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© 1999 American Society for Clinical Oncology
Lung Cancer Presenting With Solitary Bone MetastasesArthur Skarin, MD, Consultant Editor
Lowe Center for Thoracic Oncology, Department of Adult Oncology, Dana Farber Cancer Institute, and Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA CASE 2: ACROMETASTASIS AS AN INITIAL PRESENTATION OF NON–SMALL-CELL LUNG CARCINOMA A 35-year-old woman presented to her primary-care physician with a 3-month history of pain in her right foot. The pain was achy in nature and was localized to the base of the right fourth metatarsal. There was no history of trauma, swelling, overlying redness, or fever. The pain was initially relieved with nonsteroidal anti-inflammatory agents, but it intensified, with associated right foot swelling over the subsequent few months. A radiograph of the foot showed a destructive lesion at the base of the fourth metatarsal along with a pathologic fracture (Fig 1). These findings led to an excisional biopsy of the lesion. Pathology was consistent with metastatic carcinoma of breast, lung, or gynecologic origin. There were nests of gland-forming tumor cells infiltrating the bone marrow space with associated bone destruction (Fig 2A, high power view). The tumor cells stained positive for pan-keratin, epithelial membrane antigen, cytokeratin-7 (Fig 2B), and carcinoembryonic antigen but were negative for cytokeratin-20.
The patient was a 30 pack-year smoker but had quit 6 years before presentation. She had no other significant medical history and was taking no medications at the time of presentation. She had recently been treated for bronchitis, which was slowly improving and prompted a chest radiograph. Her physical examination was within normal limits apart from her right foot, which was in a cast following the excisional biopsy. The chest radiograph revealed a cavitary mass in the left upper lobe (Fig 3). A computed tomography scan of the chest confirmed a 6-cm left upper lobe cavitary lung mass extending into the mediastinum. There was left-sided hilar and mediastinal lymph node enlargement. A prebiopsy bone scan revealed intense uptake in the area of the right fourth metatarsal (Fig 4). Magnetic resonance imaging of the brain revealed multiple brain metastases. The patient was treated with whole-brain and foot irradiation followed by systemic chemotherapy.
Metastatic disease to bones is a common occurrence in patients with advanced carcinomas, particularly in those with lung, breast, or prostate cancer. However, acrometastases or metastases to the hand and foot are rare and occur in less than 0.5% of cases.1,2 Most cases have been reported in the orthopedic and radiologic literature, but exposure of this entity to the practicing oncologist is important, as demonstrated by this rather dramatic example. Acrometastases are rarely the initial presentation of metastatic carcinoma. In a series by Healey et al,1 they were seen as the first manifestation of an occult malignancy in four (14%) of 29 patients. Digital metastases have been described with various malignancies, including breast, gastrointestinal tract, head and neck, and small-cell and non–small-cell lung carcinomas.1-6 Osseous metastases to the hand are most commonly caused by bronchogenic carcinomas, whereas foot metastases are more often seen with tumors originating in the gastrointestinal or genitourinary tracts.1,3,7 The most commonly involved bones are the phalanges in the hand and the tarsal bones in the foot.3 Acrometastases are often initially mistaken for more benign processes, such as infection, trauma, inflammatory arthritis, osteomyelitis, or gout. Persistent symptoms, unresponsiveness to conservative therapy, or prior history of malignancy should prompt the physician to consider metastases when evaluating a patient. Plain films often demonstrate a lytic lesion without involvement of the adjacent joint space.1,3 A biopsy of the affected area is critical in the absence of other overt signs of malignancy. Acrometastases have been treated with various modalities, including systemic chemotherapy, curettage, amputation, and radiation therapy.1 Treatment is directed toward the relief of symptoms and restoration of functional capacity.
REFERENCES
1.
Healey JH, Turnbull ADM, Miedema B, et al: Acrometastases: A study of twenty-nine patients with osseous involvement of the hands and feet. J Bone Joint Surg Am 68:743-746, 1986 2. Abrahams TG: Occult malignancy presenting as metastatic disease to the hand and wrist. Skeletal Radiol 24:135-137, 1995[Medline] 3. Baran R, Tosti A: Metastatic carcinoma to the terminal phalanx of the big toe: Report of two cases and review of the literature. J Am Acad Dermatol 31:259-263, 1994[Medline] 4. Delgadillo LA, Nichols DE: Oat cell carcinoma metastasis to the foot. J Foot Ankle Surg 37:55-62, 1998[Medline] 5. Kemnitz MJ, Erdmann BB, Julsrud ME, et al: Adenocarcinoma of the lung with metatarsal metastasis. J Foot Ankle Surg 35:210-212, 1996[Medline] 6. Wu KK: Bronchogenic carcinoma with metastases to the foot: A report of two cases. J Foot Ankle Surg 34:322-326, 1995[Medline] 7. Maeseneer MD, Machiels F, Naegels S, et al: Hand and foot acrometastases in a patient with bronchial carcinoma. J Belge Radiol 78:274-275, 1995[Medline] This article has been cited by other articles:
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Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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