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.