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Adenocarcinoma of the lung with metatarsal metastasis
Adenocarcinoma of the Lung with Metatarsal Metastasis Foot pain is a most unusual presentation of metastatic malignancy. Metastases to the hands or feet (acrometastases) have been recognized in only a few cases. A 68-year-old male, with a history of chronic gout, presented with left foot pain for 3 months duration. After conservative treatment failed to relieve his pain, radiographic and eventual bone biopsy of a cystic lesion involving the first metatarsal head revealed a Grade IV adenocarcinoma. (The Journal of Foot and Ankle Surgery 35(3):210-212, 1996) Key words: tumor, foot metastasis; lung tumor, metastasis
Matthew J. Kemnitz, DPM 1 Bruce B. Erdmann, DPM 1 •3 •4 Mark E. Julsrud, DPM, FACFAS2 .4
P. Michael Jacobs, DPM 1 •3 ,4 James B. Ringstrom, DPM 1 •3 ,4
Metastasis of tumors to the distal extremities is a rare occurrence. The most common tumors that metastasize to the foot are primarily tumors of the colorectum, kidney, and lung. The tarsal bones are involved in 50% of these cases, and the calcaneus is the most commonly involved tarsal (1). Lesions distal to the elbow or knee are quite rare, and metastasis to the hands and feet (acrometastases) occur in only 0.007% to 0.3% of patients with malignancies. Statistics indicate a frequency of metastatic lesions in the foot of less than 2% (2). The purpose of this study is to review the published literature on this topic and to add a case of biopsy-proven adenocarcinoma of the lung metastatic to the foot.
radiographic and bone scan with findings consistent with recurrent gout. The patient presumably had an injection of ACTH, and had been prescribed two different nonsteroidal anti-inflammatory drugs, all of which did not relieve his pain. His medical history included five-vessel coronary artery bypass surgery in 1984. The patient also had a history of hypertension and gout. Family history was noncontributory. The patient smoked about one pack of cigarettes per day for many years; however, he stopped approximately 7 years ago. He related delayed slight shortness of breath which has been somewhat progressive over the last 2 years without other associated symptoms. He had a stress-related tremor that was slight. No change in bowel habits, no urinary problems, and no constitutional or neurologic symptoms were acknowledged. Lower extremity examination revealed trace nonpitting ankle edema bilaterally. Mild erythema and edema was noted involving the first metatarsophalangeal joint of the left foot. There was no evidence of gouty tophus, and neurovascular status was grossly intact bilaterally. There was pain on palpation and range of motion of the first metatarsophalangeal joint of the left foot. Roentgenographic review revealed a cystic lesion of the first metatarsal head of the left foot, not consistent with typical roentgenographic gouty changes (Fig. 1). Chest radiographs revealed some interstitial changes, a widened upper mediastinum, and haziness behind the left heart in the infrahilar region, which was not corroborated on the lateral chest film. Fluoroscopy-guided biopsy of the cyst was obtained. Histopathologic evaluation of the biopsy material showed scant clusters of cells, which were termed atypical and suspicious for malignancy. The patient was then
Case Presentation
A 68-year-old male Caucasian presented to the podiatry clinic by referral from his internist for pain involving his left foot, which had been present for 3 months. Upon initial presentation, the patient thought he was coming down with a rather typical flare of gout which he has had numerous times in the past involving the first metatarsophalangeal joint of the left foot. Indomethacin, which usually helped, did not relieve his pain. According to the patient, he had previous From the Department of Podiatric Medicine and Surgery, Gundersen Medical Foundation, La Crosse, Wisconsin. 1 Submitted while second year resident. 2 Director of Podiatric Medical Education. Address correspondence to: Director of Podiatric Medical Education, Gundersen Clinic, Ltd., 1836 South Avenue, La Crosse, WI 54601. 3 Department of Podiatric Medicine and Surgery, Gundersen Medical Foundation, La Crosse, Wisconsin. 4 Diplomate, American Board of Podiatric Surgery. The Journal of Foot and Ankle Surgery 1067-2516/96/3503-0210$3JJO/0 Copyright © 1996 by the American College of Foot and Ankle Surgeons
210
THE JOURNAL OF FOOT AND ANKLE SURGERY
FIGURE 1
Cystic lesion of the first metatarsal head.
referred to the Medical Oncology department, prior to further radical resection. Computerized tomography scan of the chest revealed a 2.0-cm. mass in the left lower lobe near the hilum associated with small mediastinal adenopathy. The patient was referred to the Pulmonary Medicine department for bronchoscopy to secure a tissue diagnosis. He underwent brushings and biopsies from the left lower lobe and a transthoracic needle aspiration. Cytologies from these biopsies were all negative for malignancy. Treatment alternatives included a mini thoracotomy (Chamberland procedure) or a more aggressive procedure of the foot to secure a tissue diagnosis. The patient underwent a partial first ray amputation, for which histopathology revealed a Grade IV adenocarcinoma to the distal end of the first metatarsal of the left foot (Fig. 2). After the foot surgery, his pain subsided. Surgery, radiation therapy, and chemotherapy were all discussed as treatment options. The patient underwent radiation therapy. Postradiation radiographs revealed no recurrence of the tumor to the left foot. The patient expired approximately 5 months after the surgery from
FIGURE 2
Partial first ray resection immediately postoperative.
complications related to the radiation therapy of pneumonitis, hypoxia, thrombocytopenia, polycythemia, and pneumocystitis carinii pneumonia. Discussion
This is a case of adenocarcinoma of the lung presenting primarily with a symptomatic isolated metastasis to the first metatarsal. Review of the literature noted no similar reports of metastasis to the first metatarsal head. The diagnosis of solitary metastasis to the foot is difficult. Initial presentation usually includes nonspecific complaints of a swollen painful foot. Often, the patients are first treated for more common conditions (i.e., plantar fasciitis, tendonitis, heel spur syndrome) (1). Therefore, it is not unusual for symptoms in the foot to become apparent prior to detection of the primary tumor (3). Depending on tumor size and location, needle core or aspiration biopsy may be appropriate. These techniques often reveal histopathologically atypical cells suspicious for malignancy, offering no clues as to the site of the primary lesion (2). Depending on the VOLUME 35, NUMBER 3, 1996
211
adenocarcinoma presenting as an isolated calcaneal metastasis. Cancer 73:2779-2781, 1994. 2. Gauntt, K., Beykoff, T. J., Danna, A. T. Adenocarcinoma case of metastasis to the foot. J. Am. Podiatr. Med, Assoc. 80:657-659, 1990. 3. Eggold , J. F., McFarland, J. A. , Hubbard, E. R Adenocarcinoma of the lung with phalangeal metastasis. J. Am. Podiatr. Med. Assoc. 75:547-549, 1985. 4. Freedman, D. M., Henderson, R C. Metastatic breast carcinoma to the os calcis presenting as heel pain. South. Med. J. 88:232-234 , 1995.
individual circumstances, partial or total extremity amputation may be the treatment of choice. A plan of treatment of metastatic tumors must consider many factors. Therefore, a team approach involving the podiatric surgeon is necessary to decide the appropriate treatment regimen. Summary
The presence of metastatic lesions in the lower extremities is often associated with widespread metastatic disease and a poor prognosis. Survival is generally less than 1 year after onset of symptoms in the foot. Acrometastases, therefore, signifies a grave prognosis (4). References 1. Cooper, J. K., Wong, F. L. W., Swenerton, K. D. Endometrial
212
Additional References Moser, R, Madewell, J. Metastatic bone cancer, ch. 9. In Radiology, Diagnosis, Imagingand Intervention, Vol. 5, pp. 386-397, edited by J. Traveras, J. B. Lippincott, Philadelphia, 1986. Zindrick, M. R, Young, M. P., Daley, R J., Light, T. R Metastatic tumors of the foot: case report and literature review. Clin. Orthop. 170:219-225,1982.
THE JOURNAL OF FOOT AND ANKLE SURGERY
Matthew J. Kemnitz, DPM 1 Bruce B. Erdmann, DPM 1 •3 •4 Mark E. Julsrud, DPM, FACFAS2 .4
P. Michael Jacobs, DPM 1 •3 ,4 James B. Ringstrom, DPM 1 •3 ,4
Metastasis of tumors to the distal extremities is a rare occurrence. The most common tumors that metastasize to the foot are primarily tumors of the colorectum, kidney, and lung. The tarsal bones are involved in 50% of these cases, and the calcaneus is the most commonly involved tarsal (1). Lesions distal to the elbow or knee are quite rare, and metastasis to the hands and feet (acrometastases) occur in only 0.007% to 0.3% of patients with malignancies. Statistics indicate a frequency of metastatic lesions in the foot of less than 2% (2). The purpose of this study is to review the published literature on this topic and to add a case of biopsy-proven adenocarcinoma of the lung metastatic to the foot.
radiographic and bone scan with findings consistent with recurrent gout. The patient presumably had an injection of ACTH, and had been prescribed two different nonsteroidal anti-inflammatory drugs, all of which did not relieve his pain. His medical history included five-vessel coronary artery bypass surgery in 1984. The patient also had a history of hypertension and gout. Family history was noncontributory. The patient smoked about one pack of cigarettes per day for many years; however, he stopped approximately 7 years ago. He related delayed slight shortness of breath which has been somewhat progressive over the last 2 years without other associated symptoms. He had a stress-related tremor that was slight. No change in bowel habits, no urinary problems, and no constitutional or neurologic symptoms were acknowledged. Lower extremity examination revealed trace nonpitting ankle edema bilaterally. Mild erythema and edema was noted involving the first metatarsophalangeal joint of the left foot. There was no evidence of gouty tophus, and neurovascular status was grossly intact bilaterally. There was pain on palpation and range of motion of the first metatarsophalangeal joint of the left foot. Roentgenographic review revealed a cystic lesion of the first metatarsal head of the left foot, not consistent with typical roentgenographic gouty changes (Fig. 1). Chest radiographs revealed some interstitial changes, a widened upper mediastinum, and haziness behind the left heart in the infrahilar region, which was not corroborated on the lateral chest film. Fluoroscopy-guided biopsy of the cyst was obtained. Histopathologic evaluation of the biopsy material showed scant clusters of cells, which were termed atypical and suspicious for malignancy. The patient was then
Case Presentation
A 68-year-old male Caucasian presented to the podiatry clinic by referral from his internist for pain involving his left foot, which had been present for 3 months. Upon initial presentation, the patient thought he was coming down with a rather typical flare of gout which he has had numerous times in the past involving the first metatarsophalangeal joint of the left foot. Indomethacin, which usually helped, did not relieve his pain. According to the patient, he had previous From the Department of Podiatric Medicine and Surgery, Gundersen Medical Foundation, La Crosse, Wisconsin. 1 Submitted while second year resident. 2 Director of Podiatric Medical Education. Address correspondence to: Director of Podiatric Medical Education, Gundersen Clinic, Ltd., 1836 South Avenue, La Crosse, WI 54601. 3 Department of Podiatric Medicine and Surgery, Gundersen Medical Foundation, La Crosse, Wisconsin. 4 Diplomate, American Board of Podiatric Surgery. The Journal of Foot and Ankle Surgery 1067-2516/96/3503-0210$3JJO/0 Copyright © 1996 by the American College of Foot and Ankle Surgeons
210
THE JOURNAL OF FOOT AND ANKLE SURGERY
FIGURE 1
Cystic lesion of the first metatarsal head.
referred to the Medical Oncology department, prior to further radical resection. Computerized tomography scan of the chest revealed a 2.0-cm. mass in the left lower lobe near the hilum associated with small mediastinal adenopathy. The patient was referred to the Pulmonary Medicine department for bronchoscopy to secure a tissue diagnosis. He underwent brushings and biopsies from the left lower lobe and a transthoracic needle aspiration. Cytologies from these biopsies were all negative for malignancy. Treatment alternatives included a mini thoracotomy (Chamberland procedure) or a more aggressive procedure of the foot to secure a tissue diagnosis. The patient underwent a partial first ray amputation, for which histopathology revealed a Grade IV adenocarcinoma to the distal end of the first metatarsal of the left foot (Fig. 2). After the foot surgery, his pain subsided. Surgery, radiation therapy, and chemotherapy were all discussed as treatment options. The patient underwent radiation therapy. Postradiation radiographs revealed no recurrence of the tumor to the left foot. The patient expired approximately 5 months after the surgery from
FIGURE 2
Partial first ray resection immediately postoperative.
complications related to the radiation therapy of pneumonitis, hypoxia, thrombocytopenia, polycythemia, and pneumocystitis carinii pneumonia. Discussion
This is a case of adenocarcinoma of the lung presenting primarily with a symptomatic isolated metastasis to the first metatarsal. Review of the literature noted no similar reports of metastasis to the first metatarsal head. The diagnosis of solitary metastasis to the foot is difficult. Initial presentation usually includes nonspecific complaints of a swollen painful foot. Often, the patients are first treated for more common conditions (i.e., plantar fasciitis, tendonitis, heel spur syndrome) (1). Therefore, it is not unusual for symptoms in the foot to become apparent prior to detection of the primary tumor (3). Depending on tumor size and location, needle core or aspiration biopsy may be appropriate. These techniques often reveal histopathologically atypical cells suspicious for malignancy, offering no clues as to the site of the primary lesion (2). Depending on the VOLUME 35, NUMBER 3, 1996
211
adenocarcinoma presenting as an isolated calcaneal metastasis. Cancer 73:2779-2781, 1994. 2. Gauntt, K., Beykoff, T. J., Danna, A. T. Adenocarcinoma case of metastasis to the foot. J. Am. Podiatr. Med, Assoc. 80:657-659, 1990. 3. Eggold , J. F., McFarland, J. A. , Hubbard, E. R Adenocarcinoma of the lung with phalangeal metastasis. J. Am. Podiatr. Med. Assoc. 75:547-549, 1985. 4. Freedman, D. M., Henderson, R C. Metastatic breast carcinoma to the os calcis presenting as heel pain. South. Med. J. 88:232-234 , 1995.
individual circumstances, partial or total extremity amputation may be the treatment of choice. A plan of treatment of metastatic tumors must consider many factors. Therefore, a team approach involving the podiatric surgeon is necessary to decide the appropriate treatment regimen. Summary
The presence of metastatic lesions in the lower extremities is often associated with widespread metastatic disease and a poor prognosis. Survival is generally less than 1 year after onset of symptoms in the foot. Acrometastases, therefore, signifies a grave prognosis (4). References 1. Cooper, J. K., Wong, F. L. W., Swenerton, K. D. Endometrial
212
Additional References Moser, R, Madewell, J. Metastatic bone cancer, ch. 9. In Radiology, Diagnosis, Imagingand Intervention, Vol. 5, pp. 386-397, edited by J. Traveras, J. B. Lippincott, Philadelphia, 1986. Zindrick, M. R, Young, M. P., Daley, R J., Light, T. R Metastatic tumors of the foot: case report and literature review. Clin. Orthop. 170:219-225,1982.
THE JOURNAL OF FOOT AND ANKLE SURGERY