Ovarian carcinoma metastasis to the little finger. A case report

Acrometastases to the Hand: A Systematic Review

Background and Objectives: The term acrometastases (AM) refers to secondary lesions sited distally to the elbow and knee, representing 0.1% of all bony metastases. By frequency, pulmonary cancer and gastrointestinal and genitourinary tract neoplasms are the most responsible for the reported AM. Improvements in oncologic patient care favor an increase in the incidence of such rare cases. We performed a systematic review of acrometastases to the hand to provide further insight into the management of these fragile patients. We also present a peculiar case of simultaneous acrometastasis to the ring finger and pathological vertebral fracture. Material and Methods: A literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted using the PubMed, Google Scholar, and Scopus databases in December 2020 on metastasis to the hand and wrist, from 1986 to 2020. MeSH terms included acrometastasis, carpal metastasis, hand metastasis, finger metastasis, phalangeal metastasis, and wrist metastasis. Results: In total, 215 studies reporting the follow-up of 247 patients were analyzed, with a median age of 62 years (range 10–91 years). Overall, 162 out of 247 patients were males (65.6%) and 85 were females (34.4%). The median reported follow-up was 5 months (range 0.5–39). The median time from primary tumor diagnosis to acrometastasis was 24 months (range 0.7–156). Acrometastases were located at the finger/phalanx (68.4%), carpal (14.2%), metacarpal (14.2%), or other sites (3.2%). The primary tumors were pulmonary in 91 patients (36.8%). The average interval from primary tumor diagnosis to acrometastasis varied according to the primary tumor type from 2 months (in patients with mesenchymal tumors) to 64.0 months (in patients with breast cancer). Conclusions: Acrometastases usually develop in the late stage of oncologic disease and are associated with short life expectancy. Their occurrence can no longer be considered rare; physicians should thus be updated on their surgical management and their impact on prognosis and survival.

Skeletal system as a rare metastatic site in patients with ovarian carcinoma

OBJECTIVE

To evaluate the frequency and predictors of bone metastasis in patients with ovarian cancer and to determine prognostic factors associated with this finding.

METHODS

Patients diagnosed with ovarian cancer between January 2009 and December 2019 were evaluated. Patients with radiologically or pathologically confirmed bone metastasis were included in the study. Survival was analyzed using Kaplan-Meier curves and compared using the log-rank test. Multivariate analysis of prognostic factors related to survival was performed using the Cox proportional hazards model.

RESULTS

Nineteen (2.6%) of 736 patients had bone metastases. Patients with clear cell histology had a higher risk of bone metastases than patients with the other epithelial histology groups (12.3% vs 2.1%, p<0.001). Overall survival was significantly lower in patients diagnosed with bone metastasis at the time of cancer diagnosis than in those diagnosed with bone metastasis during the course of the disease (median 63 vs 6.1 months, p<0.001). However, when the survival time after the development of bone metastasis was examined, no difference was found between patients with metastasis at the time of diagnosis and at the time of first or later progression (median 13.6 vs 4 months, p=0.09). In addition, the median survival of patients with clear cell histology after bone metastasis did not differ statistically from that of patients with other epithelial histology (median 22 vs 7.5 months; p=0.13). In the clear cell subgroup, bone metastasis was an independent prognostic factor for survival after multivariate analysis. For all patients, the stage at diagnosis and serum CA125 and alkaline phosphatase levels at the time of bone metastasis were prognostic factors for survival.

DISCUSSION

Bone metastasis is rare in patients with ovarian cancer. However, the risk of bone metastasis is highest in patients with clear cell histology.

Pathologic Tuft Fracture in a Thumb: A Rare Presentation of Metastatic Endometrioid Ovarian Carcinoma: A Case Report and Review of the Literature

CASE

A 51-year-old woman with a medical history noteworthy for endometrioid ovarian carcinoma presented with progressive left thumb swelling in the absence of trauma or injury. Radiographs revealed a lytic lesion in the distal phalanx. Inflammatory markers and white blood-cell count were mildly elevated. The thumb was amputated at the interphalangeal joint, and pathologic examination identified the lesion as an adenocarcinoma, consistent with the known endometrioid ovarian carcinoma.

CONCLUSION

The similar presentation of tumor and infection can present a diagnostic challenge. Despite the rare incidence of osseous metastases to the hand, orthopaedic surgeons must consider metastatic bone lesions in patients presenting with swollen or painful fingers.

Metastases to the hand and wrist: an analysis of 221 cases

PURPOSE

To identify demographic trends, survival rates, the most common metastatic locations, and the most common primary malignant tumors in the reports of hand and wrist metastases published over the past 27 years.

METHODS

A keyword search was performed across PubMed, Google, Science Direct, and Springer databases with a time-range restriction set between April 1986 and April 2013. A total of 193 articles were located describing 221 patients. The data were analyzed for patient age, sex, known history of malignancy, primary tumor site, histological diagnosis, metastatic location, hand involvement, and survival rates.

RESULTS

Lung, gastrointestinal tract, and kidney malignancies were the 3 leading metastatic tumors. The mean age among patients was 61 ± 13 years, and involvement among men was almost twice as common as among women. The mean survival from the time of the diagnosis was 7 ± 7 months. There were no predilections for either the right or the left hand. The distal phalanx was the most frequently involved bone, and the thumb was the most frequently involved digit.

CONCLUSIONS

The frequency of published hand and wrist metastasis has increased dramatically within the last decade. Metastases have been reported for every bone of the hand and wrist as well as for the soft tissues. Compared with the previous studies, the mean age of reported patients has slightly increased even though the mean survival time has not changed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Unusual cause of painful shoulder in an elderly woman with rheumatoid arthritis

The painful shoulder is a very common condition encountered in the rheumatology clinic with rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease and referred neck pain being the most common causes. Other rare causes have to be considered in the presence of "red flag" indicators. We describe a case of a patient with mild rheumatoid arthritis and a past medical history of stage 2C epithelial ovarian carcinoma who presented to the rheumatology clinic with a painful shoulder and who was initially diagnosed with rotator cuff tendinopathy. When seen 3 months later she was found to have a 15 x 10-cm firm, non-tender soft tissue mass over the right scapula and X-rays showed a large lytic mass destroying much of the upper border of the scapula, suggestive of metastasis. Bone metastases in patients with ovarian carcinoma are very rare; they occur in about 2% of cases and are invariably predictors of poor prognosis. To our knowledge, this is the first case of ovarian cancer metastasised to the scapula. We suggest that rheumatologists should be aware of the differential diagnosis of painful shoulder and look for "red flag" indicators in patients with known rheumatic conditions.

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.

Multivariate analysis of serum tumor markers for diagnosis of skeletal metastases

Serum tumor markers, including carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), carbohydrate antigen 15-3 (CA 15-3), carbohydrate antigen 19-9 (CA 19-9), cancer antigen 125 (CA 125), and tissue polypeptide antigen (TPA), were measured in 26 patients with skeletal metastases and 11 patients with primary malignant bone tumors. TPA, which was elevated in 16 patients (61.5%), was the most sensitive marker for detection of skeletal metastases. Combined measurement of these markers was useful in detecting skeletal metastases from primary lesions, although tumor markers had little organ specificity. In addition, skeletal metastases could be completely differentiated from primary lesions by the use of multivariate discriminant analysis of markers. The most and least powerful discriminating factors were AFP and CA 19-9, respectively. On multidimensional scaling, the distance between AFP and CEA was longest, with the other markers scattered between them. Expression of individual markers can not be linked to that of other markers.