Metastasis of bronchogenic carcinoma to the 5thmetacarpal bone: a case report
© Tzaveas et al; licensee BioMed Central Ltd. 2008
Received: 09 October 2008
Accepted: 30 October 2008
Published: 30 October 2008
Metastatic lesions to the hand are very rare and represent 0.1% of all osseous metastases.
We present a patient with metastasis of bronchogenic carcinoma of the lung to the 5th metacarpal to draw the attention for the potential of such lesions to be developed in this region. Due to the extensive metastasis to the hand the patient was referred to the oncologists.
The surgeon should be cautious regarding the differential diagnosis, the usual poor prognosis of such patients and the questionable need for reconstructive surgery.
Metastases to the hand are rare events with around 200 cases reported in the literature [1–6]. They comprise only 0, 1% of all osseous metastases . The terminal phalanges are the most frequent site of metastasis, followed by the metacarpals and the proximal phalanges [3, 4]. We report a metastasis of bronchogenic lung cancer to the 5th metacarpal.
The most common site of metastatic deposits to the hand is the distal phalanx. The incidence of metastasis to the metacarpals is 17%, phalanges 66% and carpal bones 17% . Keramidas and Brotherston  published a case with metastasis to both metacarpal and carpal bones, which is extremely rare.
It is rare to see bronchogenic carcinoma metastases to the bones distal to the elbow and knee. Floridis was the first to describe this rare entity in the United States in 1934 . Depass (1958) was the first to report a metacarpal metastasis in the English literature .
The lung is the most common source with 42% followed by the breast and kidney each of which account for 11% [3, 7]. Other sources include colon, prostate, thyroid, oesophageal and bone cancers . Men are more commonly involved than women . Metastases in the hand are the first clinical sign of an undiagnosed tumor in only 16% of all metastases .
The exact reason for this rarity of such metastases is not known. In 1889 Paget  suggested the "seed and soil" theory for metastasis, which states that one needs to have both seed (i.e. tumor emboli) and good soil (or proper site) for this tumor emboli to settle down and grow. Prostaglandins have been implicated as possible chemotactic factors that influence cell migration and adherence to the skeleton . Tumor deposits occur mainly in the bones hematopoietically active and multiply to produce typical lytic lesions or, occasionally, formation of reactive bone . The infrequent development of metastases to the hand may be related to the smaller amount of red marrow present in these bones. Piney  observed, as early as 1922, the absence of bone marrow in phalanges – spared metastasis. Recent trauma and increased blood flow have also been implicated as a nidus for tumor metastasis [1, 3, 4]. Joll  suggested that repeated trauma might play a role in reducing the local tissue resistance thus producing a fertile ground for "seed". Shinz  pointed out that primary malignancies erode veins (systemic or portal) and tumor emboli are filtered by lung or liver. But in the case of bronchogenic carcinoma, the tumor erodes the pulmonary vein and thus has access to systemic circulation and, consequently, widespread metastasis. In contrast to this, the vertebral venous plexus of Batson permits mostly axial skeleton metastases .
The patient usually presents with a painful, swollen, erethymatous and warm hand [8, 9]. The x-rays show lytic bony lesion. The differential diagnosis includes gout, pulp space infection, osteomyelitis, septic arthritis, rheumatoid arthritis, tenosynovitis and reflex sympathic dystrophy .
The prognosis of these patients is poor, with the median survival being usually six months . This should be taken in account in the management of these patients. Radiotherapy and chemotherapy may be appropriate and amputation could be an option for lesions at the distal phalanx. Reconstructive surgery is not indicated due to poor prognosis .
The surgeon should have a high level of clinical suspicion when examining patients with the above symptomatology and concomitant malignancies or lytic lesions and age over 45 years . Management of such cases should be multifactorial, due to the rarity and the poor prognosis. The cooperation of the orthopaedic surgeon with the radiologist, the pathologist and the oncologist is imperative for the accurate diagnosis and the avoidance of overtreatment and unnecessary reconstructive surgery.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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