Disclosures: Christopher A. Meadows, MD: Nothing to disclose

Case Description: Patient presented with worsening right hip pain and immobility after a fall 5 months prior. Pelvic and hip x-rays were unremarkable. Physical therapy failed to improve her symptoms. Lumbar x-ray demonstrated mild degenerative changes. MRI lumbar spine revealed mild degenerative changes. Right lower extremity EMG was unremarkable. She underwent epidural spine injections that were also ineffective. On presentation, she required crutches for ambulation and was unable to weight-bear on the right leg. Patient has no significant past medical history and was a non-smoker.

Setting: Outpatient Spine Center

Patient: 74F with progressive right hip and lumbar back pain.

Assessment/Results: Pelvic MRI was ordered and noted abnormal right proximal femur consistent with a metastatic process. Urgent bone biopsy confirmed metastatic lung adenocarcinoma. During arthroplasty for risk of pathologic fracture, she sustained a code arrest for hypoxia and hypotension secondary to a large left-sided pulmonary embolism. Cardiac function gradually declined. Ultimately, she was transitioned to comfort care. Time course from clinic evaluation in the Spine Center to death was 13 days.

Discussion: Bone is the third most common organ affected by metastasis and is one of the most common sites of extra-thoracic spread in Non-small cell lung cancer (NSCLC). NSCLC is associated with osteolytic lesions which primarily affect the trabecular bone, particularly in the early phase of the disease. For this reason, osteolytic metastatic lesions can only be seen if 50% or more of the bone substance is destroyed. Advanced imaging may be more sensitive to detect metastatic, particularly osteolytic, disease.

Conclusion: This patient demonstrated a rapidly metastatic process that was unable to be visualized on initial imaging. This case highlights the importance of understanding the limitations of basic imaging, particularly in certain patient populations. As patient demographics change and life expectancies increase, malignant processes should remain high on the differential for musculoskeletal type pain of unclear etiology.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/extremely-rapid-metastatic-adenocarcinoma-masquerading-as-musculoskeletal-disease/