphogenic proteins) that promote new bone growth. Biopsy of a bone lesion would most likely show disordered trabecular growth and evidence of prostate cancer cells such as irregular glands with enlarged nuclei and prominent nucleoli. (Choices A, C, D, and E) Osteolytic bone metastases appear on radiology and gross pathology as moth-eaten bone, not areas of bony growth. These bone lesions are typically seen with metastatic melanoma (pleomorphic cells with coarse, brown melanin pigment), multiple myeloma (effacement of marrow with plasmablasts and plasma cells), renal cell carcinoma (sheets of neoplastic cells with abundant clear cytoplasm), and thyroid papillary carcinoma (complex papillary pattern and psammoma bodies). Educational objective: Prostate cancer is common in older men and metastasizes primarily to bone due to bone-specific tumor adhesion molecules and receptor ligands on the cellular surface. Prostate cancer causes osteoblastic lesions that result in new bone growth. Biopsy would show disordered trabeculae and signs of prostate cancer such as irregular glands with enlarged nuclei and prominent nucleoli.

A 77-Year-Old Man Is Brought to the Emergency Department Due