Introduction
Acrometastasis to the hands are not commons and
often misdiagnoses. Only 0,1 % of all metastatic have osseous involvement1.
Despite the rarity of the lesion, awareness of its possibility is important to prevent this misdiagnosis of
infection and a delay in proper treatment2. The most common location
is the distal phalanx and the primary side the lung. We describe an 81-year-old
patient who presents an erythema and swelling in distal right thumb phalanx, whose
final diagnosis was an acrometastasis of primary lung neoplasm.
Case Report
An 81-year-old right hand man was referred to
our orthopaedic unit following an one week history of painful and inflammation
at right thumb initially treated with antibiotics for suspected whitlow that
not evolved correctly. His past medical history included Alzheimer disease, benign
prostatic hyperplasia, obstructive pulmonary disease and an undifferentiated
lung neoplasm diagnosed five months previously. The tumour was initially
evaluated as T2N2M0 and the patient was not treated due to family refusal for
aggressive treatments because of the patient's clinical situation.
On physical examination the patient was no febrile
with stable status. He present an intensive painful swelling, redness with
increased temperature completing a fluctuating wound in the volar aspect of the
distal right thumb phalanx. Active interphalangeal flexion was decreased for
pain. Radiographs showed an osteolytic process without reactive new bone
formation involving the distal epiphysis. There was no evidence of pathologic
fracture (fig 1-A). It also identified a soft tissue component but no periostal
reaction. Blood tests not revealed an inflammatory syndrome. The suspected
diagnosis was acute osteomyelitis of the right thumb distal phalanx.
Emergency abscess opening is necessary to
obtain samples of exudate, it was dense but not smelly. Because of the poor
outcome we decided initial hospitalization for intravenous antibiotic therapy
with levofloxacin, rifampin, and symptomatic control of pain.
The lesion of the distal thumb had no good
evolve, the exudation is very low but after 48 hours of emergency drainage it
maintained septic appearance and showed a friable granulation tissue and soft
protruding in the primary incision area (figure 1-B). The bacterial cultures
were sterile. After five days, the tissue reagent has grown and acquired a greyish
appearance. We decided amputation.
Amputation was performed with a fish mouth
incision and resection of the proximal phalanx. A piece of 4x3,5 cm was
reviewed in pathologic examination. Histological test revealed an squamous
metastasis of the primary lung tumour (Fig 2A y B). The postoperative course
was uneventful maintain a prophylactic antibiotic who was removed early and he
has discharged after 72 hours. The patient was review after ten days with good
evolve. He remained asymptomatic with good healing. Six months after surgery,
he died due to a pulmonary complication.
Discussion
The distal digital metastases are uncommon. The
frequency varies according to the series but is generally closer to 0.1% in the
hands1. Lookingbill et al3 identify only 9 of 7319 in her retrospective study but concludes that
the effect may be even smaller if one takes into account those that were not
bone disease. In the Cohen’s revision4 of distal metastasis its represent
one of the initial signs of internal malignancy unknown in half the patients,
but other locations are the first sign of less than 1%.
The most
common location of distal acrometastasis are the fingers in hand. Topographic
distribution of 62% for the phalanges, shows that most often location of
this are the distal phalanx and the lowest frequency in the middle phalanx,
where there are so rare5. The finger most commonly affected is the thumb.
Simple Radiographs shows an osteolytic disease,
except in a few cases of prostatic osteoblastic acrometastasis. Physical examination
is variable but typically is very painful. The distal phalanx appears red,
swollen, painful and fluctuating. Deforming the finger ends showing a so-called
"false Acropachy"6. At this point it is necessary to make
differential diagnosis with conditions such as paronychia, osteomyelitis2,
rheumatoid arthritis, gouty arthritis, algodistrophy9 or
tenosynovitis. Biopsy under local anaesthesia can provide the definitive diagnosis in
superficial lesions. As in our case the initial confusion of acrometastasis as
an infectious disease can delay diagnosis and lead to an initial mishandling of
this.
The most frequent primary tumour side is the
lung (41%), gastric (11 %) and then the breast. Other less common primary tumours
are the gastrointestinal tract, uterus, testis or secondary cases have been
described in melanoma, chondrosarcoma, or cancers of the oral cavity. When the
source of the primary tumor is the urogenital tract or the colon tend to lead
to lower limb acrometastasis4. All tumours can produce an
acrometastasis8 but the chief histologist type is the epidermoid.
The way that the distal spread happens is no
well know. Factors like traumatism, hormonal and immune changes, the
temperature gradient and the inherent properties in the cell that spears are
certainly involved10. When metastatic disease appears indicates an
ominous prognosis, most patients survived less than six months. Improved survival
has been published since the diagnosis for certain types of tumours, especially
the kidney, with survival up to 15 months11. Advances in the
diagnosis and treatment of primary tumours are the cornerstone of this
improvement.
The
treatment of this disease may include chemotherapy, excision, amputation, or
ray resection with curettage and filling of the cavity for small lesions in
terms of overall patient. It should be considered as a palliative for
symptomatic relief, extended survival, maintaining quality of life, and
preservation of maximal hand function.
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of 7316 cancer patients. J Am Acad Dermatol 1990;22:19e26.
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AUT ORES: ANTONIO TORRES CAMPOS, MIGUEL RANERA GARCÍA (HCU LOZANO BLESA ZARAGOZA)
