Hypertrophic osteoarthropathy in childhood malignancy

Digital clubbing occurring in intrathoracic Hodgkin lymphoma: A case report

RATIONALE

Digital clubbing is rarely associated with lymphoma. This study reports a case of intrathoracic Hodgkin lymphoma with digital clubbing and reviews the current literature regarding the clinical characteristics of this condition.

PATIENT CONCERN

A 21-year-old woman presented with a 3-month history of cough and 1 month of fever, with apparent digital clubbing. A computed tomography (CT) scan of the lungs revealed a large pulmonary mass.

DIAGNOSIS

A CT-guided transthoracic needle biopsy was conducted. Pathology determined a diagnosis of Hodgkin lymphoma.

INTERVENTIONS

The patient underwent 6 courses of chemotherapy and intensification, followed by autografting.

OUTCOMES

The patient recovered and a complete hematological remission was obtained. The patient is alive with no evidence of disease 60 months after diagnosis, with the digital clubbing of the fingers and toes completely resolved.

CONCLUSION

Patients with digital clubbing and intrathoracic lesions need to be examined carefully to determine tumor malignancy.

Cardiac metastasis and hypertrophic osteoarthropathy in recurrent infantile fibrosarcoma

Cardiac metastasis and hypertrophic osteoarthropathy are both quite rare. We describe a patient presenting with hypertrophic osteoarthropathy as the first symptom of recurrent infantile fibrosarcoma (IF). During surgical resection of lung metastasis, the patient suffered sudden cardiac arrest. Autopsy demonstrated a metastatic lesion in the intraventricular septum of the heart, which is previously undescribed in the literature. This case demonstrates that IF can be aggressive despite its more typical benign course.

Gastric juvenile polyposis with high-grade dysplasia in pachydermoperiostosis

Pachydermoperiostosis (PDP) is the primary form of hypertrophic osteoarthropathy. It is a very rare disease consisting of pachydermia, digital clubbing and radiologic periostosis. Various digestive symptoms in PDP are seen in 11-49% of patients and juvenile polyps may be found at gastric endoscopy. We report here the history of a patient with PDP who was referred for assessment of severe anemia. Endoscopy of the upper digestive tract showed multiple polyps of the stomach with two huge lesions exhibiting foci of high-grade dysplasia. This observation suggests that PDP can be considered as a precancerous condition of the stomach and systematic screening using endoscopy should be considered in these patients.

Lung carcinoma with hypertrophic osteoarthropathy in a teenager

Hypertrophic osteoarthropathy (HOA) characterised by arthralgia, clubbing and periosteal proliferation of long bones, is rarely encountered in children and adolescents. Whereas in adults over 80% of cases are associated with malignancy, in children the majority of cases are due to non-neoplastic causes such as cystic fibrosis, bilary atresia and congenital heart disease. Up to 5% of adults with lung cancer demonstrate signs of HOA. However, lung cancer is extremely uncommon in children and young people. Here we report a case of lung adenocarcinoma in an 18 year old male associated with HOA present both at diagnosis and at subsequent disease progression.

Rhabdomyosarcoma associated hypertrophic osteoarthropathy in a child: detection by bone scintigraphy

Hypertrophic osteoarthropathy (HOA) is characterized by digital clubbing, long bone periosteal reaction, and polyarthralgias. Primary familial HOA is very rare and is not associated with underlying disorders and has a good prognosis. Secondary pediatric nonneoplastic HOA is associated with cystic fibrosis, congenital heart disease, biliary atresia, and inflammatory bowel disease. Secondary neoplastic HOA may be associated with intra or extrathoracic tumors.A 5-year-old girl was admitted to our hospital for an abdominal mass, digital clubbing, and diffuse articular pain. The bone scan revealed symmetrical tracer uptake in the long bones. Upper and lower extremity x-rays were diagnostic for HOA. Paraneoplastic HOA in childhood accounts for not more than 12% of HOA paitents. HOA has been reported in 2 other cases of rhabdomyosarcoma.

Incidental solitary knee mass as the first manifestation of hidden lung cancer

Hypertrophic pulmonary osteoarthropathy (HPOA), also known as secondary hypertrophic osteoarthropathy, is a clinical syndrome characterized by proliferative periostitis of the long bones especially in the distal and periarticular aspects, proliferation of the synovial membranes, causing painful and swollen joints, and often with finger clubbing. It is associated with various underlying causes, including pulmonary, pleural, cardiac, abdominal and miscellaneous conditions. Its pulmonary causes include bronchogenic carcinoma, tuberculosis, pulmonary abscess, bronchiectasis, emphysema, etc. Its radiographic presentation involves periostitis in the lower extremities. We report one case that had an incidental finding of HPOA with initial complaint about an incidental solitary knee mass with painful swelling of right knee, leading to early diagnosis of occult bronchogenic carcinoma. The radiographs and magnetic resonance imaging (MRI) revealed periosteal reactions without definite intraosseous lesion. Chest radiography and CT scan disclosed an infiltrating right upper lobe lesion suspicious malignancy. Patient received right S2 segmentectomy of lung with pathological confirmation of adenocarcinoma of lung cancer. It is important for the clinician to be aware of the radiographic findings of periostitis of HPOA, which may be the clues leading to early detection of lung cancer without significant pulmonary symptoms and to avoid possible tumor progression and distant metastases.

Periostitis and hypertrophic pulmonary osteoarthropathy: report of 2 cases and review of the literature

OBJECTIVES

To demonstrate the clinical spectrum of hypertrophic osteoarthropathy (HOA).

METHODS

We report 2 cases of HOA and performed a computer-assisted search of Medline/PubMed for the medical literature from 1960 to June 2008 using the keywords HOA, periostitis, and clubbing. These were also combined with the text words cancer, rheumatic disease, etiology, pathogenesis, hypothesis, transplant, and treatment. Only the English language literature, with pertinent information, was included.

RESULTS

Our 2 cases include 1 HOA case with clubbing, in a patient with a right to left shunt from cryptogenic cirrhosis and interstitial lung disease, and 1 HOA case without apparent clubbing, in a patient with chronic lung transplant rejection secondary to tobacco smoking and related emphysema. Review of the literature has shown that HOA is associated with a wide variety of disorders, approximately 80% are found with primary or metastatic pulmonary malignancies. Various rheumatic diseases, such as systemic vasculitis, can also be associated with HOA. With respect to the pathogenesis, vascular endothelial growth factor, platelet-derived growth factor, and platelets may play crucial roles. Therapeutically, bisphosphonates, such as pamidronade or octreotide, may be tried to relieve symptoms in refractory cases.

CONCLUSIONS

HOA, especially periostitis without clubbing, may go unrecognized. Involvement of vascular endothelial growth factor, platelet-derived growth factor, and platelets in the pathogenesis of HOA has been postulated and supported by recent data. HOA may present as a partial syndrome without clubbing and about 20% of cases have HOA without detectable malignancy. One of our cases represents the first report of the association of HOA with lung transplantation.

Childhood intrathoracic Hodgkin lymphoma with hypertrophic pulmonary osteoarthropathy: a case report and review of the literature

Hypertrophic osteoarthropathy (HOA) is characterized by clubbing, periosteal new bone formation and polyarthritis. The pathogenesis of clubbing involves an increased expression of platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) from the digitally lodged platelet clumps, which bypass the pulmonary capillary network as a result of various systemic disorders. Intrathoracic neoplasms are rare causes of HOA in children. We report here a 14-year-old boy with digital clubbing, who eventually received the diagnosis of intrathoracic Hodgkin lymphoma (HL) and HOA. Eight cases previously reported with these two diagnoses are reviewed to emphasize the prognostic significance of HOA in childhood HL.

CONCLUSION

Given the pathogenesis of clubbing and the prognostic significance of HOA, intrathoracic disease should be considered when HOA is detected in a child with a known or suspected malignant disease, and the occurrence of HOA during follow-up should alert the physicians for possible recurrence of the neoplastic disease or intrathoracic involvement.

Imaging in the investigation of paraneoplastic syndromes

Paraneoplastic syndromes are a heterogeneous group of disease presentations caused by underlying tumours. As they are non-metastatic in nature an intensive diagnostic evaluation is warranted to identify potentially curable lesions. The selection of the appropriate method of imaging is important in these cases, especially when history and physical examination are unrevealing. In this review the important paraneoplastic syndromes and underlying malignancies are discussed along with relevant imaging strategies.

MRI diagnosis of hypertrophic osteoarthropathy from a remote childhood malignancy

Hypertrophic osteoarthropathy (HOA) is a clinico-radiological syndrome characterized by digital clubbing, periosteal proliferation, bone pain, synovitis and arthralgia, all of these being commonly symmetrical. It is occasionally associated with nasopharyngeal lymphoepitheliomas and may develop before or after development of lung metastases in these patients. We report a case of a healthy 22-year-old female who presented to our institution with pain and swelling in the thighs and legs. She had a history of childhood nasopharyngeal lymphoepithelioma. Radiographs of the knees were negative. Magnetic resonance imaging (MRI) showed features suggestive of bilateral periostitis. Because of the propensity of the rare childhood nasopharyngeal lymphoepithelioma to present with HOA, this entity was included in the differential diagnosis. A subsequent chest radiograph and CT demonstrated a lung and mediastinal mass that were histologically confirmed to be metastatic. To the best of our knowledge, HOA and metastases from nasopharyngeal lymphoepithelioma occurring after such a long time interval have not been previously reported. Early demonstration and consideration of HOA on the basis of MRI, lead to expeditious and appropriate subsequent investigation.

Paraneoplastic syndromes in patients with primary head and neck cancer

Paraneoplastic syndromes represent the clinical manifestations of the indirect and remote effects produced by tumor metabolites or other products. The clinical spectrum of the various paraneoplastic syndromes related to primary malignancies of the head and neck region is presented. A review of the literature on paraneoplastic syndromes in patients with primary head and neck cancer was carried out. Paraneoplastic syndromes related to primary malignancies of the head and neck region can be categorized as: endocrine, cutaneous or dermatologic, hematologic, neurologic, osteoarticular or rheumatologic, ocular syndromes. Sometimes, paraneoplastic syndromes can be more serious than the consequences of the primary tumor itself and can precede, follow or be concurrent to the diagnosis of a malignancy; moreover, they can dominate the clinical picture and thus lead to errors with respect to the origin and type of the primary tumor. Physicians who deal with cancer-associated syndromes should be able to differentiate the paraneoplastic syndromes from the benign disorders that mimic them. Patients with a suspected paraneoplastic disorder should undergo a complete panel of laboratory studies, in addition to imaging studies and endoscopy. Identification of paraneoplastic syndromes allow the clinician to make an early diagnosis and to provide adequate treatment of tumors, with a favorable oncologic outcome and improved life expectancy for the patient. These syndromes can follow the clinical course of the tumor and thus be useful for monitoring its evolution.

Thymic lymphoepitheliomalike carcinoma in children: clinicopathologic features and molecular analysis

Thymic lymphoepitheliomalike carcinoma (LELC) in children is extremely rare and we report 2 such cases with molecular analysis of Epstein-Barr virus (EBV) and its encoded latent membrane protein-1 as well as a literature review. Both of our patients were male, presented with a huge anterior mediastinal mass, expired within a year after diagnosis despite treatment. There were altogether 9 cases of thymic LELC in children. Their common clinical features include a male predominance, large tumor size, advanced clinical stage, and poor clinical outcome. All cases were associated with EBV and nearly half developed concurrent hypertrophic osteoarthropathy (HOA). Thymic LELC in children is an aggressive EBV-associated malignant tumor frequently accompanied by HOA. We proposed that EBV might play a role in the development of HOA through the interactions of latent membrane protein-1, vascular endothelial growth factor, and cyclooxygenases-2.

Hypertrophic pulmonary osteoarthropathy (HPOA) (Pierre Marie-Bamberger syndrome): two cases presenting as acute inflammatory arthritis. Description and review of the literature

We report the cases of two middle-aged male smokers who presented to the early synovitis clinic with an acute phase response, synovitis of the wrists and ankles and clubbing of the fingers, but no respiratory symptoms. Both proved to have primary lung tumours with hypertrophic pulmonary osteoarthropathy, in one case resolving promptly with treatment of the carcinoma. We review the literature, including theories on pathogenesis.

Hypertrophic osteoarthropathy and intrathoracic Hodgkin's disease in children

BACKGROUND

Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by clubbing of the fingers and toes, periosteal new bone formation of the long bones and polyarthritis.

CASE REPORT

In this report, two children with intrathoracic Hodgkin's disease and HOA are presented.

CONCLUSIONS

Intrathoracic neoplasms are one of the major causes of HOA in adults; however HOA is rarely associated with intrathoracic malignancies in children. HOA associated with intrathoracic Hodgkin's disease is even more rare, but should be kept in mind.

Arthralgia and digital clubbing in a child: hypertrophic osteoarthropathy with inflammatory pseudotumour of the lung

Arthralgia in childhood is an unspecific symptom. One rare cause of arthralgia is hypertrophic osteoarthropathy associated with digital clubbing. We present a child where hypertrophic osteoarthropathy led to the rare diagnosis of an inflammatory pseudotumour of the lung. In a 12-year-old girl with arthralgia and digital clubbing, a chest radiograph disclosed a large round mass in the right upper lobe, and the following chest computed tomography scan showed a large solid homogenous, round, well marginated lesion with little contrast enhancement. A lobectomy of the right upper lobe was performed, and histological examination showed an inflammatory pseudotumour. The postoperative course was without problems: arthralgia and digital clubbing disappeared.

Hypertrophic osteoarthropathy in a child with biliary atresia

Hypertrophic osteoarthropathy is a syndrome characterized by clubbing of the digits of the hand/foot, periosteal reaction and arthralgia or arthritis which is usually secondary to cyanotic congenital heart disease and chronic pulmonary infections. This syndrome rarely occurs in association with chronic liver disease in childhood. Here, we report on a child with biliary atresia who developed arthralgia and arthritis during follow-up and which was diagnosed as hepatic hypertrophic osteoarthropathy. It is emphasized that hypertrophic osteoarthropathy should be considered in the differential diagnosis of arthralgia and arthritis in children with long-standing chronic liver diseases, especially if finger clubbing is also present.

[Hypertrophic pulmonary osteo-arthropathy revealed by a pulmonary epithelioid hemangioendothelioma in a 15-year-old girl]

Pulmonary epithelioid hemangioendothelioma is a rare vascular tumor of the lung, that may be revealed by hypertrophic pulmonary osteo-arthropathy.

CASE REPORT

A 15-year-old patient was admitted because of a 1-month history of pneumonia associated with clubbing. A hypertrophic pulmonary osteo-arthropathy due to a paraneoplastic syndrome associated with lung epithelioid hemangioendothelioma was diagnosed. Despite surgical resection and chemotherapy, the patient died 6 months later.

COMMENTS

Hypertrophic pulmonary osteo-arthropathy is a rare syndrome in childhood, and is frequently associated with chronic respiratory failure. Diagnosis is confirmed by long bones proliferative periostitis on standard X-ray examination. Pulmonary epithelioid hemangioendothelioma is a rare vascular malignant tumor, that spreads from the vascular pulmonary or hepatic tissues. The prognosis is variable, depending on the malignancy of the tumor. In the absence of a chronic cardiorespiratory disease, the diagnosis of a pulmonary hypertrophic osteo-arthropathy in childhood should prompt the search for a tumoral cause.

Multiple cavitating pulmonary nodules and clubbing in a 12-year-old girl

We report on a 12-year-old girl with a prolonged history of cough and hemoptysis on three occasions. X-ray and computed tomography of the chest showed several cavitating lesions and mediastinal lymphadenopathy. Lung biopsy revealed nodular sclerosing Hodgkin's disease. Hodgkin's disease should be considered in the differential diagnosis of cavitating pulmonary lesions.

Hypertrophic osteoarthropathy: an unusual manifestation in nasopharyngeal cancer

A patient with nasopharyngeal carcinoma developed clubbing and hypertrophic osteoarthropathy 6 months before radiological detection of secondary deposits in the lung. Another patient with nasopharyngeal carcinoma developed digital clubbing and hypertrophic osteoarthropathy 6 months after the discovery of lung metastases. Development of a paraneoplastic syndrome in the form of hypertrophic osteoarthropathy and digital clubbing is very rare. This manifestation of nasopharyngeal cancers is presented, with a short review of its biology and pathogenesis.

Rheumatic syndromes: clues to occult neoplasia

OBJECTIVES

Rheumatic disorders associated with cancer include a variety of conditions, most of which have no features distinguishing them from idiopathic rheumatic disorders. It is generally held that an extensive search for occult malignancy in most rheumatic syndromes is not recommended unless accompanied by specific findings suggestive of malignancy. The objective of this review are to identify rheumatic syndromes associated with cancer, to call attention to features that may suggest the presence of a hidden cancer, and to examine the role to additional clinical and laboratory data as clues to the possible neoplastic cause of those syndromes.

METHODS

A MEDLINE search of the literature dealing with cancer-associated rheumatic syndromes was conducted.

RESULTS

Review of the literature identified significant progress in this area. First, the association of malignancy with certain rheumatic syndromes was convincingly established, such as asymmetric polyarthritis presenting in the elderly with an explosive onset, rheumatoid arthritis with monoclonal gammopathy, Sjögren's syndrome with monoclonality, hypertrophic osteoarthropathy, dermatomyositis, polymyalgia rheumatica with atypical features, Lambert-Eaton myasthenic syndrome, palmar fasciitis and arthritis, eosinophilic fasciitis poorly responsive to corticosteroid therapy, erythema nodosum lasting more than 6 months, and onset of Raynaud's phenomenon or cutaneous leukocytoclastic vasculitis after age 50 years. Second, the list of cancer-associated rheumatic syndromes was extended by including additional entities such as benign edematous polysynovitis, sacroiliitis, adult-onset Still's disease, dermatomyositis sine myositis, systemic sclerosis, Sweet's syndrome, osteomalacia, skeletal hyperostosis, antiphospholipid syndrome, and essential mixed cryoglobulinemia. Third, evidence was provided substantiating that certain long-standing rheumatic syndromes, in particular rheumatoid arthritis, Felty's syndrome, Sjögren's syndrome, dermatomyositis, systemic sclerosis, systemic lupus erythematosus, and temporal arteritis behave like "premalignant conditions." Fourth, it was shown that the recognized tumor markers alpha-fetoprotein, prostate-specific antigen, CA-125, CA 19-9, and CA-3 have low sensitivity and specificity in screening for occult cancer in a population of rheumatic patients, whereas the presence of a monoclonal gammopathy in rheumatoid arthritis and the monoclonal antibody 17-109 in Sjögren's syndrome are reliable signs of malignant transformation.

CONCLUSIONS

The presence of specific rheumatic syndromes and certain clinical and laboratory findings may justify a workup for hidden cancer. Studies of the epidemiology of the cancer-associated rheumatic syndromes and evaluation of the validity of aforementioned clues in prospective studies are goals for future investigations.

Skeletal complications in pediatric oncology patients

Pediatric oncology patients are at risk for the development of numerous skeletal complications, and radiologic studies are important in the identification and evaluation of these conditions. Methotrexate osteopathy manifests as osteopenia, dense provisional zones of calcification, pathologic fractures, and sharply outlined epiphyses. Hypertrophic osteoarthropathy may occur with nasopharyngeal carcinoma or tumors of the lungs or pleura and manifests as cortical thickening, lamellar periosteal new bone formation, and soft-tissue swelling. Biomechanical abnormalities are often seen at bone scintigraphy in patients who have undergone surgery for bone tumors. Growth plate injury may manifest as marked deformity, sclerotic metaphyseal bands, metaphyseal fraying, and longitudinal striations. Radiation "osteitis" is seen as an initial decrease in bone density with subsequent development of a mixed radiolucent and sclerotic appearance. Ischemic necrosis of the femoral heads is best demonstrated at magnetic resonance (MR) imaging and has low signal intensity on T1-weighted images and a high-signal-intensity rim on T2-weighted images. Bone infarcts are seen as well-demarcated, often ring-shaped areas of decreased signal intensity on T1-weighted MR images and as areas of increased signal intensity on short-inversion-time inversion recovery images. Radiographic signs of infection include bone destruction, periosteal new bone formation, and sclerotic changes. Short-inversion-time inversion recovery MR imaging is particularly useful in evaluating posttherapy changes in bone marrow. Osteochondroma may demonstrate a cartilaginous cap at MR imaging, whereas the most important finding in radiation-induced sarcoma is a soft-tissue mass. Radiologists who work with children with cancer need to be familiar with these complications and their imaging appearances.

Hypertrophic osteoarthropathy and intrathoracic Hodgkin disease of childhood

BACKGROUND

Hypertrophic osteoarthropathy (HOA), well known in adults, is rarely encountered in children. The clinical features include clubbing of the fingers and toes, arthritis, and painful periosteal new bone formation of the tubular bones. The association of malignant disorders with HOA is more common in adults than in children.

CASE

In this paper, a 12-year-old boy with intrathoracic Hodgkin disease and HOA is presented and four other children with HOA and Hodgkin disease in the literature reviewed.

DISCUSSION

The presence of HOA has been thought to be a bad prognostic sign, but complete remission of Hodgkin disease and regression of clinical signs and symptoms of HOA were attained in our patient after chemotherapy and radiotherapy, and continue during 9 months post-therapy follow-up.

CONCLUSIONS

HOA accompanying a malignant tumor in children is very rare. Only 5 cases have been associated with Hodgkin disease, including the present boy. It is important that patients with symptoms of HOA and an intrathoracic mass be examined carefully to rule out a malignancy.

Thoracic metastases from nasopharyngeal carcinoma presenting as hypertrophic pulmonary osteoarthropathy: scintigraphic and CT findings

The imaging findings in a group of 33 patients who developed thoracic metastases following prior therapy for nasopharyngeal carcinoma (NPC) were reviewed. Four (12.1%) patients had scintigraphic or radiographic evidence of hypertrophic pulmonary osteoarthropathy (HPOA) on presentation. In one case this developed prior to radiographic or CT evidence of pulmonary metastatic disease. Evidence of hilar or mediastinal metastatic involvement was seen in three of four patient, and a pulmonary metastasis alone in one. Similarity in appearance of the hilar or mediastinal deposits to primary bronchial carcinoma and the presence of HPOA necessitated biopsy confirmation of NPC metastasis in all four cases. The scintigraphic and CT appearances of this unusual radiological association are discussed.

Cancer-associated rheumatic disorders: clues to occult neoplasia

Interest in the rheumatologic manifestations of cancer is related in part to practical considerations, ie, earlier cancer diagnosis is possible through enhanced awareness of cancer-associated rheumatic syndromes. The spectrum of rheumatic disorders associated with cancer includes over 30 conditions, including hypertrophic osteoarthropathy, polymyalgia rheumatica, palmar fasciitis with polyarthritis, most autoimmune connective tissue diseases, and the more recently described antiphospholipid syndrome. It is generally held that extensive search for occult malignancy in most rheumatologic disorders is not cost efficient and not recommended unless accompanied by specific findings suggestive of malignancy. The present article discusses the supplementary findings that may justify malignancy evaluation.

Hypertrophic osteoarthropathy caused by lipoid pneumonia

A case of hypertrophic osteoarthropathy in a 5-year-old Saudi boy is presented. The child developed painful joints, was found to have clubbing of fingers and radiologically hypertrophic osteoarthropathy was demonstrated. The underlying cause of the condition was ingestion of animal fat in infancy, with a history of ghee oil aspiration which caused a chronic lung inflammation, lipoid pneumonia, proven by lung biopsy.