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lba9587
Might be helpful to consider eg. of a lung tumor. one lesion? youโre leaning lung primary. Multiple lesions in lung? METS. Q stem here included, โnumerous lytic lesions along the vertebral column.โ Thus, METS.
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jurrutia
Also, pain that is worse at nights and persists regardless of activity.
Paget's is typically asymptomatic (although pain is the most common symptom) and would have other findings (deformities, AV shunts, etc.)
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jurrutia
Also, pain that is worse at nights and persists regardless of activity.
Paget's is typically asymptomatic (although pain is the most common symptom) and would have other findings (deformities, AV shunts, etc.)
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umpalumpa
increased ALP is weird, considering that the lesion is lytic..
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l0ud_minority
@umpalumpa I agree lytic lesions don't make sense with an elevated ALP. Like an idiot I thought isolated ALP and chose Paget Disease
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seagull
ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer.
+32
aesalmon
I think the "Worse at night" lends itself more towards mets, and the pt demographics lean towards prostate cancer, which loves to go to the lumbar spine via the Batson plexus. I picked Paget but i think they would have given something more telling if they wanted pagets, histology or another clue
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fcambridge
@seagull and aesalmon, I think you're a bit off here. Prostate mets would be osteoblastic, not osteolytic as is described in the vignette.
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sup
Yeah I chose Paget's too bcz I figured if it wasn't prostate cancer (which as @fcambridge said would present w/ osteoblastic lesions) they would give us another presenting sx of the metastatic cancer (lung, renal, skin) that might point us in that direction. I got distracted by the increased ALP too and fell for Paget :(
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kernicterusthefrog
@fcambridge, not exactly. Yes, prostate mets tends to be osteoblastic, but about 30% are found to be lytic, per this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768452/ Additionally, the night bone pains point to mets, and Paget's is much more commonly found in the cranial bones and appendicular skeleton, than axial. This could also be RCC mets!
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sweetmed
I mainly ruled out pagets because they said the physical examination was normal. He would def have other symptoms.
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cathartic_medstu
From what I remember from Pathoma:
Metastasis to bone is usually osteolytic with exception to prostate, which is osteoblastic.
Therefore, stem says NUMEROUS lytic lesions and sounds more like metastasis.
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medguru2295
If this is Metastatic cancer, it is likely MM. MM spreads to the spinal cord and causes Lytic lesions.
It is NOT prostate as stated above. While Adenocarcinoma does spread to the Prostate, it produces only BLASTIC lesions.
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but prostate cancer is not lytic as blastic lesions
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medguru2295
Possibly Multiple Myeloma. That is classic for an older person with back pain and lytic lesions in the back.
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asharm10
osteolytic- multiple myeloma, Osteoblastic- Prostate; dont think beyond this for this exam, i have never seen a question in NBME or uworld they tried to fool us off on this concept so far.
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skuutnasty
I'd like to reiterate what's stated above... dx NOT MM in this question because MM is PRIMARY not METASTATIC @ bone (answer reads: metastatic carcinoma)
<3
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imgdoc
I honestly thought this was multiple myeloma before I went the metastatic carcinoma route lol
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submitted by โnotadoctor(175)
Metastatic disease is more common than primary bone tumors.