Metastasis of a Poorly Differentiated Sarcoma

A kind 79-year-old gentleman named Arthur presented to our office for chiropractic care. Upon entering Dr. Demetrious's exam room, he was wearing a smart Fedora. He took off his hat and related that he was suffering with a pins- and-needles sensation affecting the anterolateral aspect of his left leg along the L2 to L4 dermatomes.

Posted in Risk Management on Friday, October 27, 2017

Arthur indicated that his symptoms began insidiously five weeks earlier. No injuries or illnesses were reported. His discomfort was not exacerbated nor alleviated by any means and the symptoms did not disturb his sleep. Upon further questioning, he denied spinal pain, weakness or alteration in bowel or bladder function.

Arthur reported a past history that included hypertension, hypercholesterolemia, chronic tinnitus, ulcerative colitis and a recent diagnosis of basal cell carcinoma for which he was undergoing medical assessment. His surgical history included partial left knee arthroplasty and left inguinal surgery. He reflected a familial history that included renal failure and bladder cancer. He was a former smoker. Arthur was the primary caregiver to his wife who was diagnosed with Amyotrophic Lateral Sclerosis.

I carefully examined Arthur. He weighed 185 pounds without recent weight loss and was 73 inches tall. His vital signs were normal. He was alert and oriented to person, place, time and situation. Chiropractic subluxations of the L3 and L4 vertebrae were manifest as decreased intersegmental mobility with increased paraspinal muscular tone. The patient’s lumbar spine ranges of motion were restricted but not painful. Orthopedic tests were negative. Neurologic assessment revealed a normal cranial nerve examination. Alteration of sensitivity to pinprick along the L2 to L4 dermatomes was reported on the left. Motor evaluation revealed 5/5 throughout the upper and lower extremities. Deep tendon reflexes measured 2/5 throughout. A Babinski response was not elicited. Peripheral vascular assessment was normal. No other abnormalities were noted. X-rays revealed mild to moderate degenerative changes throughout the lumbar spine.

An initial primary Medicare diagnosis of chiropractic subluxation of L3 and L4 with a secondary diagnosis of meralgia paresthetica was made. I recommended a prescription of Cox distraction spinal manipulation at a frequency of three visits per week for two to four weeks. Following careful discussion related to his condition, other diagnostic possibilities, recommendations, adverse events and alternative care, Arthur consented to chiropractic care. I noted this discussion of informed consent in the patient’s file with the date and my signature.

In our office, on a weekly basis, our patients complete and sign visual analog scales, pain diagrams and answer questions related to their clinical progression. After three weeks of chiropractic care, Arthur reported to me persistent lower extremity paresthesias, mild soreness of his lower back, new perceived weakness of his lower extremities and increased urinary frequency. Upon re-examination, I found no change from the onset of care. Due to unremitting and new neurologic symptoms, I referred him to his primary care physician with a prescription for an MRI of the lumbar spine without contrast.

The MRI was performed and revealed a 2.2 x 1.9 cm soft tissue mass posterior to the right lamina at L4. I reviewed the MRI findings with Arthur. The results were inconclusive, and he needed further testing. It is always difficult to provide patients with bad news. In this case, I was heartened by the strength of character displayed by Arthur upon learning that he may have cancer. This gentleman from the greatest generation displayed bravery in a manner that was truly exceptional and inspirational.

A follow-up MRI of the lumbar spine with contrast revealed a 2.3 x 2.3 x 2.8 cm mass at L4 in the paraspinal soft tissues with peripheral solid enhancement on the post-contrast sequences (see Image 1). In addition, a 10-mm nodule was noted in the right paraspinal subcutaneous fat and a heterogeneous area of enhancement was noted in the pedicle of T12. The patient was referred to an oncologist. Suspicious for malignancy and possible metastasis, Arthur underwent MRI of the thoracic spine, CT scan of the chest with contrast and CT scan of the abdomen and pelvis with IV contrast. Unfortunately, the studies revealed multiple soft-tissue metastases within the paraspinal soft tissues, buttock, retroperitoneum and lungs (see Images 2–4).

Image 1:

A 2.3 x 2.3 x 2.8 cm mass at L4 in the paraspinal soft tissues with peripheral solid enhancement on the post contrast sequences.

Image 2:
Poorly differentiated sarcoma in paraspinal subcutaneous soft tissues.

Image 3:

CT reveals poorly differentiated sarcoma in paraspinal gluteal subcutaneous soft tissues.

Image 4:

Poorly differentiated metastatic sarcomas in lungs.

Arthur underwent biopsies and was provided a diagnosis of poorly differentiated sarcoma. While waiting for the results of his biopsy, he suffered a seizure, lost consciousness and subsequently passed away due to metastatic disease of the brain (See Image 5).

Sadly, the gentleman with the smart Fedora progressively deteriorated and succumbed within four months from the initial onset of seemingly innocuous symptoms that began as mild numbness with pins and needles affecting his lower extremity.

Image 5:
Poorly differentiated sarcoma in the brain.