Introduction

This case highlights the diagnostic and therapeutic challenges encountered in managing an elderly patient presenting with multifocal symptoms, raising suspicion for malignancy. The interplay of urinary symptoms, systemic complaints, and imaging findings underscores the importance of a systematic approach to diagnosis and treatment.

Case Presentation

A 97-year-old male presented with difficulty urinating, pain in the waist and thighs, cough, nasal congestion, chest pain, abdominal pain, and dizziness. Physical examination revealed:

• Drooling
• Decreased muscle strength
• A hard non-tender mass in the left axilla
• Reduced breath sounds in the left lung
• An enlarged prostate
• Bipedal edema

Vital signs were stable (temperature 36.2°C, pulse 90 bpm, blood pressure 136/80 mmHg, oxygen saturation 97%).

Initial Workup

Laboratory Findings:

• Hemoglobin: 11 g/dL (anemia)
• White blood cell count: 2.43 x 10³/µL (leucopenia)
• Kidney function test: Normal
• Liver function test: Normal
• Prostate-specific antigen (PSA): 24.65 ng/mL (elevated)
• HbA1c: 5.8% (normal)

Imaging:

Chest CT scan: Subpleural and intrapulmonary nodules, bronchiectasis, fibrosis, and a lytic lesion in the right 6th rib with cortical destruction.

Differential Diagnosis

The clinical presentation and findings raised suspicion for:

1. Metastatic Prostate Cancer (most likely, given elevated PSA and lytic bone lesion).
2. Primary Lung Cancer with Metastases (less likely due to elevated PSA).
3. Infectious Etiologies (e.g., tuberculosis, though less likely given imaging features).
4. Paraneoplastic Syndrome (drooling and muscle weakness as possible neurological manifestations).

Diagnostic Approach

• Prostate Biopsy: To confirm adenocarcinoma.
• CT-Guided Biopsy: Of the lytic rib lesion or axillary mass to evaluate for metastasis.
• Bone Scan: To assess for additional skeletal involvement.
• PSMA PET-CT: For staging if available.

Treatment Plan

Based on the findings, the working diagnosis was metastatic prostate cancer. The treatment plan included:

Systemic Therapy:

• Androgen deprivation therapy (ADT) with leuprolide or goserelin.
• Bone-targeted therapy (denosumab or zoledronic acid) for lytic lesions.
• Consideration of docetaxel or AR-targeted agents (e.g., abiraterone, enzalutamide) if castration-resistant disease develops.

Symptom Management:

• Tamsulosin for urinary symptoms.
• Opioids and NSAIDs for pain control.
• Nutritional support for dysphagia (due to drooling).

Supportive Care:

• DVT prophylaxis given immobility risk.
• Multidisciplinary palliative care consultation to address quality of life.

Outcome and Follow-Up

The patient underwent a transrectal ultrasound-guided biopsy, which confirmed adenocarcinoma of the prostate. Imaging studies demonstrated widespread metastatic disease involving the ribs, lungs, and lymph nodes. He was started on ADT and received radiation therapy for symptomatic bone metastases. Pain improved significantly, and urinary symptoms were managed effectively with tamsulosin.

Despite the advanced stage of the disease, the patient reported improved well-being with supportive care measures. Close follow-up with oncology and palliative care teams ensured ongoing symptom management and adjustment of therapies.

Discussion

This case illustrates the importance of considering malignancy in elderly patients with systemic symptoms, particularly when laboratory and imaging findings point toward metastatic disease. Elevated PSA, combined with lytic bone lesions and pulmonary nodules, strongly suggests metastatic prostate cancer. Early involvement of multidisciplinary teams (oncology, radiology, and palliative care) is crucial for optimizing outcomes in such cases. Etiology: Patients with HOXB13 gene and BRAC2 are more likely to develop prostate cancer.

Key takeaways include:

• High index of suspicion for malignancy in elderly patients with unexplained systemic symptoms.
• Comprehensive workup (biopsies, imaging, lab tests) to confirm diagnosis and guide treatment.
• Holistic approach balancing curative and palliative strategies, especially in advanced disease.

Conclusion

This case underscores the complexity of diagnosing and managing metastatic prostate cancer in older adults. A systematic approach to evaluation and a focus on patient-centered care are essential for achieving the best possible outcomes. By integrating evidence-based treatments with supportive care, clinicians can improve both survival and quality of life for patients facing advanced malignancies.