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Curtis KL, Lipner SR. Metastases to the nail unit and distal phalanx: a systematic review. Arch Dermatol Res 2023; 315:347-358. [PMID: 36260150 DOI: 10.1007/s00403-022-02411-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/02/2022] [Accepted: 10/13/2022] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Kaya L Curtis
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA
| | - Shari R Lipner
- Weill Cornell Dermatology, 1305 York Avenue, New York, NY, 10021, USA.
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Acrometastases to the Hand: A Systematic Review. MEDICINA-LITHUANIA 2021; 57:medicina57090950. [PMID: 34577873 PMCID: PMC8471162 DOI: 10.3390/medicina57090950] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 11/28/2022]
Abstract
Background and Objectives: The term acrometastases (AM) refers to secondary lesions sited distally to the elbow and knee, representing 0.1% of all bony metastases. By frequency, pulmonary cancer and gastrointestinal and genitourinary tract neoplasms are the most responsible for the reported AM. Improvements in oncologic patient care favor an increase in the incidence of such rare cases. We performed a systematic review of acrometastases to the hand to provide further insight into the management of these fragile patients. We also present a peculiar case of simultaneous acrometastasis to the ring finger and pathological vertebral fracture. Material and Methods: A literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted using the PubMed, Google Scholar, and Scopus databases in December 2020 on metastasis to the hand and wrist, from 1986 to 2020. MeSH terms included acrometastasis, carpal metastasis, hand metastasis, finger metastasis, phalangeal metastasis, and wrist metastasis. Results: In total, 215 studies reporting the follow-up of 247 patients were analyzed, with a median age of 62 years (range 10–91 years). Overall, 162 out of 247 patients were males (65.6%) and 85 were females (34.4%). The median reported follow-up was 5 months (range 0.5–39). The median time from primary tumor diagnosis to acrometastasis was 24 months (range 0.7–156). Acrometastases were located at the finger/phalanx (68.4%), carpal (14.2%), metacarpal (14.2%), or other sites (3.2%). The primary tumors were pulmonary in 91 patients (36.8%). The average interval from primary tumor diagnosis to acrometastasis varied according to the primary tumor type from 2 months (in patients with mesenchymal tumors) to 64.0 months (in patients with breast cancer). Conclusions: Acrometastases usually develop in the late stage of oncologic disease and are associated with short life expectancy. Their occurrence can no longer be considered rare; physicians should thus be updated on their surgical management and their impact on prognosis and survival.
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Puri S, Holle LM, Forouhar FA, Clement JM. Subcutaneous metastasis from recurrent basaloid squamous cell carcinoma of the esophagus. J Oncol Pharm Pract 2017; 25:492-496. [DOI: 10.1177/1078155217736920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Esophageal cancer is the 11th most common cause of cancer mortality in the United States. It is aggressive in nature and has an ability to spread rapidly through direct extension, lymphatic spread, or hematogenously. With an estimated incidence of 1%, cutaneous metastases from esophageal cancer are extremely rare. Case presentation In this case study and review, we describe a case of recurrent esophageal basaloid squamous cell carcinoma presenting as multiple, rapidly progressing and tender subcutaneous nodules. A 69-year-old male with history of basaloid squamous cell carcinoma of the esophagus treated with concurrent chemoradiation, presented to his oncologist with complaints of a large, painful nodule at the nape of his neck approximately two years after completing treatment. On further examination, he was noted to have multiple, well circumscribed, solid, tender nodules on his abdominal wall along with a painful nodule on the pulp of his index finger. Histopathology from all sites revealed skin infiltration by high-grade invasive basaloid subtype of squamous cell carcinoma, similar to patient’s prior known and treated primary esophageal cancer. Further imaging work up showed extensive metastatic disease involving lung, liver, and brain. Conclusion Esophageal squamous cell carcinoma rarely metastasize to the skin. Subcutaneous nodules can be the first presentation of recurrent disease. The lesions are commonly confused with skin infections and treated inappropriately with antibiotics, leading to delay in diagnosis of recurrent disease. Early biopsy of suspicious lesions should be performed, especially in patients with history of cancer, such that prompt diagnosis and treatment can occur to maximize patient outcomes.
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Affiliation(s)
- Sonam Puri
- Department of Hematology and Oncology, H Lee Moffitt Cancer Center/University of South Florida, Tampa, FL, USA
| | - Lisa M Holle
- Department of Pharmacy Practice, UConn School of Pharmacy, Storrs, CT, USA
| | - Faripour A Forouhar
- Department of Pathology and Laboratory Medicine, UConn Health, Farmington, CT, USA
| | - Jessica M Clement
- Department of Hematology and Oncology, UConn Health, Farmington, CT, USA
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Afshar A, Farhadnia P, Khalkhali H. Metastases to the hand and wrist: an analysis of 221 cases. J Hand Surg Am 2014; 39:923-32.e17. [PMID: 24612837 DOI: 10.1016/j.jhsa.2014.01.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify demographic trends, survival rates, the most common metastatic locations, and the most common primary malignant tumors in the reports of hand and wrist metastases published over the past 27 years. METHODS A keyword search was performed across PubMed, Google, Science Direct, and Springer databases with a time-range restriction set between April 1986 and April 2013. A total of 193 articles were located describing 221 patients. The data were analyzed for patient age, sex, known history of malignancy, primary tumor site, histological diagnosis, metastatic location, hand involvement, and survival rates. RESULTS Lung, gastrointestinal tract, and kidney malignancies were the 3 leading metastatic tumors. The mean age among patients was 61 ± 13 years, and involvement among men was almost twice as common as among women. The mean survival from the time of the diagnosis was 7 ± 7 months. There were no predilections for either the right or the left hand. The distal phalanx was the most frequently involved bone, and the thumb was the most frequently involved digit. CONCLUSIONS The frequency of published hand and wrist metastasis has increased dramatically within the last decade. Metastases have been reported for every bone of the hand and wrist as well as for the soft tissues. Compared with the previous studies, the mean age of reported patients has slightly increased even though the mean survival time has not changed. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ahmadreza Afshar
- Department of Orthopedics, Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran; Department of Biostatistics and Epidemiology, Urmia University of Medical Sciences, Urmia, Iran; University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada.
| | - Payam Farhadnia
- Department of Orthopedics, Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran; Department of Biostatistics and Epidemiology, Urmia University of Medical Sciences, Urmia, Iran; University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Hamidreza Khalkhali
- Department of Orthopedics, Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran; Department of Biostatistics and Epidemiology, Urmia University of Medical Sciences, Urmia, Iran; University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
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Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review. Am J Dermatopathol 2012; 34:347-93. [PMID: 22617133 DOI: 10.1097/dad.0b013e31823069cf] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.
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Riahi RR, Cohen PR. Clinical manifestations of cutaneous metastases: a review with special emphasis on cutaneous metastases mimicking keratoacanthoma. Am J Clin Dermatol 2012; 13:103-12. [PMID: 22229935 DOI: 10.2165/11590640-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Approximately 5% of oncology patients develop cutaneous metastases, with only a small number of these patients (less than 1%) having metastatic skin lesions as the first sign of their visceral cancer. Metastases tend to occur on skin surfaces in the vicinity of the primary tumor. However, any site may be affected by cutaneous metastases. Skin metastases can present with several morphologies including, albeit rarely, keratoacanthoma-like lesions. Keratoacanthoma is a keratinous tumor that morphologically appears as a nodule with a central keratin-filled crater. This article reviews the characteristics of oncology patients whose cutaneous metastases mimicked a keratoacanthoma, including illustrations from our patient, a 53-year-old Caucasian man whose metastatic esophageal adenocarcinoma not only presented with a keratoacanthoma-like tumor on his upper lip but also a forehead macule and a scalp nodule. We also report keratoacanthoma-like presentations from literature cases of breast cancer, chondrosarcoma, and pulmonary malignancies. The lesions were discovered 3-24 months after diagnosis of visceral cancer and led to the discovery of unsuspected lung cancer in two patients. Most of the patients (60%) died within 2 months of discovery of the keratoacanthoma-like cutaneous metastases. We also reviewed the literature and discuss other morphologies of cutaneous metastases in patients whose primary tumors were in the breast, lung, and esophagus. In addition, we review from the literature other examples of tumors that present as metastatic nodules on the scalp. The possibility of cutaneous metastasis should be entertained and pathologic evaluation should be considered in an oncology patient with underlying visceral malignancy who develops a keratoacanthoma-like lesion.
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Affiliation(s)
- Ryan R Riahi
- Medical School, University of Texas Medical Branch, Galveston, TX, USA
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Abstract
Skin metastasis is defined as the spread of malignant cells from a primary malignancy to the skin. It is one manifestation of systemic spread of cancer. The tumor cells originate either from an internal malignancy or from a primary skin cancer. This study presents a literature review concerning these issues as well as this author's experience encountered throughout 19 years of surgical pathology and dermatopathology practice. Several conclusions are evident. Generally, skin metastases are encountered in 0.7-9% of all patients with cancer and as such the skin is an uncommon site of metastatic disease when compared to other organs. There is usually a long-time lag between the diagnosis of the primary malignancy and the recognition of the skin metastases. However, these metastases may be the first indication of the clinically silent visceral malignancies. The regional distribution of the skin metastasis, although not always predictable, is related to the location of the primary malignancy and the mechanism of metastatic spread. The relative frequency of skin metastasis correlates with the type of primary cancer, which occurs in each sex. For instance, lung and breast carcinomas are the most common primaries that send skin metastasis in men and women, respectively. The head and neck region and the anterior chest are the areas of greatest predilection in men. The anterior chest wall and the abdomen are the most commonly involved sites in women. Skin metastases usually appear as non-specific groups of discrete firm painless nodules that emerge rapidly without any explanation. They vary in size from so tiny as to be of 'miliary lesions' to as large as 'Hen's egg size'. Some skin metastasis may mimic specific dermatological conditions such as cutaneous cyst, dermatofibroma, pyogenic granuloma, hemangioma, papular eruptions, herpes zoster eruptions, rapidly infiltrating plaques, alopecic patches, cellulitis and erysipelas. Histologically, the skin metastases usually show features reminiscent of the primary malignancy, but with variable degrees of differentiation. Molecularly, skin metastasis is an organized, non-random and organ-selective process orchestrated by interaction among several heterogeneous molecules, which are largely unknown. Metastasis to the skin is often a pre-terminal event that heralds poor outcome.
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Chen TJ, Chiou CC, Chen CH, Kuo TT, Hong HS. Metastasis of mediastinal epithelioid angiosarcoma to the finger. Am J Clin Dermatol 2008; 9:181-3. [PMID: 18429648 DOI: 10.2165/00128071-200809030-00007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Epithelioid angiosarcoma (EA) is a rare malignant, vascular tumor that is usually observed in middle-aged and elderly males. Cutaneous metastasis of EA is extremely rare. We report the case of a 41-year-old woman presenting with a painful bluish, bulla-like lesion on the distal extent of the left third finger. The patient had recently been diagnosed with mediastinal EA with disseminated metastases. The skin biopsy specimen revealed metastatic EA. This is thought to be the first reported metastasis of EA to the finger. Whenever a patient has metastatic disease, acrometastases should be considered in the differential diagnosis of inflammatory lesions of the digits and a skin biopsy should be performed.
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Affiliation(s)
- Ting-Jui Chen
- Department of Dermatology, Buddhist Tzu Chi General Hospital, Taipei, Taiwan
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Hayden RJ, Sullivan LG, Jebson PJL. The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004; 20:335-43, vii. [PMID: 15275692 DOI: 10.1016/j.hcl.2004.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Metastatic tumors to the hand and wrist are rare, accounting for approximately 0.1% of all metastatic lesions to the skeleton. The biochemically mediated pathways of bone metastases, the location of the hand at the distal extremity, and the small amount of marrow in the bones of the hand and wrist account for the low prevalence of acrometastases. More rarely, hand dermatologic and soft tissue changes of paraneoplastic syndromes herald an occult malignancy.
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Affiliation(s)
- Radford J Hayden
- Division of Hand, Elbow, and Microsurgery, Department of Orthopaedic Surgery, University of Michigan Medical Center, 2098 South Main Street, Ann Arbor, MI 48103, USA.
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Dobson CM, Azurdia RM, King CM. Squamous cell carcinoma arising in a psoriatic nail bed: case report with discussion of diagnostic difficulties and therapeutic options. Br J Dermatol 2002; 147:144-9. [PMID: 12100198 DOI: 10.1046/j.1365-2133.2002.04725.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a squamous cell carcinoma arising from a psoriatic nail bed. The tumour had a verrucous surface and was very well differentiated, raising the possibility of early verrucous carcinoma. Occurrence of any type of squamous carcinoma in this site and background is extremely rare. Particular diagnostic and therapeutic questions arise in this unusual setting. We discuss the aetiology and diagnostic differentiation from other nail bed squamoproliferative lesions, particularly so-called subungual keratoacanthoma. We also discuss therapeutic options, including Moh's surgery and retinoids.
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Affiliation(s)
- C M Dobson
- Department of Dermatology, Royal Liverpool University Hospital, Prescot Street, UK.
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