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Lung Cancer |

Metastatic Lung Adenocarcinoma Presenting as Thumb Pain

David Ferraro*, MD; Pedro Lucero, MD
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San Antonio Military Medical Center, Fort Sam Houston, TX


Chest. 2012;142(4_MeetingAbstracts):567A. doi:10.1378/chest.1390463
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Abstract

SESSION TYPE: Cancer Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The incidence of solid organ cancer with metastasis to bones of the digits (acrometastasis) is exceedingly rare, occurring in only 0.1% of cases with osseous involvement. We describe a 52 year-old female who was found to have metastatic lung adenocarcinoma with acrometastasis during evaluation of left thumb pain.

CASE PRESENTATION: A 52 year-old female with history of migraines and 20 pack-year smoking was evaluated by orthopedics for left thumb swelling, pain, and absent flexion, and determined to have a trigger finger. Hand radiographs revealed no osseous abnormalities. She received a flexor sheath injection of corticosteroids, with subsequent improvement in pain and range of motion. However, 6 weeks later she developed new thumb erythema, relapse of symptoms, and a palpable mass. Surgical exploration revealed complete destruction of the proximal phalanx and no viable bone remaining. Histologic evaluation of the mass revealed a poorly differentiated adenocarcinoma, suggestive of a primary lung tumor by immunohistochemical staining. Survey imaging with CT chest revealed a large left upper lobe mass, extensive adenopathy of the mediastinum and left hilum, and suggestion of lymphangitic carcinomatosis. Additionally, PET imaging illustrated widespread disease, with involvement of the brain, adrenal glands, pelvis, and spine.

DISCUSSION: Bony metastases are common and frequently occur from a wide array of primary tumors, including lung, prostate, kidney, breast, and gastrointestinal. However, bones of the hand rarely harbor metastatic disease, accounting for only 0.1% of metastatic osseous involvement. Acrometastasis was first identified in 1906 in a female with breast cancer and metastases to the metacarpals. The etiology of acrometastasis is almost exclusively a lung primary tumor, accounting for approximately 44% of all reported cases. The mechanism of spread to the digits is unknown, but hypotheses include increased blood flow and chemotaxis of prostaglandins during trauma. The high predilection towards a primary lung tumor among acrometastases is thought to be secondary to direct systemic arterial supply, whereas tumor emboli of other primary malignancies must first pass through capillary beds of the liver or the lung.

CONCLUSIONS: Acrometastasis is a rare occurrence, and typically suggests concomitant widespread malignancy with poor prognosis. Our patient presented with thumb pain, and subsequent evaluation revealed metastatic lung adenocarcinoma. She died 6 weeks later. This emphasizes the importance of identifying non-benign causes of finger symptoms in a timely manner.

1) Flynn CJ, et al. Two Cases of Acrometastasis to the Hands and Review of the Literature. Current Oncology 2008;15(5):51-58.

DISCLOSURE: The following authors have nothing to disclose: David Ferraro, Pedro Lucero

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San Antonio Military Medical Center, Fort Sam Houston, TX

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