A 71-year-old man was admitted to the internal medicine department for a study of constitutional syndrome. Over the previous 6 months he had experienced progressive deterioration manifested by asthenia, anorexia, loss of about 20 kg of weight and inability to ambulate. His personal history included having been a smoker and heavy drinker up to 23 years previously and presenting type 2 diabetes mellitus and prostatism of approximately 5 years of evolution. Physical examination revealed a patient who appeared to be chronically ill and bradypsychic, with pale skin and mucous membranes and generalised loss of strength in all 4 limbs. No adenopathies. Crackles in the left lung base. Pain on percussion of the spine, more intense at the cervical and dorsal levels. Soft and depressible abdomen, painful on palpation in the right hypochondrium and periumbilical area, where on inspection and palpation there is a hard nodule, fixed to deep planes and measuring approximately 3 x 3 cm, covered with skin of normal characteristics. No visceromegaly. Rectal examination revealed a slightly enlarged prostate, with no irregularities, and the rest of the physical examination was normal.
Laboratory tests were normal: ALT: 47 U/l; GGT: 259 U/l; Alkaline phosphatase: 277 U/l; Urates 2.29 mg/dl. Moderate leukocytosis and thrombocytosis. ESR 41 mm at 1 hour. Rest of the general protocol including TSH within normality. Ferritin: 515 ng/ml; absence of M component in the proteinogram; normal alpha-fetoprotein; PSA: 11.5 ng/ml (normal values from 0.4 to 4); Carcinoembryonic antigen: 221 ng/ml (normal values up to 5); and Ca 19.9 of 188 U/ml (normal values up to 37). No 24-hour uricosuria was performed.
FNA of the periumbilical nodule showed the presence of malignant cells suggestive of adenocarcinoma and the primary tumour was then searched for: Chest X-ray showed an alveolar infiltrate in the left lower lobe; abdominal ultrasound: poorly assessable due to abdominal air distension, although the periumbilical nodule was visible. Bone scintigraphy showed multiple hypercapillary accumulations in the axial and peripheral skeleton. Thoracic-abdominal CT revealed a nodule measuring 1.4 x 1.6 cm in the right upper lobe, in contact with the visceral pleura, which appeared thickened and with lytic lesions in the posterior costal arch. Lytic metastases at the level of the dorsal spine and sternum. Minimal bilateral pleural effusion. Multiple focal hepatic lesions in segment III with vascular pattern compatible with haemangiomas. Lesion of 1.1 cm in segment IV probably metastatic. Nodule of 1.4 cm in left adrenal gland suggestive of adenoma. Hypodense lesion in the tail of the pancreas measuring 1.7 x 1 cm possibly related to primary tumour. Tumour implants in soft tissues, one of them at periumbilical level, compatible with the nodule of the sister María José, and another in the right iliac muscle, with metastatic bone infiltration in the pelvis, sacrum and lumbar vertebrae. After performing the aforementioned imaging techniques, which did not define a clear origin of her carcinomatosis, after 2 weeks in hospital she was transferred to the Palliative Medicine unit, where she died.
