PROSTATE CANCER – ASSOCIATED BONE LESIONS

This 80-year-old patient presents with lower back pain after having been recently told that his prostate cancer was in remission. Observe the multiple radiopaque lesions scattered throughout the lumbar spine, pelvis and sacrum. There are very large round radiopaque lesions present within the L1, L2, L3 and L4 vertebral bodies. These radiopacities represent osteoblastic metastatic disease from this patient’s previously docomented prostate cancer. When prostate cancer spreads it usually seeds the lower abdominal and paraspinal lymph nodes as well as spreading to the bone. All of these radiopaque lesions in the pelvis and lumbar spine represent osteoblastic metastatic carcinoma from the patient’s prostate cancer. On some occasions the osteoblastic lesions can produce a classic “Ivroy vertebrae” with more uniform sclerosis. Paget’s disease often can produce an ivory vertebrae but will produce bone expansion to help differentiate this from osteoblastic metastasis which should not produce bone expansion. The most common location for osteoblastic metastasis from prostate cancer is to the proximal femurs, pelvis, sacrum and lumbar spine as noted in this case.

BEWARE OF CALCIFICATION IN THE NECK

Note the calcification present lateral to the facet structure at the C3/4 and C4/5 levels. This is consistent with conduit vessel calcification and in this location, is related to advanced atherosclerosis in the carotid arteries. Atherosclerosis of the carotid artery often occurs at its bifurcation (bulb) at the C4 to C5 level. This degree of atherosclerosis is quite severe. It is best seen on the AP lower cervical spine radiograph but occasionally it could be seen anterior to the vertebral bodies at the C4 level on the lateral film. This type of atherosclerotic calcification is “hard” plaquing which is visualized on radiography but there can also be “soft” plaquing which cannot be seen without further imaging. This can narrow the artery even further and both can lead to reduced blood flow to the brain stem. Patient’s with atherosclerosis of the carotid arteries should have a diagnostic ultrasound to determine the degree of stenosis of the patient’s blood flow. If the reduction of blood flow reaches approximately 70% or above most vascular surgeons would consider surgical intervention to reduce the plaque. The usual surgical procedure performed is an endarterectomy removing the plaque which is usually quite successful in restoring adequate blood flow. This degree of atherosclerotic plaque within the carotids can predispose the patient to a possible stroke. High-velocity, low-amplitude manipulation in a patient with this degree of atherosclerosis is not recommended, particularly before ultrasound is performed. Any extension rotation manipulation of an area with this degree of atherosclerosis should be avoided. If cervical manipulation is performed, it should be done in the supine, flexed position