Orthopedics

Case Reports 

Rapid Progression Of Metastatic Bronchogenic Carcinoma After Felon Drainage

Bryan Gawley, MD; Gary Motykie, MD; Julie Holding, BS; Rocco C. Piazza, BA; Lisa J. Gould, MD, PhD

Abstract

Despite the rarity of phalangeal metastases (incidence <0.01%), spread of bronchogenic carcinoma to the hand is well documented.1-8 This article presents a case of metastatic bronchogenic carcinoma of the hand distinguished by the impressive growth of the metastatic hand lesion following felon drainage.

A 65-year-old man presented with a 3-week history of left small finger swelling and pain. The patient reported being bitten by a dog two weeks prior to presentation; his primary care physician had treated him with a 1-week course of oral antibiotics. The patient reported no significant medical problems, but had a long history of smoking. Initial review of symptoms was unremarkable for cough, shortness of breath, or weight loss.

figure 1
Figure 1: Initial presentation of swollen, painful, left small finger distal phalanx. Figure 2: Initial radiograph showing complete destruction of left small finger distal phalanx.

On physical examination the distal small finger appeared swollen and erythematous and was tender to palpation (Figure 1). Radiographs showed soft-tissue swelling and complete destruction of the left small finger distal phalanx suggestive of osteomyelitis or metastatic lesion (Figure 2).

The patient underwent incision and drainage in the emergency room and was admitted for intravenous antibiotics and further work-up. Cultures were negative for bacteria or fungus. Chest radiographs revealed a large right lower lobe mass consistent with a tumor. The patient was lost to follow-up and presented 5 weeks later with lower extremity weakness. At that time he was found to have diffuse spinal and cerebral metastases. His left small finger lesion had progressed to a large fungating mass originating from his left small fingertip (Figure 3).

Biopsies of the phalangeal and pulmonary tumors revealed poorly differentiated squamous cell carcinoma. The patient received palliative spinal radiation followed by digital amputation to alleviate persistent bleeding and pain. The patient died <3 months after initial presentation.

Figure 3: Five weeks after initial presentation and felon drainage, the patient returned with a large fungating mass from the left small finger distal phalanx. The mass measured 7x7x4 cm.

Since the first report of metastases to the hand bones by Handley in 1906, <200 subsequent cases have been reported.6 In Libson et al’s review, 6 the most common sites of primary carcinoma were the lung (47%), breast (12.5%), kidney (11%), and colorectum (5%). The distal phalanx is most commonly involved (56% in one study), and affected men outnumber affected women almost 2:1.2,8

Bronchogenic carcinoma frequently metastasizes to bone in the end stage. Radiographic findings usually include lytic lesions or bony destruction; however, several authors have noted that adjacent articular surfaces are spared.1,2,5,7 Distant bony spread is hematogenous, with predilection for bones rich in red marrow, which likely explains the rarity of hand metastases.1,5,7 Spread usually is to an area of relative increased blood flow and is dependent on chemotactic factors and selective malignant cell adherence to and migration through endothelial cells at the site of deposit.1

Clinically, bronchogenic carcinoma metastatic to the hand can present as infection or chronic inflammation.3,5,6,8,9 As illustrated by this case report, complete bony destruction of the distal phalanx should be a red flag in the appropriate clinical setting. Although not apparent in our patient, review of systems often reveals pulmonary symptoms or weight loss. In cases where hand metastases are the first indication of malignancy, errors in diagnosis are frequent and can lead to a delay in treatment. Although bony spread indicates advanced stage of disease with average survival <6 months, digital amputation can provide palliative relief of pain or bleeding.2,3,8

The rapid local growth of this metastatic lesion after the incision and drainage was impressive (Figure 3). The growth of the…

Despite the rarity of phalangeal metastases (incidence <0.01%), spread of bronchogenic carcinoma to the hand is well documented.1-8 This article presents a case of metastatic bronchogenic carcinoma of the hand distinguished by the impressive growth of the metastatic hand lesion following felon drainage.

Case Report

A 65-year-old man presented with a 3-week history of left small finger swelling and pain. The patient reported being bitten by a dog two weeks prior to presentation; his primary care physician had treated him with a 1-week course of oral antibiotics. The patient reported no significant medical problems, but had a long history of smoking. Initial review of symptoms was unremarkable for cough, shortness of breath, or weight loss.

figure 1
Figure 1: Initial presentation of swollen, painful, left small finger distal phalanx. Figure 2: Initial radiograph showing complete destruction of left small finger distal phalanx.

figure 2

On physical examination the distal small finger appeared swollen and erythematous and was tender to palpation (Figure 1). Radiographs showed soft-tissue swelling and complete destruction of the left small finger distal phalanx suggestive of osteomyelitis or metastatic lesion (Figure 2).

The patient underwent incision and drainage in the emergency room and was admitted for intravenous antibiotics and further work-up. Cultures were negative for bacteria or fungus. Chest radiographs revealed a large right lower lobe mass consistent with a tumor. The patient was lost to follow-up and presented 5 weeks later with lower extremity weakness. At that time he was found to have diffuse spinal and cerebral metastases. His left small finger lesion had progressed to a large fungating mass originating from his left small fingertip (Figure 3).

Biopsies of the phalangeal and pulmonary tumors revealed poorly differentiated squamous cell carcinoma. The patient received palliative spinal radiation followed by digital amputation to alleviate persistent bleeding and pain. The patient died <3 months after initial presentation.

figure 3

Figure 3: Five weeks after initial presentation and felon drainage, the patient returned with a large fungating mass from the left small finger distal phalanx. The mass measured 7x7x4 cm.

Discussion

Since the first report of metastases to the hand bones by Handley in 1906, <200 subsequent cases have been reported.6 In Libson et al’s review, 6 the most common sites of primary carcinoma were the lung (47%), breast (12.5%), kidney (11%), and colorectum (5%). The distal phalanx is most commonly involved (56% in one study), and affected men outnumber affected women almost 2:1.2,8

Bronchogenic carcinoma frequently metastasizes to bone in the end stage. Radiographic findings usually include lytic lesions or bony destruction; however, several authors have noted that adjacent articular surfaces are spared.1,2,5,7 Distant bony spread is hematogenous, with predilection for bones rich in red marrow, which likely explains the rarity of hand metastases.1,5,7 Spread usually is to an area of relative increased blood flow and is dependent on chemotactic factors and selective malignant cell adherence to and migration through endothelial cells at the site of deposit.1

Clinically, bronchogenic carcinoma metastatic to the hand can present as infection or chronic inflammation.3,5,6,8,9 As illustrated by this case report, complete bony destruction of the distal phalanx should be a red flag in the appropriate clinical setting. Although not apparent in our patient, review of systems often reveals pulmonary symptoms or weight loss. In cases where hand metastases are the first indication of malignancy, errors in diagnosis are frequent and can lead to a delay in treatment. Although bony spread indicates advanced stage of disease with average survival <6 months, digital amputation can provide palliative relief of pain or bleeding.2,3,8

The rapid local growth of this metastatic lesion after the incision and drainage was impressive (Figure 3). The growth of the tumor over a relatively short time may represent activation of the metastatic deposit or a mechanical release of neoplastic cells as the fibrous septae of the fingertip pulp were incised.1

References

  1. Berrettoni BA, Carter JR. Mechanisms of cancer metastasis to bone. J Bone Joint Surg Am. 1986; 68:308-312.
  2. Bunkis J, Mehrhof A, Stayman JWI. Resident review #23: metastatic lesions of the hand and foot. Orthopedic Rev J. 1980; 9:97-101.
  3. Healey JH, Turnbull AD, Miedema B, Lane JM. Acrometastases. A study of twenty-nine patients with osseous involvement of the hands and feet. J Bone Joint Surg Am. 1986; 68:743-746.
  4. Kerin R. Metastatic tumors of the hand. A review of the literature. J Bone Joint Surg Am. 1983; 65:1331-1335.
  5. Kerin R. The hand in metastatic disease. J Hand Surg [Am]. 1987; 12:77-83.
  6. Libson E, Bloom RA, Husband JE, Stoker DJ. Metastatic tumours of bones of the hand and foot. A comparative review and report of 43 additional cases. Skeletal Radiol. 1987; 16:387-392.
  7. Vaezy A, Budson DC. Phalangeal metastases from bronchogenic carcinoma. JAMA. 1978; 239:226-227.
  8. Wu KK, Guise ER. Metastatic tumors of the hand: a report of six cases. J Hand Surg [Am]. 1978; 3:271-627.
  9. Rose BA, Wood FM. Metastatic bronchogenic carcinoma masquerading as a felon. J Hand Surg [Am]. 1983; 8:325-328.

Authors

Drs Gawley, Motykie, and Gould, Mr Piazza, and Ms Holding are from the Department of Surgery, The University of Texas Medical Branch, Galveston, Tex.

Reprint requests: Lisa J. Gould, MD, PhD, Dept of Surgery, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0724.

10.3928/01477447-20061101-11

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