Palliative and supportive care in acrometastasis to the hand: case series.

Acrometastasis to the hand is an unusual presentation which might mimic an infectious, inflammatory, or a metabolic pathology. We herein describe a case series of three patients of acrometastasis to the hand. We encountered three cases of acrometastasis to the hand attending the departmental clinics from 2007 to 2010. The median age at presentation was noted to be 55 years. All were males. The primaries included squamous cell carcinoma of the skin, larynx, and esophagus. In two patients, acrometastasis was detected at presentation and in one it was detected 2 years postcompletion of radical therapy. Two patients were offered palliative radiation to acrometastasis, and best supportive care was given to one. Palliation achieved after radiation was noted to be modest to good. The brief report highlights the importance of the clinical awareness of metastatic dissemination to unusual sites in the face of increasing cancer survivorship. Acrometastasis portends a poor prognosis with limited survival, and optimal integration of the best supportive care is mandatory. A short course of hypofractionated palliative radiation therapy results in modest to good palliation.

INTRODUCTION

Acrometastasis to the hand is an unusual presentation. We herein describe a series of three cases of acrometastasis to the hand [Table 1]. We have also reviewed the pathogenesis, clinical presentation, and therapeutic management of acrometastasis to the hand.

Table 1

Patient characteristics

CASE REPORTS

Case 1

A 60-year-old gentleman presented to our clinic with the chief complaints of a nonhealing ulcer in the right groin for the last 8 years and a growth in the right thumb for the last 6 months. On examination, an 8 × 8 cm ulcer in the right inguinal area adjoining the root of the penis with a necrotic base and rolled up margin was noted [Figure 1]. There was a presence of two firm, mobile, and tender lymph nodes (4 × 4 cm and 2 × 2 cm, respectively) in the left horizontal inguinal chain. Besides, a 3 × 3 cm ulceroproliferative growth involving the distal phalanx of the right thumb with subungual and periungual involvement was seen [Figure 2].

Figure 1

An 8 × 8 cm ulcer in the right inguinal area adjoining the root of the penis with a necrotic base and rolled up margin

Figure 2

A 3 × 3 cm ulceroproliferative growth involving the distigal phalanx of the right thumb with subungual and periungual involvement

Fine needle aspiration cytology (FNAC) of the left inguinal lymph node was suggestive of metaststic squamous cell carcinoma. FNAC of the right thumb showed squamous cell carcinoma, keratinizing type. A skiagram of the hand revealed a lobulated, homogenous soft tissue mass around the distal phalanx of the right thumb with no definite evidence of bony erosion. A contrast-enhanced CT scan of the chest and whole abdomen was unremarkable excepting the findings of enlarged left inguinal lymphadenopathy. A careful examination of the skin did not reveal any other lesion. A short course of palliative radiation 30 Gy/10 fractions for 2 weeks to the primary lesion and metastatic lymphadenopathy was delivered. This was followed by radiation of 54 Gy/27 fractions for 5.5 weeks to the site of acrometastasis. Palliation achieved was noted to be good.

Case 2

A 55-year-old gentleman was diagnosed with carcinoma supraglottic larynx (stage T4N1M0). He was treated with combined modality therapy: radiation 66 Gy/33 fractions for 6.5 weeks with concurrent cisplatin 100 mg/m2q 3 week. He had complete clinical response and was disease free for 2 years. Subsequently, he presented with swelling of the tip of all fingers of the left hand with nail bed involvement [Figure 3], and multiple subcutaneous nodules in the upper and lower limb. FNAC of acral lesions was suggestive of metastatic carcinoma. A contrast-enhanced CT scan of the chest, abdomen, and pelvis revealed metastasis in bilateral lungs and liver [Figures 4 and 5]. There was however no evidence of locoregional disease on clinical examination and laryngoscopy. In view of the poor performance status (ECOG 3) and widespread dissemination of disease, he was offered best supportive care.

Figure 3

Metastatic swelling of all five distal phalanges of the left hand

Figure 4

Multiple bilateral lung metastasis

Figure 5

Multiple liver metastasis

Case 3

A 52-year-old gentleman presented to our clinic with the complaints of dysphagia to solids progressing to liquids, headache, and a nodule in the little finger of the left hand for the last 6 months [Figure 6]. On endoscopy, a friable tumor involving half of the circumference of the esophageal lumen was seen 25-30 cm from the incisors. Endoscopic biopsy revealed moderately differentiated squamous cell carcinoma. A contrast-enhanced CT scan of the chest showed circumferential mural thickening of the midesophagus with mediastinal lymphadenopathy. FNAC of the nodule involving the distal phalanx of the little finger of the left hand was suggestive of metastatic squamous cell carcinoma. He underwent palliative radiation to esophagus and acrometastasis, 30 Gy/10 fractions for 2 week. Palliation achieved was modest.

Figure 6

Acrometastasis involving the distal phalanx of the little finger of the left hand

DISCUSSION

Due to the increasing longevity of patients afflicted with cancer, there is a surge in the metastatic dissemination of disease, often to unusual sites. Acrometastasis to the hand is distinctly uncommon.[12] The underlying mechanism of the deposition of metastatic cells within the hand is unclear, but an increase in vascularity and trauma has been suggested in the past.[12] It is because of the above-mentioned reasons, Healey and colleagues have reported an increased incidence of acrometastasis to the dominant hand. In most patients, the tumor initially metastasizes to the bone and subsequently spreads to the adjacent soft tissue, though the reverse may also be occasionally observed.[3] In a review of 257 cases of acrometastasis to the hand by Flynn and colleagues, the median age at presentation was noted to be 58 years and men were twice likely to be affected compared to females.[2] The most common primaries were in the lung (44%), kidney (12%), and breast (10%) whereas the remaining cases had primaries in the colon, stomach, liver, prostate, and rectum. The common sites of involvement in the hand were noted to be distal phalanx (74 lesions), metacarpals (56 lesions), proximal phalanx (26 lesions), and middle phalanx (16 lesions). Bronchogenic carcinoma usually led to monoostotic lytic lesions, whereas polyostotic sclerotic, lytic, or mixed lesions were preponderant in carcinoma of the breast.

Acrometastasis to the hand can be asymptomatic or can present with painful swelling and movement restriction. Subungual metastasis may present with a painful erythematous enlargement of the distal digit, or a red, violaceous nodule leading to nail dystrophy.[3] The common differentials include acute infection in the form of abscess, felon, or paronychia; underlying osteomyelitis; or metabolic conditions like gout and pseudogout.

As acrometastasis generally accompanies widespread disease, the prognosis is poor with an anticipated survival of 6 months.[4] So palliation of pain and movement restriction is the main clinical concern.[5] Amputation, wide excision, curettage, cementation, radiotherapy, and chemotherapy are the therapeutic options in this rare presentation.[2]

Solitary acrometastasis to the thumb from cutaneous squamous cell carcinoma of the groin is indeed a rarity.[6-8] Hematogenous dissemination to the skin and subcutaneous tissue of the thumb without underlying osseous involvement is all the more striking. The other possibility in the first case is the synchronous double primary. Tumor implantation due to contact is not unknown in squamous cell carcinoma and is another possibility. Taking into account the advanced age, performance status (ECOG 2), and lack of family support, a course of palliative radiation to the primary and acrometastasis was considered in the patient.

Cutaneous metastasis has been reported to occur in 1–2 % of patients with squamous cell carcinoma of the head and neck and accounts for less than 10% of all distant metastasis in such cases.[9] A review of the surgical literature revealed only seven previously reported cases of cutaneous metastases from squamous cell carcinoma of the larynx.[1011] The common sites of cutaneous metastasis include neck, chest, scalp, face, lips, axilla, areola, back, arms, and digits. It is evident on the literature search that multiple metastases from laryngeal carcinoma involving all five distal phalanges of hand, bilateral lungs, and liver have not been reported till date. Considering the poor performance status and widespread metastases in the second case, the best supportive care was offered to the patient.

Acrometatsasis to the hand has rarely been reported in esophageal cancer.[11213] The third patient in the series had an esophageal primary with simultaneous acrometatsasis. Following palliative radiation to esophagus and acrometatsasis, a brief course of systemic chemotherapy was given. The patient had progressive disease and the best supportive care was considered in his case.

CONCLUSION

Acrometastasis to the hand is an unusual presentation which might mimic an infectious or inflammatory pathology. Clinical awareness of unusual sites of metastatic dissemination is a must in the face of increasing cancer survivorship. A short course of hypofractionated radiation therapy results in modest to good palliation. Acrometastasis portends a poor prognosis with limited survival, and optimal integration of the best supportive care is mandatory.