Case History: A 79 year old gentleman sustained a traumatic fracture of his left humerus in November 2016. Given his age and non-union of fracture, he was referred for a dual X-ray absorptiometry (DXA) scan in May 2017. This demonstrated markedly elevated bone mineral density (BMD) and subsequent investigation was performed.
The patient has a past medical history of type 2 diabetes mellitus, hypertension, asthma and kidney stones. He was started on finasteride in 2011, presumably for treatment of prostatic symptoms.
Investigations and Method: The patient attended for DXA scan which demonstrated markedly elevated T-score of 6.6 in lumbar spine 2-4 as well as hip T-score of 2.5. On review of his plain X-rays, he appeared to have multiple sclerotic lesions around the left humerus site. In light of his results, his prostate specific antigen (PSA) was checked and a nuclear medicine bone scan as well as a whole body scan.
Results and Treatment: PSA came back at 1478.5 and alkaline phosphatase was also significantly raised. His isotope bone scan revealed significant uptake in his axial, appendicular skeleton and facial bones which was concordant for his whole body scan.
Conclusion and Points for Discussion: The results are in line with a diagnosis of metastatic prostate cancer. An interesting point about this case was the route of diagnosis. Unfortunately, the sclerotic bone lesions identified on this patients admission x-rays were missed and it was in fact interpretation of the DXA scan that identified the bony metastases. Ideally, the lesions would have been identified along with the fracture of the humerus, and if this was the case the patient would have had the same line of investigations as above, but significantly earlier.