Successful Treatment of ROS1-rearranged Lung Cancer Complicated by Hypertrophic Pulmonary Osteoarthropathy with Crizotinib Therapy

Hypertrophic pulmonary osteoarthropathy (HPO) is a paraneoplastic syndrome characterized by digital clubbing, arthritis, and periostitis. Tumor removal usually leads to the resolution of these symptoms. We herein report the efficacy of crizotinib treatment for treating the symptoms of HPO associated with c-ros oncogene 1 receptor tyrosine kinase (ROS1)-rearranged lung cancer. A 71-year-old woman presented with a pulmonary tumor and arthritis. She was diagnosed with a ROS1-rearranged lung adenocarcinoma [stage IIIB (cT4N2M0) ] with HPO. Crizotinib dramatically reduced the tumor size and resolved the symptoms. After two months of crizotinib treatment, she underwent lobectomy, and a pathological evaluation revealed ypstage IIIA (ypT3a, ypN1). Crizotinib treatment was effective for reducing the tumor size and improving the symptoms of HPO.

You're the Flight Surgeon

Chumbley EM. You're the flight surgeon: a case of bilateral leg pain and swelling in a loadmaster. Aerosp Med Hum Perform. 2017; 88(5):511-515.

[A woman with red, swollen lower legs]

A 32-year old female patient with Graves' disease was diagnosed with pretibial myxedema. It is part of the triad of extrathyreoidal manifestations of Graves' disease: exophthalmia, pretibial myxedema, and acropachy. The patient was successfully treated with topical corticosteroids.

[Hypertrophic osteoarthropathy: a rare manifestation of an amygdalar tumour]

A case of hypertrophic osteoarthropathy in association with malignant tonsil tumour is reported. It involved a patient in whom the bone disorder was detected 10 months prior to the clinical manifestation of the tumour. Hypertrophic pneumic osteoarthropathy is a clinical and radiological syndrome characterized by proliferation of periosteum in long bones with digital clubbing. In over 90 % of the cases, it has been associated with an intra-thoracic tumour and more rarely secondary to a malignant haemopathy or ENT cancer, particularly of the rhinopharynx. As far as we know, the association with carcinoma of the tonsils has not previously been described.

[A case of pulmonary hypertrophic osteoarthropathy associated with primary lung cancer in a young adult successfully treated with gefitinib]

The patient was a 39-year-old woman admitted with complaints of fever, clubbed fingers and arthralgia. A chest roentgenogram and chest computed tomographic scan revealed a mass in the left lower lobe. Transbronchial lung biopsy was performed, and a diagnosis of moderately differentiated adenocarcinoma was made. Physical examination confirmed finger clubbing in both hands. Bone scintigram showed marked accumulation of 99mTc-MDP in the long bones, bones of the elbows, and patellae. These findings yielded a diagnosis of pulmonary hypertrophic osteoarthropathy associated with primary lung cancer in young adult. The patient had fever and disturbance of gait of arthralgia on admission, and was treated with an oral non-steroidal anti-inflammation drug (NSAID). Advanced non small cell lung cancer (clinical stage T2 N3 M1, Stage IV) was then diagnosed. Gefitinib was administered after EGFR mutation was found in the tumor specimen. NSAID therapy alleviated the fever and arthralgia. After starting gefitinib and discontinuing the NSAID, She had kept a remission of rational symptom with cytoreductive effect. The abnormal findings of bone scintigrams subsequently disappeared and the patient's serum ICTP dropped.

Hypertrophic osteoarthropathy pathogenesis: a case highlighting the potential role for cyclo-oxygenase-2-derived prostaglandin E2

BACKGROUND

A 65-year-old woman presented with weakness, 9 kg weight loss, dysphagia, facial and bilateral upper-extremity swelling, and debilitating, bilateral lower-extremity pain. The patient had undergone a right upper lobectomy for a 5 mm, poorly differentiated adenocarcinoma of the lung 4 years previously. Medical history included chronic obstructive pulmonary disease (emphysema), hypertension, cerebrovascular disease and multinodular goiter. Surgical history included a right carotid endarterectomy. The patient's history was remarkable for 50+ pack-years of smoking.

INVESTIGATIONS

Physical examination, comprehensive metabolic panel and complete blood counts, CT, bone scintigraphy, quantification of urinary 11a-hydroxy-9,15-dioxo-2,3,4,5-tetranor-prostane-1,20-dioic acid (also known as PGE-M).

DIAGNOSIS

Recurrent non-small-cell lung cancer with adrenal metastasis, hypertrophic osteoarthropathy associated with non-small-cell lung cancer, and hyperprostaglandinuria.

MANAGEMENT

Rofecoxib 25 mg daily for hypertrophic osteoarthropathy, palliative external-beam radiation (44 Gy in 22 fractions) for mediastinal mass, palliative external-beam radiation (30 Gy in 12 fractions), followed 2 years later with radiofrequency ablation, for left adrenal metastasis.

Successful treatment of hypertrophic osteoarthropathy by gefitinib in a case with lung adenocarcinoma

Hypertrophic osteoarthropathy is an important manifestation of lung carcinoma, particularly in a non-small cell tumor, and hampers quality of life. Although removal of the primary tumor usually resolves this syndrome, effective treatment in patients with advanced lung carcinoma has not been established. Recently, an orally active, selective epidermal growth factor receptor tyrosine kinase (EGFR) inhibitor ("Gefitinib") provided clinical anti-tumor activity. We describe a 71-year-old male smoker with cough, who presented with clubbed fingers. A transbronchial lung biopsy (stage T2N3M1-IV) on a cavity lesion in the left lower lobe showed the features of adenocarcinoma, while bone scintigram revealed bilaterally symmetrical abnormal uptakes in the lower extremities, suggesting secondary hypertrophic osteoarthropathy. The serum level of growth hormone was increased to 1.42 ng/ml. Chemotherapy (cisplatin, vinorelbine) was not effective. Gefitinib, as a second-line therapy, induced disappearance of the abnormal accumulation on bone scintigraphy and decrease of the cavity in the lung and of serum growth hormone. The presented case suggests that the EGFR inhibitor might be a promising option for the treatment of hypertrophic osteoarthropathy with advanced lung adenocarcinoma.

Hypertrophic pulmonary osteoarthropathy: control of pain and symptoms with pamidronate

This case presents a patient with hypertrophic osteoarthropathy of the lower extremities that developed secondary to congenital cyanotic heart disease. The major clinical manifestation was severe bilateral leg pain. The pain that was debilitating in nature completely resolved following a single administration of 60 mg pamidronate. Hypertrophic osteoarthropathy (HOA) is an acquired, uncommon disorder of obscure etiology. It has been described mainly in association with chronic suppurative pulmonary diseases, bronchogenic carcinoma and lung metastases, cystic fibrosis, and cyanotic congenital malformations of the heart.

Pamidronate results in symptom control of hypertrophic pulmonary osteoarthropathy in cystic fibrosis

Hypertrophic pulmonary osteoarthropathy (HPOA) may complicate the advanced lung disease that is associated with cystic fibrosis, resulting in severe joint pain and early-morning stiffness. Symptoms are usually controlled with the administration of nonsteroidal anti-inflammatory drugs, physiotherapy, and, on occasions, oral corticosteroids. This report describes a case of refractory HPOA with complete remission following the administration of IV pamidronate, which is a potent inhibitor of osteoclastic bone resorption. Symptom relief resulted for up to 3 months, but repeated courses of pamidronate have been required to maintain symptom control.

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.

Epithelioid haemangioendothelioma

Epithelioid haemangioendothelioma is a rare pulmonary neoplasm with less than 40 cases described world wide. We describe the only case to have presented with hypertrophic pulmonary osteoarthropathy who has been treated with azathioprine and has remained alive and well with no deterioration in pulmonary function since being diagnosed 16 years ago. The progression of the chest radiograph and spiral CT appearances of this rare neoplasm are described, and current views regarding the cellular origin of the neoplasm, its cytological appearance, clinical presentation and prognosis are discussed.

The use of pamidronate in hypertrophic pulmonary osteoarthropathy (HPOA)

BACKGROUND

Hypertrophic pulmonary osteoarthropathy (HPOA) secondary to bronchogenic carcinoma can be associated with severe, disabling pain which is not always responsive to conventional treatment.

AIM

To report on the use of pamidronate to control resistant pain in HPOA in three cases.

METHODS

A retrospective review of reported pain, chest X-ray and radionuclide bone scans was made.

RESULTS

Pain relief was achieved in all three cases together with reduced radiolabel uptake in two cases.

CONCLUSIONS

Pamidronate appears to be an effective therapy for HPOA. Further investigation is warranted.

Treatment of resistant pain in hypertrophic pulmonary osteoarthropathy with subcutaneous octreotide

Pain in hypertrophic pulmonary osteoarthropathy (HPOA) due to periostitis and arthropathy can be a particularly disabling symptom, and resistant to a wide variety of treatments. The effectiveness of subcutaneous octreotide in relieving this pain in a patient with HPOA is reported.

Radiotherapy for extreme hypertrophic pulmonary osteoarthropathy associated with malignancy

A patient with florid hypertrophic pulmonary osteoarthropathy (HPOA) associated with metastatic nasopharyngeal carcinoma is presented. Despite the presence of metastatic disease in the thorax and in bone, the patient's main symptom was severe pain from the HPOA, which was temporarily relieved by chemotherapy. Her disease subsequently progressed during chemotherapy and the pain became resistant to conventional treatment, including high dose morphine, non-steriodal anti-inflammatory agents and steriods. It was only with local radiation to the involved joints that the pain could be controlled. Our patient demonstrates that local radiotherapy is an option for the palliation of extreme HPOA.

Takayasu's arteritis presenting with unilateral digital clubbing

Unilateral clubbing has been associated with local vascular lesions of the arm, axilla, and thoracic outlet and with hemiplegia. We describe a patient with Takayasu's arteritis, a disease that affects the aorta and its major branches, who presented with unilateral digital clubbing. A review of the literature on unilateral clubbing is included.

Reversible digital clubbing in acute myeloid leukaemia

A 43 year old woman presented with acute myeloid leukaemia, marked finger and toe clubbing, and a hilar mass. Biopsy of the hilar mass was not technically possible, but it almost certainly represented a granulocytic sarcoma since chemotherapy induced rapid resolution of the mass along with reversal of the clubbing and remission of the leukaemia. Relapse of the leukaemia 21 months later was associated with return of the clubbing. It is hypothesized that an abnormal circulation within the granulocytic sarcoma may have accounted for the development of clubbing.

Treatment of resistant pain in hypertrophic pulmonary arthropathy with ketorolac

Pain associated with hypertrophic pulmonary osteoarthropathy (HPOA) may be extremely disabling and resistant to treatment. The successful use of ketorolac, a new non-steroidal anti-inflammatory drug, given by subcutaneous infusion is reported in two patients with uncontrolled pain caused by HPOA.

The medical and surgical treatment of finger clubbing and hypertrophic osteoarthropathy. A blind study with colchicine and a surgical approach to finger clubbing reduction

In fourteen patients affected with pachydermoperiostosis (PDP), or primary hypertrophic osteoarthropathy, the efficacy of colchicine (0.5 mg day for one month) versus placebo on the main clinical features of the disease (finger clubbing, arthritis and pachydermia) was evaluated. In addition, in one patient the usefulness of surgical reduction of clubbed fingertips was investigated. Colchicine did not demonstrate any appreciable effect on finger clubbing (expressed in degrees) or pachydermia, while an effect on arthralgia (as evaluated by the Ritchie Index and Pain Scale) was observed. The surgical treatment of clubbed fingertips failed to show a satisfactory and stable reduction of the fingertips; two months after surgery the nail matrix apparently produced new tissue, once again enlarging and deforming the finger. These results suggest that low dose colchicine cannot be considered the drug of first choice for the treatment of PDP, while higher dosages, although effective, are not tolerated because of the severe side effects. An effective medical and surgical treatment for PDP will be found only when the pathogenetic mechanisms of the disease are clarified.

Hypertrophic pulmonary osteoarthropathy in four patients with interstitial pulmonary disease

The association between digital clubbing and idiopathic pulmonary fibrosis has been well established; however, the simultaneous occurrence of hypertrophic pulmonary osteoarthropathy and interstitial fibrosis, in the absence of neoplastic disease, has only been described in two case reports and was not mentioned in any of 336 patients described in several recent reviews. Among 70 patients referred for investigation of pulmonary infiltrates, four were found to have hypertrophic pulmonary osteoarthropathy associated with interstitial pulmonary disease, in the absence of malignant disease. We conclude that the use of bone scans and roentgenographic examination of the extremities may draw attention to an association between hypertrophic pulmonary osteoarthropathy and idiopathic pulmonary fibrosis.

Indomethacin therapy for hypertrophic pulmonary osteoarthropathy in patients with bronchogenic carcinoma

Hypertrophic pulmonary osteoarthropathy (HPO) is a disabling complication of lung cancer often requiring thoracotomy with vagotomy for control of pain. This condition was confirmed by scintigraphy in six consecutive patients with biopsy-proved lung cancer. All had characteristic bone and joint pain unresponsive to a variety of analgesics. Treatment with indomethacin gave dramatic relief of pain within 72 hours in all six. Consideration should be given to instituting a controlled trial to establish the efficacy of indomethacin for the treatment of HPO.

Hypertrophic pulmonary osteoarthropathy inactivated by antitumor chemotherapy

A case of hypertrophic pulmonary osteoarthropathy (HPO) associated with carcinoma of the lung is reported. HPO in this patient was documented by Tc-99m methylene diphosphonate scans over a period of seven months. He was treated solely by antitumor chemotherapy, and his HPO was inactivated in three months. Whereas most reports refer to surgery, vagotomy, or radiotherapy for the treatment of lung carcinoma, this case demonstrates the effect of palliative chemotherapy in inactivating HPO in a rather short period of time.

Hypertrophic pulmonary osteoarthropathy: response to chemotherapy without documented tumour response

A case is reported of severe hypertrophic pulmonary osteoarthropathy associated with bronchogenic carcinoma which successfully responded to chemotherapy, despite the fact there was no objective response in the primary lesion. Previous treatment and responses are briefly reviewed. The method or methods by which chemotherapy may alleviate HPOA in the absence of response to the primary lesion are discussed. The marked discrepancy between progression of the HPOA and progression of the clubbing is noted. The fact that HPOA is potentially treatable despite the prognosis of the primary is emphasised.

Pseudoclubbing in a patient with sarcoidosis of the phalangeal bones

We treated a patient who had sarcoidosis with pseudoclubbing. The involvement was asymmetric and involved some fingertips more than others. It did not involve the toes. The pseudoclubbing totally disappeared with effective prednisone therapy. Roentgenograms of the hands showed bone cysts of the distal and middle phalanges, and a gallium citrate Ga 67 scan showed uptake in two of the phalanges. We believe the pseudoclubbing in this patient is a manifestation of phalangeal bone involvement by sarcoidosis with associated dactylitis. A literature review indicates that true clubbing can exist in patients with sarcoidosis, but this case indicates that it must be distinguished from dactylitis.

Effect of atropine sulfate in pulmonary hypertrophic osteoarthropathy

A 49-year-old patient with pulmonary hypertrophic osteoarthropathy was treated with 0.4 mg of atropine sulfate every 4 hours for 14 days. A good clinical response was obtained as measured by handgrip strength, range of motion, and quantitative thermography. Chemical vagotomy supports the hypothesis of the vagal reflex as the pathophysiological mechanism in pulmonary hypertrophic osteoarthropathy.

[Hypertrophic osteoarthropathy of the child. One case cured by antibiotherapy (author's transl)]

Hypertrophic osteoarthropathy in a child is reported. It is caused by intrathoracic suppuration secondary to costal osteomyelitis. After antibiotherapy complete resolution of arthropathy, clubbing and periostitis is obtained. The literature is reviewed.

Reversal of hypertrophic osteoarthropathy after chemotherapy for bronchogenic carcinoma

A patient with hypertrophic osteoarthropathy (HO) secondary to large cell anaplastic carcinoma of the lung was treated with combination chemotherapy (CAP-1). Systemic tumor symptoms resolved within 3 wk. Relief from the bone and articular symptoms of HO was noted after 3 months of treatment, coincident with a partial remission (greater than 50% tumor regression). Objective improvement in the radionuclide bone scan and radiographic periostitis was demonstrated after 6 months. Symptomatic improvement continued despite evidence of tumor progression after 10 months of treatment. Systemic chemotherapy should be considered in the management of symptomatic osteoarthropathy secondary to unresectable bronchogenic carcinoma.

Hypertrophic pulmonary osteoarthropathy in Hodgkin's disease: reversal with chemotherapy

A case of nodular sclerosis Hodgkin's disease, stage IVB, with lung involvement and hypertrophic pulmonary osteoarthropathy (HPOA), was treated with quadruple cytotoxic chemotherapy. The pulmonary lesions, which were thin walled cavities, and the lymphadenopathy resolved completely after two courses of chemotherapy. The clubbing and all evidence of periosteal new bone formation disappeared after six courses of treatment. Complete reversal of the syndrome by chemotherapy has not been previously described. A literature review revealed 13 more cases of Hodgkin's disease associated with HPOA. The syndrome occurred for the first time at the time of diagnosis of Hodgkin's disease in 11 cases, and at recurrence in two. Tha majority of patients had advanced disease (Stage IIIB or IV). Mediastinal involvement was present in all 12 cases for which data were given; lung involvement was present in six cases and pleural involvement in three. Three cases were of the nodular sclerosis type, and one of the lymphocyte-depletion type. The HPOA syndrome in young patients with malignancy is indicative of tumors other than primary bronchial carcinomas.

Hypertrophic osteoarthropathy and rheumatoid arthritis: simultaneous occurrence in association with diffuse interstitial fibrosis

A patient is described who was treated with high-dose prednisone in an attempt to halt progressive respiratory insufficiency associated with diffuse interstitial fibrosis. On cessation of steroid therapy the patient was noted to have radiologic manifestations of hypertrophic osteoarthropathy (HOA) as well as clinical and laboratory features of rheumatoid arthritis (RA). Subsequently a diffuse vasculitis developed with bowel perforation and sepsis leading to death.

The effect of adrenergic blockade in hypertrophic pulmonary osteoarthropathy (HPOA)

A case of hypertrophic pulmonary osteoarthropathy (HPOA) is described, together with synovial fluid cytology and synovial histology. A new approach to therapy is described using adrenergic blockade. The effectiveness of this regime was assessed by quantitative thermography. The successful results support the neurogenic hypothesis for the aetiology of HPOA.