Hypertrophic osteoarthropathy: a 10-year retrospective analysis

Hypertrophic pulmonary osteoarthropathy due to lung cancer: A case report and literature review

Hypertrophic pulmonary osteoarthropathy (HPOA) is a rare paraneoplastic syndrome. Our literature review shows the location of arthralgia and existence of edema are referable information for the differential diagnosis in paraneoplastic arthralgia.

Impact of hypertrophic pulmonary osteoarthropathy on patients with lung cancer

Purpose

Hypertrophic pulmonary osteoarthropathy (HPOA) is a rare disease that most commonly occurs secondary to lung cancer. However, the clinical significance of HPOA remains unclear. The aim of this study was to evaluate the impact of HPOA on patients with lung cancer in Taiwan.

Patients and methods

Data regarding lung cancer patients who demonstrated findings of HPOA on bone scintigraphy between 2010 and 2016 were retrospectively analyzed. Pathological confirmation of cases was conducted at Chiayi and Kaohsiung Chang Gang Memorial Hospital. Clinical characteristics, including gender, smoking status, histology subtype, clinical stage, and epidermal growth factor receptor (EGFR) status were investigated.

Results

We identified 69 lung cancer patients with typical HPOA findings on bone scintigraphy. Among them, 56 were male (81.2%) and 51 were ex-smokers or current smokers (73.9%). Adenocarcinoma was the most common histology subtype (n=42, 60.9%). Of 34 patients subjected to EGFR mutation analysis, only 4 (11.8%) had EGFR-tyrosine kinase inhibitor (EGFR-TKI)-sensitive mutations.

Conclusion

Male, smoking, and adenocarcinoma were the most common clinical characteristics of lung cancer patients with HPOA in our cohort. However, the proportion of EGFR-TKI-sensitive mutation cases was extremely low.

Hypertrophic pulmonary osteoarthropathy with primary lung cancer

Hypertrophic pulmonary osteoarthropathy (HPO) is a rare paraneoplastic syndrome that is frequently associated with lung cancer; however, the incidence of clinically apparent HPO is not well known. The clinical data of 6,151 patients with advanced lung cancer between January 1996 and December 2008 were retrospectively analyzed in Zhejiang Cancer Hospital (Hangzhou, China). Data pertaining to the presentation of HPO, diagnosis, treatment, pathology, follow-up and clinical course were documented. HPO was confirmed using bone scintigraphy by the identification of symmetrical, abnormally high uptake in the joints, and/or long bones with digital clubbing in the extremities as well as joint pain. The clinical characteristics were investigated based on clinical and pathological records. The patients were presenting with lung cancer for the first time and had not received treatment. Among the 6,151 lung cancer patients, 115 (1.87%) demonstrated an abnormally high uptake on bone scintigraphy and digital clubbing in the extremities combined with joint pain. A total of 109 patients received surgery or chemotherapy treatment and 92 exhibited improved symptoms. The improvement rate of HPO was lower in the non-surgery compared with the surgery patients (77.4 vs. 91.1%; P=0.049). Bone scintigraphy was repeated in 85 patients within 3-6 months, and the HPO symptoms improved in 70 patients. The present retrospective study indicated that 1.87% of patients with lung cancer showed characteristics that were identified as HPO. The majority of the patient symptoms and the bone scintigram of HPO improved as a result of treatment.

Hypertrophic osteoarthropathy: what a rheumatologist should know about this uncommon condition

This article presents an updated overview of hypertrophic osteoarthropathy and digital clubbing for the practicing rheumatologist. Discussion includes a brief historical perspective, its definition, incidence and prevalence, classification, pathology and pathophysiology, clinical manifestations, demographics, findings on physical examination, imaging techniques for its detection, differential diagnosis, and treatment modalities.

[Bronchial carcinoma and knee pain. Secondary hypertrophic osteoarthropathy]

Secondary hypertrophic osteoarthropathy (HOA), also known as Marie-Bamberger syndrome, is a rare neoplastic syndrome featuring clubbing of the tips of the digits, periosteal proliferation and synovial effusion of adjacent joints. We report a case where a patient without any other known medical condition developed persistent arthralgia and mobility restriction after bruising the left knee. As the initial X-ray examination of the knee showed a distinct periosteal proliferation of the left femoral bone, extended diagnostics were initiated during which a bronchial carcinoma was identified. After surgical removal of the primary tumor the symptoms of irritation in the knee joint recovered totally.

[Hypertrophic osteoarthropathy. Bamberger-Marie disease]

Hypertrophic osteoarthropathy (HOA) is the classical neoplastic disease in rheumatology characterized by a combination of digital clubbing, joint and bone pain, and proliferative periostitis. This combination of symptoms should initiate an intensive search for an underlying malignant disease usually of thoracic organs. Here we report the case of a patient with HOA and neuroendocrine carcinoma of the esophagus. Other non-malignant disorders of the lungs, heart and other organs should be considered in the differential diagnosis. In addition, rare cases of a primary hereditary form of HOA exist and the genetic background has recently been discovered. Thus, new insights into the pathophysiology have improved diagnostic and therapeutic options for this disorder.

Esophageal adenocarcinoma and hypertrophic osteoarthropathy with improvement following resection of esophageal cancer

Esophageal cancer usually presents late and carries a grave prognosis. Early diagnosis dramatically improves outcomes, and hence recognition of the varied presenting features, including hypertrophic osteoarthropathy (HOA), may be important. Hypertrophic osteoarthropathy is a rare manifestation of esophageal adenocarcinoma and indeed may herald the presence of this neoplasm, as it did in the case we present. A 59-year-old man presented with signs and symptoms suggestive of inflammatory wrist, ankle, and knee arthritis, and imaging revealed changes of HOA. He reported dysphagia mainly to solids, and endoscopic biopsy showed adenocarcinoma. Cancer resection treatment led to clinical resolution of his musculoskeletal symptoms. This case highlights the importance of recognition of HOA as a feature of this increasingly common cancer.

Primary hypertrophic osteoarthropathy

Pachydermoperiostosis PDP (idiopathic or primary hypertrophic osteoarthropathy) is a rare congenital disease that inherited in an autosomal fashion. The disease is more common in males and develops gradually from adulthood. The disease is characterized by coarse facial features, clubbing of the fingers and radiographic periostitis of the distal long bones. The patient was a 37-year-old man with acroosteolysis and digital clubbing of hands and feet fingers and lion facies.

Hypertrophic pulmonary osteoarthropathy as a paraneoplastic manifestation of lung cancer

INTRODUCTION

This study examined the frequency of hypertrophic pulmonary osteoarthropathy (HPO) and the clinical characteristics of lung cancer with HPO.

METHODS

The results of 2625 lung cancer patients who underwent bone scintigraphy were reviewed to identify patients with HPO, which was diagnosed when the bone scintigram showed a diffuse, symmetric pattern of bilateral increased uptake in the long tubular bones. Clinical characteristics were investigated based on the clinical and pathologic records.

RESULTS

Nineteen patients (0.72%) were found to have HPO: 17 were men, 17 were heavy smokers, and 13 had clinical stage IIIB or IV disease. Ten patients complained of pain or edema in the extremities, and seven of them had stage IIIB or IV disease. In four patients with clinical stage IIIB or IV disease, HPO was not detected at the first presentation, and the diagnosis was made after disease progression. The symptoms of HPO improved in two patients who underwent surgical resection but in only three of five patients who received chemotherapy. The HPO findings on the bone scintigram improved in 2 of 3 patients who underwent surgical resection and 5 of 11 patients who received chemotherapy.

CONCLUSIONS

Less than 1% of the lung cancer patients developed HPO as a paraneoplastic manifestation. Males, heavy smokers, and advanced disease predominated in lung cancer patients with HPO. The symptoms and bone scintigram findings of HPO improved in half of the patients on treating the lung cancer.

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.

Pachydermoperiostosis-critical analysis with report of five unusual cases

Pachydermoperiostosis (idiopathic hypertrophic arthropathy) {MIM 167100} is an uncommon disease characterized by unique phenotype (digital clubbing and pachydermia) and distinctive radiographic appearances (periostosis). Two families are reported that, in additional to the typical phenotype and radiographic characteristics of pachydermoperiostosis, show some rare and/or unusual, not yet reported, clinical findings. In the first family, distinctive features were severe progressive arthritis with villonodular involvement of the knees. The clinical course of the disease was much more severe than usually reported. The older brother was disabled at the age of 29 years. In the second family, the clinical history was exceptional, with unique early appearance of clinical signs. Pachydermoperiostosis is usually inherited as a dominant trait, but probable autosomal recessive inheritance has been reported. Also in the present families, autosomal recessive inheritance is likely, possibly explaining the severe clinical course of the disease. Differential diagnosis and the confusing nomenclature of pachydermoperiostosis are discussed.

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.

Unusual presentation of thymic carcinoma: hypertrophic osteoarthropathy

Hypertrophic osteoarthropathy is characterized by clubbing and periosteal new bone formation along the shaft of the long bones of the extremities. Although various intrathoracic malignancies have been associated with the development of HOA, it has been extremely rare for HOA to occur in a patient with a thymic carcinoma. Recently, we experienced a 63-year-old woman diagnosed as a thymic carcinoma with hypertrophic osteoarthropathy. She had both digital clubbing and cortical thickening in her lower extremities identified radiologically. We herein describe this case with a review of the literature.

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.

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.

Periosteal new bone formation in a canine neuropathic model of osteoarthritis

OBJECTIVE

To characterize, for the first time, periosteal new bone formation in a well-established canine model of accelerated osteoarthritis (OA) with features of neuropathic arthropathy.

METHODS

Seven dogs underwent left L4-S1 dorsal root ganglionectomy (DRG), followed 3 weeks later by transection of the anterior cruciate ligament of the ipsilateral knee (ACLT). Eight weeks thereafter, a postmortem examination was performed to assess the severity of cartilage changes of OA and the formation of new bone on the distal femur and proximal tibia in the cruciate-deficient limb.

RESULTS

As described previously, extensive full-thickness ulceration of the articular cartilage was present in the unstable knee of every dog. The femoral shaft immediately proximal to the condyles in the unstable limb was consistently wider (mean +/- SD diameter 22.4 +/- 2.2 mm) than that in the contralateral limb (19.9 +/- 1.3 mm; P = 0.01). Xeroradiography and histologic examination of the distal femur revealed extensive formation of woven bone on the periosteal surfaces of the medial, lateral, and anterior aspects of the femoral shaft in the OA limb of every dog. These bony changes were not seen in radiographs of dogs that underwent DRG with the cruciate ligament left intact (n = 8) or of neurologically intact dogs that underwent ACLT (n = 7) and were examined 24 weeks after surgery.

CONCLUSION

Formation of new periosteal bone on the distal femur and tibia is a feature of this model of accelerated OA that is not seen in the conventional ACLT model of OA in the neurologically intact dog. This observation suggests that interruption of sensory input from the limb may affect the regulation of osteogenesis in the mechanically unstable joint.

Cutaneous paraneoplastic syndromes in solid tumors

OBJECTIVE

To provide an overview of the clinical manifestations, pathophysiology, and oncologic implications of the cutaneous paraneoplastic syndromes that occur predominantly in patients with solid tumors.

METHODS

A review was performed of the literature identified by a comprehensive MEDLINE search.

RESULTS

Diverse cutaneous paraneoplastic syndromes may be associated with underlying tumors. They include musculoskeletal disorders (clubbing, hypertrophic osteoarthropathy, dermatomyositis, and multicentric reticulohistiocytosis), reactive erythemas (erythema gyratum repens and necrolytic migratory erythema), vascular dermatoses (Trousseau's syndrome), papulosquamous disorders (acanthosis nigricans, tripe palms, palmar hyperkeratosis, acquired ichthyosis, pityriasis rotunda, Bazex's syndrome, florid cutaneous papillomatosis, the sign of Leser-Trélat, and extramammary Paget's disease), and disorders of hair growth (hypertrichosis lanuginosa acquisita). The clinical manifestations of these dermatoses may precede, coincide with, or follow the diagnosis of cancer. The presence of a cutaneous paraneoplastic syndrome is often associated with a poor prognosis.

CONCLUSIONS

Cutaneous paraneoplastic syndromes are specific constellations of mucous membrane and/or skin abnormalities that are caused by an underlying tumor. Since they may be the presenting sign of an occult cancer, cognizance of their features and clinical implications are of considerable importance. Individuals with these syndromes should have a thorough workup for an associated malignancy.

Pachydermoperiostosis: dermatological, neurological and radiological observations

A case of pachydermoperiostosis is described. Interesting features were the presence of carpal and tarsal tunnel syndromes, chronic leg ulcerations and large calcification of the Achilles tendon. Neurological alterations were explained by the stenosis of the tunnels secondary to the periosteal apposition. Chronic leg ulcerations were probably due to neurological and circulatory alterations.

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 related to end stage cholestatic cirrhosis: reversal after liver transplantation

A case is reported of hypertrophic osteoarthropathy with recovery after a liver graft in a young man with end stage cholestatic cirrhosis related to non-Wilsonian copper overload. To our knowledge this is the first case in the literature illustrating the curative role of liver grafting on hypertrophic osteoarthropathy associated with chronic cholestatic liver disease.

Periosteal new bone formation complicating juvenile polyarteritis nodosa

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