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+A 60-year-old man, with no pathological history of interest, who was referred to us from the Urology Department of our Centre with a diagnosis of stage IV prostate adenocarcinoma with multiple metastatic bone involvement and in a phase of hormone resistance.
+In February 2004, due to prostatic syndrome (pollakiuria and urinary urgency), his Primary Care Physician (PCP) had performed a PSA test which showed a value of 12 ng/ml, and for this reason he was referred to the specialist. He underwent transrectal ultrasound and ultrasound-guided prostate biopsy which was reported as: bilobular adenocarcinoma, Gleason 7 (4+3). In the extension study (blood tests, MRI and bone scintigraphy), retroperitoneal lymph node metastases and multiple foci of pathological hypercaptation (spine, neck and femoral diaphysis, bony pelvis) were observed. Complete androgen blockade with gonadotropin-releasing hormone analogue (A-LHRH) and antiandrogen was instituted. With this treatment, the PSA level normalised within 4 months (June 04).
+The patient was receiving analgesic treatment for bone pain with NSAIDs and morphine. He was also treated with dorsolumbar vertebral irradiation with 30 Gy administered in 10 sessions.
+In April 2006, and with the patient asymptomatic, the PSA began to rise progressively to 7.3, 13.1, 21 ng/ml, maintaining testosterone at castration levels. It was decided, at this point, to discontinue the antiandrogen. The biochemical response was good and normalisation was achieved in August 06.
+Unfortunately, in November 06, she attended the emergency department with intense generalised and incapacitating bone pain despite the increase in analgesic doses (EAV=8-9), for which she received treatment with strontium (St) in the Nuclear Medicine Department. In addition, the clinical picture is accompanied by PSA figures of 850 ng/ml.
+In December 06 we decided, with his informed consent, to start palliative QT with Docetaxel and prednisone. We also started therapy with bone resorption inhibitors (zoledronic acid). The clinical response was satisfactory with analgesic control (VAS=2-3) and a reduction in PSA to 150 ng/ml.
+On 15-02-07, she attended the emergency department and reported that for the last 15 days she had been noticing protrusion of the left eyeball and difficulty in fully separating the eyelids.
+Neurological examination
+Proptosis, eyelid ptosis, mydriasis with little reactivity secondary to involvement of the third pair. No orbital murmurs.
+Orbital MRI
+Metastatic replacement of the entire central segment of the cranial base, the bone marrow of the vertebrae included in the study and part of the cranial diploe. Involvement of the roof and lateral wall of the left orbit which appear expanded and cause proptosis of the eyeball. The left greater sphenoid wing is replaced and thickened and there is a clear extension to the wall of the left cavernous sinus and the cleft. Similar changes are seen in the bones comprising the contralateral orbit, but less advanced. The lesion of the roof of the left orbit is accompanied by a soft tissue lesion causing inferior displacement of the orbital musculature. Contrast sequences show heterogeneous hyperenhancement of all the lesions described.
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+He received palliative irradiation of the affected areas and presented a frank and rapid deterioration, dying on 21-03-07.
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