A fifty-four year-old Caucasian male presented to the emergency department with a chief complaint of progressively worsening left shoulder pain that had been ongoing for the past three weeks. He described the pain as initiating in his left shoulder radiating down his arm, worsening with movement and improving with rest. He had been evaluated by his primary care provider a week before presentation, was thought to have a muscle spasm, and was prescribed a muscle relaxant. The pain progressed despite muscle relaxant administration and he noticed weakness developing in his left extremity. He denied any trauma to his shoulder, any numbness or tingling, or any similar symptoms in the past.
On physical exam, he was unable to abduct his left shoulder, and had diminished strength and absent deep tendon reflexes on the left upper extremity. The rest of his physical examination was normal. Magnetic resonance imaging (MRI) of the cervical spine was performed, revealing a left C5 vertebral body lesion (Image 1) with an extraosseous extension likely compressing the exiting C5 nerve root, with neoplasm being the primary consideration. He subsequently had a computed tomography (CT) of the chest and abdomen. CT revealed an hypoenhancing mass in the pancreatic tail, concerning for malignancy (Image 2). His CA 19-9 was elevated at 323 U/ml. MRI of the abdomen confirmed the pancreatic tail lesion and also revealed multiple hepatic lesions concerning for metastatic lesions. A subsequent bone biopsy of the C5 vertebrae revealed moderately differentiated metastatic adenocarcinoma (Image 3). Oncology service was consulted. They felt that he would not benefit from chemotherapy, given the grave diagnosis of metastatic pancreatic cancer. He subsequently underwent palliative radiation to the C5 lesion. Unfortunately, he passed away three months after his diagnosis.
The usual sites of metastases in pancreatic cancer include the liver and peritoneum. Other less common sites are the lung, brain, kidney, and bone. Skeletal metastases are less prevalent but contribute to significant morbidity associated with pancreatic cancer. The exact prevalence of osseous metastases is not known, but has been estimated to be between 5% and 20%. The most common osseous lesions are osteolytic in nature, but rarely the osteoblastic ones can be seen. The spine, in the form of vertebral metastases is the most common site of skeletal metastasis of pancreatic cancer. Bone pain, pathological fractures, and hypercalcemia are possible symptoms of skeletal metastases. Early diagnosis and treatment for bone metastases is important to maintain quality of life.
