Co-existent Paget's Disease of the Bone, Prostate Carcinoma Skeletal Metastases and Fracture on Skeletal Scintigraphy-Lessons to be Learned

Paget Disease of Bone Harboring Bone Metastatic Neuroendocrine Cancer: A Case Report

In this case report, we describe an uncommon case of neuroendocrine cancer of unknown origin began with cauda equina syndrome in a patient affected by Paget disease of bone (PDB). A 76-year-old man with diagnosis of PDB, without history of pain or bone deformity, developed sudden severe low back pain. Bone alkaline phosphatase was increased and MRI and whole-body scintigraphy confirmed the localization of the disease at the third vertebra of the lumbar spine. Treatment with Neridronic Acid was started, but after only 2 weeks of therapy anuria and bowel occlusion occurred together with lower limb weakness and walking impairment. Cauda equina syndrome consequent to spinal stenosis at the level of L2-L3 was diagnosed after admission to Emergency Department and the patient underwent neurosurgery for spinal medulla decompression. The histologic results showed a complete subversion of bone structure in neoplastic tissue, consistent with metastatic neuroendocrine carcinoma of unknown origin. In conclusion, low back pain in the elderly may require deep investigation to individuate rare diseases. In asymptomatic patients with apparently stable PDB, the sudden appearance of pain or neurologic symptoms may alert the clinician for the possibility of other superimposing diseases, like bone metastases.

Hypercalcemia in a patient with a bowing femur

Hypercalcemia in PDB is rare; its occurrence requires thorough investigations as it may reveal several diseases, such as primary hyperparathyroidism, malignant transformation, metastases, or myeloma.

Paget's Disease of Bone in Tunisia: A Study of 69 Patients

CONTEXT

Paget's disease of bone is a common bone disease with a striking variation in its incidence and characteristics in different parts of the world. It is uncommonly reported in African patients.

AIMS

Given the lack of studies describing the characteristics of patients with Paget's disease of bone in North Africa, we aimed to describe demographic, clinical, biochemical, and imaging characteristics, as well as treatment outcomes of Tunisian patients with Paget's disease of bone.

SUBJECTS AND METHODS

This bicentric and retrospective study included patients with Paget's disease of bone. Clinical, laboratory, radiological profile, and response to treatment were analyzed.

RESULTS

Sixty-nine patients were identified. The mean age was 64.9 ± 11.6 years and 52.2% were women. One patient reported a positive family history. Seven patients were asymptomatic. Bone pain was the most common presenting symptom. Eight patients had a history of malignancy. In three patients, Paget's disease of bone was diagnosed as part of a metastatic workup. Monostotic disease was found in half of the cases. The most commonly involved sites were pelvis (43.5%), femur (21.7%), and spine (21.7%). The mean serum alkaline phosphatase level at presentation was 591 U/L (68-8380). Two patients received salmon calcitonin (2.8%) and 47 patients (68.1%) received bisphosphonates. After a mean follow-up of 55 months (2-240 months), bone pain improved in 43.1% of patients and the serum alkaline phosphate levels had normalized in 22 of them (43.1%). During follow-up, there was no malignant transformation.

CONCLUSIONS

In this series of Tunisian patients, Paget's disease of bone had a female predominance and was usually monostotic. The clinical and radiological presentations were similar to the European series.

Synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease in a case of newly diagnosed prostatic carcinoma

Tc-99m methylene diphosphonate bone scintigraphy (bone scan) is a highly sensitive technique for the evaluation of osseous pathology. However, the nonspecificity of the method can present diagnostic challenges in differentiating benign from malignant processes. Often, Paget’s disease and osseous metastasis can coexist in elderly patients. Therefore, it is important to accurately distinguish the two pathologies, as each has a different prognosis and impacts clinical management. Obtaining the appropriate clinical diagnosis often involves a combination of laboratory, radiographic, and clinical data. We present a case of newly diagnosed prostatic carcinoma presenting with synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget’s disease.

An unusual presentation of metastatic bone disease in a subject with Paget's disease of bone

Solid organ malignancies involving breast, prostate, and lung frequently metastasize to the skeleton. However, the occurrence of Paget's disease and metastatic bone disease in the same patient is uncommon. We report a case of a 63-year-old man who presented with back pain and a lump in the right breast. He was earlier diagnosed to have Paget's disease of bone based on characteristic skeletal radiological features,^99mTc methylene diphosphonate bone scan and elevated alkaline phosphatase, and treated with bisphosphonates, and his disease was in remission. Further evaluation revealed an underlying skeletal metastatic disease secondary to a breast malignancy. He underwent radical mastectomy with axillary node clearance, radiotherapy, and chemotherapy. In addition, he also received parenteral bisphosphonates for his skeletal metastatic bone disease.