Paraneoplastic Raynaud's phenomenon

Raynaud's phenomenon as a presenting manifestation of ovarian cancer: A case report

Raynaud's phenomenon (RP) is characterized by episodes of vasospasm affecting the hands and feet. Paraneoplastic RP, as a single presenting symptom is rarely seen in cases of ovarian cancer (OC), and thus may lead to misdiagnosis. We present a case of paraneoplastic RP in a patient with high-grade serous OC. A 66-year-old female presented with dyspnea and bilateral peripheral cyanosis involving her fingers. CA125 was elevated (423 U/mL). CT revealed a pleural effusion on the left side, suspicious omental lesions and ascites. Omental biopsy and pleural cytology demonstrated high-grade serous OC. Neoadjuvant chemotherapy (carboplatin/paclitaxel) resulted in objective improvement in finger ischemia and complete regression of vasospastic features. However, the patient's disease was refractory to post-surgical treatment and eventually she deceased of multiple organ failure. To conclude, RP may be a presenting symptom of OC. It is important to determine the underlying disease and develop an effective treatment strategy.

Paraneoplastic acral vascular syndrome in a patient with metastatic melanoma under immune checkpoint blockade

BACKGROUND

Paraneoplastic acral vascular syndrome (PAVS) is a rare phenomenon which is observed in patients with adenocarcinomas and other malignancies. Various potential pathogenic mechanisms such as tumour invasion of sympathetic nerves, hyperviscosity, hypercoagulability, vasoactive tumour-secreted substances, and immunological mechanisms have been suggested.

CASE PRESENTATION

We report a 60-year-old Caucasian male attended our hospital with a bulky lymph node mass in the right axilla. Extirpation of a lymph node conglomerate revealed 5 melanoma lymph node metastases. Computed tomography showed a liver metastasis (diameter: 3.8 cm), several retroperitoneal metastases, bilateral metastases in the lung hilus, and prepectoral subcutaneous metastases (Stage IV; pTx, N3, M1c). Lactate dehydrogenase and S100B were slightly elevated. Combination therapy of nivolumab (1 mg/kg BW) and ipilimumab (3 mg/kg BW) was started. Three weeks after the first combination therapy he developed progressive erythema, paraesthesia and pain on the fingertips of both hands. Both cold and warmth was not well tolerated by the patient. Complete work-up excluded associated conditions or factors such as haematological disorders, rheumatologic disorders, hypertension, diabetes or smoking. Treatment was initiated with prostacyclin 20 μg twice daily and oral prednisolone 50 mg in tapering dosage. However, prostacyclin was stopped after the first applications because the pain increased during infusion. The second course of nivolumab and ipilimumab was administered. About 2 weeks later, the patient presented with increased pain and small subungual necrosis. We treated the patient with oral analgetics and intravenous prednisolone 500 mg in tapering dosage. On digital substraction angiography occlusion of all arteries of the fingers was demonstrated. Further rheologic and anti-melanoma treatments were refused by the patient. About 2 months after the second course of nivolumab and ipilimumab combination therapy several fingers showed severe gangrene which finally led to amputations of end phalanges of several fingers. Histopathology did not reveal evidence for vasculitis or other primary vascular pathologies. During the following 2 months the patient experienced dramatic progress of his metastatic disease and finally died at multi-organ failure.

CONCLUSION

Presence of rapidly progressive digital ischemia in an elderly patient with cancer should always raise clinical suspicion of a paraneoplastic phenomenon when other possible causes have been excluded. In patients treated with immune checkpoint inhibitors such as CTLA-4 and PD-L1 blockers PVAS-like events have not been reported so far. However, it is debatable whether immune checkpoint blockade may play a pathogenetic role in the development of PAVS in patients with malignancies.

Fludarabine Treatment of Patient with Chronic Lymphocytic Leukemia Induces a Digital Ischemia

We report a 63-year-old man with a history of chronic lymphocytic leukemia (CLL) who presented with asymmetrical Raynaud's phenomenon of sudden onset which progressed to acral gangrene rapidly in a week. These symptoms began approximately one week after the fourth cycle of fludarabine and cyclophosphamide chemotherapy and were accompanied by pain, numbness, and cyanosis in the fingers of his right hand except the first finger. Fludarabine may play a role in acral vascular syndrome. The treatment with fludarabine in patients with evolving digital ischemia should be carried out with caution.

Digital ischemia associated with cancer: results from a cohort study

Digital ischemia associated with cancer (DIAC) is increasing in frequency and recent reports have suggested the concept of paraneoplastic manifestation. The aims of this study were to characterize the clinical presentation of DIAC and identify clinical features that could lead physicians to diagnose underlying cancer.From January 2004 to December 2011, 100 patients were hospitalized in the Department of Internal Medicine at Rouen University Hospital, France for a first episode of DI. Fifteen (15%) exhibited symptomatic or asymptomatic cancer during the year preceding or following vascular episode and constituted the DIAC group. Other patients without cancer made up the digital ischemia (DI) group.Median time between diagnosis of cancer and episode of digital necrosis was 2 months [0.25-9]. Diagnosis of DI and concomitant cancer was made in 7 of the 15 patients, while DI preceded the malignant disorder in 2 cases and followed it in 6 cases. Histological types were adenocarcinoma for 7 (46.7%), squamous cell carcinoma for 4 (26.7%), and lymphoid neoplasia for 3 patients (20%). Six patients (40%) had extensive cancer. Three patients were lost to follow-up and 5 patients died <1 year after diagnosis of cancer. Cancer treatment improved vascular symptoms in 6 patients (40%). Patients with DIAC, compared to patients with DI, were significantly older (56 years [33-79] vs 46 [17-83] P =0.005), and had significantly lower hemoglobin and hematocrit levels (12.7 g/dl vs 13.9 g/dl; P =0.003 and 38% vs 42%; P =0.003, respectively). Patients with DIAC had a higher platelet rate (420 vs 300 G/L P =0.01), and 6 patients with DIAC (40%) had thrombocytosis. There was no difference between groups either in C-reactive protein level (12 mg/L vs 5 mg/L; P =0.08) or regarding cardiovascular risk factors, presence of autoimmunity, or monoclonal protein.This retrospective study suggests that DIAC may be more prevalent than previously reported. Outcomes of the 2 diseases were not strictly chronologically parallel. However, in the majority of cases, treatment of the tumor resolved vascular involvement. Our findings suggest that age >50 years and thrombocytosis should alert physicians to consider a possible occult malignancy when digital necrosis occurs.

Paraneoplastic Raynaud's phenomenon manifesting before the diagnosis of lung cancer

This description pertains to a previously healthy gentleman aged 54 years who developed symptoms coherent with Raynaud's phenomenon. The patient never had any prior episodes of peripheral cyanosis. The patient's first presentation was in summer and the paroxysms of peripheral cyanosis were not associated with any specific aggravating factor. The paroxysms went on to become more severe and painful across a span of 6 months, when he also developed non-radiating pain in the right lateral chest-wall, which would aggravate after episodes of cough. A chest roentgenogram then demonstrated the presence of a mass lesion in the right lung and a fine-needle-aspiration cytology confirmed malignancy- an adenocarcinoma. There was a dramatic relief in pain and a reduction in the intensity and duration of paroxysms of peripheral cyanosis within 2-weeks of initiation of chemotherapy for lung cancer.

Paraneoplastic Raynaud's phenomenon manifesting before the diagnosis of lung cancer

This description pertains to a previously healthy gentleman aged 54 years who developed symptoms coherent with Raynaud's phenomenon. The patient never had any prior episodes of peripheral cyanosis. The patient's first presentation was in summer and the paroxysms of peripheral cyanosis were not associated with any specific aggravating factor. The paroxysms went on to become more severe and painful across a span of 6 months, when he also developed non-radiating pain in the right lateral chest-wall, which would aggravate after episodes of cough. A chest roentgenogram then demonstrated the presence of a mass lesion in the right lung and a fine-needle-aspiration cytology confirmed malignancy- an adenocarcinoma. There was a dramatic relief in pain and a reduction in the intensity and duration of paroxysms of peripheral cyanosis within 2-weeks of initiation of chemotherapy for lung cancer.

[Gastrointestinal tumors. Clinical manifestations of paraneoplastic rheumatic symptoms]

Paraneoplastic syndromes, as syndromes associated with malignancy, can present unrelated to tumor invasion or metastases. They can occur with varying clinical appearance and are often indistinguishable from idiopathic rheumatic symptoms. Some musculoskeletal disorders are more associated with malignancies. The therapy of rheumatic syndromes can itself have an effect on the tumorigenic process. The clinical severity of paraneoplastic rheumatic symptoms can in many cases aid in the assessment of tumor activity and the response to therapy. While generally an extensive search for occult malignancies in every older rheumatoid patient in cases with no indications of malignancy is not advisable, knowledge of rheumatic symptoms associated with malignancies aids in the important early detection of tumors, while avoiding unnecessary examinations.

[Hemato-oncological diseases. Associated rheumatic symptoms]

Paraneoplastic syndromes are observed in up to 8% of tumor patients. These disorders arise from tumor secretion of hormones, peptides, growth factors or cytokines or from immune cross-reactivity between malignant and normal tissues. Among many others paraneoplastic syndromes may also affect the rheumatologic system resulting in various musculoskeletal symptoms and/or syndromes. On the other hand, mainly hematological or lymphoproliferative diseases may also cause rheumatic symptoms by cell invasion or when affecting cellular elements of blood or the coagulation system. The aim of this article is to provide an overview of the various associations between rheumatic symptoms and hemato-oncological diseases which might be of importance in clinical practice.

Paraneoplastic Raynaud's phenomenon--good palliation after a multidisciplinary approach

Paraneoplastic Raynaud's phenomenon is a rare complication of a number of different malignancies (carcinomas, sarcomas, lymphomas, and leukemias). We present a case of paraneoplastic Raynaud's phenomenon in a patient with non-small-cell lung cancer that was associated with significant morbidity, involved a multidisciplinary approach, and eventually responded to a specialized intervention (i.e., iloprost trometamol).

Severe digital ischemia–a presenting symptom of malignancy–associated antiphospholipid syndrome

The association of the antiphospholipid syndrome with malignancy has been extensively reported. Raynaud’s phenomenon has also been reported to be associated with various malignancies. In this report, we describe two patients who presented with severe digital ischemia mimicking Raynaud’s phenomenon. The patients were found to have antiphospholipid syndrome, and upon extensive evaluation, a diagnosis of a malignancy was made. This report highlights the importance of malignancy workup in patients with severe digital ischemia associated with antiphospholipid syndrome.

Cutaneous vascular disorders associated with internal malignancy

This article provides a detailed review of the vascular manifestations affecting the skin in relationship to internal malignancies. Vascular abnormalities heralding internal malignancies can be divided into three main categories, consisting of disorders related to vascular dilatation (flushing, palmar erythema, and telangiaectasia), and disorders related to vascular occlusion or hypercoagulability states (purpura, cutaneous ischemia, and thrombophlebitis). Entities are discussed according to etiology. The treatment of these entities is mostly related to treating the underlying malignancy. The goal of this article is to enlighten the practicing dermatologist about the association of these vascular manifestations with internal malignancy, thus leading to prompt initiation of the proper workup and management.

A case of hepatocellular carcinoma who admitted with Raynaud’s phenomenon

Hepatocellular carcinoma (HCC) may be present in one of the several ways. The classical presentation is with right upper quadrant abdominal pain, abdominal swelling and weight loss. HCC may also be associated with several paraneoplastic manifestations. The mechanisms of these manifestations are not well known. The association of digital ischemia and malignancy was reported as early as 1884 and 1891. We report a case of HCC associated with Raynaund's phenomenon.

Cutaneous paraneoplastic syndromes: uncommon presentations

Paraneoplastic syndromes are a group of clinical manifestations associated with a malignancy, but not directly related to the primary tumor itself or to its metastases. Characteristically, they follow a course parallel to the tumor, resolve with successful treatment of the primary tumor, and tend to recur with its relapse or the onset of metastases. The mechanism by which they occur is not well understood, but may be related to the production of bioactive substances by or in response to the tumor, such as polypeptide hormones, hormone-like peptides, antibodies or immune complexes, cytokines, or growth factors.

Warfarin-associated multiple digital necrosis complicating heparin-induced thrombocytopenia and Raynaud's phenomenon after aortic valve replacement for adenocarcinoma-associated thrombotic endocarditis

Necrosis of the digits is a rare complication of warfarin therapy of obscure pathogenesis. We report a 61-year-old woman with a 12-month history of Raynaud's phenomenon who developed multiple digital necrosis following aortic valve replacement with mechanical prosthesis for aortic insufficiency caused by nonbacterial thrombotic endocarditis. Exacerbation of Raynaud's phenomenon occurred during the postoperative period, with daily episodes of ischemia of the fingers and toes that improved with local warming. However, coincident with the occurrence of immune heparin-induced thrombocytopenia, and while undergoing routine warfarin anticoagulation because of the mechanical valve prosthesis, the patient abruptly developed progression of digital ischemia to multiple digital necrosis on postoperative day 8, at the time the international normalized ratio reached its peak value of 4.3. All limb pulses were readily palpable, and vascular imaging studies showed thrombosis only in the superficial femoral and popliteal veins of the right leg. Coagulation studies showed greatly elevated levels of thrombin-antithrombin complexes and prothrombin fragment F1.2 levels, consistent with uncontrolled thrombin generation. After vitamin K administration, no abnormalities of the protein C anticoagulant pathway were identified, consistent with previous studies of other patients with warfarin-induced necrosis complicating heparin-induced thrombocytopenia. Subsequently, the patient was shown to have metastatic breast adenocarcinoma, which explained the patient's initial presentation with nonbacterial thrombotic endocarditis. This patient case suggests that multiple digital gangrene can result from the interaction of various localizing and systemic factors, including compromised microvascular blood flow (Raynaud's phenomenon), increased thrombin generation (heparin-induced thrombocytopenia, adenocarcinoma), and warfarin-induced failure of the protein C natural anticoagulant pathway.

Paraneoplastic Raynaud phenomenon and idiopathic thrombocytopenic purpura in non-small-cell lung cancer

The association of Raynaud phenomenon with malignancy has rarely been reported. Idiopathic thrombocytopenic purpura is also an infrequent complication of solid tumors. We report a 62-year-old man who sought treatment for severe Raynaud phenomenon requiring medical therapy and was subsequently diagnosed to have non-small-cell lung cancer. After chemotherapy and radiotherapy, his cancer was in complete remission and the Raynaud phenomenon resolved. Severe thrombocytopenia later developed for which no apparent cause was found, and which was responsive to steroid therapy. This heralded relapse of his lung cancer. This is a case of lung cancer with two rare paraneoplastic syndromes.

Rheumatic syndromes associated with malignancy

The relation between rheumatic syndromes and an underlying malignancy is a complex one. As a result of autoimmunity, an aberrant immune response, or the use of immunomodulatory drugs, many of the rheumatic diseases appear to pose an increased risk for the development of malignancy. Unfortunately, for many of the same reasons, the presence of an underlying malignancy can result in the development of features of rheumatic disease. Awareness of the associations between rheumatic syndromes and malignancy will aid the clinician in the accurate diagnosis of underlying pathology, more effective treatment of both the symptoms and underlying disease, and appropriate surveillance for the development of later complications.

Paraneoplastic acral vascular syndrome: epidemiologic features, clinical manifestations, and disease sequelae

BACKGROUND

Acral vascular syndromes associated with malignancy have rarely been reported.

OBJECTIVE

Our purpose was to assess the clinical and evolving features of paraneoplastic acral vascular syndromes.

PATIENTS AND METHODS

Two cases of paraneoplastic gangrene are described and analyzed together with previously reported cases identified by a MEDLINE search.

RESULTS

Among the 68 patients identified, 40 had gangrene, 16 had acrocyanosis, and 12 had Raynaud's phenomenon. The male to female ratio was 0.89; median age was 59 years. Fingers were affected in 94%. Adenocarcinomas were the predominant associated malignancies (41%), and metastases were observed in 41%. The acral vascular syndromes in 48% of the patients definitively regressed after tumor treatment. Forty-four percent of the patients died within 2 years. A favorable cutaneous outcome was obtained with prostacyclin infusions in 6 patients.

CONCLUSION

A neoplastic origin of acral vascular syndrome should be considered in elderly patients, especially men, in the absence of usual causative conditions.

Anti-cardiolipin antibodies, Raynaud's phenomenon with digital ischemia, and non small cell carcinoma of the lung

Raynaud's phenomenon, digital ischemia, antinuclear antibodies and anticardiolipin antibodies are uncommon features of malignancy. The association of all of these in a patient with malignancy has not previously been reported. We describe a 52 year old woman with non small-cell carcinoma of the lung who also had Raynaud's phenomenon, digital ischemia, anti-nuclear antibodies and anticardiolipin antibodies.

Paraneoplastic rheumatic syndromes

Malignant neoplasms are associated with a wide variety of paraneoplastic rheumatological syndromes. Among these, hypertrophic osteoarthropathy, carcinoma polyarthritis, dermatomyositis/polymyositis, and paraneoplastic vasculitis are the most frequently recognized. Other less known associations are based upon a smaller number of reported patients, and include fasciitis, panniculitis, erythema nodosum, Raynaud's syndrome, digital gangrene, erythromelalgia and lupus-like syndromes. Musculoskeletal manifestations of malignancy may coincide, follow or antedate the diagnosis of cancer, or herald its recurrence. The clinical course generally parallels that of the primary tumour, and treatment of the underlying malignancy often results in regression of the rheumatic disorder. Awareness that cancer can cause certain non-metastatic symptoms is important for early diagnosis and treatment of an occult neoplasm. Rheumatic manifestations suggesting a hidden cancer include: rapid onset of an unusual inflammatory arthritis clubbing or diffuse bone pains in a patient 50 years of age or older, chronic unexplained vasculitis, refractory fasciitis, Raynaud's syndrome unresponsive to vasodilator therapy, rapidly progressive digital gangrene or Lambert-Eaton myasthenic syndrome. Management consists of control of the underlying cancer and symptomatic treatment of the rheumatic syndrome with non-steroidal anti-inflammatory drugs or corticosteroids.

Paraneoplastic rheumatic syndromes

Paraneoplastic rheumatic syndromes are challenging from both a clinical and research standpoint. Progress over the past decade has provided clarification of clinical syndromes. At the same time, our increasing ability to define and quantitate mediators of inflammation is shedding new light on pathogenesis. In turn, this understanding may answer questions regarding more common rheumatic diseases.

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.

Diagnosis of cancer-associated vascular disorders

BACKGROUND

Unexplained thromboembolism may be an early indicator of the presence of a malignant tumor before signs and symptoms of the tumor itself become obvious.

METHODS

A survey of the MEDLINE data-base was conducted concerning cancer-associated vascular disorders and their role in the diagnosis of hidden cancer. The spectrum of vascular disorders heralding occult cancer and the associated laboratory abnormalities were scrutinized.

RESULTS

Deep venous thrombosis was associated with a significantly higher frequency of malignancy during the first 6 months after diagnosis. Malignancies were found using simple clinical and diagnostic methods; additional screening was not cost-efficient. Other signs associated with deep venous thrombosis that increased the probability of an occult cancer were age older than 50 years, multiple sites of venous thrombosis, associated venous and arterial thromboembolism, thromboembolism resistant to warfarin therapy, and paraneoplastic syndrome. Among vascular syndromes, only cutaneous leukocytoclastic vasculitis presenting after the age of 50 years was consistently associated with cancer. Preliminary data with an antigen specific to tumor tissue, the cancer procoagulant, suggested its possible role as a tumor marker. The sensitivity for all samples analyzed from cancer patients was 80% and the specificity was 83%.

CONCLUSIONS

Data from the literature enabled us to outline clinical clues that might distinguish patients with cancer-associated vasculopathies from those unaffected by malignancies. Preliminary data with an antigen specific to tumor tissue, the cancer procoagulant, suggested its possible role in detecting early stage cancer. However, large-scale prospective studies are not currently available to evaluate the role of these clues and laboratory assays in the diagnosis of early stage cancer.

Ovarian cancer and gangrene of the digits: case report and review of the literature

Digital ischemia has been reported with various types of cancer, especially gastrointestinal. It is more common in elderly women than in any other group, and the most common symptom is a gangrenous finger (or fingers). More than half of the patients have metastatic involvement. Once the primary disease has been treated, when feasible, the digital symptoms usually regress or disappear. The presence of digital ischemia without other rheumatologic stigmata or vascular predisposition in an elderly patient should raise clinical suspicion of a paraneoplastic phenomenon. Herein we describe a 65-year old woman with digital ischemia associated with ovarian cancer. The diagnosis was established by biopsy after extremely high levels of cancer antigen 125 were detected.

Rheumatic manifestations of occult cancer

BACKGROUND

The frequency with which rheumatic disorders occur when malignant neoplasms first present is unknown, and the significance of rheumatic conditions as cancer markers is unappreciated.

METHODS

Patients admitted to a medical ward of a general hospital (Bnai Zion Medical Center, Haifa, Israel) during a 10-year period were surveyed. The frequency of the diagnostic evaluation of rheumatic disorders resulting in uncovering occult neoplasia at the time of index hospitalization and during the 2-year follow-up period was assessed.

RESULTS

The incidence of occult cancer among patients admitted to a general medical ward with previously unclarified rheumatic disorders was 23.1%. Seventy-two percent of the group of patients with rheumatic diseases and occult cancer were male; 69% with rheumatic disease without cancer (control group) were female. The median age in the group with occult cancer was an average of 10 years older than the group without cancer, 67 versus 57 years (P < 0.001). Weight loss or anemia occurred in 52% of the group with occult cancer and in 37.3% of the control cases (not significant). Typically, there were no distinguishing features of the rheumatic syndromes suggesting the coexistence of cancer. In 19 of 25 cases, the malignancy was uncovered by routine examinations. In four instances, neoplasia was not immediately apparent but was identified in a specific search. In two cases, no search for malignancy initially was undertaken, and Hodgkin's lymphoma was diagnosed 6 and 12 months later. In 9 of 25 cases, long term remission of neoplasia was achieved by cancer therapy with improvement of rheumatic manifestations coinciding with regression.

CONCLUSIONS

A significant number of patients who are referred to a general medical ward for evaluation of previously unclassified rheumatic disorders may be found to have a previously undetected malignancy. For most patients, the symptoms of cancer are found by routine physical and laboratory examinations. The importance of the association of rheumatic disorders and malignancy requires greater awareness, appreciation, and clinical study.

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.

Reversible findings of methylene diphosphonate bone scintigraphy in Raynaud's phenomenon: case report and review of the literature

A 53-year-old woman with carcinoma of the right breast, spinal metastases and right arm lymphoedema was referred for bone scintigraphy prior to commencement of chemotherapy. The patient arrived in the department complaining of pain in the left hand, which appeared red and slightly swollen. Bone scintigraphy revealed increased tracer uptake in the first four metacarpal and all the carpal bones of the left hand. A repeat three-phase bone scintigram, performed 1 week later when the patient was asymptomatic, showed equal blood flow to both hands with normal blood pool and uptake in bone images. The case demonstrates a state of reversibly increased bone uptake in a patient injected at the time of an episode of Raynaud's phenomenon and the possible implications for scan interpretation.

Paraneoplastic Raynaud's phenomenon

A testicular tumour could be diagnosed by the occurrence of a Raynaud's phenomenon complicated by severe digital arteritis. The arteritis rapidly regressed under prostacyclin therapy. Such vascular manifestations are frequent in testicular carcinoma, but they usually develop after chemotherapy. To our knowledge, this is the first case where they preceded the diagnosis and specific treatment of a tumour of the testis.