A 68-year-old man comes to the office due to persistent back pain for the past several months. He is a retired veteran and has not seen a doctor for many years. He has smoked a pack of cigarettes daily for 36 years. His blood pressure is 145/85 mm Hg and pulse is 88/min and regular. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender. There is focal tenderness over the 10th rib and L1-L2 vertebral region. Neurologic examination is normal. Radionuclide bone imaging reveals increased activity in multiple vertebrae and ribs, corresponding to the patient's painful areas. Routine radiographs show sclerotic lesions matching the bone scan areas of increased uptake, which are highly suspicious for metastatic cancer. Which of the following additional findings is most likely to be seen in this patient?

Question

A 68-year-old man comes to the office due to persistent back pain for the past several months.  He is a retired veteran and has not seen a doctor for many years.  He has smoked a pack of cigarettes daily for 36 years.  His blood pressure is 145/85 mm Hg and pulse is 88/min and regular.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and nontender.  There is focal tenderness over the 10th rib and L1-L2 vertebral region.  Neurologic examination is normal.  Radionuclide bone imaging reveals increased activity in multiple vertebrae and ribs, corresponding to the patient's painful areas.  Routine radiographs show sclerotic lesions matching the bone scan areas of increased uptake, which are highly suspicious for metastatic cancer.  Which of the following additional findings is most likely to be seen in this patient?

Quizplus · Accepted Answer

11ec160b_39fa_50c6_9249_6d22ab2c9ab9_MD0001_00 This patient with sclerotic bony metastases most likely has prostate cancer. Imaging of bone metastases assists in cancer diagnosis, as it allows the lesions to be characterized as: Metastatic prostate cancer commonly has osteoblastic (sclerotic) bone lesions. Bone pain is a typical clinical presentation; other symptoms include cancer cachexia and urinary symptoms (which are not always present). Prostate cancer is the most common non-skin cancer in men, and African American men are at highest risk. An irregular prostate gland on digital rectal examination is suggestive of the diagnosis, which is then confirmed by biopsy. The prostate-specific antigen tumor marker is commonly elevated. (Choice A) Hematuria and polycythemia (due to erythropoietin release) are suggestive of renal cell cancer. Renal cell cancer bone metastases are commonly osteolytic. (Choice B) Monoclonal immunoglobulin spikes are found in multiple myeloma. Myeloma cells suppress osteoblasts and would cause osteolytic lesions, which are not present in this patient. Patients commonly have bone pain, recurrent infections, and symptoms of anemia. (Choice C) Elevated parathyroid hormone-related peptide (PTH-rP) levels can occur with non-small cell lung cancer (NSCLC) and are associated with symptoms of hypercalcemia (confusion, abdominal pain, bony pain). Osteolytic bone lesions would be seen in NSCLC. (Choice D) Lymphadenopathy and BCL-2 overexpression are found in lymphomas. BCL-2 is an anti-apoptosis factor, and overexpression plays a role in resistance to chemotherapy. Common manifestations of lymphoma also include night sweats, weight loss, and fatigue. (Choice F) A rapidly enlarging irregular mole is suggestive of a melanoma. The liver, bone, and brain are the most common metastatic sites. Melanoma causes lytic bone lesions. Educational objective: Imaging of bone metastases assists in cancer diagnosis. Bone metastases are characterized as osteolytic or osteoblastic. Bony pain in an older man with osteoblastic lesions on imaging is highly suspicious for prostate cancer. __________ References: Mechanism of bone metastasis. (http://www.ncbi.nlm.nih.gov/pubmed/15084698) Bone metastasis: mechanism and therapeutic opportunities. (http://www.ncbi.nlm.nih.gov/pubmed/21200394)

A 68-Year-Old Man Comes to the Office Due to Persistent