Case Letters
Case report: Non‑small‑cell lung carcinoma presenting as a foot swelling Sir, Acrometastases are defined as malignant secondary lesions of the bones located in the hands and/or feet. Acrometastases are very rare and are generally late manifestations of occult cancer and associated with a poor prognosis. In literature, only few cases of acrometastases due to occult lung cancer have been reported.[1] We report a case of acrometastasis to the left foot from an occult lung cancer. A 55‑year‑old female patient presented with complains of pain and swelling in the left foot of two‑month duration. Magnetic Resonance Imaging (MRI) of the left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex [Figure 1]. Biopsy from the second metatarsal bone was suggestive of metastatic deposit and tumor cells were positive for cytokeratin 7 (CK‑7), Epithelial membrane antigen (EMA), Thyroid transcription factor‑1 (TTF‑1), and NAPSIN, suggestive of Non‑Small Cell Lung Cancer, Adenocarcinoma (NSCLC) [Figure 2]. On careful history taking, she was a 15‑pack‑a‑year smoker. The whole body positron emission tomography (PET) computed tomography (CT) showed a left lung lower lobe, hypermetabolic, soft tissue mass and subcarinal and left hilar lymphnodes [Figure 3a]. A hypermetabolic soft‑tissue mass in the left base of the second metatarsal, with enlarged lymphnodes, was seen in the proximal left external iliac, left obturator, left inguinofemoral, and popliteal regions [Figure 3b]. The epidermal growth factor receptor (EGFR) mutation was not detected in the biopsy specimen. The patient was started on external beam radiation therapy (EBRT) to the left foot, followed by systemic chemotherapy with Pemetrexed‑ and Cisplatin‑based palliative chemotherapy. Post two courses of chemotherapy she had a dramatic response to the treatment with a decrease in pain in the left foot. Bone metastasis is a common occurrence in patients with advanced carcinomas, particularly in those with lung, breast, and prostate cancer. However, metastases distal to the knee are very rare and metastases to the bones of the foot are even rarer. Metastases to bone develop in 30% of all patients with cancer, with only 0.007 to 0.3% having acrometastasis. [1] The most 292
Figure 1: MRI of left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex
a
b
c
d
Figure 2: (a) H & E section showing tumor cells arranged in nests and glandular pattern. Tumor cells were positive for, (b) CK-7, (c) TTF-1, and (d) NAPSIN
common sources of acrometastasis are colorectal, renal, and lung carcinomas (50%), with the bladder, uterus, and breast responsible for 25% of the metastases to the foot.[2] Acrometastases are rarely the initial presentation of metastatic carcinoma. In a series by Healey et al., they were seen as the initial manifestation of an occult malignancy in four (14%) of the 29 patients.[3] Acrometastasis are often initially mistaken for more benign processes, such as infection, trauma, inflammatory Lung India • Vol 32 • Issue 3 • May - Jun 2015
Case Letters
Mithun Chacko John, Varun Goel, Srikant Tiwari, Vineet Talwar, Nivedita Patnaik1 Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, 1Department of Pathology, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi, India E‑mail: [email protected]
REFERENCES a
b
Figure 3: (a) PET CT showed a hypermetabolic soft tissue mass seen in the left foot with destruction of the underlying base of the second metatarsal, (b) Left lung lower lobe showed a peripheral lobulated hypermetabolic soft tissue mass
arthritis, osteomyelitis or gout. Persistent symptoms, unresponsiveness to conservative therapy or prior history of malignancy should prompt the physician to consider metastases, when evaluating a patient. Given the bleak prognosis of digital acrometastatic lung cancer, treatment is largely palliative. Amputation and chemotherapy have been used, but recent literature suggests that localized radiotherapy can successfully relieve the pain and return the function to the affected foot.[4] There may also be a targeted role for bone‑remodeling and pharmacotherapies, such as, bisphosfonates or denosumab, which have demonstrated utility in treating other bony metastases.[5] Treatment is directed toward the relief of symptoms and restoration of functional capacity.
1. 2. 3. 4. 5.
Zindrick MR, Young MP, Daley RJ, Light TR. Metastatic tumors of the foot: Case report and literature review. Clin Orthop Relat Res 1982:219‑25. Baran R, Tosti A. Metastatic carcinoma to the terminal phalanx of the big toe: Report of two cases and review of the literature. J Am Acad Dermatol 1994;31:259‑63. 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;68:743‑6. Flynn CJ, Danjoux C, Wong J, Christakis M, Rubenstein J, Yee A, et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008;15:51‑8. Smith MR, Egerdie B, Hernández Toriz N, Feldman R, Tammela TL, Saad F, et al. Denosumab in men receiving androgen‑deprivation therapy for prostate cancer. N Engl J Med 2009;361:745‑55.
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Website: www.lungindia.com DOI: 10.4103/0970-2113.156259
Necrotic mediastinal lymph node enlargement in a middle‑aged female Sir, A 47‑year‑old female presented with a history of fever and cough for a duration of four months. The physical examination was unremarkable. Contrast‑enhanced computed tomography (CECT) thorax demonstrated a large conglomerate lymph nodal enlargement in the right paratracheal, pretracheal, precarinal, and subcarinal stations [Figure 1]. The nodes appeared hypodense, with areas of central necrosis and demonstrated peripheral rim enhancement. The tuberculin skin test demonstrated an 18 mm induration. Other routine investigations were normal. The patient had been diagnosed with squamous cell carcinoma of the cervix three years previously and had received combination chemotherapy and radiotherapy. Six months following that, inguinal lymph node tumor
recurrence occurred, for which external beam radiotherapy was administered. The patient remained asymptomatic subsequently. The current CECT scan of the abdomen and pelvis did not reveal any lymphadenopathy or local recurrence. A possibility of disseminated tuberculosis (TB) was considered. Endobronchial ultrasound‑guided transbronchial needle aspiration (EBUS‑TBNA) was done under conscious sedation using the Olympus BF‑UC‑180 F EBUS bronchoscope (Olympus Corporation, Japan). On EBUS, enlarged lymph nodes were observed at the right lower paratracheal ‑ size 38.1 mm × 28.4 mm, subcarinal ‑ size 21 mm × 20.4 mm, and left lower paratracheal ‑ size 12 mm × 12 mm, lymph node stations. The right lower paratracheal lymph node had indistinct margins with a
Lung India • Vol 32 • Issue 3 • May - Jun 2015 293
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Case report: Non‑small‑cell lung carcinoma presenting as a foot swelling Sir, Acrometastases are defined as malignant secondary lesions of the bones located in the hands and/or feet. Acrometastases are very rare and are generally late manifestations of occult cancer and associated with a poor prognosis. In literature, only few cases of acrometastases due to occult lung cancer have been reported.[1] We report a case of acrometastasis to the left foot from an occult lung cancer. A 55‑year‑old female patient presented with complains of pain and swelling in the left foot of two‑month duration. Magnetic Resonance Imaging (MRI) of the left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex [Figure 1]. Biopsy from the second metatarsal bone was suggestive of metastatic deposit and tumor cells were positive for cytokeratin 7 (CK‑7), Epithelial membrane antigen (EMA), Thyroid transcription factor‑1 (TTF‑1), and NAPSIN, suggestive of Non‑Small Cell Lung Cancer, Adenocarcinoma (NSCLC) [Figure 2]. On careful history taking, she was a 15‑pack‑a‑year smoker. The whole body positron emission tomography (PET) computed tomography (CT) showed a left lung lower lobe, hypermetabolic, soft tissue mass and subcarinal and left hilar lymphnodes [Figure 3a]. A hypermetabolic soft‑tissue mass in the left base of the second metatarsal, with enlarged lymphnodes, was seen in the proximal left external iliac, left obturator, left inguinofemoral, and popliteal regions [Figure 3b]. The epidermal growth factor receptor (EGFR) mutation was not detected in the biopsy specimen. The patient was started on external beam radiation therapy (EBRT) to the left foot, followed by systemic chemotherapy with Pemetrexed‑ and Cisplatin‑based palliative chemotherapy. Post two courses of chemotherapy she had a dramatic response to the treatment with a decrease in pain in the left foot. Bone metastasis is a common occurrence in patients with advanced carcinomas, particularly in those with lung, breast, and prostate cancer. However, metastases distal to the knee are very rare and metastases to the bones of the foot are even rarer. Metastases to bone develop in 30% of all patients with cancer, with only 0.007 to 0.3% having acrometastasis. [1] The most 292
Figure 1: MRI of left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex
a
b
c
d
Figure 2: (a) H & E section showing tumor cells arranged in nests and glandular pattern. Tumor cells were positive for, (b) CK-7, (c) TTF-1, and (d) NAPSIN
common sources of acrometastasis are colorectal, renal, and lung carcinomas (50%), with the bladder, uterus, and breast responsible for 25% of the metastases to the foot.[2] Acrometastases are rarely the initial presentation of metastatic carcinoma. In a series by Healey et al., they were seen as the initial manifestation of an occult malignancy in four (14%) of the 29 patients.[3] Acrometastasis are often initially mistaken for more benign processes, such as infection, trauma, inflammatory Lung India • Vol 32 • Issue 3 • May - Jun 2015
Case Letters
Mithun Chacko John, Varun Goel, Srikant Tiwari, Vineet Talwar, Nivedita Patnaik1 Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, 1Department of Pathology, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi, India E‑mail: [email protected]
REFERENCES a
b
Figure 3: (a) PET CT showed a hypermetabolic soft tissue mass seen in the left foot with destruction of the underlying base of the second metatarsal, (b) Left lung lower lobe showed a peripheral lobulated hypermetabolic soft tissue mass
arthritis, osteomyelitis or gout. Persistent symptoms, unresponsiveness to conservative therapy or prior history of malignancy should prompt the physician to consider metastases, when evaluating a patient. Given the bleak prognosis of digital acrometastatic lung cancer, treatment is largely palliative. Amputation and chemotherapy have been used, but recent literature suggests that localized radiotherapy can successfully relieve the pain and return the function to the affected foot.[4] There may also be a targeted role for bone‑remodeling and pharmacotherapies, such as, bisphosfonates or denosumab, which have demonstrated utility in treating other bony metastases.[5] Treatment is directed toward the relief of symptoms and restoration of functional capacity.
1. 2. 3. 4. 5.
Zindrick MR, Young MP, Daley RJ, Light TR. Metastatic tumors of the foot: Case report and literature review. Clin Orthop Relat Res 1982:219‑25. Baran R, Tosti A. Metastatic carcinoma to the terminal phalanx of the big toe: Report of two cases and review of the literature. J Am Acad Dermatol 1994;31:259‑63. 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;68:743‑6. Flynn CJ, Danjoux C, Wong J, Christakis M, Rubenstein J, Yee A, et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008;15:51‑8. Smith MR, Egerdie B, Hernández Toriz N, Feldman R, Tammela TL, Saad F, et al. Denosumab in men receiving androgen‑deprivation therapy for prostate cancer. N Engl J Med 2009;361:745‑55.
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.156259
Necrotic mediastinal lymph node enlargement in a middle‑aged female Sir, A 47‑year‑old female presented with a history of fever and cough for a duration of four months. The physical examination was unremarkable. Contrast‑enhanced computed tomography (CECT) thorax demonstrated a large conglomerate lymph nodal enlargement in the right paratracheal, pretracheal, precarinal, and subcarinal stations [Figure 1]. The nodes appeared hypodense, with areas of central necrosis and demonstrated peripheral rim enhancement. The tuberculin skin test demonstrated an 18 mm induration. Other routine investigations were normal. The patient had been diagnosed with squamous cell carcinoma of the cervix three years previously and had received combination chemotherapy and radiotherapy. Six months following that, inguinal lymph node tumor
recurrence occurred, for which external beam radiotherapy was administered. The patient remained asymptomatic subsequently. The current CECT scan of the abdomen and pelvis did not reveal any lymphadenopathy or local recurrence. A possibility of disseminated tuberculosis (TB) was considered. Endobronchial ultrasound‑guided transbronchial needle aspiration (EBUS‑TBNA) was done under conscious sedation using the Olympus BF‑UC‑180 F EBUS bronchoscope (Olympus Corporation, Japan). On EBUS, enlarged lymph nodes were observed at the right lower paratracheal ‑ size 38.1 mm × 28.4 mm, subcarinal ‑ size 21 mm × 20.4 mm, and left lower paratracheal ‑ size 12 mm × 12 mm, lymph node stations. The right lower paratracheal lymph node had indistinct margins with a
Lung India • Vol 32 • Issue 3 • May - Jun 2015 293
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
