Metastatic malignancy of the hand

Acrometastasis: The Tip of the Iceberg of Metastatic Disease from Thyroid Cancer. Two Cases Report

Acrometastasis, especially in the hands and fingers, is a rare clinical condition resulting from primary cancers such as lung, breast, kidney, and, rarely, thyroid cancer. Acrometastasis tends to be the tip of the iceberg in patients with extensive systemic disease, which could be regional, pulmonary, skeletal, neurological, or all of them combined. Even though these tumors are clearly visible and symptomatic, the diagnosis is usually misleading because such distal metastatic disease is not thought of at first. In general, systemic treatments should be given to any patient presenting digital acrometastasis. We describe two cases of papillary thyroid carcinoma and digital acrometastasis as a sign of advanced disease.

Acrometastases to the hand in stomach carcinoma: a rare entity

Acrometastasis caused by malignancy is a very rare phenomenon, and gastric malignancy metastasising to the hands is an even rarer entity. It accounts for only 0.1% of all metastatic osseous involvement, and may be a late manifestation of malignancy or may even be a presenting symptom. It is generally seen with lung primary, followed by kidney and breast, and less frequently with colon, liver, prostate, rectum and stomach primaries. The terminal phalanges are the most common sites of metastases, followed by the metacarpals and the proximal phalanges. We present a case of stomach carcinoma with metastases to the liver and adrenals which was managed with three lines of chemotherapy. He was lost to follow-up and reported after 1 year with swelling over his left hand, which was managed with palliative radiation to the hand in view of severe pain, followed by chemotherapy.

Imaging of Pelvic Bone Metastasis from Malignant Phyllodes Breast Tumor

The author reports a patient with a malignant phyllodes breast tumor, who then had a ten-year disease free interval before she developed a left pelvic bone metastasis and soft tissue invasion. Cross-sectional and radionuclide imaging of its musculoskeletal metastasis is presented. Literature concerning bone metastasis from phyllodes tumor is also briefly reviewed and discussed, along with its epidemiology.

Palmar metastasis of an adenocarcinoma of the esophago-gastric-junction: First case report

INTRODUCTION

Hand metastasis represents only approximately 0.007-0.2% of all metastatic lesions. The most common origin of hand metastasis is the lung, which is approximately 50% of all cases, followed by breast and kidney. Hand metastasis from gastric or esophagic cancer is even much more rare.

PRESENTATION OF CASE

This is the first case report of a metastasis to the palm of hand (tendon) due to an adenocarcinoma of esophago-gastric-junction.

DISCUSSION

While most of the esophagic and gastric carcinomas metastasizes to liver, lungs and brain, the rare possibility of encountering metastasis to the hand either to the bone, but also to the tendon exists. Therefore, we recommend obtaining a thorough history and a detailed clinical examination, plain radiographs, followed by axial imaging techniques like MRI and a histopathologic evaluation.

CONCLUSION

Even if metastatic lesions to the hand are really rare, the surgeon should always be suspicious of a metastatic lesion, when presented with a patient older than 40 years who has a history of cancer.

An atypical metastasis of follicular-type adenocarcinoma of the thyroid gland to thumb

Bone metastasis in the hand is rare. The etiology of metastatic hand cancers is different from other bones. Bronchogenic carcinoma is the most common primary tumor metastasis to hand. In this paper a rare case of thumb metastasis from "follicular-type carcinoma" of the thyroid is presented.

Metastasis of lung adenocarcinoma to the fifth distal phalange of right hand

A 46-year-old male was diagnosed of lung adenocarcinoma with right adrenal gland metastasis in January 2009, and underwent chemotherapy (DC (docetaxel and cisplatin) regimen) and stereotactic radiotherapy. In December 2009, whole brain radiotherapy was given to the patient due to brain metastasis. In January 2010, he complained of redness, swelling and tenderness of the fifth terminal phalange of his right hand. Open surgery and biopsy confirmed bone metastasis to the finger. The patient then received local injection of OK-432 combined with radiotherapy. The symptoms were greatly relieved after treatment and the patient has survived for 28 months at the time of this report.

Metastatic phalangeal osteolysis as an initial presentation of carcinoma colon

Metastatic malignancies of the hand are rare and usually develop from lung, breast, or kidney tumors. Metastases from tumors and sarcomas of the gastrointestinal system are even more uncommon. The authors report a case of differentiated adenocarcinoma of the colon in a 76-year-old man who presented with distal phalangeal metastasis and osteolysis in the form of a painful swelling at the tip of the right little finger of 6 months duration. Computed tomography of the abdomen and colonoscopy revealed a mass in the transverse colon. Diagnosis was confirmed by biopsy. Treatment was given with palliative local radiation and systemic chemotherapy. After 4 weeks of chemotherapy, the patient discontinued treatment and eventually succumbed to the disease.

Two cases of acrometastasis to the hands and review of the literature

This paper reports two cases of acrometastasis to the hands. The first case involved a 78-year-old woman with a permeative osteolytic lesion in her proximal second metacarpal. A biopsy of this lesion suggested a diagnosis of non-small-cell lung carcinoma with secondary osseous metastasis. This was the first presentation of the woman’s primary diagnosis. A single 8-Gy fraction of palliative radiotherapy was delivered to the patient’s left hand. The treatment proved successful: the woman soon experienced pain relief and regained the use of her hand. The second case involved a 69-year-old woman with extensive lytic destruction involving the proximal two thirds of her third metacarpal. This patient had been diagnosed with carcinoma of the breast in 1990. She also received a single 8-Gy fraction of radiation, which improved both her pain and her hand mobility.

An extensive review of the literature uncovered 257 previously reported cases of acrometastasis. Articles were analyzed based on age and sex of the patient, site of the primary carcinoma, metastatic locations within the hand and affected appendage or appendages, the treatment given, and the patient’s length of survival. Men were almost twice as likely to experience acrometastasis as women, and the median age of the patients overall was 58 years (range: 18 months–91 years). Lung, kidney, and breast carcinoma were the three most prevalent primary diagnoses reported in the literature. Cancers of the colon, stomach, liver, prostate, and rectum affected the remainder of the population.

Overall, the right hand was more often host to the metastatic lesions. In addition, almost 10% of the patients experienced lesions in both hands. The third finger was the digit most affected by osseous metastases reported in the literature. Lesions of the thumb, fourth finger, second finger, and fifth finger were less commonly reported. The region of the digit most often affected within the patient population was the distal phalanx. The metacarpal bones, proximal phalanges, and middle phalanges comprised the remainder of the four most frequent acrometastatic sites. In the literature, single lesions were more prevalent than multiple bony lesions.

Based on the reported cases, amputation appeared to be the preferred method of treatment. Radiation, excision, and systemic therapy were the next most frequently used treatments. Patient survival was not well documented within the literature. However, the median survival of patients in the reported cases was 6 months. Thus, our review suggested that a diagnosis of hand metastasis is an indication of poor prognosis.

This report serves to emphasize the importance of properly diagnosing acrometastases. Identifying and effectively treating these metastases in a timely manner can lead to a dramatic improvement in a patient’s quality of life.

Cancer lung: An unusual presentation

Phalanx bone metastasis as the initial manifestation of lung cancer is a rare presentation. A 70-year-old man presented with swelling and pain in his right ring finger. He had no other complaints or abnormal findings on clinical examination. A right hand radiograph showed an osteolytic lesion in the first phalanx of the ring finger. Fine needle aspiration cytology of the swelling suggested a metastatic adenocarcinoma. A skeletal survey, hematological, biochemical, and other radiological tests were found to be normal, except for an opacity seen in the right lung midzone. A bronchoscopic biopsy revealed adenocarcinoma of the lung.

Extensive metastasis to the hand from undiagnosed adenocarcinoma of the lung

Metastatic tumours of the hand are uncommon; we present a case of undiagnosed adenocarcinoma of the lung with extensive metastases to the carpal, and to the third, fourth, and fifth metacarpal, bones. Biopsy confirmed the diagnosis and the patient died three months later, no surgical treatment being offered.

Metastasis of bronchogenic carcinoma to the 5th metacarpal bone: a case report

Background

Metastatic lesions to the hand are very rare and represent 0.1% of all osseous metastases.

Case presentation

We present a patient with metastasis of bronchogenic carcinoma of the lung to the 5^th metacarpal to draw the attention for the potential of such lesions to be developed in this region. Due to the extensive metastasis to the hand the patient was referred to the oncologists.

Conclusion

The surgeon should be cautious regarding the differential diagnosis, the usual poor prognosis of such patients and the questionable need for reconstructive surgery.

The hand in metastatic disease and acral manifestations of paraneoplastic syndromes

Metastatic tumors to the hand and wrist are rare, accounting for approximately 0.1% of all metastatic lesions to the skeleton. The biochemically mediated pathways of bone metastases, the location of the hand at the distal extremity, and the small amount of marrow in the bones of the hand and wrist account for the low prevalence of acrometastases. More rarely, hand dermatologic and soft tissue changes of paraneoplastic syndromes herald an occult malignancy.

Metastatic thymic carcinoma in a digit: a case report

Acrometastases are a rare but important clinical entity. We present the case of a 54-year-old man with a metastasis to a digit from a primary thymic carcinoma. The prognostic implications of such a diagnosis are discussed.

Bronchogenic carcinoma mimicking paronychia and osteomyelitis in the great toe

Bone metastases from malignant tumors are common, but metastatic lesions to the bones of the foot are very rare. The most common primary lesion is the genitourinary tract, and the tarsal bones are most commonly involved. We present a rare case of squamous cell carcinoma of the lung, metastatic to the right great toe, that presented clinically as paronychia and osteomyelitis. This was the primary manifestation of an occult and disseminated disease.

Metastatic carcinoma to the terminal phalanx of the big toe: report of two cases and review of the literature

Metastasis to the distal phalanges of the fingers and toes is rare and is associated with a poor prognosis. Phalangeal metastases commonly display inflammatory symptoms that mimic an acute infection. We describe two men with metastasis to the distal phalanx of the great toe. A review of the literature revealed 118 cases of nonmelanoma metastatic tumors to a distal digit.

Hand metastases from urothelial tumor

Metastases to the hand are rare, particularly those of soft tissues. As a rule they arise in lung, breast, or kidney but other primary sites such as the bladder, have been described. We report a silent primary malignant tumor of the bladder, which came to light as soft tissue hand metastases.

Flexion contracture of the thumb: a malignant etiology

A patient was first seen with a flexion deformity of the thumb interphalangeal joint that was initially diagnosed and treated as traumatic in origin. A painful forearm soft tissue mass was ultimately discovered; biopsy of the flexor pollicis longus tendon showed metastatic adenocarcinoma. Extensive evaluation failed to locate the origin of the primary tumor. Treatment consisted of local radiation and systemic chemotherapy. After 1 year, the patient is alive and well, has no evidence of disease, and refuses correction of the thumb interphalangeal flexion contracture.

Metastatic tumours of bones of the hand and foot. A comparative review and report of 43 additional cases

Metastases in the bones of the hands and feet are rare. The literature relating to these tumours has been reviewed, and 43 new cases are reported. In the cumulative total of cases, metastases to the hand outnumber those to the foot 2:1 (196 cases as against 94). Bronchial carcinoma is the most common neoplasm metastasising to the hand. Subdiaphragmatic neoplasms such as gastrointestinal, vesical, renal and uterine malignancies, metastasize more frequently to the foot. A possible explanation for this latter finding is the retrograde spread of tumour emboli from the vertebral venous plexus down incompetent leg veins.

Metastatic tumors of the hand

During a 43-year period, 18 patients with 22 lesions metastatic to the hand were treated at our institution. Twelve lesions were located in the distal phalanges, and the remainder were found in the carpus, metacarpals, proximal phalanges, and soft tissues of the hand. The primary tumor was in the lung in five cases and in the kidney in five cases. Treatment consisted of local excision or radiation for proximal lesions and amputation for distal lesions. Although the median survival was only 5 months, five patients lived longer than 2 years; including two who had no further evidence of malignant disease. In two patients, hand metastasis was the first sign of malignant disease. Metastatic malignancy should be considered in the differential diagnosis of inflammatory lesions of the hand. Although in general, the goal of treatment should be palliation, in some patients long disease-free intervals can be provided by wide excision of the metastatic focus.

Metastatic tumors in the hand from adenocarcinoma of the colon

Osseous metastases to the hand are rare. The primary site is usually in the lung, breast, or kidney. Two cases of metastatic tumor in the hand from adenocarcinoma of the colon are reported herein. These patients presented two and four years after initial resections of colonic carcinomas. General aspects of diagnosis, etiology, and management are discussed.

The hand in metastatic disease

A review of the world literature shows 163 cases of tumors metastatic to the hand; we report three additional cases. The incidence of primary tumors elsewhere metastasizing to the hand is a little more than 0.1%. In over 16% of cases, a tumor of the hand was the first manifestation of a primary tumor elsewhere. The lung is the chief source, followed by the breast and the kidney. The terminal phalanges are the most frequent site of metastasis, followed by the metacarpals and the proximal phalanges. The mechanism of dissemination remains obscure.

Metastatic tumor of the hand from malignant cystosarcoma phylloides of the breast. A case report

In this case report, a malignant cystosarcoma phylloides of the breast metastasized to the pulp of the little finger in a 47-year-old woman. It initially masqueraded as a whitlow. The diagnosis was helped by radionuclide bone scanning, which showed multiple areas of increased focal uptake including the terminal phalanx of the fifth finger, and the diagnosis was established by a frozen section biopsy of the tumor. The patient underwent a palliative fifth ray resection. She died within six weeks of surgery from extensive pulmonary and osseous metastases. Review of literature revealed only one other case of malignant cystosarcoma phylloides of the breast that metastasized to the hand and was initially misdiagnosed as a whitlow.

The significance of metastasis to the bones and soft tissues of the hand

We have treated six patients with cancer metastatic to the hand. All patients died within 6 months after the appearance of hand metastasis. We polled the combined membership of the American Association for Surgery of the Hand and the American Society for Surgery of the Hand to determine their experience with this problem. We also reviewed the pertinent literature concerning this subject. The information obtained from the literature and the poll confirmed our experience. We have managed these patients by amputation, feeling that reconstructive procedures were not indicated if the time necessary to rehabilitate the patient after reconstruction exceeds the patient's life expectancy.

Metastatic malignancy to the bones of the hand

Metastatic involvement of the bones of the hand is extremely rare with an incidence of 0.007%. As of this report there are 55 cases reported in the English-language literature. This paper reports two additional cases and the literature is reviewed.

Osseous metastases in the hand. A general review of three cases

Osseous metastases in the hand are rare. The authors report 3 cases, bringing the total number of reported cases up to 106. They affect mainly men; their clinical features are local swelling and pain frequently ascribed to a trauma. The diagnosis is often mistaken, many patients being initially treated for a distal felon. Distal phalanx is the main involved area, with irregular osteolysis and cortical destruction. The etiology is quite different from that of metastases to other bones: bronchopulmonary cancer is by far the most frequent with 46% of cases, followed by breast cancer (15%). Other types of cancer are much less frequently involved. The evolution is sombre; average life expectancy is 3 1/2 months. Treatment may involve, as needed, distal digital amputation on antalgic radiotherapy.