The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign...
Transcript of The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign...
A N G E L A L A U ( P M H )
I H G M 2 2 / 2 / 2 0 1 4
Bone lesions: Malignant or Benign or Both?
Case Profile
M/71 (PK Ho) Good past health
Retired E&M supervisor
Father of 3 sons
Lives with elder son, GS & wife (recent #Patella with OT done) at public housing
Premorbid: main carer at home, ADL/iADL-I
Hospitalized PMH twice for 2 falls: 14/9/2012
4/11/2012
History
One minor fall in 7/2012 fell on bottom while attempting to sit on sofa, could get up by
himself, no severe pain, no medical consultation
1st presented to AED on 14/9/2012 12/9/12: fell from sofa backwards onto ground while standing
on sofa to clean a fan; severe pain and could not get up
R hip and L chest wall contusion
XR (CXR, L lower ribs, Pelvis & R hip) taken
Rx Voltaren & Triact prn
XRays
Called back AED
Called back & admitted EM ward 18/9/2012 Persistent R hip pain
XR R hip (14/9, 18/9): no fracture
Noted high BP 245/107
Cr 98, LFT normal, Hb 13.0; ECG normal
Rx Norvasc 7.5mg, Ibuprofen, Panadol, Pepcidine, Analgesic ointment
Refer GOPC
GOPD FU
FU GOPD for hypertension Persistent BP upon FU (21/9/12) Norvasc (28/9/12) Moduretic (3/10/12) Atenolol
Persistent mechanical R hip pain, able to walk unaided (3/10/12) Panadol (16/10/12) Voltaren SR
GOPC visit on 29/10/2012 not taking atenolol because feel dizziness with it still pain over R hip radiate to R LL, worst when weight bearing impression: HT , at least partially due to hip pain refer physiotherapy, NSAID, off atenolol , repeat other anti-HT
Admission
Admitted PMH on 4/11/12 Sliding down from sofa to floor due to L LL weakness
L sided weakness since last episode of fall 14/9/12
Leaned on L side while walking; with unsteadiness & recurrent falls (e.g. fell while attempting to hang up clothes)
Persistent R hip pain
Power
L side muscle tone
5 4
5 3
Investigations
CXR (4/11/12): RUZ fibrocaclifications show no interval change
XR pelvis (4/11/12): no fracture
CT brain (6/11/12): R frontal lobe infarct, Lacunar infarcts in genu of L internal capsule & R BG
TCD: Normal screening on IC & EC neck arteries
Dx: Stroke, delayed presentation
Progress during Rehabilitation
R hip pain and LBP XR LS spine (11/12/12)
Mild diffuse osteopenia
Degenerative changes with marginal
osteophytes noted in lumbar spine
Disc spaces and pedicles intact
XR R Hip & Pelvis
Normal alignment. No fracture seen
Phleboliths noted over both sides
XR Pelvis
Progress during Rehabilitation
R hip pain and LBP Failed to tolerate Tramadol due to GI upset
Analgesics
Voltaren SR (100mg) with PPI cover + Gabapentin (100mg bd & 300mg nocte) + Analgesic balm
Stroke prophylaxis
Aspirin (160mg) + Zocor (20mg) + Enalapril (5mg) + Norvasc (10mg)
Complication
Progressive Anaemia Hb 13 (18/9/12) 13.2(4/11/12) 10.1 (22/2/13) 8.4
(8/3/13)
OGD with Bx: mild chronic gastritis at antrum, HP –ve
FE/TIBC 8.6/48.8; FeSat 18%; Ferritin 843
FOB –ve X 3
VitB12 203 (28/11/12) ; 166 (13/3/13) pmol/L
RBC Folate 438 ; Serum Folate 6.8 (28/11/12) nmol/L
TSH 1.0 (normal)
Aspirin/Voltaren SR taken off
Rx: DF118
Colonoscopy booked
Progress during Rehabilitation
Team round (19/2/13): Patient is not participating in rehabilitation due to pain Pain score 5/10 (despite given analgesics)
PE showed marked tenderness over Rt pelvis and sacrum
Previous X-rays of Ribs, Hips, LS spine & pelvis revealed osteopenia and #Rib
?Sacral insufficiency fracture complicating fall & osteoporosis
Check VitD level
Rx Calcitonin & anti-osteoporosis Rx
Book CT sacrum
Vitamin D Deficient
Serum vitamin D level (20/2/13) 25OH D2 <10 nmol/L
25OH D3 18 nmol/L
Total 25OH VitD 18 nmol/L
<12.5 nmol/l Severe deficiency
12.5-29 nmol/l Moderate deficiency
30-49 nmol/l Mild deficiency
Ca/PO4: 2.31/1.25, iCa 1.19
Albumin: 36 (4/11/12)
ALP: 105 (4/11/12) 898 (15/5/13)
CT sacrum (11/3/2013)
Mixed sclerotic & lytic areas in L5, S2 to S4 sacrum and L iliac bone; small lytic area in R iliac bone.
Findings are suggestive of multiple bone metastasis, with pathological fractures in L5 vertebra and R iliac bone.
Prostate enlarged
Prominent right groin lymph node (1.5cm)
Approach to CT bone lesion
Morphology & Age Well-defined osteolytic
<40 years old Giant cell tumor / Osteblastoma / Enchondroma
Chondrosarcoma / HyperPTH with Brown tumor >40 years old
Metastases / Myeloma
Ill-defined osteolytic <40 years old
Giant cell tumor >40 years old
Metastases / Myeloma / Chondrosarcoma
Sclerotic <40 years old
Bone island / Healed lesions / Enchondroma / Osteoma >40 years old
Metastases Bone island
Infection
Images from www.radiologyassistant.nl
What is in our mind?
Differential Diagnoses
Malignant: Metastases
Prostate / Breast / Lung / Lymphoma / Carcinoid
Benign: Severe Vitamin D deficiency
Paget’s disease
ALP with normal Ca & PO4
Tuberculosis infection
Sacral insufficiency fractures
Post-traumatic osteomyelitis of Rt iliac bone & L5 vertebra
Bone island
Sacral Insufficiency Fracture
Stress fracture: normal stress applied to abnormal bone that lost elastic resistance
Causes: Osteoporosis / metabolic bone disease
Imaging CT / MRI
Therapy Conservative – strict bed rest & pain control
Rehabilitation – after 6-15months
Sacroplasty
Complications Immobilization
Work Up
PE DRE – Anal tone intact, Hard Prostate 3FB
Shotty R groin LN ~0.5cm
Inflammatory markers CRP 7.7 (3/4/13) / ESR 41 (22/2/13)
Spt AFB smear C/ST –ve
EMU AFB C/ST -ve
Tumor markers (13/3/13) PSA: 355
CEA: 2.2 / AFP: 8.2 / CA 19.9: 13
IgA 2.29 / IgG 13.1 / IgM 1.08 / SPE – no abnormal band
Spt Cytology -ve
XRays
Private CT thorax & Abdomen (13/3/2013)
Primary site at R prostate gland Evidence of R extra-capsular spread and neurovascular bundle
encasement.
Multiple bone metastases Sclerotic metastases with compression # over C7, T4, T9 and L5 Sclerotic-lytic metastases of L 1st 3rd & 7th ribs Mixed sclerotic-lytic metastases at sacrum and bilateral ilium
Lymphadenopathy: Extensive pelvic & intra-abdominal nodal metastases Thorax: pre-vascular and right axillary region
Lungs: A large area of fibrocalcific scarring with concave borders seen at R lung
apex, measuring 2 X 5.8cm Cluster of small centrilobular nodules over RLL, more likely infection
than malignancy
Bone scan (20/3/2013)
US Urinary
Prominent irregular prostatic mass protruding into bladder
R kidney 8.2cm & L kidney 9.6cm, no focal lesion or hydronephrosis
Disease Progress
Disseminated Ca prostate Oncology (5/4/2013)
Metastatic CA prostate for androgen ablation with medical or surgical castration
Refer Urology x TRUS Bx Orchidectomy
Urology (22/4/2013)
Patient opted for bil Orchidectomy without TRUS Bx
Bil Orchidectomy done 24/4/13
Patho: No evidence of malignancy
PSA 355 10.7 (9/13) 28 (12/13)
ALP 898 (15/5/13) 590 (17/6/13) 108 (31/12/13)
Problem lists
Pathological # L5 vertebra and R iliac bone Morphine SR 90mg bd & Panadol 500mg q4h prn
Attempted palliative RT to L spine but patient cannot tolerate set up position, RT cancelled
Moderate VitD deficiency CaCO3 & Alfacalcidol (switched to cholecalciferol later)
Total 25OH VitD 90 (7/8/2013)
NcNc anaemia On B12 & Folate & Fe supplement
Hb 8.4 (8/3/13) 10.2 (15/5/13) 11 (31/12/13)
Problem lists
HT BP 88/45 – 115/65 mmHg
Atenolol, Enalapril, Norvasc taken off
Hyperlipidaemia TC 5.8/LDL 3.9 (6/11/2012), Rx: Zocor
Taken off with CK 488
Recheck TC 2.7/LDL 1.3 (8/3/2013)
Constipation Senokot 15mg bd & Fleet enema alternate daily
Depression GDS (18/7/13) 10/15 (very depressed), Rx Zoloft
Rehabilitation Progress
Upon discharge to OAH (31/7/2013) Tolerate 10 min of sit out
BI 56/100
ADL-I up to feeding and grooming, dressing with assistance, transfer with 2 assistance
Discussion
Prostate cancer
Incidence 3rd most common cancer in men
10.7% of new cancer cases in male in 2010
45.3 per 100,000 male
~1000 newly dx case/year
Mortality 5th leading cause of male cancer deaths in HK
3.8% of male cancer deaths
~300 deaths/year
Risk factors
Age, Median age of dx 72
Family hx BRCA2 & BRCA1 mutations
Ethnic African-Americans
Smoking
Obesity
Others Prostatitis (RR=1.6)
Hx of Syphilis / gonorrhea (RR=1.4)
Decision for PSA screening
Information
Support for decision-making
Decision for Prostate Bx
PSA level
DRE findings
Risk factors
Risk & benefit of Bx Having to live with the dx of clinically insignificant prostate
cancer
When clinical suspicion of prostate cancer is high (high PSA /evidence of bone met identified by positive isotope bone scan or sclerotic metastases on plain radiographs) No prostate bx for histological confirmation needed
TNM Staging
Extend of tumor
Evaluation of LN
Distant metastasis
Risk Stratification
National Comprehensive Cancer Network (NCCN)
Low-risk
Localized to 1 lobe of prostate, PSA <10 ng/ml, GS 6
Intermediate-risk
Intracapsular extension, PSA 10-20 ng/ml, GS 7
High-risk
Extracapsular extension, PSA >20 ng/ml, GS 8-10
Prostatectomy / ADT / RT
Watchful wait / Active surveillance
Low-risk
1st visit Multiparametric MRI
Year 1-4 PSA every 3-4 months
DRE every 6-12 months
Prostate Re-Bx
Year 5 onwards PSA every 6 months
DRE every 12months
Radical Tx for disease progression
*NICE guideline 2014
Intermediate/High-risk
Radical Prostatectomy Intermediate / high-risk patient * High-risk : Post-op RT
ADT plus RT (2-3 years) High-risk patient ADT & RT 10-year overall survival then ADT alone ** ADT & RT 15-year cancer specific mortality rate #
Androgen Deprivation Therapy (ADT) Bilateral Orchiectomy Gonadotropin releasing hormone (GnRH) agonist Antiandrogen
Radiation Therapy (RT) External beam RT External beam & brachytherapy
*PIVOT trial. N Engl J Med.2012;367(3):203 **NCIC Intergroup phase III trial. Lancet.2011;378(9809):2104 #Scandinavian Prostate Cancer Gp Study, open randomised phase III trial.2014 ASCO
Disseminated Tx
Medical (ADT) / Surgical Orchiectomy
Chemotherapy
Table from 2014UpToDate
Monitor Adverse effects
Radical Prostatectomy Sexual dysfunction Urinary incontinence
ADT Hot flushes Sexual dysfunction Osteoporosis
Zoledronic acid/Denosumab* (for castration-resistant CA prostate with bone met, failed analgesics & palliative RT)
Gynaecomastia Fatigue Anaemia
RT Radiation-induced enteropathy
* Efficacy and safety of zoledronic acid in men with castration-sensitive prostate cancer and bone metastases: Results of CALGB 90202 (Alliance). J Clin Oncol 2013; 31
Same in Elderly?
Prostate Cancer in Elderly
Effect of Age, Tumor Risk, and Comorbidity on Competing Risks for Survival in a U.S Population-Based Cohort of Men with Prostate Cancer Annals of Internal Medicine Sept2013 Population-based cohort 3183 men with non-metastatic prostate cancer at diagnosis Baseline comorbidity
DM / HT CHF / IHD / MI / Angina / CVA GIB / Cirrhosis or liver disease / IBD Chronic lung disease Arthritis Depression
Tumor characteristics Initial treatment Overall & Disease-specific mortality through 14years FU
Mortality Curve
Assess Comorbidities
Cumulative Illness Score Rating-Geriatrics (CISR-G) Grade 0: no problem
Grade 1: current mild problem or past significant problem
Grade 2: moderate disability or morbidity, requires first-line therapy
Grade 3: severe/constant significant disability/uncontrollable chronic problem
Grade 4: extremely severe/immediate treatment required/end-organ failure/severe Impairment in function
ADL & iADL
Nutritional status
Health Status of Elderly
Society of Geriatric Oncology (SIOG) Healthy
No serious comorbidities, ADL/iADL-I, no malnutrition Same as young
Vulnerable with reversible problem 1 uncontrolled comorbidity, iADL-d but functionally-I, at risk of
malnutrition Same as young exclude radical prostatectomy
Frail with non-reversible problem ADL-pd, malnutrition Symptomatic mx without definitive Tx (e.g androgen deprivation)
Terminal Bedridden, major comorbidities, cognitive impairment Palliative
Discussion
2008 US Preventive Services Task Force >75 cessation of screening and treatment *
Life expectancy <10 years
50% other-cause mortality
Against PSA screening in healthy men
Effect of Age, Tumor Risk, and Comorbidity on Competing Risks for Survival in a U.S Population-Based Cohort of Men with Prostate Cancer Age 60 with 3 comorbidities
10 years mortality ~50%
All cause mortality >potential survival benefit from aggressive therapy
*Screening for prostate cancer: U.S.Preventive Services Task Force recommendation statement. Ann Intern Med.2008;149:185-91. [PMID: 18678845]
Progress of Mr Ho
Progress of Mr Ho
Upon FU (18/12/2013) Kyphotic
Bedchair bound
Complicated with UTI with AROU (31/12/2013) with foley inserted, Rx Augmentin
Foley weaned 15/1/2014
Xrays (22/7 & 21/8/13)
Take Home Message
Sacral / Pelvic fractures may be subtle on XR
Sclerotic bone lesions take time to develop on XR
Devastating pain warrant further imaging
Screening & Mx of prostate cancer is subjected to individual’s health & risk of disease progression Healthy / Vulnerable elderly with 1 comorbidity &
functionally-I
Radical prostatectomy / ADT / RT / Watchful wait / Active surviellance
Frail elderly ADL-pd, malnutritioned / Bedridden
Symptomatic Tx / Palliative
~Thank you~