alexa A Thumb Acrometastasis Revealing Lung Adenocarcinoma: A
ISSN: 2165-7920

Journal of Clinical Case Reports
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Case Report

A Thumb Acrometastasis Revealing Lung Adenocarcinoma: A Case Report and Review

Keywords
Acrometastasis; Thumb; Lung adenocarcinoma
Introduction
Bone metastasis in the hand are extremely rare, it is a concept common to many classic extremities [1]. It is generally accepted that acrometastases are difficult to diagnose. They are often confused with paronychia, osteomyelitis, rheumatoid arthritis, gout, fractures, tenosynovitis, and other diseases. [2]. The etiology of digital acrometastases is almost exclusively bronchogenic carcinoma [3]. Fortunately, digital acrometastatic lung cancer is seldom seen, accounting for approximately one out of 500 lung cancers with bony metastases [4]. It carries a grim prognosis, with a mean survival of three to six months after presentation [5,6]. We report the case of a tumor of the thumb that revealed a pulmonary adenocarcinoma.
Case Report
A 72 year old man, with twenty pack- year of smoking, weaned ten years ago, suffered from a swollen, erythematous, painful tip of the left thumb, which appeared last month, evolving in a deterioration of his general condition.
Physical examination found a patient with performance status at 2 (ECOG 2) (=Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities). The swelling was red, and painful with onychomycosis (Figure 1). The radiographs of the left thumb revealed the presence of a highly aggressive osteolytic lesion involving the phalanx (Figure 2). There was no evidence of pathological fracture. A Biopsy under local anesthesia was performed, and histopathological study suggested a bone metastasis of a poorly differentiated adenocarcinoma of the lung. The patient underwent an amputation of the thumb (Figure 3). As part of the staging, a chest radiograph revealed a left upper lung mass (Figure 4). Bone scan showed increased tracer uptake at the right clavicle, the rib cage, left sacrum, right spin, and the cortex of left femur, evoking multiple secondary osseous metastases.
The patient was referred to department of oncology and radiotherapy for palliative treatment, but the evolution has been marked by a deterioration of the general condition of the patient and he died one month after surgery.
Discussion
Bone metastases in the hand and foot (acrometastases) are rarely observed, their incidence have been reported to be as low as 0.3% of cancer patients [7]. The primary tumors that have predilection to the hands are lung, kidney, breast, gastrointestinal tract, oesophageal, and head and neck cancers. Men were twice likely to be affected compared to womans [6]. Acrometastasis to the hand secondary to the lung cancer can be asymptomatic or can present with painful swelling and movement restriction. The symptoms are observed only in 10% of acrometastases before the primary tumor was determined [8]. The literature review found different presentations of acrometastatic lesions. The finger affected by the lesion may present with a painful erythematous, heat and swelling [9]. Addition to this, the overlying skin can weep, bleed or ulcerate [5,10]. Because of the uncommon presentation of secondary disease in the hands, it is difficult for doctors to consider the possibility of acrometastasis when diagnosing unusual hand conditions. The most commonly involved bones are the terminal phalanges in the hand. The radiographs of the hand often demonstrate a lytic lesion [6].
The mechanism responsible for the deposition of metastatic tumour cells within the hand is unclear, but an increase in blood flow or a trauma has been suggested in the past [2]. Predisposing factors are reported in the literature: trauma, temperature gradient, hormonal and immune factors [2,11]. As acrometastasis to the pulmonary cancer accompanies with a poor prognosis, treatment is largely palliative. So, palliation of pain and movement restriction is the objective of the clinicians. Acrometastases have been treated with various modalities such as amputation, curettage, wide excision, chemotherapy and radiotherapy [6]. The recent literature showed that a short course of hypofractionated radiation therapy can successfully relieve pain and restore function capacity to the affected finger [6]. The bisphosphonates and recently denosumab have demonstrated a role to prevent and reduce skeletal related events in patients with bone metastasis from solid tumors [12,13]. Any patient presenting digital symptoms must be carefully monitored especially for patients at risk for lung cancer.
Conclusion
Acrometastases are rare disorders and particularly difficult to detect. Their prognosis is very poor and treatment is essentially palliative.
Conflicts of Interests
All the authors have no conflict of interest.
References
 

Abstract

Lung cancer is the commonest cause of acrometastatic disease to the fingers. Treatment of acrometastasis is palliative with radiation or amputation and the prognosis is poor. The authors report a case of phalangeal metastasis in a man aged 72 years old, diagnosed as a painful swelling of the thumb, revealing a bronchial adenocarcinoma. An amputation of the thumb was performed. Histology confirmed a metastasis from the lung adenocarcinoma. The patient died one month after discovery of the primary tumor.

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