Metastatic bronchogenic carcinoma to the bones of the hand

Metastases to the nail unit and distal phalanx: a systematic review

Metastases to the nail unit/distal phalanx (NU/DP), although rare, carry a poor prognosis and are frequently misdiagnosed due to variable clinical presentation. Metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy. Since the most recent systematic review of case reports (133 patients total) was conducted in 2001, we conducted a systematic review from 1900 to 2021 (244 patients total) to assess any changes in trends in demographics, clinical presentation, and morphology and to report on more updated differential diagnoses. We also examined cases for age, sex, race, ethnicity, Fitzpatrick skin type, laterality, distribution, and diagnostic methods. The PubMed database (1900-2021) was used to detect case-level data per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that the most common primary tumors were lung, kidney, and esophagus. A NU/DP metastasis was the presenting sign of malignancy in 31.00% of patients without a former cancer diagnosis. Male to female ratio was 2:1, with average age at diagnosis 58 years. Metastases most often affected a single digit (79.91%), particularly the thumb, followed by the fourth digit. This systematic review corroborates that metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy and provides updated diagnostic guidelines. NU/DP metastasis should be considered in both healthy patients and patients with a former malignancy diagnosis presenting with nail changes involving a single digit. Prompt diagnosis and treatment may improve prognosis.

Diagnoses and Clinical Outcomes Associated with Surgically Amputated Feline Digits Submitted to Multiple Veterinary Diagnostic Laboratories

Amputation is commonly performed in an attempt to both treat and diagnose conditions affecting the digits of cats. The records of multiple veterinary diagnostic laboratories were searched to identify submissions of amputated digits from cats. Eighty-five separate submissions were reviewed for diagnosis, age, sex, limb of origin, and digits affected; and the original submitting clinics were surveyed to determine clinical outcome. The Kaplan-Meier product-limit method was used to determine the disease-free interval and survival time. Neoplastic disease was identified in 63 of 85 submissions, with exclusively inflammatory lesions composing the other 22 cases. In 60 (95.2%) of the neoplastic cases, a malignant tumor was identified. Squamous cell carcinoma was the most commonly identified malignant tumor ( n = 15; 23.8%) and was associated with a median survival time of 73 days. Other diagnoses included fibrosarcoma ( n = 14; 22.2%); adenocarcinoma, likely metastases of a primary pulmonary neoplasm ( n = 13; 20.6%); osteosarcoma ( n = 5; 7.9%); mast cell tumor ( n = 4; 6.3%); hemangiosarcoma ( n = 5; 7.9%); malignant fibrous histiocytoma ( n = 2; 3.2%); giant cell tumor of bone ( n = 2; 3.2%); and hemangioma ( n = 2; 3.2%). Giant cell tumor of bone has not been previously described in the digits of cats. Various neoplasms can occur in the digits of cats, and submission of the amputated digit for histopathologic diagnosis is essential to determine the histogenesis and predict the clinical outcome.

Feline lung-digit syndrome: unusual metastatic patterns of primary lung tumours in cats

PRACTICAL RELEVANCE

Feline 'lung-digit syndrome' describes an unusual pattern of metastasis that is seen with various types of primary lung tumours, particularly bronchial and bronchioalveolar adenocarcinoma. Tumour metastases are found at atypical sites, notably the distal phalanges of the limbs; the weightbearing digits are most frequently affected, and multiple-digit and multiple-limb involvement is common. Often primary lung tumours in cats are not detected because of clinical signs referable to the primary tumour; rather, many cases present with signs referable to distant metastases. Other sites of metastases from feline primary lung tumours include the skin, eyes, skeletal muscle and bone, as well as multiple thoracic and abdominal organs. These lesions are thought to arise from direct arterial embolisation from the tumour. Indeed tumour embolisation to the aortic trifurcation is possible.

PATIENT GROUP

Primary lung neoplasms are uncommon in the cat. Older animals are most affected (mean age at presentation 12 years, range 2-20 years). There is no apparent sex or breed predilection.

CLINICAL CHALLENGES

Feline lung-digit syndrome presents a diagnostic challenge. Typically there is swelling and reddening of the digit, purulent discharge from the nail bed, and dysplasia or fixed exsheathment of the associated nail. While these signs might be suggestive of infection, this could be secondary to a digital metastatic lesion, particularly in a middle-aged or elderly cat. Radiographic evidence of extensive bony lysis of the distal phalanx, which can be trans-articular to the second phalanx, raises the index of clinical suspicion for metastasis of a primary pulmonary tumour. Thoracic radiography is warranted prior to any surgery or digital amputation as the prognosis is generally grave for cats with this syndrome, with a mean survival time of only 58 days after presentation.

EVIDENCE BASE

This article reviews the previous literature and case reports of feline lung-digit syndrome and feline primary pulmonary neoplasia in general, discussing the course of this disease and the varying clinical presentations associated with different sites of metastasis.

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.

Occult lung malignancy presenting with finger pain: a case report

Introduction

Lung cancer is currently one of the most common malignancies in the world. Early detection is an important prognostic factor. Unfortunately, initial symptoms may be vague and a substantial proportion of cases present with the effects of metastases.

Case presentation

We discuss a case of occult lung malignancy in a 61-year-old man. The only symptom at presentation was pain in the right ring finger due to metastasis from the lung primary.

Conclusion

This case highlights the need for vigilance when a patient presents with unusual or unexplained symptoms, especially if they have known risk factors for cancer.

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.

Appendicular arterial tumor embolization in two cats with pulmonary carcinoma

A 13-year-old neutered male Persian cat and an 11-year-old neutered female Persian cat were examined because of an acute onset of lameness. In both cats, conscious proprioception and reflexes were diminished in the affected limb. In 1 cat, no blood flow was detected in the left brachial artery with a Doppler ultrasonic flow detector, whereas blood flow in the right brachial artery was easily documented. In the other cat, the right femoral pulse was not palpable. Neither cat had any echocardiographic evidence of cardiac disease. In both cats, treatment was primarily supportive. One cat died, and the other was euthanatized. At necropsy, lung lobe consolidation was seen. Microscopically, there was multifocal infiltration of the lung parenchyma with cuboidal to columnar neoplastic epithelial cells. Neoplastic epithelial cells of similar morphology were identified in nodular masses in sections of muscle, and intravascular tumor emboli were identified obliterating small and large arterioles. Immunohistochemical staining of pulmonary and muscular tissue for pan-cytokeratin antigen revealed intense cytoplasmic staining of neoplastic cells. Staining for factor VIII-related antigen confirmed that clusters of neoplastic cells represented intravascular emboli. Clinical signs in the cats were attributed to arterial occlusion by tumor emboli.

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.

Metastasis of bronchogenic carcinoma to the thumb

Bone metastasis in the hand is rare. The etiology is quite different from that of metastasis to other bones; bronchogenic carcinoma is by far the most frequent case. Distal phalanges are mainly involved with irregular osteolysis and cortical destruction. Differential diagnosis of phalangeal metastasis includes osteomyelitis, rheumatoid arthritis and gout. The prognosis is always that of metastatic bronchial cancer with an average survival of three months. Treatment may involve distal digital amputation or antalgic radiotherapy. A case of bronchogenic carcinoma with metastasis to the thumb is presented. The metastasis was located in the distal phalanx of the left thumb. The primary tumor was located in the lung. Treatment consisted of amputation. The overall survival was five months.

Skeletal metastasis as the initial clinical manifestation of metastatic carcinoma in 19 dogs

Although the skeleton represents a potentially important target for the metastatic spread of carcinoma, the clinicopathologic features of skeletal metastases in dogs have not been documented extensively. In particular, no reports have focused on dogs in which skeletal metastasis was the initial clinical manifestation of their malignancy. Medical records were reviewed for dogs with skeletal carcinoma and cases were subdivided into 2 groups based upon the temporal relationship between the diagnosis of carcinoma and recognition of skeletal metastases. In 19 of 24 (79%) dogs, skeletal metastasis was the initial clinical manifestation of malignancy, and these dogs were studied in detail. Most affected dogs were elderly and weighted less than 25 kg. Thirty-six skeletal lesions were identified in 19 dogs. Skeletal metastases occurred most frequently in the axial skeleton and proximal long bones. Only 4 of 36 (11%) skeletal carcinomas occurred distal to the elbow or stifle. Mammary gland, prostate, and urinary bladder were the most common primary sites. In 11 of 19 (58%), dogs, the primary tumor could not be determined, and in 6 of these dogs, the primary tumor could not be identified despite complete postmortem evaluation. Physical examination and abdominal ultrasonography were most valuable in detecting the primary tumor. Although biopsy or fine-needle aspirate of skeletal lesions was essential in the diagnosis of skeletal carcinoma, these procedures did not yield definitive information on the primary tumor site. This report documents that the majority of skeletal metastases are diagnosed in dogs without a previous diagnosis of carcinoma. Detection of the primary tumor in these cases may be challenging, and skeletal metastases are frequently attributable to carcinoma of unknown origin.

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.

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.

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.

Metastatic bronchogenic carcinoma masquerading as a felon

This report describes a rare occurrence of a subcutaneous metastatic bronchogenic carcinoma to the distal fingertip. The original clinical presentation suggested an infectious process. Subsequent roentgenograms, sterile cultures, and positive biopsy material revealed that the lesion started as a subcutaneous metastasis that secondarily involved adjacent bone. Amputation of the digit was performed.