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Bone metastasis to the foot: report of three cases
Foot and Ankle Surgery 1998
4:207--212
Bone metastasis to the foot: report of three cases L. DE PALMA, C. CHILLEMI A N D G. ZANOLI Department of Orthopaedics, University of Ancona, Italy
Summary Bone metastases to the foot are rare and often misdiagnosed. Only tarsal localizations are relatively frequent. Primary tumours are mostly adenocarcinomas (colon, kidneys, lungs). Three cases of acrometastases, localized, respectively, on the ungual phalanx of the hallux, the first metatarsal and the first cuneiform, are reported. Primitive tumour sites differed in the three cases (renal, pulmonary and mammary origin). Adequate therapy must be preceded by an accurate staging. Surgery should aim to excise the tumour and restore, when possible, a good function of the foot without any pain. Amputation should only be resorted to if is not possible to perform the excision of the tumour in patients whose life expectancy is not too short. Wide local and systemic diffusion of the tumour and a short life expectancy contraindicate any surgical approach. Treatment, in these cases, must try to achieve a satisfactory pain control and decrease the local expansion of the tumour. Keywords: foot; bone tumour; metastatic disease; bone metastasis; acrometastases
Introduction Bone metastases to the foot are rare (0.1% of all secondary localizations [1]) and 4.2% of all the primary tumours of the foot [2, 3]). After reviewing the literature, we tried to analyse the clinical features and the therapeutic problems of metastatic lesions to the foot, starting with three original observations.
Case reports First case A 59-year-old woman had been operated on for a clear cell renal carcinoma 3 years before the observation. For a month she been reporting the
sudden onset of intense pain in the first distal phalanx of the right foot, reducing her walking capacity and ability to wear shoes. The toe appeared swollen and signs of phlogosis were evident (Figure la). A radiograph (Figure lb) showed a widespread lysis of the whole ungual phalanx, and a bone scan revealed a single area of abnormal uptake corresponding to the first toe. A needle biopsy suggested the diagnosis of metastatic clear cell renal carcinoma. Disarticulation (Figure lc) was necessary to completely remove the tumour which had infiltrated the surrounding soft tissues. Hystological examination confirmed the bioptic diagnosis (Figure ld). The patient is still alive after 3 years of followup. Second case
Correspondence to: Professor Luigi de Palrna, Clinica Ortopedica, Universit~ di Ancona, Cattedra di Traumatologia, Odpedale Umberto I°, Largo Cappelli, 1, 60100, Ancona, Italy. © 1998 Blackwell Science Ltd
A 60-year-old man had adenocarcinoma of the
been diagnosed with lung 2years before 207
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ET AL.
Figure 1 Case 1: renal metastasis to the phalanx (a) Clinical presentation: swelling of the distal phalanx of the hallux of the right foot. (b) Xray: widespread lysis of the whole ungual phalanx. Post-operative aspect of the excised tumour which infiltrated surrounding tissues. Hystological examination of the distal phalanx confirmed the metastatic clear cell renal carcinoma (H/E, 40 x ). (Figure 1a-b: published in Chir. Piede 1996; 20: 27-32; reprinted with permission.)
© 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 207-212
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Figure 2
Case 2: pulmonary metastasis to the metatarsal (a) Clinical presentation: circumscribed swelling of the dorsal region of the right foot. (b) X-rays:wide lysis of the first metatarsal. MRI: extensive infiltration of the soft and bony tissues surrounding the lesion. Histological aspect of the metatarsal lesion showed the pulmonary adenocarcinoma metastases (H/E, 20 x ).
observation. For 3 m o n t h s he h a d experienced dull pain in the dorsal region of the right foot, w h i c h subsequently b e c a m e swollen (Figure 2a). The patient © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 207-212
w a s unable to e n d u r e weightbearing. R a d i o g r a p h s (Figure 2b) s h o w e d a w i d e lysis of the first metatarsal, w h e r e a s magnetic resonance i m a g i n g (MRI) (Figure
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L. DE P A L M A E T A L .
2c) revealed an extensive infiltration of the surrounding soft and bony tissues. A bone scan elicited multiple areas of abnormal uptake around the first metatarsal and on the seventh and 10th ribs. A biopsy was performed which confirmed the diagnosis of pulmonary adenocarcinoma (Figure 2d). Since the patient was generally in good condition, a foot amputation was advised because of the impossibility of a radical local excision and the risk of skin ulceration; but the patient refused. He underwent radiotherapy and died after 14 months.
Third case The third case was a 45-year-old woman operated on for a breast adenocarcinoma 3 years before observation. Mid-foot pain and swelling (Figure 3a) appeared in the last 2 months; the ability of the patient to bear weight and walk was as a result reduced. Radiographs (Figure 3b) and computed tomography (CT)-scan of the right foot showed a widespread rarefaction of the first cuneiform. A bone scan revealed multiple areas of abnormal uptake (mid-foot, pelvis, humerus and spine). Biopsy confirmed the diagnosis of mammary adenocarcinoma (Figure 3c). Because of the patient's poor general condition (multiple skeletal and visceral metastasis were present) surgical intervention was not advised. The lesion was treated with radiotherapy. The patient died 3 months later.
Discussion The literature is in agreement regarding the low incidence of metastatic lesions to the foot. Gall eta]. [4], for example, reported 11 skeletal metastases of the foot out of 2800 observed bone tumours; and Wu and Guise [5] cited only four cases of secondary lesions of the foot out of 41 833 treated neoplastic patients. Casadei et al. [2, 3] have observed 11 cases of acrometastases out of over 13 000 muscolo-skeletal tumours treated between 1904 and 1988, at the Tumour Centre of the Rizzoli Orthopedic Institute (Bologna, Italy). The reasons for such a low incidence are not completely clear. As it is known, metastases to bone follow two different pathways: local spread and blood flow dissemination; the latter is responsible for the distal localization to hands and feet [6]. Factors
affecting targets and stages of metastatic diffusion are many and can be referred essentially to the ability of the neoplastic cells to enter blood flow, and to survive the circulatory turbulence and the immunological defences of the patient. These two aspects influence, respectively, the wide spread diffusion of neoplastic cells to distant sites and their capability to grow there [6]. Other conditions which favour acrometastases are trauma, temperature differences among districts, hormonal influences and immunological response [7-9]. It has also been suggested that a local increase in blood flow (which can be caused by repeated microtraumatisms, fractures, functional overload) could be related to a subsequent higher incidence of metastases [10]. On the other hand, metastatic lesions may involve the foot more than is generally recognized, and most of them are probably overlooked [4, 11]. Besides, in patients with an extensive dissemination, acrometastases can be easily misdiagnosed [12], since the attention of the clinicians is concentrated on other viable organs [11]. Even during autopsies insufficient care is often taken in searching for foot localizations [4]. Another indirect proof of this, is the increasing number of cases reported in literature in the last few years, which is essentially due to the prolonged survival and to the better quality of life of the patients [10]. Single lesions on the feet or clinical onset of the symptoms before the first diagnosis of cancer has been made remain exceptional. Tarsal bones are affected in 50% of the cases [8, 13, 14], followed by metatarsals (23%) [8, 13] and phalanxes (11-17%) [8, 13]. Among tarsal bones, the os calcis is most frequently involved (six cases out of 13 tarsal localizations according to Libson [9]; five out of nine according to Healy [10]) followed by the talus, cuneiform, cuboid and navicular bones. Phalangeal involvement usually affects the first ray. To our knowledge, the only case of metastasis to the other toes is the one reported by Andreasi et al. [15]. Primary tumours are mostly adenocarcinomas (colon, 17-19%; kidneys, 17-18%; lung, 15%) [8, 9]. Metastatic lesions from breast, bladder, uterus, ovarium and prostate are very rare [16]. There are very rare papers reporting acrometastasis from sarcomas in the literature [17], such as some authors even regard this eventuality as impossible [13]. © 1998BlackwellScienceLtd, Foot and Anlcle Surgery, 4, 207-212
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Figure 3
Case 3: mammary metastasis to the cuneiform (a) Clinical presentation: impressive swelling of the dorsal region of the right foot. Radiogram of the right foot (lateral view): widespread rarefaction of the first cuneiform. Hystologicalfinding of the metastatic lesion confirmedthe diagnosis of mammary adenocarcinoma (H/E, 20 x ).
When the patient presents with an extensive metastatic dissemination, lesions of the foot usually don't cause any diagnostic problem. On the other hand, diagnosis can be difficult w h e n the acrometastasis is the first clinical manifestation of an occult t u m o u r [15, 18]. In these early presentations symptoms can also precede radiological signs [9]. Pain, swelling, erythema and functional impairment are the hallmarks of the lesion, though clinical presentation is usually not specific; differential diagnosis between metastatic and other inflammatory or infectious diseases must be made. Very seldom in later stages a palpable bulk can develop, which eventually becomes ulcerated in the most aggressive presentations. © 1998 BlackwellScience Ltd, Foot and Ankle Surgery, 4, 207-212
Standard radiographs are rarely sufficient for a correct diagnosis of the injury. Moreover, their interpretation is often questionable and not univocal. However, radiographs usually one to make a tentative diagnosis, evaluating extent, spread and aggressiveness of the lesion, and searching for the particular radiological hallmarks of one lesion or another. Lytic presentation is by far the most frequent (80%) which can lead to massive destruction in the advanced stages. Again, in the initial stages, differential diagnosis on standard radiographs must be m a d e between metastases and osteomyelitis, septic arthritis rheumatic or metabolic arthropaties, osteoarthritis and algodystrophy [9, 11]. The absence of a periosteal reaction without any articular,
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ET AL.
cartilaginous or s u b c h o n d r a l i n v o l v e m e n t , increase the likelihood of a metastatic p r o c e s s [11]. W h e n clinical signs of i n f l a m m a t i o n are missing, radiological differential d i a g n o s i s s h o u l d c o n s i d e r other b e n i g n ( e p i d e r m o i d cysts, e n c h o n d r o m a , g i a n t cell tumour) and malign (osteosarcoma, c h o n d r o s a r c o m a ) p r i m a r y t u m o u r s [8, 9]. A d v a n c e d i m a g i n g t e c h n i q u e s are u s u a l l y n e e d e d for an accurate diagnosis, a n d t h e y s h o u l d be p e r f o r m e d a c c o r d i n g to the diagnostic r e q u i r e m e n t s of each case. A b o n e scan, b e c a u s e it is v e r y n o n specific, u s u a l l y d o e s n ' t c o n t r i b u t e a n y t h i n g useful t o w a r d s a differential d i a g n o s i s [19], b u t it is p e r f o r m e d o n a l m o s t e v e r y p a t i e n t for its essential c o n t r i b u t i o n in s t a g i n g a n d m o n i t o r i n g the disease. The CT-scan a n d M R I are u s u a l l y quite h e l p f u l for u n d e r s t a n d i n g the internal architecture of the p a t h o l o g i c a l tissue a n d d e f i n i n g t o p o g r a p h i c a l relations b e t w e e n the lesion itself a n d the s u r r o u n d i n g b o n e a n d soft tissues. H o w e v e r , o n l y b i o p s y - i n o u r o p i n i o n - i s able to settle diagnostic c o n t r o v e r s i e s on the n a t u r e of the i n j u r y a n d it s h o u l d be a l w a y s p e r f o r m e d before p l a n n i n g a n y k i n d of treatment. T h e r a p y m u s t o n l y be r e c o m m e n d e d after a n accurate staging. The aim of the o p e r a t i o n s h o u l d be to r e s t o r e - w h e n e v e r p o s s i b l e - a g o o d a n d painless f u n c t i o n of the foot; this implies that t r e a t m e n t s s h o u l d be as c o n s e r v a t i v e as possible (extraqesional excisions, or intra-lesional c u r e t t a g e w i t h c e m e n t antiblastic filling). A m p u t a t i o n s h o u l d be r e s e r v e d for those patients w i t h a g o o d life e x p e c t a n c y in w h i c h local excision is technically impossible. Surgical a d j u v a n t s are h e l p f u l w h e t h e r i n t r a q e s i o n a l or excisional p r o c e d u r e s are considered. R a d i a t i o n t h e r a p y is the principal surgical adjuvant. M o r e o v e r , it is p a r t i c u l a r l y effective in relieving p a i n a n d r e d u c i n g the n e e d for narcotic analgesics. M o s t s y m p t o m a t i c b o n y m e t a s t a s e s b e g i n to r e s p o n d o v e r the course of 10-14 days. R a d i a t i o n also arrests local t u m o u r g r o w t h of m o s t cancers, so that m o r e t h a n 80% of patients w i t h a limited n u m b e r of welllocalized b o n y m e t a s t a s e s can be t r e a t e d effectively b y external b e a m r a d i a t i o n [20]. W h e n there is a w i d e s p r e a d local a n d s y s t e m i c diffusion of the t u m o u r w i t h n u m e r o u s areas of skeletal i n v o l v e m e n t , or p o o r g e n e r a l conditions c o n t r a i n d i c a t e surgery, systemic therapy should be considered.
C h e m o t h e r a p y or e n d o c r i n e t h e r a p y are tile most a p p r o p r i a t e . If s y m p t o m s persist o v e r the course of several m o n t h s alternative m a n a g e m e n t for the localized disease s h o u l d be c o n s i d e r e d to control the m o s t s y m p t o m a t i c a n d t r o u b l e s o m e areas [20].
References 1 McLeod RA. Bone and soft tissue neoplasm. In: Berquist Th Ed., Radiology of the Foot and Ankle. New York: Raven Press, 1989. 2 Casadei R, Nigrisoli M, De Cristofaro R. et aI. Indagine strumentale nella patologia neoplastica del piede. Chir Pie& 1990; 14:15-24 (in Italian). 3 Casadei R, Ferraro A, Ferruzzi A. et al. Tumori ossei del piede: epidemiologia e diagnosi. Chit Org Mov 1991; 76:47-62 (in Italian). 4 Gall RJ, Sire FH, Pritchard DJ. Metastatic tumors to the bones of the foot. Cancer 1976; 37: 1492-1495. 5 Wu KK, Guise ER. Metastatic tumors of the foot. South Med J 1978; 71: 807-811. 6 Berrettoni BA, Carter JR. Mechanisms of cancer metastasis to bone. [ Bone Joint Surg 1986; 68A: 308-312. 7 Johnston AD. Pathology of metastatic tumors in bone. Clin Orthop 1970; 73: 8-32. 8 Zindrick MR, Young MP, Daley RJ. et al. Metastatic tumors of the foot. Case report and literature review. Clin Orthop 1982; 170: 219-225. 9 Libson E, Bloom RA, Husband JE. et al. Metastatic tumours of bones of the hand and foot: a comparative review and report of 43 additional cases. Skeletal Radiol 1987; 16: 387-392. 10 Healy JH, Turnbull ADM, Miedema B. et aL Acrometastases: a study of twenty-nine patients with osseous involvement of the hand and feet. J Bone Joint Surg 1986; 68A: 743-746. 11 Leonheart EE, Di Stazio J, Acrometastases. Initial presentation as diffuse ankle pain. [ Am Podiatr Med Assoc 1994; 84: 625-627. 12 de Palma L, Tamburrelli F, Coletti Vet al. Lesioni osteolitiche falangee del piede. Problemi di diagnosi differenziale. Chir Piede 1996; 20:27-32 (in Italian). 13 Dini P, Bardelli M, Allegra M. I tumori ossei del piede. Chit Piede 1984; 8:379-400 (in Italian). 14 Letanche G, Dumontet C, Euvrard P. et al. M6tastases distales des cancers bronchiques: m6tastase osseuse et m6tastase des tissus mous. Bull Cancer 1990; 77:1025-1030 (in French). 15 Andreasi A, Danda F, Vison~ A. Su un case di rara metastasi ossea di un dito del piede da carcinoma a cellule renali asintomatico. Chit Org Mov 1982; 67:123-129 (in Italian). 16 Helal B, Wilson D. The Foot. London: Churchill Livingston, 19881 17 Ochsener PE. Knochentumoren des fusses. SystematiL Differentialdiagnose und Therapie. Stuttgart: Ferdinand Enke Verlag, 1984. 18 Desmanet E, Amrani M, Fievez R. Les acrometastases: apropos de deux cas. Revue de la litt6rature. Ann Chir Main 1991; 2: 54-157 (in French). 19 de Palma L, Greco F, Bucca C. et aL L'angioscintigrafia ossea sequenziale nella patologia del piede. Chir Piede 1989; 13: 357-361 (in Italian). 20 DeVita VT, Hellman S, Rosenberg SA. Cancer. Principle and Practice ofOncology, 5th edn. New York: Lippincott-Raven, 1997.
© 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 207-212
4:207--212
Bone metastasis to the foot: report of three cases L. DE PALMA, C. CHILLEMI A N D G. ZANOLI Department of Orthopaedics, University of Ancona, Italy
Summary Bone metastases to the foot are rare and often misdiagnosed. Only tarsal localizations are relatively frequent. Primary tumours are mostly adenocarcinomas (colon, kidneys, lungs). Three cases of acrometastases, localized, respectively, on the ungual phalanx of the hallux, the first metatarsal and the first cuneiform, are reported. Primitive tumour sites differed in the three cases (renal, pulmonary and mammary origin). Adequate therapy must be preceded by an accurate staging. Surgery should aim to excise the tumour and restore, when possible, a good function of the foot without any pain. Amputation should only be resorted to if is not possible to perform the excision of the tumour in patients whose life expectancy is not too short. Wide local and systemic diffusion of the tumour and a short life expectancy contraindicate any surgical approach. Treatment, in these cases, must try to achieve a satisfactory pain control and decrease the local expansion of the tumour. Keywords: foot; bone tumour; metastatic disease; bone metastasis; acrometastases
Introduction Bone metastases to the foot are rare (0.1% of all secondary localizations [1]) and 4.2% of all the primary tumours of the foot [2, 3]). After reviewing the literature, we tried to analyse the clinical features and the therapeutic problems of metastatic lesions to the foot, starting with three original observations.
Case reports First case A 59-year-old woman had been operated on for a clear cell renal carcinoma 3 years before the observation. For a month she been reporting the
sudden onset of intense pain in the first distal phalanx of the right foot, reducing her walking capacity and ability to wear shoes. The toe appeared swollen and signs of phlogosis were evident (Figure la). A radiograph (Figure lb) showed a widespread lysis of the whole ungual phalanx, and a bone scan revealed a single area of abnormal uptake corresponding to the first toe. A needle biopsy suggested the diagnosis of metastatic clear cell renal carcinoma. Disarticulation (Figure lc) was necessary to completely remove the tumour which had infiltrated the surrounding soft tissues. Hystological examination confirmed the bioptic diagnosis (Figure ld). The patient is still alive after 3 years of followup. Second case
Correspondence to: Professor Luigi de Palrna, Clinica Ortopedica, Universit~ di Ancona, Cattedra di Traumatologia, Odpedale Umberto I°, Largo Cappelli, 1, 60100, Ancona, Italy. © 1998 Blackwell Science Ltd
A 60-year-old man had adenocarcinoma of the
been diagnosed with lung 2years before 207
208
L. D E P A L M A
ET AL.
Figure 1 Case 1: renal metastasis to the phalanx (a) Clinical presentation: swelling of the distal phalanx of the hallux of the right foot. (b) Xray: widespread lysis of the whole ungual phalanx. Post-operative aspect of the excised tumour which infiltrated surrounding tissues. Hystological examination of the distal phalanx confirmed the metastatic clear cell renal carcinoma (H/E, 40 x ). (Figure 1a-b: published in Chir. Piede 1996; 20: 27-32; reprinted with permission.)
© 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 207-212
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Figure 2
Case 2: pulmonary metastasis to the metatarsal (a) Clinical presentation: circumscribed swelling of the dorsal region of the right foot. (b) X-rays:wide lysis of the first metatarsal. MRI: extensive infiltration of the soft and bony tissues surrounding the lesion. Histological aspect of the metatarsal lesion showed the pulmonary adenocarcinoma metastases (H/E, 20 x ).
observation. For 3 m o n t h s he h a d experienced dull pain in the dorsal region of the right foot, w h i c h subsequently b e c a m e swollen (Figure 2a). The patient © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 207-212
w a s unable to e n d u r e weightbearing. R a d i o g r a p h s (Figure 2b) s h o w e d a w i d e lysis of the first metatarsal, w h e r e a s magnetic resonance i m a g i n g (MRI) (Figure
210
L. DE P A L M A E T A L .
2c) revealed an extensive infiltration of the surrounding soft and bony tissues. A bone scan elicited multiple areas of abnormal uptake around the first metatarsal and on the seventh and 10th ribs. A biopsy was performed which confirmed the diagnosis of pulmonary adenocarcinoma (Figure 2d). Since the patient was generally in good condition, a foot amputation was advised because of the impossibility of a radical local excision and the risk of skin ulceration; but the patient refused. He underwent radiotherapy and died after 14 months.
Third case The third case was a 45-year-old woman operated on for a breast adenocarcinoma 3 years before observation. Mid-foot pain and swelling (Figure 3a) appeared in the last 2 months; the ability of the patient to bear weight and walk was as a result reduced. Radiographs (Figure 3b) and computed tomography (CT)-scan of the right foot showed a widespread rarefaction of the first cuneiform. A bone scan revealed multiple areas of abnormal uptake (mid-foot, pelvis, humerus and spine). Biopsy confirmed the diagnosis of mammary adenocarcinoma (Figure 3c). Because of the patient's poor general condition (multiple skeletal and visceral metastasis were present) surgical intervention was not advised. The lesion was treated with radiotherapy. The patient died 3 months later.
Discussion The literature is in agreement regarding the low incidence of metastatic lesions to the foot. Gall eta]. [4], for example, reported 11 skeletal metastases of the foot out of 2800 observed bone tumours; and Wu and Guise [5] cited only four cases of secondary lesions of the foot out of 41 833 treated neoplastic patients. Casadei et al. [2, 3] have observed 11 cases of acrometastases out of over 13 000 muscolo-skeletal tumours treated between 1904 and 1988, at the Tumour Centre of the Rizzoli Orthopedic Institute (Bologna, Italy). The reasons for such a low incidence are not completely clear. As it is known, metastases to bone follow two different pathways: local spread and blood flow dissemination; the latter is responsible for the distal localization to hands and feet [6]. Factors
affecting targets and stages of metastatic diffusion are many and can be referred essentially to the ability of the neoplastic cells to enter blood flow, and to survive the circulatory turbulence and the immunological defences of the patient. These two aspects influence, respectively, the wide spread diffusion of neoplastic cells to distant sites and their capability to grow there [6]. Other conditions which favour acrometastases are trauma, temperature differences among districts, hormonal influences and immunological response [7-9]. It has also been suggested that a local increase in blood flow (which can be caused by repeated microtraumatisms, fractures, functional overload) could be related to a subsequent higher incidence of metastases [10]. On the other hand, metastatic lesions may involve the foot more than is generally recognized, and most of them are probably overlooked [4, 11]. Besides, in patients with an extensive dissemination, acrometastases can be easily misdiagnosed [12], since the attention of the clinicians is concentrated on other viable organs [11]. Even during autopsies insufficient care is often taken in searching for foot localizations [4]. Another indirect proof of this, is the increasing number of cases reported in literature in the last few years, which is essentially due to the prolonged survival and to the better quality of life of the patients [10]. Single lesions on the feet or clinical onset of the symptoms before the first diagnosis of cancer has been made remain exceptional. Tarsal bones are affected in 50% of the cases [8, 13, 14], followed by metatarsals (23%) [8, 13] and phalanxes (11-17%) [8, 13]. Among tarsal bones, the os calcis is most frequently involved (six cases out of 13 tarsal localizations according to Libson [9]; five out of nine according to Healy [10]) followed by the talus, cuneiform, cuboid and navicular bones. Phalangeal involvement usually affects the first ray. To our knowledge, the only case of metastasis to the other toes is the one reported by Andreasi et al. [15]. Primary tumours are mostly adenocarcinomas (colon, 17-19%; kidneys, 17-18%; lung, 15%) [8, 9]. Metastatic lesions from breast, bladder, uterus, ovarium and prostate are very rare [16]. There are very rare papers reporting acrometastasis from sarcomas in the literature [17], such as some authors even regard this eventuality as impossible [13]. © 1998BlackwellScienceLtd, Foot and Anlcle Surgery, 4, 207-212
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Figure 3
Case 3: mammary metastasis to the cuneiform (a) Clinical presentation: impressive swelling of the dorsal region of the right foot. Radiogram of the right foot (lateral view): widespread rarefaction of the first cuneiform. Hystologicalfinding of the metastatic lesion confirmedthe diagnosis of mammary adenocarcinoma (H/E, 20 x ).
When the patient presents with an extensive metastatic dissemination, lesions of the foot usually don't cause any diagnostic problem. On the other hand, diagnosis can be difficult w h e n the acrometastasis is the first clinical manifestation of an occult t u m o u r [15, 18]. In these early presentations symptoms can also precede radiological signs [9]. Pain, swelling, erythema and functional impairment are the hallmarks of the lesion, though clinical presentation is usually not specific; differential diagnosis between metastatic and other inflammatory or infectious diseases must be made. Very seldom in later stages a palpable bulk can develop, which eventually becomes ulcerated in the most aggressive presentations. © 1998 BlackwellScience Ltd, Foot and Ankle Surgery, 4, 207-212
Standard radiographs are rarely sufficient for a correct diagnosis of the injury. Moreover, their interpretation is often questionable and not univocal. However, radiographs usually one to make a tentative diagnosis, evaluating extent, spread and aggressiveness of the lesion, and searching for the particular radiological hallmarks of one lesion or another. Lytic presentation is by far the most frequent (80%) which can lead to massive destruction in the advanced stages. Again, in the initial stages, differential diagnosis on standard radiographs must be m a d e between metastases and osteomyelitis, septic arthritis rheumatic or metabolic arthropaties, osteoarthritis and algodystrophy [9, 11]. The absence of a periosteal reaction without any articular,
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L. D E P A L M A
ET AL.
cartilaginous or s u b c h o n d r a l i n v o l v e m e n t , increase the likelihood of a metastatic p r o c e s s [11]. W h e n clinical signs of i n f l a m m a t i o n are missing, radiological differential d i a g n o s i s s h o u l d c o n s i d e r other b e n i g n ( e p i d e r m o i d cysts, e n c h o n d r o m a , g i a n t cell tumour) and malign (osteosarcoma, c h o n d r o s a r c o m a ) p r i m a r y t u m o u r s [8, 9]. A d v a n c e d i m a g i n g t e c h n i q u e s are u s u a l l y n e e d e d for an accurate diagnosis, a n d t h e y s h o u l d be p e r f o r m e d a c c o r d i n g to the diagnostic r e q u i r e m e n t s of each case. A b o n e scan, b e c a u s e it is v e r y n o n specific, u s u a l l y d o e s n ' t c o n t r i b u t e a n y t h i n g useful t o w a r d s a differential d i a g n o s i s [19], b u t it is p e r f o r m e d o n a l m o s t e v e r y p a t i e n t for its essential c o n t r i b u t i o n in s t a g i n g a n d m o n i t o r i n g the disease. The CT-scan a n d M R I are u s u a l l y quite h e l p f u l for u n d e r s t a n d i n g the internal architecture of the p a t h o l o g i c a l tissue a n d d e f i n i n g t o p o g r a p h i c a l relations b e t w e e n the lesion itself a n d the s u r r o u n d i n g b o n e a n d soft tissues. H o w e v e r , o n l y b i o p s y - i n o u r o p i n i o n - i s able to settle diagnostic c o n t r o v e r s i e s on the n a t u r e of the i n j u r y a n d it s h o u l d be a l w a y s p e r f o r m e d before p l a n n i n g a n y k i n d of treatment. T h e r a p y m u s t o n l y be r e c o m m e n d e d after a n accurate staging. The aim of the o p e r a t i o n s h o u l d be to r e s t o r e - w h e n e v e r p o s s i b l e - a g o o d a n d painless f u n c t i o n of the foot; this implies that t r e a t m e n t s s h o u l d be as c o n s e r v a t i v e as possible (extraqesional excisions, or intra-lesional c u r e t t a g e w i t h c e m e n t antiblastic filling). A m p u t a t i o n s h o u l d be r e s e r v e d for those patients w i t h a g o o d life e x p e c t a n c y in w h i c h local excision is technically impossible. Surgical a d j u v a n t s are h e l p f u l w h e t h e r i n t r a q e s i o n a l or excisional p r o c e d u r e s are considered. R a d i a t i o n t h e r a p y is the principal surgical adjuvant. M o r e o v e r , it is p a r t i c u l a r l y effective in relieving p a i n a n d r e d u c i n g the n e e d for narcotic analgesics. M o s t s y m p t o m a t i c b o n y m e t a s t a s e s b e g i n to r e s p o n d o v e r the course of 10-14 days. R a d i a t i o n also arrests local t u m o u r g r o w t h of m o s t cancers, so that m o r e t h a n 80% of patients w i t h a limited n u m b e r of welllocalized b o n y m e t a s t a s e s can be t r e a t e d effectively b y external b e a m r a d i a t i o n [20]. W h e n there is a w i d e s p r e a d local a n d s y s t e m i c diffusion of the t u m o u r w i t h n u m e r o u s areas of skeletal i n v o l v e m e n t , or p o o r g e n e r a l conditions c o n t r a i n d i c a t e surgery, systemic therapy should be considered.
C h e m o t h e r a p y or e n d o c r i n e t h e r a p y are tile most a p p r o p r i a t e . If s y m p t o m s persist o v e r the course of several m o n t h s alternative m a n a g e m e n t for the localized disease s h o u l d be c o n s i d e r e d to control the m o s t s y m p t o m a t i c a n d t r o u b l e s o m e areas [20].
References 1 McLeod RA. Bone and soft tissue neoplasm. In: Berquist Th Ed., Radiology of the Foot and Ankle. New York: Raven Press, 1989. 2 Casadei R, Nigrisoli M, De Cristofaro R. et aI. Indagine strumentale nella patologia neoplastica del piede. Chir Pie& 1990; 14:15-24 (in Italian). 3 Casadei R, Ferraro A, Ferruzzi A. et al. Tumori ossei del piede: epidemiologia e diagnosi. Chit Org Mov 1991; 76:47-62 (in Italian). 4 Gall RJ, Sire FH, Pritchard DJ. Metastatic tumors to the bones of the foot. Cancer 1976; 37: 1492-1495. 5 Wu KK, Guise ER. Metastatic tumors of the foot. South Med J 1978; 71: 807-811. 6 Berrettoni BA, Carter JR. Mechanisms of cancer metastasis to bone. [ Bone Joint Surg 1986; 68A: 308-312. 7 Johnston AD. Pathology of metastatic tumors in bone. Clin Orthop 1970; 73: 8-32. 8 Zindrick MR, Young MP, Daley RJ. et al. Metastatic tumors of the foot. Case report and literature review. Clin Orthop 1982; 170: 219-225. 9 Libson E, Bloom RA, Husband JE. et al. Metastatic tumours of bones of the hand and foot: a comparative review and report of 43 additional cases. Skeletal Radiol 1987; 16: 387-392. 10 Healy JH, Turnbull ADM, Miedema B. et aL Acrometastases: a study of twenty-nine patients with osseous involvement of the hand and feet. J Bone Joint Surg 1986; 68A: 743-746. 11 Leonheart EE, Di Stazio J, Acrometastases. Initial presentation as diffuse ankle pain. [ Am Podiatr Med Assoc 1994; 84: 625-627. 12 de Palma L, Tamburrelli F, Coletti Vet al. Lesioni osteolitiche falangee del piede. Problemi di diagnosi differenziale. Chir Piede 1996; 20:27-32 (in Italian). 13 Dini P, Bardelli M, Allegra M. I tumori ossei del piede. Chit Piede 1984; 8:379-400 (in Italian). 14 Letanche G, Dumontet C, Euvrard P. et al. M6tastases distales des cancers bronchiques: m6tastase osseuse et m6tastase des tissus mous. Bull Cancer 1990; 77:1025-1030 (in French). 15 Andreasi A, Danda F, Vison~ A. Su un case di rara metastasi ossea di un dito del piede da carcinoma a cellule renali asintomatico. Chit Org Mov 1982; 67:123-129 (in Italian). 16 Helal B, Wilson D. The Foot. London: Churchill Livingston, 19881 17 Ochsener PE. Knochentumoren des fusses. SystematiL Differentialdiagnose und Therapie. Stuttgart: Ferdinand Enke Verlag, 1984. 18 Desmanet E, Amrani M, Fievez R. Les acrometastases: apropos de deux cas. Revue de la litt6rature. Ann Chir Main 1991; 2: 54-157 (in French). 19 de Palma L, Greco F, Bucca C. et aL L'angioscintigrafia ossea sequenziale nella patologia del piede. Chir Piede 1989; 13: 357-361 (in Italian). 20 DeVita VT, Hellman S, Rosenberg SA. Cancer. Principle and Practice ofOncology, 5th edn. New York: Lippincott-Raven, 1997.
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