Carcinoma of the prostate presenting as polymyalgia rheumatica

A Case of Localized Prostate Cancer Associated with Polymyalgia Rheumatica with Marked Symptomatic Improvement after Robot-Assisted Radical Prostatectomy

A 73-year-old man visited our hospital with chief complaints of fever of unknown origin and bilateral shoulder and hip joint pain. He was initially diagnosed with polymyalgia rheumatica (PMR). Although the patient was treated with prednisolone 15 mg/day, his PMR-related symptoms did not improve. Further examination was performed as the patient was suspected of having paraneoplastic syndrome. Assessment results showed prostate cancer without metastases. After undergoing robot-assisted radical prostatectomy, the patient's PMR-related symptoms dramatically improved. Hence, the prednisolone dose was decreased to 4 mg/day. PCa may have triggered the development of PMR through the activation of immune-mediated systemic inflammatory responses.

A Case of Polymyalgia Rheumatica Following Robotic-Assisted Radical Prostatectomy for High-Grade Prostate Cancer

BACKGROUND Polymyalgia rheumatica (PMR) is a common rheumatic disease in patients over the age of 50 years. Underlying triggers for PMR are not well understood, but there have been reports of cases presenting prior to the diagnosis of prostate cancer, with one case of PMR presenting following prostatectomy. This report is of a case of PMR that presented following robotic-assisted radical prostatectomy for high-grade prostate cancer and includes a discussion of the possible associations. CASE REPORT A 61-year-old man underwent a robotic-assisted radical prostatectomy for high-grade prostate adenocarcinoma, Gleason grade 4+4=8. The surgical procedure and the patient's postoperative recovery were uneventful, and he was discharged from hospital on the day after surgery. Approximately two weeks later, he developed bilateral symptoms of pain in the groin, thigh, and shoulder girdle. His erythrocyte sedimentation rate (ESR) (30 mm/h) and C-reactive protein (CRP) (16.2 mg/L) levels were raised. A diagnosis of PMR was made and treatment with tapered dosing of methylprednisolone resulted in a 90% improvement in symptoms after four weeks. CONCLUSIONS A case of PMR following robotic-assisted prostatectomy for high-grade prostate carcinoma is presented. To the author's knowledge, this is only the second report of PMR following prostatectomy and the only reported case following robotic-assisted radical prostatectomy.

Association between rheumatic diseases and cancer: results from a clinical practice cohort study

The association between cancer and immune-mediated rheumatic conditions is controversial, especially as far as polymyalgia rheumatica (PMR) is concerned. Furthermore, no clinical feature has been shown to be suggestive of a paraneoplastic rheumatic syndrome. With the present study, we aim to address both these issues. The study population comprised N = 1750 patients, including N = 100 with PMR, who attended our tertiary immuno-rheumatology clinic between January 1, 2005 and November 30, 2012. A rheumatic disease was deemed paraneoplastic if cancer had been diagnosed in the 2 years preceding or following its onset. The probability of a significant association between a specific rheumatic disease and cancer was evaluated by computing the odds ratio (OR): N = 702 patients with osteoarthritis serving as controls. Furthermore, clinical features distinguishing paraneoplastic rheumatic diseases were searched for by univariate and multivariate analysis. Sjogren's syndrome (SS) [OR 3.6 (CI 95% 1.7-7.5)], PMR (OR 5.1 CI 95% 2.9-8.9), dermatomyositis/polymyositis [OR 12.09 (CI 95% 2.6-55.8)] and vasculitis [OR 3.70 (CI 95% 1.81-7.52)] are associated with cancer. At multivariate analysis, older age is associated with cancer among SS patients (p = 0.03), while in the PMR group, older age, male gender, and ≥6 tender joints are independent predictors of paraneoplastic PMR (p < 0.0004). Cancer frequently either heralds or follows rheumatic manifestations, including PMR. Older age, male gender and a more extensive joint involvement should be considered red flags for paraneoplastic PMR.

Association of Remitting Seronegative Symmetrical Synovitis with Pitting Edema, Polymyalgia Rheumatica, and Adenocarcinoma of the Prostate

Patient: Male, 83

Final Diagnosis: Remitting seronegative symmetrical synovitis with pitting edema

Symptoms: Morning stiffness • pitting edema of the hands • shoulder and hip pain

Medication: —

Clinical Procedure: 18FDG PET/CT

Specialty: Rheumatology

Polymyalgia rheumatica following robotic radical prostatectomy

INTRODUCTION

Polymyalgia rheumatica (PMR) is an inflammatory syndrome of unknown etiology has also been associated with concurrent malignancy. Here we report PMR occurring de novo in a man following successful robotic radical prostatectomy.

PRESENTATION OF CASE

A 67-year-old gentleman underwent uneventful robotic assisted radical prostatectomy with complete excision of a T2(C) Gleason 7 tumour and a post-operative undetectable PSA. Three weeks after surgery he developed pain and weakness of the upper arms requiring increasing doses of opioids. Assessment identified a grossly elevated ESR and CRP consistent with a clinical diagnosis of PMR. Treatment with oral steroids led to a rapid resolution of symptoms.

DISCUSSION

There have been reported cases of polymyalgia rheumatica occurring following surgical procedures but not with robotic prostate surgery. It has been proposed that surgical tissue injury can cause a release of inflammatory markers. Surgical stress-related sympathetic activation can also stimulate lymphocyte dependent inflammatory reactions by modulation of cytokine production and lymphocyte expressed adrenergic receptors.

CONCLUSION

We present here the first reported case of PMR developing acutely after radical robotic prostatectomy. It is possible that the surgical procedure in this case had triggered polymyalgia rheumatica possibly through activation of immune-mediated systemic inflammatory responses.

A case of adult-onset Still's disease (AOSD)-like manifestations abruptly developing during confirmation of a diagnosis of metastatic papillary thyroid carcinoma

A 68-year-old Japanese man was admitted to our hospital suffering from abrupt onset of high fever accompanied by arthralgia, myalgia, sore throat, macular eruption, and liver dysfunction. Six months before the onset of these manifestations, (18)F-fluoro-deoxy-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) had detected, unexpectedly, three calcified thyroid lesions without (18)F-FDG uptake. Two months before the onset of the present manifestations, ultrasonography-guided fine-needle aspiration had led to a diagnosis of papillary thyroid carcinoma (PTC). Soon after the occurrence of the rheumatic manifestations, a subsequent (18)F-FDG PET/CT scan showed not only the three thyroid lesions, the same as those in the previous scan, but also (18)F-FDG uptake in the thyroid lesion. A diagnosis of adult-onset Still's disease (AOSD)-like manifestations associated with PTC was made, and treatment with 40 mg/day of prednisolone (PSL) resolved the symptoms promptly. PSL was gradually tapered, without recurrence of the (AOSD)-like manifestations. Five months after the initiation of treatment with PSL, total thyroidectomy, followed by (131)I thyroid ablation treatment, was performed while the patient was on a PSL dose of 18 mg/day. Seven months after the thyroidectomy, the dose of PSL was tapered to 2 mg/day, and neither the AOSD-like manifestations nor the PTC relapsed. On confirming a diagnosis of AOSD, it may be necessary to consider the presence of an associated malignancy, including solid tumors such as PTC.

Metastatic prostate cancer mimicking polymyalgia rheumatica

A 59-year-old male presented to the emergency department with a four-month progressive history of proximal muscle pain and weakness with elevated erythrocyte sedimentation rate and C-reactive protein. He was initially diagnosed with polymyalgia rheumatica (PMR) and admitted to the hospital. During his hospitalization he was found to have metastatic prostate cancer, which was thought to be responsible for his PMR-like syndrome. By recognizing the resemblance between metastatic malignancy and rheumatologic diseases, the emergency physician can improve diagnostic accuracy.

Cancer risk in patients hospitalized with polymyalgia rheumatica and giant cell arteritis: a follow-up study in Sweden

OBJECTIVES

Studies reporting cancer risk after PMR and GCA are few, but it remains an issue of both concern and controversy. We examined the overall and specific cancer risks among Swedish subjects following hospitalization for these diseases.

METHODS

PMR and GCA patients were identified from the Swedish Hospital Discharge Register and by linking them with the Cancer Registry. Follow-up of patients was carried out from the last hospitalization through year 2006. Standardized incidence ratios (SIRs) were calculated in these patients compared with subjects without the diseases.

RESULTS

A total of 35 918 patients were hospitalized for PMR and GCA during the years 1965-2006; the hospitalization rate increased towards late age. A total of 3941 patients developed subsequent cancer, giving an overall SIR of 1.19; and for cancer diagnosed later than 1 year of follow-up, the SIR was 1.06. A significant excess was noted for skin (squamous cell carcinoma and melanoma), stomach, lung, prostate, kidney, nervous system and endocrine gland tumours, and additionally for non-Hodgkin's lymphoma, myeloma and leukaemia. Decreased risk was noted for endometrial cancer.

CONCLUSIONS

Patients hospitalized for PMR and GCA had a marginally increased risk of cancer, with the highest risk noted for the first year after hospitalization. However, for specific cancers, such as skin cancer and leukaemia, the increases were still significant for patients diagnosed later than 1 year after hospitalization, suggesting that these could be true associations, but the mechanisms remain to be established.

Rheumatic disorders as paraneoplastic syndromes

The long-established observation that some rheumatologic disorders (RDs) are associated with--or precede--the clinical manifestations of a variety of solid and hematological tumors represents an important clue for the early diagnosis and effective treatment of the cancers. Inflammatory myopathies, seronegative rheumatoid arthritis and some atypical vasculitides are the most frequently reported paraneoplastic RDs, although paraneoplastic scleroderma- and lupus-like syndromes, erythema nodosum, and Raynaud's syndrome have also been observed. Generally, the clinical course of a paraneoplastic RD parallels that of the cancer, and surgical removal of the tumor or its medical treatment usually results in a marked regression of the clinical manifestations of the RD. Most paraneoplastic RDs are difficultly distinguishable from idiopathic RDs. Even so, some atypical features of the clinical presentation raise the suspicion of an underlying tumor. This review summarizes current hypotheses for the pathogenesis that leads a tumor to present as an RD and discusses the clinical features that help distinguish paraneoplastic from idiopathic RDs.

Evidence-based management for polymyalgia rheumatica for rheumatology practitioners, nurses and physiotherapists

Evidence-based practice is an increasingly popular term, used in a variety of clinical settings and situations. Practitioners are encouraged to use best evidence as part of clinical decision-making when caring for individual patients. This evidence, combined with practitioner expertise and knowledge, aims to inform practice, ensuring that accurate, effective and safe treatment options are utilized.

Polymyalgia rheumatica and colon malignacy: case report

Polymyalgia rheumatica (PMR) is a relatively common disorder in the elderly. Whereas the relationship between polymyalgia rheumatica and giant cell arteritis (GCA) is well recognized, there is still controversy about PMR and malignancy. We are presenting a patient with PMR and adenocarcinoma of the sygmoid colon and hypothesize a paraneoplastic relationship.