A 53-year-old female was consulted our clinic with complaints of lower back and accompanying right leg pain for about 40 days. She had never complained of LBP in her life before. The pain, which was only in the lumbar region at first, worsened gradually, and spread to the medial of the right leg and the dorsum of the foot. The pain character was burning and cramping and tended to decrease while at rest. She did not describe loss of sensation, numbness or tingling. The pain was achy all day, worsening at night and scored as 9 of 10 on a visual analog scale. She reported that she had difficulty walking for about a week due to severe pain and loss of strength in her right leg. When anamnesis was deepened, she stated that she had fatigue, sometimes night sweats, and 4 kg loss in the last month. No bowel or bladder related symptoms were reported. 5 days after the onset of LBP, the patient was evaluated and further investigated by the external medical center neurosurgery clinic, and the non-contrast lumbar spine MRI of the patient at that time was reported as having a right sided broad-based posterior protrusion at the L2-3 level and compressing the thecal sac and right L2 nerve root. Gabapentin 900 mg/daily was given in three divided doses but there was no effect on her LBP. There was no history of smoking, trauma, other chronic and systemic disorders. There was no specification about her family story.
On physical examination, vital signs were within normal limits. In the musculoskeletal exam; there was mild tenderness on T11-12 spinous processes. The lumbar range of motion (ROM) was painful and limited in the end of the ROM in all directions. Straight leg raise test, well leg raise test, Patrick FABERE and Braggard tests were positive on the right side for LBP with radiation to the right leg down. Femoral stretch test was negative for both sides. Neurological examinations revealed decreased muscle power for the right hip flexors (Manual Muscle Test (MMT) grade III), right ankle dorsiflexors (MMT grade II), right big toe extensors (MMT grade II) and right ankle plantar flexors (MMT grade IV). Her achilleas reflex at the right leg disappeared, and sensations at the posteromedial side of calf and last toe were reduced. Pathological reflexes were negative at both lower extremities.
Laboratory investigations contained complete blood count, serum biochemistry, electrolyte profile, c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Abnormal findings from laboratory was CRP: 20 mg/L and ESR 1 hour: 48 mm. Thereafter measured serum tumor markers results were CA 125: 47 U/ml and CA 15 − 3: 180 U/ml.
Anterior-posterior (AP) pelvis X-ray showed right half of the sacrum is observed with increased density and intestinal gases pushed left and caudally at the right pelvic entrance.
The first lumbar MRI of the patient which was re-examined due to worsening of the patient's symptoms and physical examination findings that cannot be explained by the L2 lumbar radiculopathy; there were multifocal lesions showing signal loss in T10-T11 vertebras in T1 sequences and a mass lesion showing signal loss in the right half of the sacrum in T2 sequences. Lumbar spine MRI, which was repeated and additionally performed with contrast imaging, revealed the metastatic lesions observed in the previous examination in T10-T11 vertebrae were enlarged and spread to both pedicles, disrupting the bone integrity of the right side, and compressing the spinal cord from the right and narrowed the right neural foramina from T10 to T12 vertebras (Fig. 1). Also, there was a large metastatic mass extending between the hip soft tissues and in the form of paravertebral muscle invasion up to the level of L4 vertebrae. This large metastatic mass was destroying the cortex, compressing S1 right nerve root and reaching 16 × 12 × 6.5 cm in the right half of the sacrum (Fig. 1). Furthermore, osteolytic metastatic involvement was observed in T2-T5-T10-T11-T12-L2-L3 and L4 vertebras, right iliac wing, right femoral neck, trochanter major of left femur and right superior pubic ramus. These masses were showed high staining at solid phase after intravenous contrast injection.
The patient was referred for an immediate consultation to medical oncology and neurosurgery clinics. F-18 FDG PET/BT results showed us a metastatic soft tissue mass, approximately 10 × 5 cm in size, invading the spinal cord between the T8-12 vertebra levels, another soft tissue mass, approximately 14 × 7 cm in size, destructing the right half of the sacrum and a hypermetabolic mass lesion at the pancreatic body-tail junction, approximately 2.8 × 2.4 cm in size, primarily compatible with primary pancreatic malignancy. The patient underwent tru-cut biopsy from the soft tissue mass on the right side of the sacrum. Histological studies reported as undifferentiated ACP. Furthermore, the tumor showed a solid-infiltrative growth pattern with small-medium round cells and focal necrosis areas. Chemotherapy and radiotherapy were started after the biopsy result. After approximately 10 days, the patient applied to the emergency department with complaints of general condition disorder, chest pain, dyspnea and hemoptysis. Bilateral massive pulmonary thromboembolism was observed in computed tomography angiography. And the patient died on the same day.