Hypertrophic osteoarthropathy associated with gastrointestinal stromal tumour

Unique role of rheumatology in establishing collaborative relationships in research. Past, present and future of patient engagement

The specialty of rheumatology takes care of people with disabling and long-term musculoskeletal conditions. For these patients, good healthcare requires the establishment of a sustainable partnership with healthcare professionals. For over two decades, rheumatology has been a frontrunner in piloting and implementing new kinds of partnerships in scientific research. In this viewpoint paper, we provide evidence for the leading role of rheumatology in developing strategies for engaging patients in research agenda setting, outcome research, developing treatment recommendations, assessing grant applications, conducting patient-centred research and transferring knowledge from research into practice. Experiences and lessons learnt in rheumatology are regularly published and are currently widely adapted and implemented in other specialties and research contexts. Challenges still exist and it is expected that rheumatology, as a leading discipline in this field, may further enhance our knowledge, expertise and understanding of the conditions for relational empowerment and meaningful patient involvement.

Secondary hypertrophic osteoarthropathy in a male from the Early Medieval settlement of Lauchheim, Germany

Hypertrophic osteoarthropathy (HOA) is rarely diagnosed in archaeological human skeletons. Here, we report on the well-preserved skeleton of a middle-adult man from the early Medieval settlement site of Lauchheim (Germany) that exhibits pronounced multi-layered shell-like periosteal new bone formation in a bilaterally symmetric fashion on the long bones, the skeletal elements of the pelvis and those of the pectoral girdle. In addition, the two distal phalanges recovered show signs of osteoclastic resorption on their distal tuberosities. The distribution and morphology of the observed lesions are consistent with a diagnosis of HOA. The adult age at death of the individual and the co-occurrence of "healed" and "active" lesions suggest a secondary form of HOA. Given that only skeletal remains were available for study, the underlying (pulmonary or non-pulmonary) primary disease cannot be definitively ascertained in the present case. No osseous changes were found on the ribs, but signs of osteoclastic resorption were observed on the dorsal surface of the sternal body, which might indicate a retrosternal or mediastinal location of the primary disease. Thus far, only a few archaeological case studies of secondary HOA reported signs of the presumed underlying primary disease, which was of a pulmonary nature in each of the individuals.

Secondary hypertrophic osteoarthropathy caused by non-pleural or pulmonary tumors

Hypertrophic osteoarthropathy (HOA) is a rare paraneoplastic syndrome characterized by digital clubbing, periosteal reaction, polyarthralgia, arthritis, and synovitis. Herein, we report a case series of patients with secondary HOA caused by non-pleural or pulmonary tumors.The radiologic databases of 2 tertiary university hospitals were retrospectively screened for secondary HOA patients. In addition, a systemic review of the published case reports. Only HOA cases with non-pleural or pulmonary malignancies were involved into the study. HOA in primary pleural or pulmonary malignant or benign disorders, as well in inflammatory diseases were excluded. In all cases, plain radiography was performed and clinical signs were documented.In our databases, 6 patients with secondary HOA were identified. In addition, the systemic review yielded 24 eligible patients. The most prevalent primary tumors were nasopharyngeal carcinoma and esophageal cancer in 6 patients (20%), respectively. In 17 patients, (56.7%) HOA was associated with lung metastases, and in 10 patients (33.3%), no lung metastases were detected. In 14 patients (46.7%), HOA was symptomatically before a tumor diagnosis was made. Plain radiography displayed typically features with periostal enlargement in every case.This study is the first report about secondary HOA caused by non-pleural or pulmonary tumors. Various primary tumors were identified, including several rare tumors such as sarcomas. HOA is a rare disorder with typically radiologically findings, which is not only associated with lung cancer or pleural mesothelioma and can even occur in tumor patients without lung metastasis.

Giant oesophageal gastrointestinal stromal tumour presenting with dyspnoea and clubbed fingers

Gastrointestinal stromal tumours (GISTs) are mesenchymal neoplasms of the gastrointestinal tract originating from the interstitial cells of Cajal. Giant oesophageal GISTs are rare since the oesophagus is rarely the primary site of GISTs, and they are usually diagnosed early due to complaints such as dysphagia. We present the case of a giant oesophageal GIST presenting with prominent clubbing. The case underlined the diagnostic importance of clubbing and the careful consideration of chemotherapy. Although clubbed fingers associated with GISTs are rare, our experience demonstrates the importance of physicians’ recognition of clubbing as a paraneoplastic phenomenon for early diagnosis of malignancies since patients seldom notice their own clubbing by themselves. Chemotherapy using imatinib, an Bcr-Abl kinase inhibitor, is the standard option for unresectable giant GISTs. However, careful consideration must be made of the risk of complications associated with rapid mass reduction due to imatinib such as bleeding, oesophageal perforation and mediastinitis.

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.