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Authors:

Dr Maninder Bhambra, Dr Amie Jade Ford, Dr Hossam Ghazzawi, Worcester Royal Hospital

We, the authors, have no conflict of interest.

Abstract

We present a case of an elderly lady presenting with symptoms of cauda equina in the accident and emergency department which was later investigated and found to have no spinal cord compression but instead was a late presentation of metastatic lung cancer.

 

Background

Over 30,000 people are diagnosed with lung cancer each year in England, and lung cancer remains the leading cause of cancer deaths in both men and women (1). More than one third of lung cancer patients are diagnosed as emergencies and the emergency route to diagnosis is sub-optimal, associated with late-stage diagnosis and poor survival (2). A retrospective analysis of Hospital Episode Statistics (HES) between 1999 and 2006 showed that 52% of patients with lung cancer in England were admitted as emergencies (5). Such admissions were more common in women, older patients and patients from deprived areas. In 2007, it was estimated using routine data (cancer registry, HES and National Cancer Waiting Times (NCWT)), that 38% of patients in England were diagnosed with lung cancer through emergency presentation (3). Despite small improvements in recent years, late diagnosis and emergency presentation remain a major concern in lung cancer (4).

Case report

A retired elderly lady presented to the emergency department with a 6 week history of lower back pain, urinary frequency and no bowel movement for the past five days, on a background of known sciatica but no other significant past medical history, except for being a smoker.

She reported no cough, no fever, no lethargy but had noticed weight loss of half a stone in the past month. No chest pain or shortness of breath. She reported increased frequency, urgency and hesitancy. No history of recent trauma or strenuous activity.

Obs in ED were stable and she was on regular co-codamol for her long-term back pain.

On examination she was alert with a GCS of 15, but visibly pale. There was no midline tenderness in the cervical, thoracic or lumbar vertebrae but reported some pain in the right mid-thoracic paraspinal area. Her abdomen was distended, with mild tenderness but was not peritonitic

A notable firm, non-mobile, tender lump was palpable in the right mid axillary line approximately between the 6th and 7th anterior ribs. She had not noticed this lump previously and said it must have recently appeared in the last month or so.

Examination of her lower limb revealed normal tone, reduced power to 4/5 in all muscle groups tested on the right side but 5/5 on the left. Good range of movement in the knees bilaterally and downgoing plantars bilaterally. Sensation to light touch was intact in the L2-3-4-5-S1 dermatomes and a PR revealed normal perianal sensation with good anal tone. She could straight leg raise to 70 degrees bilaterally.

Her bloods revealed a leucocytosis of 15.8 with a predominant neutrophilia of 12.6. Her Hb was 107 with a normocytic MCV and a Na+ of 126 with all other bloods normal. ECG was unremarkable. Urine dip was negative.

A bladder scan revealed acute urinary retention of >999ml in her bladder, and she was subsequently catheterised in A+E.

At this point there were several possible differential diagnoses: constipation secondary to recent opioid use, cauda equina syndrome, worsening of sciatica, or urinary retention secondary to a urinary tract infection.

In the context of lower back pain with urinary and faecal retention, cauda equina needed to be ruled out so the patient was referred to and accepted by T+O.

A chest X-ray and abdominal X-ray were routinely performed which incidentally picked up an oval-shaped soft-tissue density seen at the lateral border of the right mid lung, measuring 66mm with involvement of the right posterior seventh and eighth ribs.

Figure 1: Routine CXR picked up a suspicious right
sided well-defined focal mass.

Figure 2: AXR revealed constipation, mild scoliosis and osteoarthritic degenerative changes.

The T+O team performed an MRI of the spine which went on to reveal multifocal lesions in the spine, particularly in the left-sided pedicles of T6 and T7 and the anterior aspect of the vertebral body of L3 which were suspicious of metastatic disease. Thankfully no metastatic spinal cord compression was noted but there may have been some neural compression in the lower sacrococcygeal region, where a focal mass was partly visualised.

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Figure 3: MRI spine showing multifocal lesions at T6, T7 and L3.

A specialist opinion from a local tertiary spinal centre was obtained. They advised obtaining a CT-TAP to look for a primary source of malignancy, and in the mean time they would look at the MRI images to see if surgical intervention is needed. A CT-TAP was done revealing a necrotic mass occluding the left lower lobe apical segmental bronchus, measuring 59 x35mm.

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Figures 4 and 5: Lateral and saggital CT-Thorax slices, respectively, revealing the nectrotic mass situated on the right mid-thoracic area.

A review of the remaining bone window demonstrated metastatic lesions in the right 7th rub, T7 spinous process and right sacrum. A provisional staging of the tumour was given was T4N2M1.

A whole body NM bone scan was recommended by the specialist tertiary centre as well as input from the respiratory team to biopsy the potential lung primary. The bone scan revealed lytic lesions in the right lateral ribs corresponding to the rib destruction associated with the large right lateral chest wall tumour. A hot spot in the right of the sacrum also corresponds to bone destruction around a tumour seen on CT, and increased isotope uptake around the right hip was consistent with severe osteoarthritis.

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Figure 6: A nuclear medicine bone scan revealing multiple lytic lesions to the right rib region and right sacrum.

Finally the case was discussed at the tertiary orthopaedic MDT, which concluded that the images demonstrate right sided bronchogenic carcinoma with lymphadenopathy and extensive bony metastases. There was no role for surgical intervention and subsequent palliative and oncology input was needed. The patient was advised to mobilise as able and was discharged from the trauma and orthopaedic ward, fully weight bearing with a plan for respiratory to do an USS-guided biopsy as an outpatient and palliative care in the community.

Learning points:

References:

  1. Patel, V., 2016. Deaths registered in England and Wales (Series DR): 2015. Registered deaths by age, sex, selected underlying causes of death and the leading causes of death for both males and females. Release date: Nov.
  2. England, N.H.S., 2015. Achieving world-class cancer outcomes: a strategy for England 2015-2020. London, UK.
  3. National Cancer Intelligence Network, 2010. Routes to Diagnosis—NCIN Data Briefing
  4. Public Health England. Routes to diagnosis 2015 update: Lung Cancer. 2016; www.ncin.org.uk/view?rid=3120.
  5. Raine, R., Wong, W., Scholes, S., Ashton, C., Obichere, A. and Ambler, G., 2010. Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics. Bmj, 340, p.b5479.