A 76-year-old man is brought to the emergency department due to persistent back pain for the last 2 weeks. Over the last several days he has also had increasing difficulty walking. The patient was diagnosed with locally advanced prostate cancer a year ago and was treated with radiation therapy. His other medical problems include type 2 diabetes mellitus, hypertension, and hyperlipidemia.
Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 70/min. Neurological examination shows mild spastic paraparesis of the lower extremities.
Laboratory values show serum creatinine of 2.1 mg/dL and calcium of 9.8 mg/dL. MRI of the spine reveals a discrete epidural mass at the T8-T9 levels. There is surrounding spinal cord edema.
In addition to intravenous corticosteroids, which of the following would be most helpful to improve mobility in this patient?

Question

A 76-year-old man is brought to the emergency department due to persistent back pain for the last 2 weeks.  Over the last several days he has also had increasing difficulty walking.  The patient was diagnosed with locally advanced prostate cancer a year ago and was treated with radiation therapy.  His other medical problems include type 2 diabetes mellitus, hypertension, and hyperlipidemia.
Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 70/min.  Neurological examination shows mild spastic paraparesis of the lower extremities.
Laboratory values show serum creatinine of 2.1 mg/dL and calcium of 9.8 mg/dL.  MRI of the spine reveals a discrete epidural mass at the T8-T9 levels.  There is surrounding spinal cord edema.
In addition to intravenous corticosteroids, which of the following would be most helpful to improve mobility in this patient?

Quizplus · Accepted Answer

11ec193a_9671_2e56_853d_7dad651a7158_MD0002_00 This patient has neoplastic epidural spinal cord compression likely due to metastatic prostate cancer. His presentation of back pain followed by progressive spastic lower extremity paraparesis and an epidural mass with spinal cord edema is characteristic. Intravenous glucocorticoids (eg, dexamethasone) are usually given to patients with neoplastic cord compression and severe neurologic deficits, although evidence of improved neurologic outcomes is limited. Definitive therapy with spinal surgery and/or radiation therapy increases the likelihood that the patient will regain normal ambulation; choice of therapy depends on the patient's characteristics. Those with an unstable spine, limited disease burden, and favorable prognosis can benefit from spinal surgery (eg, tumor resection, spine stabilization) followed by radiation therapy as these patients have a higher likelihood of regaining neurologic function. Radiation therapy alone can be considered in patients with a stable spine and radiosensitive neoplasm (eg, breast cancer, lymphoma, multiple myeloma) or as palliative therapy in those with a poor prognosis and limited life expectancy. (Choices A, D, and E) Androgen deprivation therapy with leuprolide can be used to treat metastatic prostate cancer, and intravenous chemotherapy (eg, taxanes) can be considered in patients with castrate-resistant prostate cancer. Parenteral bisphosphonates such as pamidronate can be useful in treating bone pain and delaying pathologic fractures in patients with castrate-resistant prostate cancer and bone metastases. Pamidronate should be used very cautiously in those with renal insufficiency. This patient's spinal cord compression is a neurologic emergency, and he should first be evaluated for definitive spinal surgery to help prevent permanent disability before considering any of these therapies. (Choice C) Intrathecal chemotherapy is used to treat leptomeningeal (dura, arachnoid, and pia mater) metastases due to certain solid and hematologic malignancies (eg, breast, lymphoma, leukemia among others). This patient has extrinsic cord compression from an epidural mass, not leptomeningeal metastases. In addition, leptomeningeal spread of prostate cancer is extremely rare, and it is not treated with intrathecal chemotherapy. Educational objective: Patients with neoplastic epidural spinal cord compression and severe neurologic symptoms can benefit from intravenous corticosteroids (eg, dexamethasone). Definitive management with spinal surgery (eg, tumor resection, spine stabilization) is indicated emergently in patients with an unstable spine, limited disease burden, and favorable prognosis to increase the likelihood of regaining mobility. __________ References: Intramedullary spinal cord metastasis from rectal cancer. (http://www.ncbi.nlm.nih.gov/pubmed/25360432) Treatment of spinal cord tumors. (http://www.ncbi.nlm.nih.gov/pubmed/19523357)

A 76-Year-Old Man Is Brought to the Emergency Department Due