A 57-year-old man came from the Emergency Department complaining of pelvic pain.
She reported a personal history of adrenal insufficiency with suspected hypoaldosteronism, chronic obstructive pulmonary disease (COPD) treated with bronchodilators.
After multiple transurethral resections for bladder adenocarcinoma, a prostatectomy plus left nephrectomy with Bricker-type derivation for prostate adenocarcinoma, left vesical carcinoma and pyelonephrotic annulation were performed.
After 6 weeks drainage was performed by percutaneous puncture of pelvic abscess post-surgical.
Approximately one year after surgery, the patient started with significant PSA elevations of 858.59 ng.ml-1, hormonal blockade was established with antiandrogens, which were not effective.
Clinically, the patient presented asthenia and anorexia, with an elevation of alkaline phosphatase of 1,404 U.L-1, a decrease in hematocrit (28.1%) and hemoglobin (9.3 g.dl-1), and treatment with erythropoietin plus iron was initiated.
A computerized axial tomography (CAT) revealed non-crapelvic structures lymphadenopathic affectation of a tactical nature, pelvic metastases, and metastatic retroperitoneal spine.
A new control was carried out after three months with similar findings, calling attention to the important existing manifestation in all dorsal and first lumbar vertebral bodies as well as in all ribs, compatible with blastic metastases.
The reason for consultation in our Pain Unit was the existence of pain in the pelvis, lumbar region, both hips, right inguinal region and right lower extremity with sensation of loss of strength.
Pain was continuous, with VAS pain intensity of 8/10, difficulty sleeping, increased with mobilization and associated paresthesia of both extremities.
On physical examination, mild paresis of the right lower limb (4/5) was observed on the muscle balance scale.
An important metastatic dissemination was requested in a gamma camera, right shoulder, both shoulder joints, neck, pelvis, both tibias.
1.
Treatment was initiated with amitriptyline 25 mg.24 h-1, controlled-release morphine sulfate 15 mg.12 h-1, lysis acetyl salicylate 1800 mg.8 hmi metazol-1, analgesic lactulose-1 and 1000 mg.
During the follow-up visit, pain was poorly controlled despite analgesic treatment.
Morphine sulfate was increased 30 mg.8 h-1, starting treatment with dexamethasone and referred to the Nuclear Medicine Service to assess palliative treatment with Sm-153 Lexidronam (Quadramet®).
The patient had anemia prior to treatment.
Treatment regimen included 80 mCi of Sm-153.
After one week, the pain of the lumbar region and pelvis persisted within 48 hours, remaining in the law.
The VAS was 5/10 and ambulation had improved.
It was decided to maintain the same analgesic treatment except the dexamethasone that was withdrawn.
After 4 weeks of Sm-153, the patient was asymptomatic with a score of 1/10. Control laboratory tests showed leukopenia (3.000/mm3) and platelets without clinical repercussions (12.000/mm3).
Opioids and NSAI were progressively removed, establishing a patient with amitriptyline 25 mg.24 h-1 and metamizole on demand.
Clinical improvement was maintained after 8 weeks and laboratory tests were normalized.
