International
International Orthopaedics (SICOT) (1992) 16:282-284
Orthopaedics © Springer-Verlag 1992
Patellar metastasis from a malignant melanoma H. J. Jaeger, G. H. Kruegener, and A. G. Donovan Department of Orthopaedic Surgery, Scarborough Hospital, England
Summary. We report a patient with a patellar metastasis from a malignant melanoma. Only 16 other cases have been previously described in detail in the literature. A lyric lesion in the patella is most often caused by a benign turnout, but a primary or secondary malignant turnout has to be excluded. R~sum~. Nous rapportons un cas de mdlanome malin traduit par une mdtastase rotulienne, sans 6volution clinique pr6alable de la 16sion primitive. La revue de la littdrature n' a permis de retrouver que 16 cas de mdtastase rotulienne histologiquement prouvde et ddcrite en ddtails. Une 16sion lytique de la rotule correspond dans la majorit6 des cas ~ une tumeur bdnigne, mais 1'dventualit~ d'une tumeur maligne primitive ou d'une localisation mdtastatique secondaire ne peut 6tre exclue.
Case report A woman, aged 65 years, was admitted to hospital with pain in the front of the right knee which had gradually increased over the previous 4 months. She had been unable to bear weight on her leg for a short period. There was no injury and no relevant past medical history. A radiograph one month before admission showed only slightly reduced bone density in the patella. The right knee was swollen, red, warm and tender with almost no movement. Her right quadriceps was wasted. A slightly raised, partly ulcerated, brown skin lesion, 1 cm across, was noticed on her right shoulder. She said this had been present since birth and had not changed in size, or caused symptoms, for 26 years. The white cell count was raised to 17.5 x 109/litre and plasma viscosity to 1.98. A radiograph of the right knee showed a lytic lesion on the lateral side of the patella; the cortex was intact and there was no periosteal reaction (Fig. 1). A chest radiograph showed two large basal opacities suggestive of metastases.
Introduction Primary neoplasms of the patella are rare, 6 being reported in a review of 8542 primary bone tumours [4]. Metastases are even more rare, no case being recorded in a series of 60 tumours of the patella [11]. Only 16 cases of histologically proven patellar metastasis have been described in detail [1, 2, 5, 8, 9, 10, 12, 13, 14, 16, 17, 18, 19]. We describe a woman aged 65 years who presented with pain in the right knee which was due to a patellar metastasis from a malignant melanoma. This is only the second such case to be recorded [17]. Reprint requests to: G.H. Kruegener, Scarborough Hospital, Scalby Road, Scarborough Y012 4QR England
Fig. 1 A, B. Anteroposterior and lateral radiographs of the case reported. There is a lyric lesion on the lateral part of the patella without cortical erosion or periosteal reaction
H. J. Jaeger et al.: Patellar metastasis from a malignant melanoma
283
Table 1. Details of all 17 patients Case
Age (years)
Sex
Clinical presentation
Radiological appearance
Site of primary tumour
Primary known
Treatment
Reference
1
50
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
No
Patellectomy
[16]
2
58
M
Pain and swelling, knee; limited knee movement
Lyric lesion of patella
Malignant lymphoma
Yes
Patellectomy
[18]
3
70
F
Pain and swelling, knee; limited knee movement, non-weight bearing
Lyric lesion of patella; pathological fracture
Breast carcinoma
Yes
Patellectomy
[19]
4
66
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
Yes
None
[2]
5
48
F
Pain and swelling, knee; limited knee movement
Lyric lesion of patella
Breast carcinoma
Yes
Patellectomy
[10]
6
40
F
Pain and swelling knee
Lyric lesion of patella
Malignant lymphoma
Yes
Patellectomy, radiation
[I3]
7
52
M
Pain and swelling, knee; limited knee movement
Lytic lesion of patella; suprapatellar mass
Oesophagus carcinoma
Yes
None
[17]
8
48
F
Pain and swelling, knee; limited knee movement
Infrapatellar mass
Cervix carcinoma
Yes
Radiation
[17]
9
45
M
Pain and swelling, knee; limited knee movement
None
Adenocarcinoma from undetermined site
No
Radiation
[17]
10
48
M
Pain and swelling over patella
Lyric and blastic lesion
Malignant melanoma
Yes
None
[ 17]
11
62
M
Pain and swelling, knee; av fistula; thigh fasciculations
Lyric lesion of patella
Kidney carcinoma
Yes
Radiation
[8]
12
67
M
Pain and swelling, knee; limited knee movement, non-weight bearing
Lyric lesion of patella; pathologic fracture
Breast carcinoma
Yes
Patenectomy
[9]
13
63
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
No
None
[5]
14
56
M
Pain and swelling, knee
Lytic lesion of patella
Oesophagus carcinoma
Yes
Patellectomy
[1]
15
64
M
Pain and swelling, knee; non-weight bearing
Lyric lesion of patella
Kidney carcinoma
Yes
Patellectomy
[12]
16
71
M
Pain and swelling, knee
Lytic lesion of patella
Bronchial carcinoma
No
Patellectomy
[14]
17
65
F
Pain and swelling, knee; limited knee movement; non-weight bearing
Lyric lesion of patella
Malignant melanoma
No
Patellectomy
Our case
An excision biopsy of the skin lesion and a patellectomy were carried out to determine the diagnosis and to relieve the pain in her knee. The histology of the skin lesion showed a superficial spreading type of malignant melanoma with an invasion depth of 0.5 mm (Breslow stage 1); the changes in the patella confirmed metastatic malignant melanoma. Her condition deteriorated after operation with diarrhoea and generalised abdominal tenderness. Further investigation was not considered justifiable and she died 2 weeks later. Permission for an autopsy could not be obtained.
Discussion Twenty-two cases of patellar metastases have been reported including our own, but 5 o f these were not confirmed histologically or described in detail [3, 6, 7, 15]. They have been excluded from the following
review of the literature. The details of the 17 remaining cases are shown in Table 1. The primary sites were bronchial carcinoma 4, breast carcinoma 3 (one male), oesophageal carcinoma 2, kidney carcinoma 2, uterine cervical carcinoma 1, malignant l y m p h o m a 2, malignant melanoma 2, and adenocarcinoma of unknown origin 1. The mean age at presentation was about 58 years, range 45 to 71 years; eleven were men and five women, reflecting the sex incidence of the primary lesions. All had pain and swelling o f the knee, eight had limited movement, four were unable to bear weight on the affected leg and one had symptoms and signs o f an arterio-venous fistula. Plain radiographs showed a lytic lesion in fourteen. In one, the initial radiograph was normal, and in
284
H.J. Jaeger et al.: Patellar metastasis from a malignant melanoma
another there was an infrapatellar soft tissue mass but no bony lesion. Other findings were a mixed osteoblastic and osteolytic lesion in one, a suprapatellar soft tissue mass in 1 and pathological fractures of the patella in two. In 13 the primary lesion was k n o w n before the presentation with patellar metastases. One patient with bronchial carcinoma was treated for pulmonary tuberculosis until the patellar metastasis revealed the correct diagnosis [5], and in another the patellar metastasis was the first presentation of a previously u n k n o w n bronchial carcinoma [14]. In one the primary lesion was not determined [17]. Our case is the fourth in w h o m the presenting lesion was the patellar metastasis. One patient was initially treated for septic arthritis [1], and one had been thought to have traumatic or tuberculous arthritis. Eight patients were treated by patellectomy, 5 by radiotherapy, one had a patellectomy and radiotherapy, and three had no local treatment. Anterior knee pain is c o m m o n in y o u n g adults, but in patients over the age of 45 years the possibility of a tumour should be considered and radiographs taken. The most likely causes are chondroblastoma, giant cell tumour or simple bone cyst, but a biopsy should be done to exclude a primary malignant tumour or a metastasis.
3. Cole WH (1925) Primary tumours of the patella. J Bone Joint Surg [Am] 7:637-654 4. Dahlin DC, Unni KK (1986) Bone tumours: general aspects and data on 8542 cases, 4th edn. Charles C Thomas, Springfield 5. Gall EP, Didizian NA, Park Y (1974) Acute monarticular arthritis following patellar metastasis: A manifestation of carcinoma of the lung. J Am Med Assoc 229: 188-189 6. Handley W (1906) Cancer of the breast and its operative treatment. John Murray, London 7. Hellner (1935) Knochenmetastasen bei malignen Geschwfilsten. Erg Chir 28:72 8. Howlett SA, Caranasos GJ (1970) Metastatic renal cell carcinoma producing arteriovenous shunt. Arch Intern Med 125:493-495 9. Keeley CD (1973) Bilateral patellar metastases from carcinoma of the male breast. Can J Surg 16:328-329 10. Klenerman L (1965) A metastatic deposit in the patella from a carcinoma of the breast. Postgrad Med J 41: 284- 286 11. Kransdorf MJ, Moser RP, Vinh TN, Aoki J, Callaghan JJ (1989) Primary tumours of the patella: A review of 42 cases. Skel Radiol 18:365-371 12. Kwa S (1989) Metastasis in a patella: a rare site. Aus NZ J Surg 59:351-352 13. Linscheid RL, Dahlin DC (1966) Unusual lesions of the patella. J Bone Joint Surg [Am] 48: 1359-1366 14. Pazzaglia UE, Barbieri D, Cherubino P (1989) Solitary metastasis of the patella as the first manifestation of lung cancer. Int Orthop 13:75-76 15. Rothermel FJ, Miller FJ, Hottenstein DW, Dunn EJ (1977) Metastases to the patella with bone scan, tomography, magnification film correlation. Pa Med 80: 50- 51 16. Sabaino D (1952) Metastasi precoce nella rotula tumore primitivo del polmone. Minerva Chir 7:371 - 376 17. Stoler B, Staple TW (1969) Metastases to the patella. Radiology 93:853-856 18. Sutro CJ (1963) Lymphosarcoma of the patella: radical excision without repair of the extensor apparatus of the leg. Bull Hosp Joint Dis 24:68-74 19. Taylor GH (1964) Pathologic fracture of the patella caused by metastatic carcinoma. NY State J Med 64:430-431
References 1. Ashby ME (1976) Esophageal carcinoma metastatic to the patella: a case report. J Am Med Assoc 23:2519-2520 2. Benedek TG (1965) Lysis of the patella due to metastatic carcinoma. Arthr Rheum 8:560-567
International Orthopaedics (SICOT) (1992) 16:282-284
Orthopaedics © Springer-Verlag 1992
Patellar metastasis from a malignant melanoma H. J. Jaeger, G. H. Kruegener, and A. G. Donovan Department of Orthopaedic Surgery, Scarborough Hospital, England
Summary. We report a patient with a patellar metastasis from a malignant melanoma. Only 16 other cases have been previously described in detail in the literature. A lyric lesion in the patella is most often caused by a benign turnout, but a primary or secondary malignant turnout has to be excluded. R~sum~. Nous rapportons un cas de mdlanome malin traduit par une mdtastase rotulienne, sans 6volution clinique pr6alable de la 16sion primitive. La revue de la littdrature n' a permis de retrouver que 16 cas de mdtastase rotulienne histologiquement prouvde et ddcrite en ddtails. Une 16sion lytique de la rotule correspond dans la majorit6 des cas ~ une tumeur bdnigne, mais 1'dventualit~ d'une tumeur maligne primitive ou d'une localisation mdtastatique secondaire ne peut 6tre exclue.
Case report A woman, aged 65 years, was admitted to hospital with pain in the front of the right knee which had gradually increased over the previous 4 months. She had been unable to bear weight on her leg for a short period. There was no injury and no relevant past medical history. A radiograph one month before admission showed only slightly reduced bone density in the patella. The right knee was swollen, red, warm and tender with almost no movement. Her right quadriceps was wasted. A slightly raised, partly ulcerated, brown skin lesion, 1 cm across, was noticed on her right shoulder. She said this had been present since birth and had not changed in size, or caused symptoms, for 26 years. The white cell count was raised to 17.5 x 109/litre and plasma viscosity to 1.98. A radiograph of the right knee showed a lytic lesion on the lateral side of the patella; the cortex was intact and there was no periosteal reaction (Fig. 1). A chest radiograph showed two large basal opacities suggestive of metastases.
Introduction Primary neoplasms of the patella are rare, 6 being reported in a review of 8542 primary bone tumours [4]. Metastases are even more rare, no case being recorded in a series of 60 tumours of the patella [11]. Only 16 cases of histologically proven patellar metastasis have been described in detail [1, 2, 5, 8, 9, 10, 12, 13, 14, 16, 17, 18, 19]. We describe a woman aged 65 years who presented with pain in the right knee which was due to a patellar metastasis from a malignant melanoma. This is only the second such case to be recorded [17]. Reprint requests to: G.H. Kruegener, Scarborough Hospital, Scalby Road, Scarborough Y012 4QR England
Fig. 1 A, B. Anteroposterior and lateral radiographs of the case reported. There is a lyric lesion on the lateral part of the patella without cortical erosion or periosteal reaction
H. J. Jaeger et al.: Patellar metastasis from a malignant melanoma
283
Table 1. Details of all 17 patients Case
Age (years)
Sex
Clinical presentation
Radiological appearance
Site of primary tumour
Primary known
Treatment
Reference
1
50
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
No
Patellectomy
[16]
2
58
M
Pain and swelling, knee; limited knee movement
Lyric lesion of patella
Malignant lymphoma
Yes
Patellectomy
[18]
3
70
F
Pain and swelling, knee; limited knee movement, non-weight bearing
Lyric lesion of patella; pathological fracture
Breast carcinoma
Yes
Patellectomy
[19]
4
66
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
Yes
None
[2]
5
48
F
Pain and swelling, knee; limited knee movement
Lyric lesion of patella
Breast carcinoma
Yes
Patellectomy
[10]
6
40
F
Pain and swelling knee
Lyric lesion of patella
Malignant lymphoma
Yes
Patellectomy, radiation
[I3]
7
52
M
Pain and swelling, knee; limited knee movement
Lytic lesion of patella; suprapatellar mass
Oesophagus carcinoma
Yes
None
[17]
8
48
F
Pain and swelling, knee; limited knee movement
Infrapatellar mass
Cervix carcinoma
Yes
Radiation
[17]
9
45
M
Pain and swelling, knee; limited knee movement
None
Adenocarcinoma from undetermined site
No
Radiation
[17]
10
48
M
Pain and swelling over patella
Lyric and blastic lesion
Malignant melanoma
Yes
None
[ 17]
11
62
M
Pain and swelling, knee; av fistula; thigh fasciculations
Lyric lesion of patella
Kidney carcinoma
Yes
Radiation
[8]
12
67
M
Pain and swelling, knee; limited knee movement, non-weight bearing
Lyric lesion of patella; pathologic fracture
Breast carcinoma
Yes
Patenectomy
[9]
13
63
M
Pain and swelling, knee
Lyric lesion of patella
Bronchial carcinoma
No
None
[5]
14
56
M
Pain and swelling, knee
Lytic lesion of patella
Oesophagus carcinoma
Yes
Patellectomy
[1]
15
64
M
Pain and swelling, knee; non-weight bearing
Lyric lesion of patella
Kidney carcinoma
Yes
Patellectomy
[12]
16
71
M
Pain and swelling, knee
Lytic lesion of patella
Bronchial carcinoma
No
Patellectomy
[14]
17
65
F
Pain and swelling, knee; limited knee movement; non-weight bearing
Lyric lesion of patella
Malignant melanoma
No
Patellectomy
Our case
An excision biopsy of the skin lesion and a patellectomy were carried out to determine the diagnosis and to relieve the pain in her knee. The histology of the skin lesion showed a superficial spreading type of malignant melanoma with an invasion depth of 0.5 mm (Breslow stage 1); the changes in the patella confirmed metastatic malignant melanoma. Her condition deteriorated after operation with diarrhoea and generalised abdominal tenderness. Further investigation was not considered justifiable and she died 2 weeks later. Permission for an autopsy could not be obtained.
Discussion Twenty-two cases of patellar metastases have been reported including our own, but 5 o f these were not confirmed histologically or described in detail [3, 6, 7, 15]. They have been excluded from the following
review of the literature. The details of the 17 remaining cases are shown in Table 1. The primary sites were bronchial carcinoma 4, breast carcinoma 3 (one male), oesophageal carcinoma 2, kidney carcinoma 2, uterine cervical carcinoma 1, malignant l y m p h o m a 2, malignant melanoma 2, and adenocarcinoma of unknown origin 1. The mean age at presentation was about 58 years, range 45 to 71 years; eleven were men and five women, reflecting the sex incidence of the primary lesions. All had pain and swelling o f the knee, eight had limited movement, four were unable to bear weight on the affected leg and one had symptoms and signs o f an arterio-venous fistula. Plain radiographs showed a lytic lesion in fourteen. In one, the initial radiograph was normal, and in
284
H.J. Jaeger et al.: Patellar metastasis from a malignant melanoma
another there was an infrapatellar soft tissue mass but no bony lesion. Other findings were a mixed osteoblastic and osteolytic lesion in one, a suprapatellar soft tissue mass in 1 and pathological fractures of the patella in two. In 13 the primary lesion was k n o w n before the presentation with patellar metastases. One patient with bronchial carcinoma was treated for pulmonary tuberculosis until the patellar metastasis revealed the correct diagnosis [5], and in another the patellar metastasis was the first presentation of a previously u n k n o w n bronchial carcinoma [14]. In one the primary lesion was not determined [17]. Our case is the fourth in w h o m the presenting lesion was the patellar metastasis. One patient was initially treated for septic arthritis [1], and one had been thought to have traumatic or tuberculous arthritis. Eight patients were treated by patellectomy, 5 by radiotherapy, one had a patellectomy and radiotherapy, and three had no local treatment. Anterior knee pain is c o m m o n in y o u n g adults, but in patients over the age of 45 years the possibility of a tumour should be considered and radiographs taken. The most likely causes are chondroblastoma, giant cell tumour or simple bone cyst, but a biopsy should be done to exclude a primary malignant tumour or a metastasis.
3. Cole WH (1925) Primary tumours of the patella. J Bone Joint Surg [Am] 7:637-654 4. Dahlin DC, Unni KK (1986) Bone tumours: general aspects and data on 8542 cases, 4th edn. Charles C Thomas, Springfield 5. Gall EP, Didizian NA, Park Y (1974) Acute monarticular arthritis following patellar metastasis: A manifestation of carcinoma of the lung. J Am Med Assoc 229: 188-189 6. Handley W (1906) Cancer of the breast and its operative treatment. John Murray, London 7. Hellner (1935) Knochenmetastasen bei malignen Geschwfilsten. Erg Chir 28:72 8. Howlett SA, Caranasos GJ (1970) Metastatic renal cell carcinoma producing arteriovenous shunt. Arch Intern Med 125:493-495 9. Keeley CD (1973) Bilateral patellar metastases from carcinoma of the male breast. Can J Surg 16:328-329 10. Klenerman L (1965) A metastatic deposit in the patella from a carcinoma of the breast. Postgrad Med J 41: 284- 286 11. Kransdorf MJ, Moser RP, Vinh TN, Aoki J, Callaghan JJ (1989) Primary tumours of the patella: A review of 42 cases. Skel Radiol 18:365-371 12. Kwa S (1989) Metastasis in a patella: a rare site. Aus NZ J Surg 59:351-352 13. Linscheid RL, Dahlin DC (1966) Unusual lesions of the patella. J Bone Joint Surg [Am] 48: 1359-1366 14. Pazzaglia UE, Barbieri D, Cherubino P (1989) Solitary metastasis of the patella as the first manifestation of lung cancer. Int Orthop 13:75-76 15. Rothermel FJ, Miller FJ, Hottenstein DW, Dunn EJ (1977) Metastases to the patella with bone scan, tomography, magnification film correlation. Pa Med 80: 50- 51 16. Sabaino D (1952) Metastasi precoce nella rotula tumore primitivo del polmone. Minerva Chir 7:371 - 376 17. Stoler B, Staple TW (1969) Metastases to the patella. Radiology 93:853-856 18. Sutro CJ (1963) Lymphosarcoma of the patella: radical excision without repair of the extensor apparatus of the leg. Bull Hosp Joint Dis 24:68-74 19. Taylor GH (1964) Pathologic fracture of the patella caused by metastatic carcinoma. NY State J Med 64:430-431
References 1. Ashby ME (1976) Esophageal carcinoma metastatic to the patella: a case report. J Am Med Assoc 23:2519-2520 2. Benedek TG (1965) Lysis of the patella due to metastatic carcinoma. Arthr Rheum 8:560-567
