- Email: [email protected]
A colonic metastatic tumor in the hand
Vol. 12A, No.5, Part I September 1987
7. Price ML, MacDonald DM. Multiple granular cell tumor. Clin Exp Dermatol 1984;9:375-8. 8. Berkowitz SF, Hirsh BC, Vonderheid E. Granular cell tumor: A great masquerader. Cutis 1985;35:355-6. 9. Beeaff D. Granular cell myoblastoma. Ariz Med 1984; 41:90-1. 10. Goette DK, Olson EG. Multiple cutaneous granular cell tumors. Int J Dermatol 1982;21:271-2. 11. White SW, Gallager RL, Rodman OG. Multiple granular cell tumors. J Dermatol Surg Oncol 1980;6:57-61. 12. Kucan 10, Hagstrom WJ, Soltani K, Parsons RW. Granular cell tumor. Ann Plast Surg 1982;9:409-12.
Granular cell tumor in hand
13. Alkek DS, Johnson WC, Graham JH. Granular cell myoblastoma. Arch Derm 1968;98:543-7. 14. Christ ML, Ozzello L. Myogenous origin of a granular cell tumor of the urinary bladder. Am J Clin Pathol 1971;56:736-49. 15. Fischer ER, Wechsler H. Granular cell myoblastoma-A misnomer. Cancer 1962;15:936-54. 16. Garancis JC, Komorowski RA, Kuzma JF. Granular cell myoblastoma. Cancer 1970;25:542-50. 17. Usui M, Ishii S, Yamawaki S, Sasaki T, Minami A, Hizawa K. Malignant granular cell tumor of the radial nerve. Cancer 1977;39:1547-55.
A colonic metastatic tumor in the hand Secondary tumors in the hand are very uncommon. Of the reported cases the majority arise from primary bronchial carcinoma, with multiple secondary deposits into bone. A case is reported of bony metastasis to the middle phalanx of the small finger in a patient who had a resection of a colonic adenocarcinoma 2 years previously. (J HAND SURG 1987;12A[2 Pt 1]:803-5.)
Christopher J. Hindley, M.Ch. Orth., F.R.C.S.E., and John W. Metcalfe, M.Ch. Orth., F.R.C.S., F.R.C.S.E., Liverpool, England
We report an unusual case of an apparently isolated metastasis from a colonic carcinoma to the small finger. The literature has been reviewed to ascertain the incidence of such lesions and the differential diagnosis is discussed. Case report A 44-year-old man was referred by his family practitioner because of a 7-week history of a painful swelling of the right small finger. The radiograph was reported as showing osteo-
From the Department of Orthopaedic Surgery, Walton Hospital, Liverpool, England. Received for publication Oct. 16, 1986; accepted in revised form Jan. 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mr. C. J. Hindley, M.Ch. Orth., F.R.C.S.E., 30, Highfield Rd., Ormskirk, Lancashire, L39 1NR, England.
myelitis (Fig. I). Treatment with oral fusidic acid (Fucidin) was started, and he was referred for an orthopedic opinion. A provisional diagnosis of osteomyelitis was made, and the patient was admitted for exploration of the small finger. At operation through a dorsal incision a tumor-like mass encircling and partly replacing the middle phalanx was found. An incisional biopsy showed necrotic secondary carcinoma, with a poorly differentiated adenocarcinomatous structure, consistent with a colonic primary site (Fig. 2). Clinical details concerning the previous bowel resection were then obtained, and these showed that a Dukes' Stage C colonic carcinoma had been resected from the splenic flexure 2 years previously. Subsequently, an incisional hernia had been repaired, but no intra-abdominal recurrence was noted. Routine follow-up showed no suggestion of metastatic disease. A technetium bone scan showed, in addition to the "hot spot" in the small finger, an area of increased uptake in the right elbow although this area was radiographically normal. The patient was readmitted and a ray amputation of the small finger was done. Histologic examination of the specimen showed that the previous report was confirmed, and the proximal resection line was found to be free of tumor.
THE JOURNAL OF HAND SURGERY
803
804
Hindley and Metcalfe
The Journal of HAND SURGERY
Fig. 1. Radiograph showing the secondary deposit and associated soft-tissue swelling in the middle phalanx of the small finger.
Fig. 2. Photomicrograph of the biopsy specimen showing clumps of poorly-differentiated adenocarcinoma. (Hematoxylin and eosin stain x 100.)
Discussion Gold and Reefe ' in a report involving 3000 patients with malignant disease found only two cases (0.07%) with metastases in the hand. This location for metastases is usually a late feature in the disease process. Isolated metastases have rarely been reported. 2 Such lesions may occasionally be the presenting feature of an occult primary carcinoma. 3 The splenic flexure of the colon accounts for less than 3% of cancers of the large bowel4 and only 6% to
10% of all these tumors metastasize to bone. 5-7 Kerin, 8 in a review of 16 fully documented cases of osseous hand metastases, found that the most common site was the terminal phalanx of the thumb followed by the metacarpal bones. No case involving the middle phalanges or the carpus ~as included, although Smith9 in a later report, reviewed two cases of carpal secondary deposits and described an additional case. The most usual primary site was the bronchus (48%) and the least common was the colon (4%). Weston and Feit6 have further em-
Vol. 12A, No.5, Part 1 September 1987
phasized the rarity of colonic secondary deposits in the hand. The site of a hand metastasis, in keeping with this case, is often inflamed, and a provisional diagnosis of osteomyelitis is often made. A tuberculous dactylitis may be confused with a secondary deposit, but its tendency to affect persons in a younger age group and invade adjacent joints help to differentiate these two entities. Primary malignant tumors in the hand are extremely rare and are thought to arise from the sweat glands. Clifford and KellyJO quote an overall incidence of 0.008%. El-Domeiri et al. II have reviewed a 35-year experience of 83 patients, with confirmed sweat gland carcinoma, and found only seven (12%) that involved the hand. Benign tumors and tumor-like conditions usually have sufficiently characteristic radiologic appearances to avoid confusion with the metastatic lesion. 12 REFERENCES 1. Gold GL, Reefe WE. Metastases to the bones of the hand. JAM A 1963;184:237-9. 2. Smithers DW, Price LRW. Isolated secondary deposit in terminal phalanx in case of squamous cell carcinoma. Br J Radiol 1945;18:299-300.
Colonic metastatic tumor in hand
805
3. Bertin EJ. Metastasis to bone as the first symptom of cancer of the gastrointestinal tract. Am J Roentgenol 1944;51:614-22. 4. Falterman KW, Hill CB, Markey JC, Fox JW, Cohn I Jr. Cancer of the colon, rectum and anus: A review of 2313 cases. Cancer 1974;34:951-9. 5. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: Analysis of 1000 autopsied cases. Cancer 1950;3:74-85. 6. Weston SD, Feit HL. Osseous metastasis from cancer of the colon with a review of the literature. Dis Colon Rectum 1964;9:61-4. 7. Turek SL. In: Orthopaedics: Principles and their application. 4th ed. Philadelphia: 18 Lippincott Co, 1984: 664-77. 8. Kerin R. Metastatic tumors of the hand. J Bone Joint Surg [Am] 1958;40:263-77. 9. Smith RJ. Involvement of the carpal bones with metastatic tumor. Am J Roentgenol 1963;89:1253-5. 10. Clifford RH, Kelly AP. Primary malignant tumors of the hand. Plast Reconstr Surg 1955;15:227-32. 11. EI-Domeiri AA, Brasfield RD, Huvos AG, Strong EW. Sweat gland carcinoma: A clinico-pathologic study of 83 patients. Ann Surg 1971;173:270-4. 12. Dahlin DC. Bone tumors. 3rd ed. Springfield, Ill: Charles C. Thomas, 1978:28-70.
7. Price ML, MacDonald DM. Multiple granular cell tumor. Clin Exp Dermatol 1984;9:375-8. 8. Berkowitz SF, Hirsh BC, Vonderheid E. Granular cell tumor: A great masquerader. Cutis 1985;35:355-6. 9. Beeaff D. Granular cell myoblastoma. Ariz Med 1984; 41:90-1. 10. Goette DK, Olson EG. Multiple cutaneous granular cell tumors. Int J Dermatol 1982;21:271-2. 11. White SW, Gallager RL, Rodman OG. Multiple granular cell tumors. J Dermatol Surg Oncol 1980;6:57-61. 12. Kucan 10, Hagstrom WJ, Soltani K, Parsons RW. Granular cell tumor. Ann Plast Surg 1982;9:409-12.
Granular cell tumor in hand
13. Alkek DS, Johnson WC, Graham JH. Granular cell myoblastoma. Arch Derm 1968;98:543-7. 14. Christ ML, Ozzello L. Myogenous origin of a granular cell tumor of the urinary bladder. Am J Clin Pathol 1971;56:736-49. 15. Fischer ER, Wechsler H. Granular cell myoblastoma-A misnomer. Cancer 1962;15:936-54. 16. Garancis JC, Komorowski RA, Kuzma JF. Granular cell myoblastoma. Cancer 1970;25:542-50. 17. Usui M, Ishii S, Yamawaki S, Sasaki T, Minami A, Hizawa K. Malignant granular cell tumor of the radial nerve. Cancer 1977;39:1547-55.
A colonic metastatic tumor in the hand Secondary tumors in the hand are very uncommon. Of the reported cases the majority arise from primary bronchial carcinoma, with multiple secondary deposits into bone. A case is reported of bony metastasis to the middle phalanx of the small finger in a patient who had a resection of a colonic adenocarcinoma 2 years previously. (J HAND SURG 1987;12A[2 Pt 1]:803-5.)
Christopher J. Hindley, M.Ch. Orth., F.R.C.S.E., and John W. Metcalfe, M.Ch. Orth., F.R.C.S., F.R.C.S.E., Liverpool, England
We report an unusual case of an apparently isolated metastasis from a colonic carcinoma to the small finger. The literature has been reviewed to ascertain the incidence of such lesions and the differential diagnosis is discussed. Case report A 44-year-old man was referred by his family practitioner because of a 7-week history of a painful swelling of the right small finger. The radiograph was reported as showing osteo-
From the Department of Orthopaedic Surgery, Walton Hospital, Liverpool, England. Received for publication Oct. 16, 1986; accepted in revised form Jan. 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mr. C. J. Hindley, M.Ch. Orth., F.R.C.S.E., 30, Highfield Rd., Ormskirk, Lancashire, L39 1NR, England.
myelitis (Fig. I). Treatment with oral fusidic acid (Fucidin) was started, and he was referred for an orthopedic opinion. A provisional diagnosis of osteomyelitis was made, and the patient was admitted for exploration of the small finger. At operation through a dorsal incision a tumor-like mass encircling and partly replacing the middle phalanx was found. An incisional biopsy showed necrotic secondary carcinoma, with a poorly differentiated adenocarcinomatous structure, consistent with a colonic primary site (Fig. 2). Clinical details concerning the previous bowel resection were then obtained, and these showed that a Dukes' Stage C colonic carcinoma had been resected from the splenic flexure 2 years previously. Subsequently, an incisional hernia had been repaired, but no intra-abdominal recurrence was noted. Routine follow-up showed no suggestion of metastatic disease. A technetium bone scan showed, in addition to the "hot spot" in the small finger, an area of increased uptake in the right elbow although this area was radiographically normal. The patient was readmitted and a ray amputation of the small finger was done. Histologic examination of the specimen showed that the previous report was confirmed, and the proximal resection line was found to be free of tumor.
THE JOURNAL OF HAND SURGERY
803
804
Hindley and Metcalfe
The Journal of HAND SURGERY
Fig. 1. Radiograph showing the secondary deposit and associated soft-tissue swelling in the middle phalanx of the small finger.
Fig. 2. Photomicrograph of the biopsy specimen showing clumps of poorly-differentiated adenocarcinoma. (Hematoxylin and eosin stain x 100.)
Discussion Gold and Reefe ' in a report involving 3000 patients with malignant disease found only two cases (0.07%) with metastases in the hand. This location for metastases is usually a late feature in the disease process. Isolated metastases have rarely been reported. 2 Such lesions may occasionally be the presenting feature of an occult primary carcinoma. 3 The splenic flexure of the colon accounts for less than 3% of cancers of the large bowel4 and only 6% to
10% of all these tumors metastasize to bone. 5-7 Kerin, 8 in a review of 16 fully documented cases of osseous hand metastases, found that the most common site was the terminal phalanx of the thumb followed by the metacarpal bones. No case involving the middle phalanges or the carpus ~as included, although Smith9 in a later report, reviewed two cases of carpal secondary deposits and described an additional case. The most usual primary site was the bronchus (48%) and the least common was the colon (4%). Weston and Feit6 have further em-
Vol. 12A, No.5, Part 1 September 1987
phasized the rarity of colonic secondary deposits in the hand. The site of a hand metastasis, in keeping with this case, is often inflamed, and a provisional diagnosis of osteomyelitis is often made. A tuberculous dactylitis may be confused with a secondary deposit, but its tendency to affect persons in a younger age group and invade adjacent joints help to differentiate these two entities. Primary malignant tumors in the hand are extremely rare and are thought to arise from the sweat glands. Clifford and KellyJO quote an overall incidence of 0.008%. El-Domeiri et al. II have reviewed a 35-year experience of 83 patients, with confirmed sweat gland carcinoma, and found only seven (12%) that involved the hand. Benign tumors and tumor-like conditions usually have sufficiently characteristic radiologic appearances to avoid confusion with the metastatic lesion. 12 REFERENCES 1. Gold GL, Reefe WE. Metastases to the bones of the hand. JAM A 1963;184:237-9. 2. Smithers DW, Price LRW. Isolated secondary deposit in terminal phalanx in case of squamous cell carcinoma. Br J Radiol 1945;18:299-300.
Colonic metastatic tumor in hand
805
3. Bertin EJ. Metastasis to bone as the first symptom of cancer of the gastrointestinal tract. Am J Roentgenol 1944;51:614-22. 4. Falterman KW, Hill CB, Markey JC, Fox JW, Cohn I Jr. Cancer of the colon, rectum and anus: A review of 2313 cases. Cancer 1974;34:951-9. 5. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: Analysis of 1000 autopsied cases. Cancer 1950;3:74-85. 6. Weston SD, Feit HL. Osseous metastasis from cancer of the colon with a review of the literature. Dis Colon Rectum 1964;9:61-4. 7. Turek SL. In: Orthopaedics: Principles and their application. 4th ed. Philadelphia: 18 Lippincott Co, 1984: 664-77. 8. Kerin R. Metastatic tumors of the hand. J Bone Joint Surg [Am] 1958;40:263-77. 9. Smith RJ. Involvement of the carpal bones with metastatic tumor. Am J Roentgenol 1963;89:1253-5. 10. Clifford RH, Kelly AP. Primary malignant tumors of the hand. Plast Reconstr Surg 1955;15:227-32. 11. EI-Domeiri AA, Brasfield RD, Huvos AG, Strong EW. Sweat gland carcinoma: A clinico-pathologic study of 83 patients. Ann Surg 1971;173:270-4. 12. Dahlin DC. Bone tumors. 3rd ed. Springfield, Ill: Charles C. Thomas, 1978:28-70.