Paraneoplastic palmar fasciitis and polyarthritis syndrome in a patient with advanced prostate cancer

Update on Palmar Fasciitis and Polyarthritis Syndrome: A systematic review

OBJECTIVES

This systematic review aims to (1) summarize the clinical, laboratory, and imaging characteristics of Palmar Fasciitis and Polyarthritis Syndrome (PFPAS) patients and (2) evaluate the effectiveness of different treatments.

METHODS

We conducted a systematic search of three electronic databases (Scopus, Embase, and PubMed) from inception to December 31, 2023. We presented demographic and clinical features, along with laboratory factors and imaging examinations of PFPAS patients. Additionally, we outline main treatments and evaluate therapeutic effectiveness.

RESULTS

A total of 121 patients were included in the analysis, with a mean onset age of 61.4 years. Swelling or thickening (49.6%, n=60/121) and pain (41.3%, n=50/121) were characteristic musculoskeletal symptoms of the hands. The median time between onset of PFPAS symptoms and detection of malignancy was 4 months, with a median survival of 13.0 months (range=2 to 69). The abnormal rate of ultrasound, magnetic resonance imaging, and bone scan of the musculoskeletal system was more than 80%. Effective therapeutic responses were observed in 66.0% (n=33/50) of cases treated with chemotherapies and 79.2% (n=19/24) with operations. Two patients who received biologics achieved partial remission.

CONCLUSION

PFPAS is a rare paraneoplastic condition, and early recognition of its distinctive symptoms may lead to the detection of underlying malignancy and timely treatments, potentially saving lives.

Advances of autoimmune rheumatic diseases related to malignant tumors

BACKGROUND

Malignant neoplasms are a well-recognized global public health concern, with significant impacts on human health and quality of life. The interplay between tumors and autoimmune rheumatic diseases is complex, and the resulting tumor-associated rheumatic diseases represent a rare and intricate group of conditions that occur in the context of malignant tumors. In addition, various rheumatic diseases can arise as a consequence of oncology treatment. These diseases present with intricate clinical manifestations and pathological features, often rendering them challenging to diagnose and impacting patients' quality of life. Despite this, they have yet to be fully recognized.

METHODS

This article presents a literature review of published original articles and review articles concerning paraneoplastic rheumatic syndromes and rheumatic diseases associated with cancer treatment. We conducted a comprehensive literature search in PubMed, Web of Science and Google Scholar databases, excluding duplicated and irrelevant studies. In cases of duplicated research, we selected articles with higher impact factors for the review.

RESULTS

This review focuses on the clinical features, diagnosis, and treatment of paraneoplastic rheumatic diseases, as well as the pathogenesis of these diseases. Additionally, we summarize the autoimmune rheumatic diseases associated with cancer treatment. Ultimately, the goal of this review is to enhance recognition and improve the management of autoimmune rheumatic diseases related to tumors.

Paraneoplastic Syndromes from Head to Toe: Pathophysiology, Imaging Features, and Workup

Patients often have symptoms due to the mass effect of a neoplasm on surrounding tissues or the development of distant metastases. However, some patients may present with clinical symptoms that are not attributable to direct tumor invasion. In particular, certain tumors may release substances such as hormones or cytokines or trigger an immune cross-reactivity between malignant and normal body cells, resulting in characteristic clinical features that are broadly referred to as paraneoplastic syndromes (PNSs). Recent advances in medicine have improved the understanding of the pathogenesis of PNSs and enhanced their diagnosis and treatment. It is estimated that 8% of patients with cancer develop a PNS. Diverse organ systems may be involved, most notably the neurologic, musculoskeletal, endocrinologic, dermatologic, gastrointestinal, and cardiovascular systems. Knowledge of various PNSs is necessary, as these syndromes may precede tumor development, complicate the patient's clinical presentation, indicate tumor prognosis, or be mistaken for metastatic spread. Radiologists should be familiar with the clinical presentations of common PNSs and the selection of appropriate imaging examinations. Many of these PNSs have imaging features that can assist with arriving at the correct diagnosis. Therefore, the key radiographic findings associated with these PNSs and the diagnostic pitfalls that can be encountered during imaging are important, as their detection can facilitate early identification of the underlying tumor, reveal early recurrence, and enable monitoring of the patient's response to therapy. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Association between systemic sclerosis, palmar fasciitis with polyarthritis, Raynaud's phenomenon and erythromelalgia with underlying malignancy

The symptoms of a rheumatic disease may also be a sign of a proliferative process. These include conditions that present with skin and vascular changes such as systemic sclerosis and Raynaud's phenomenon with peripheral ischaemia and ulceration. Furthermore, the less common conditions - erythromelalgia or palmar fasciitis with polyarthritis may also accompany cancer. In this article, we discuss the association of diffuse systemic sclerosis with anorectal tumor, palmar fasciitis and polyarthritis with ovarian cancer, erythromelalgia with underlying ovarian malignancy and Raynaud's phenomenon and digital ischemia associated with renal carcinoma. Based on the literature review on this topic we highlighted the importance of recognizing paraneoplastic syndromes at an early stage. This is a crucial point in the adequate management of a patient. Many of the paraneoplastic symptoms of rheumatic and other described conditions may regress with the management of the underlying malignancy.

Palmar Fasciitis and Polyarthritis Syndrome: A Rare Paraneoplastic Syndrome in a Patient With Prostate Carcinoma

A 73-year-old patient was seen in our hospital for treatment of metastatic adenocarcinoma of the prostate (pT_1aN₀M_1a R₀, BRCA-2 gene mutation). Prostatectomy and regional radiotherapy were performed and goserelin, a luteinizing hormone-releasing hormone (LHRH) analog, had been started because of disease progression. Castration-resistant progressive disease developed, and enzalutamide was added. A decrease of the prostate-specific antigen (PSA) level was achieved. Before the start of enzalutamide, the patient developed bilateral pain and stiffness of both hands combined with thickening of the hands. The symptoms progressed rapidly to bilateral flexion and extension contractures. The patient became unable to tie his shoelaces and had to use adjusted cutlery to eat. Consultation of the rheumatologist, X-rays, ultrasound and palmar skin biopsy of the hands were performed. The clinical picture resembles descriptions of “palmar fasciitis and polyarthritis syndrome” (PFPAS), a rare paraneoplastic syndrome. Positive effects of immunosuppressive medication have been reported in some cases. In our patient, treatment with oral prednisone (30 mg daily) showed no effect, therefore treatment was switched to methylprednisone pulses and methotrexate. PFPAS is an uncommon paraneoplastic syndrome characterized by rapid onset of bilateral arthritis of the hands, fasciitis of the palms, progressive stiffness and contractures. The scarcity of knowledge about PFPAS makes it difficult to recognize it at an early stage. As a paraneoplastic syndrome, it has been linked to various malignancies. Thus far, PFPAS has been described in only two other cases of prostate cancer.

Cutaneous Manifestations in Pancreatic Diseases-A Review

Pancreatic pathology, comprising acute and chronic pancreatitis, autoimmune pancreatitis and pancreatic neoplasms, primarily presents with gastrointestinal symptoms and signs; however, it is well recognized that it can also associate a wide range of extra-digestive features. Among these systemic manifestations, cutaneous involvement plays an important role both as a diagnostic clue for the pancreatic disease itself and serving as a prognostic factor for the severity of the condition. Recognition of these cutaneous signs is, however, far from being satisfactory, all the more as some of them are relatively rare. In the current review, we discuss skin involvement in pancreatic diseases, referring to pancreatic panniculitis, cutaneous hemorrhagic manifestations, skin metastasis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema and cutaneous fistula. We highlight the clinical characteristics, treatment and prognostic value of these lesions. Better awareness among medical specialties other than dermatology is needed for detection of the skin clues associated with pancreatic pathology.

Paraneoplastic Palmar Fasciitis and Polyarthritis Syndrome in a Metastatic Breast Cancer Patient: Rare Case Report

Palmar fasciitis and polyarthritis syndrome (PFAPS) is a rare paraneoplastic event that has been reported mainly in ovarian cancers. Clinical diagnosis of PFAPS is characterized by the diagnosis of neoplasm with accompanying flexion contractures, inflammatory fasciitis, fibrosis, and generalized arthritis of the hands. Since first published report, only rare few additional cases of PFPAS have been reported. In this case report, we describe a patient with metastatic breast cancer who subsequently developed PFPAS in association with advanced breast cancer. She had clinical rheumatological symptoms course parallel to her primary breast cancer disease status.

Palmar fasciitis and polyarthritis, a rare paraneoplastic syndrome related to ovarian cancer

Palmar fasciitis and polyarthritis syndrome (PFPAS) is an uncommon disorder characterized by diffuse inflammation of the palmar fascia, tendon sheaths, and joints of the fingers and wrists, which rapidly progresses to flexion contracture of the hands. This paraneoplastic syndrome, originally linked to ovarian carcinoma, has also been associated with multiple different malignancies. As PFPAS usually precedes the detection of cancer, its symptoms should raise the suspicion of an underlying malignancy and should be thoroughly investigated.

Migrating Polyarthritis as a Feature of Occult Malignancy: 2 Case Reports and a Review of the Literature

Malignant disease may be associated with a wide variety of musculoskeletal syndromes. Rarely the musculoskeletal system can be indirectly affected by paraneoplastic phenomena, such as carcinomatous polyarthritis (CP). The differential diagnosis for CP is broad and is often a diagnosis of exclusion. CP often presents similarly to other forms of inflammatory arthritis, and a detailed history and physical examination can often distinguish CP from other more common causes of polyarticular arthritis. However serological tests such as rheumatoid factor (RF) and anti-citrullinated peptide (anti-CCP) antibody positivity, while rare, can be misleading. Clinical awareness and suspicion are paramount in achieving an accurate diagnosis and early detection of an occult neoplasm is critical for prompt management and therapy. We report two cases presenting with this unique clinical phenotype associated with paraneoplastic polyarthropathy and review the literature.

Two Paraneoplastic Autoimmune Syndromes: Limbic Encephalitis and Palmar Fasciitis in a Patient with Small Cell Lung Cancer

Small cell lung cancer (SCLC) is characterized by a relatively high rate of autoimmune phenomena. Paraneoplastic limbic encephalitis (PLE) is an autoimmune syndrome in which a non-neural tumor containing an antigen normally present in the nervous system precipitates an antibody attack on neural tissues. Patients with PLE usually present with rapidly progressive short-term memory deficits, confusion or even dementia. Palmar fasciitis and polyarthritis syndrome (PFPAS) is another autoimmune syndrome characterized by rheumatologic manifestations, especially involving the palms of the hands. We report a case of a 59-year old woman who presented with worsening neurological symptoms of two-week duration, and later coma. The combined clinical, serological, and imaging studies suggested a diagnosis of PLE. A chest computed tomographic scan showed a 1.2 cm-diameter mass in the upper lobe of the left lung that was surgically removed and showed SCLC. Following surgery, neurological symptoms rapidly improved, allowing the patient to receive adjuvant chemotherapy. While in remission for both SCLC and PLE, the patient developed pain, soft-tissue swelling, and stiffness in both palms, suggesting the diagnosis of PFPAS. Five months following the diagnosis of palmar fasciitis, SCLC relapsed with mediastinal and cervical lymphadenopathy. This case report underlines the continuous interaction of SCLC with the immune system, expressed by coexistence of two rare paraneoplastic diseases, PLE, and PFPAS, in a patient with SCLC. While symptoms related to PLE preceded the initial diagnosis of SCLC, other symptoms related to PFPAS preceded relapse.