A 54-year-old male patient with no personal history of interest.
He attended the Emergency Department of our hospital in September 2005 due to right frontoparietal headache and lateral gaze diplopia of 2 weeks' duration, as well as right eyelid oedema for the last week.
He was initially assessed by the Ophthalmology Department, which found moderate exophthalmos in the right eye, inflammation, hyperemia and moderate upper and lower right eyelid swelling, limitation in all gaze positions and diplopia. Visual acuity was not impaired. The intraocular pressure (IOP) of the right eye was 20 mmHg, the IOP of the left eye was 10 mmHg. Fundus examination was normal.
An orbital CT scan was requested, showing an enlargement of the sphenoid bone with a permeative pattern and hyperostosis of the orbital face with a soft tissue mass bulging the lateral rectus muscle. There was also occupation of the ethmoid cells.

The patient was admitted to the neurosurgery department and a cranial MRI was requested, which was reported as a possible hyperostosis meningioma in the right periorbital plate of the greater wing of the sphenoid, without being able to rule out fibro-osseous sphenoid lesions.
Surgical biopsy of these lesions was scheduled. The anatomopathological result of the biopsy was connective tissue, striated skeletal muscle and isolated bony trabeculae with nests and cords of epithelial cells with ample cytoplasm that focally formed glandular lumina, in the bone there was metastasis of adenocarcinoma with immunohistochemical positivity for Prostate Specific Antigen (PSA).
In view of these findings, the Urology Department was consulted. A directed anamnesis revealed alterations in urination in recent months (pollakiuria and nocturia) and haemospermia.
Physical examination
Rectal examination: prostate volume II/IV, stony consistency in both lobes, fixed, suspicious for prostate cancer.
Complementary tests
PSA: 389 ng/ml
Transrectal prostate biopsy: prostatic adenocarcinoma Gleason 4+4=8, extensively affecting both lobes.
Tc99m bone scan: imaging showed multiple areas of hyperenhancement involving the right zygomatic region and right internal orbital region, both costal ribs, dorsolumbar spine, iliac spine, right acetabular and ischiopubic region, left iliac spine and acetabular region and middle third of left femoral diaphysis.

Diagnosis
Adenocarcinoma of the prostate Gleason 4+4=8 with multiple bone metastases.
Treatment
Treatment with complete hormonal blockade (Bicalutamide 50 mg/24h and Goserelin 10.8 mg/12 weeks) and bisphosphonates (Zoledronic acid 4 mg iv /4 weeks).
Evolution
After the establishment of the androgen blockade, there was a progressive improvement of the ocular symptoms. During the first 7 months of follow-up the patient remained asymptomatic.
At 8 months the patient was admitted to the Urology Department with haematuria, which did not improve with continuous bladder lavage and required bladder TUR, which revealed a large prostatic neoformative process invading the bladder floor. Pathological anatomy of the resection fragments: foci of prostatic adenocarcinoma with involutive changes secondary to hormone treatment.
Nine months after the initial diagnosis, the patient was admitted to our department again due to obstructive voiding syndrome, decreased diuresis, deterioration of renal function and dyspnoea. A thoracoabdominal-pelvic CT scan was performed, showing right pleural effusion with compressive atelectasis, multiple mediastinal adenopathies, multiple pulmonary metastases, ureteropielocaliceal dilatation of the left kidney and the already known multiple metastatic bone lesions of the blastoma type.
Right pleurocentesis was performed (pleural fluid cytology was positive for malignant tumour cells). Percutaneous nephrostomy was not considered.
The patient was monitored by the Palliative Care Unit. He died 10 months after the initial diagnosis.