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\begin{document}

\title{Prostate adenocarcinoma presenting as diffuse osteolytic metastases}



\author[1]{Mohanad Faisal}%
\author[2]{Abdulrahman  Al-Mashdali }%
\author[1]{Noor Jasim}%
\author[1]{Mohamed Khalil}%
\affil[1]{Hamad Medical Corporation}%
\affil[2]{Hamad Medical Corporation Department of Medical Education}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\begin{abstract}
Prostate cancer is one of the most common cancers that metastasize to
the bone. bone metastasis is usually osteoblastic, and diffuse
osteolytic lesion on presentation is unusual. Here, we are reporting MRI
image of patient presented with diffuse osteolytic lesion and found to
have metastatic prostate cancer.%
\end{abstract}%



\sloppy


\textbf{Title: Prostate adenocarcinoma presenting as diffuse osteolytic
metastases}

Mohanad Faisal*, Abdulrahman F. Al-Mashdali, Noor Jasim, Mohamed Salem
Ismail Khalil

Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar.

*Corresponding author, email: mmfobaidy@gamil.com

\textbf{Abstract:}

Prostate cancer is one of the most common cancers that metastasize to
the bone. bone metastasis is usually osteoblastic, and diffuse
osteolytic lesion on presentation is unusual. Here, we are reporting MRI
image of patient presented with diffuse osteolytic lesion and found to
have metastatic prostate cancer.

\textbf{Key clinical message:}

Prostate cancer can present as diffuse osteolytic bony lesions and
clinician should keep in mind such differential when encountering such
presentation.

\textbf{Case presentation}

A 44-year-old Asian male who is not known to have chronic diseases and
presented with a 1-year history of dull aching backache. Initially, it
was mild, relapsing-remitting in nature, but it has become more
progressive lately. It is not related to movement and is present both
day and night. It was not associated with stiffness, but the patient
reported 8 kg unintentional weight loss during the last six months. The
patient reported some leg weakness also during the last few days. He
denied fever and sensory symptoms with no urinary or fecal incontinence.
The patient is a nonsmoker and drinks alcohol on social occasions. He
has no family history of cancer. The examination was unremarkable except
for mild lower limb weakness due to pain in the back and lower limbs.
Laboratory workups were shown a normal complete blood count and renal
function test. His serum alkaline phosphatase was 153 U/l, and serum
prostate-specific antigen was 633 ng/ml. MRI spine (image 1)revealed
widespread multiple variable size osteolytic metastatic lesions in the
cervical, dorsal, lumbar, and sacral vertebral bodies and a few
appendicular sites showing T1 low, T2/STIR bright signal with
postcontrast enhancement mainly at C5, C7, T2, T3, T6, T7, T9, T11, T12,
and to, L4, S1, and S2 levels. Computed tomography of the abdomen and
pelvis redemonstrated multiple spines and diffuse destructive lytic
pelvic bony lesions. It showed large expansile soft tissue lesions with
bony destruction involving bilateral sacroiliac joints, multiple
enlarged iliac lymph nodes, and an enlarged non-homogenous prostate. PET
scan confirmed our findings. CT-guided right iliac Bone lesion biopsy
was done, and histopathology showed metastatic adenocarcinoma of
prostatic origin. IHC stains for NKX3.1 and AMACR showed that tumor
cells are robust and diffusely positive and IHC stain for PSA is focally
positive. The patient was diagnosed with metastatic prostate cancer, and
we planned to start him on androgen deprivation therapy and bone
modifying therapy.

\textbf{Discussion}

Prostate cancer is one of the most common cancers that manifest as bone
metastasis. The nature of the bone lesion in prostate cancer is
typically osteoblastic, but osteolytic bony metastasis as first
presentation has been reported.\textsuperscript{1,2} it's not uncommon
to see osteolytic lesion in prostate cancer as seen in one study by
Cheville et al. which found that 16.4\% of osseous prostatic cancer
metastatic lesions were lytic but prostate cancer with first
presentation of diffuse osteolytic lesion was not commonly reported
.\textsuperscript{3}Although the pathophysiology of prostate cancer was
thought to be osteoblastic; emerging evidence suggests that the
development of prostate cancer bone metastases requires osteoclastic
activity and osteoblastic activity. Prostate cancer cells produce a
variety of pro-osteoblastic factors that promote bone mineralization. In
addition to factors that enhance bone mineralization, prostate cancer
cells produce factors like the receptor activator of NF\selectlanguage{greek}κ\selectlanguage{english}B ligand (RANKL)
that promote osteoclast activity .\textsuperscript{4} Indeed, Osteolysis
has been implicated in tumor cell seeding and nourishment of tumor
growth via the development of pro-tumorigenic changes in the
microenvironment.\textsuperscript{5} clinicians and radiologists should
keep in mind that prostate cancer can present with diffuse osteolytic
lesions in a good proportion of patients and prostate cancer should be
an important differential to be considered in such cases.

\textbf{ACKNOWLEDGMENT}

The authors would like to acknowledge Qatar national library (QNL) for
this publication's funding and the HMC internal medicine residency
program for scientific support.

\textbf{CONSENT}

Written informed consent was obtained from the patient for the
publication of this case report

\textbf{CONFLICT OF INTEREST}

The authors have no conflict of interest to declare.

\textbf{AUTHOR CONTRIBUTIONS}

Mohanad Faisal: Data collection, literature review, consent taking, and
manuscript writing.

Abdulrahman F. Al-Mashdali : Final manuscript review and editing.

Noor Jasim: image editing, manuscript writing

Mohamed Salem Ismail Khalil: supervision, clinical follow up

All authors reviewed and approved the final version of the article.

\textbf{DATA AVAILABILITY STATEMENT}

Available upon request\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Image 1 : MRI of the spine showing} widespread multiple variable
size osteolytic metastatic lesions in the cervical, dorsal, lumbar, and
sacral vertebral bodies and a few appendicular sites showing T1 low,
T2/STIR bright signal with postcontrast enhancement mainly at C5, C7,
T2, T3, T6, T7, T9, T11, T12, and to, L4, S1, and S2 levels.

\textbf{References}

1. Rummel K, Benson J, Roller L. Prostate adenocarcinoma with osteolytic
metastases: Case report and review of the literature. \emph{Radiol Case
Rep} . 2021;16(11):3565-3568. doi:10.1016/j.radcr.2021.08.056

2. Idowu BM. Prostate carcinoma presenting with diffuse osteolytic
metastases and supraclavicular lymphadenopathy mimicking multiple
myeloma. \emph{Clin Case Rep} . 2017;6(2):253-257. doi:10.1002/ccr3.1336

3. Cheville JC, Tindall D, Boelter C, et al. Metastatic prostate
carcinoma to bone: clinical and pathologic features associated with
cancer-specific survival. \emph{Cancer} . 2002;95(5):1028-1036.
doi:10.1002/cncr.10788

4. Keller ET, Brown J. Prostate cancer bone metastases promote both
osteolytic and osteoblastic activity. \emph{J Cell Biochem} .
2004;91(4):718-729. doi:10.1002/jcb.10662

5. Sottnik JL, Keller ET. Understanding and targeting osteoclastic
activity in prostate cancer bone metastases. \emph{Curr Mol Med} .
2013;13(4):626-639. doi:10.2174/1566524011313040012

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