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Upper limb reflex sympathetic dystrophy associated with cccult malignancy
726
CLINICAL NOTES
Upper Limb Reflex Sympathetic Occult Malignancy Aubrey Ku, MD, Elisabeth Lachmann,
Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressivephysical therapy measures,the patients’ symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases,medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.
0 1996 by the American Congress ofRehabilitation Medicine and the American Academy ofPhysical Medicine and Rehabilitation
R
EFLEX SYMPATHETIC DYSTROPHY (RSD) is a syndrome of burning pain, swelling, vasomotor instability, and trophic changes in an extremity.’ RSD of the upper extremity often presents as a painful disability of the shoulder with swelling, stiffness, and pain of the hand and fingers.2,1 The most common precipitating factors of this syndrome include myocardial infarction, stroke, and trauma.4-6 We report two casesof RSD of the upper extremity in patients with a history of cancer. Despite aggressive physical therapy measures, the patients’ symptoms persisted. Workup of the first patient found recurrent breast cancer; in the second case, lymphoma, a second primary malignancy, was diagnosed. Appropriate treatment of the underlying malignancy in each case resulted in improved hand and shoulder function and decreased pain. In both cases,prolonged hospitalization and multiple procedures could have been avoided if malignancy had been suspected as a cause of RSD. CASE ONE A 68-year-old woman presented with a 4-month history of painful restriction of right shoulder movement with progressive From Rehabilitation Medicine, New York Hospital-Cornell Medical Center, New York, NY. Submitted for publication September 19, 1995. Accepted December 20. 1995. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Aubrey Ku, MD, 435 East 70th Street, 25 C, New York, NY 10021. 0 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Arch
Phys
Med Rehabil
Vol77,
July
1996
Associated With
MD, Richard Tunkel, MD, Willibald Nagler, MD
ABSTRACT. Ku A, Lachmann E, Tunkel R, Nagler W. Upper limb reflex sympathetic dystrophy associated with occult malignancy. Arch Phys Med Rehabil 1996;77:726-8.
0003.9993/96/7707-3700$3.M)IO
Dystrophy
swelling, stiffness, and burning pain of the ipsilateral hand and fingers. Her medical history was significant for breast cancer, treated 6 years before by left lumpectomy with axillary dissection and subsequent radiation therapy, which was in remission. There was no evidence of lymphedema. A left frontal lobe meningioma was removed 2 years before, leaving her with residual hand weakness without pain. Physical examination found 2+ pitting edema of the distal right upper extremity with shiny, pale skin over the hand and fingers. Sensation was intact, but painful dysesthesia was present. Range of motion of the shoulder, wrist, and fingers was decreasedto approximately 50% of normal. Reflexes were intact and laboratory values were within normal limits, with the exception of the alkaline phosphatase level, which was mildly elevated at 13lU/L (normal range, 30 to 1lOU/L). This patient’s upper extremity dysfunction was believed to be secondary to chronic right hemiparesis resulting from her left frontal lobe meningioma. Physical therapy consisted of contrast baths, paraffin baths, active assistedrange of motion exercises, and edema-controlling techniques, which included massage, arm elevation, and use of compressivegarments. A total of eight fluoroscopy-guided stellate ganglion blocks were performed by anesthesiologists, each with 5 to 1OmL of .25% bupivacaine without epinephrine at the C6 level. Reduced pain in the right arm and hand with increased range of motion lasted only a few hours after each block. Evaluation of the etiology of the patient’s RSD included a chest X-ray, which showed a right paratracheal mass. Computed tomography (CT) of the chest (fig 1A) showed this mass compressing the sympathetic ganglion chain. Biopsy of the mass revealed breast adenocarcinoma. Further workup for other sites of metastatic disease, including mammography, was negative. The patient received radiation therapy of 4,600cGy to the area of the mass, and administration of tamoxifen, 20mg each day, was begun. Complete amelioration of pain, normal right shoulder and hand range of motion, and resolution of edema was observed 6 months later on examination. Repeat CT 1 year later (Fig 1B) showed almost complete resolution of the right paratracheal mass. CASE TWO A 42-year-old woman presented with a 6-month history of presumed right axillary cellulitis unresponsive to antibiotics. She complained of increasing pain and decreasing range of motion of the right hand, fingers, and shoulder. Her medical history included medullary carcinoma of the thyroid 3 years earlier treated with thyroidectomy, without recurrence. Physical examination was significant for right axillary mass, 2+ pitting edema and erythema throughout the entire upper extremity, and atrophic changes of the integument. There was significant allodynia with light touch. Range of motion of the shoulder, wrist, and fingers was markedly limited, with significant pain at end-range. Laboratory values were significant for anemia, thrombocytosis, and an elevated erythrocyte sedimentation rate of 65mm/h (normal range, 0 to 2OmnVh).
RSD AND
MALIGNANCY,
727
Ku
Fig 1. IA) CT of the chest shows parsvertebbral mass (arrow) in the apical right lung. (6) CT 1 Year later shows residual scarring of the paravertebral mass (anowl.
During the medical workup physical therapy was begun, consisting of active assisted range of motion exercises, arm clevation, and systemic desensitization directed toward reducing the patient’s allodynia. CT showed a right axillary mass (fig 2) contiguous with the lower brachial plexus. Subsequent biopsy revealed pleomorphic lymphoma. Treatment with chemotherapy and radiation therapy was instituted, with marked improvement of shoulder, wrist, and finger range of motion and decreased complaints of pain.
DISCUSSION Mitchell and coworkers’ in 1864 described the syndrome of painful hands and feet in wounded soldiers of the American Civil War who wrapped their affected limbs in wet rags to “extinguish the fire.” Although RSD has been associated with many clinical conditions, its etiology is still poorly understood. There are many theories on the pathogenesis of RSD concerning both peripheral and central mechanisms.’ Sympathetic dysfunction is currently the presumed etiology of RSD.’ The clinician must bc aware of the clinical manifestation of RSD, because early recognition and aggressive treatment often produces the best clinical response.“ The clinical features of RSD include pain out of proportion to injury and progression in stages! Stage I is the acute stage, marked by burning or aching pain increased by dependency of the affected part of physical contact. Edema occurs in the affected part, and bony
Fig 2. CT of the chest
shows
mass
in the right
axilla
(arrow).
changes may be seen on X-rays.5 Stage 2 is the dystrophic stage in which pain is constant and the indurated tissue is cool and hypcrhydrotic. X-rays may show patchy osteoporosis.“’ Stage 3 is the atrophic stage. Pain spreads proximally, and irreversible tissue damage occurs. The skin is thin and shiny, and flexion contracturc may occur. X-rays show bony demineralization and ankylosis.“’ Each stage may last from 1 to 6 months or more.” RSD is a clinical diagnosis that may be supplemented by several diagnostic studies. Successful sympathetic blockade can bc both diagnostic and therapeutic.“,” Erythrocyte sedimentation rate is elevated in approximately 70% percent of RSD patients but is nonspecific.“’ Triple-phase bone scan may show increased uptake in the wrist, metacarpophalangeal, and interphalengeal joints, with a reported sensitivity of 96% and specificity of 86% for RSD.” Electrodiagnostic study results are usually normal. Thirty-eight cases of malignancies have been associated with RSD, primarily involving the upper extremity.16 RSD may represent a paraneoplastic syndrome in some cases, supported by the close temporal relationship with the development of malignancy. RSD of the upper extremity has been associated with meningiomas, primary and metastatic cerebral tumors, pancreatic carcinoma, and Pancoast tumors of the lung.“,‘“.” RSD has been reported in association with gynecologic malignancy. RSD of the lower extremity has been precipitated by cervical and vulvar carcinomas.” Ovarian carcinomas have been associated with shoulder-hand syndrome, possibly through paraneoplastic effects.‘x Radiation therapy in a patient with ovarian cancer resulted in regression of the neoplasm with improvemcnt in shoulder-hand syndrome.” Signs of RSD of the upper extremity have been found to precede the diagnosis of ovarian cancer by 2 years.” The two cases presented suggest a casual relationship between the malignancy and the RSD. In each case, RSD preceded the discovery of the neoplastic process by 4 to 6 months. Brcmer? described a similar history of RSD and subsequent diagnosis of cancer in 1966. Six months after the onset of RSD, ovarian cancer was diagnosed. The tumor regressed with radiation therapy, with coincident improvement in the RSD. Similarly, in our cases, treatment of the malignancy with radiation therapy or radiation therapy and chemotherapy resulted in tumor shrinkage and improved upper extremity functions.
Arch
Phys Med
Rehabil
Vol 77, July
1996
728
RSD AND
MALIGNANCY,
There are two likely etiologies of RSD in these two patients. Direct tumor effects may include mechanical irritation of the sympathetic ganglia or nerves. Space-occupying tumors may cause local ischemia to the sympathetic nervous tissue in the region. Macrometastatic invasion may also compromise sympathetic function. A second possible mechanism to explain RSD resulting from neoplasm is an immunologically mediated paraneoplastic effect. There are no established treatment protocols for RSD. The principle of treatment is to maintain range of motion and decreasepain and edema. To disrupt the destructive cycle of RSD, physical therapy and related modalities may be supplemented by sympathetic ganglion blockade or systemic corticosteroid if indicated.2’,24In our two patients, aggressive occupational and physical therapy in conjunction with the treatment of the underlying malignancy led to the resolution of RSD. CONCLUSION We presented two cases of occult malignancy preceded by RSD which resolved after successfultreatment of the neoplasia. A review of the literature found an infrequent association between RSD and malignancy. Onset of RSD without a clear precipitant or effective response to treatment may warrant a search for occult malignancy. References 1. Schutzer SF, Gossling HR. Current concept review: the treatment of reflex sympathetic dystrophy. J Bone Joint Surg Am 1989;66A: 625-9. 2. Bremer C. Shoulder-hand syndrome: a case of unusual aetiology. Ann Phys Med 1966;9:168-71. 3. Steinbrocker 0. The shoulder-hand syndrome: associated painful homolateral disability of the shoulder and hand with swelling and atrophy of the hand. Am J Med 1947; 3:402-7. 4. Lankford LL. Reflex sympathetic dystrophy. In: Hunter JM, editor. Rehabilitation of the hand: surgery and therapy. St. Louis: Mosby, 1990:763-86. 5. Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy: a review. Arch Neurol 1987;44:555-61. 6. Kozin F. The painful extremity-consider reflex sympathetic dystrophy. Diagnosis 1988; 10:86-91. 7. Mitchell SW, Morehouse GR, Keen WW. Gunshot wounds and other injuries of nerves. Philadelphia: Lippincott, 1864.
Arch
Phys Med Rehabil
Vol77,
July
1996
Ku
8. Dimitru D. Reflex sympathetic dystrophy. In: Walsh NE, editor. Physical medicine and rehabilitation: state of the art reviews. Philadelphia: Hanley & Belfus, 199 1; 5:89-l 02. 9. Philip PA, Philip M, Monga TN. Reflex sympathetic dystrophy in central cord syndrome: case report and review of the literature. Paraplegia 1990;28:48-54. 10. Hodges DL, McGuire TJ. Burning and pain after injury: is it causalgia or reflex sympathetic dystrophy? Postgrad Med 1988; 83: 18592. 11. Goldberg MI, Kennedy SF. Reflex sympathetic dystrophy-recognition and management in gynecologic oncology. Gynecol Oncol 1979; 8:288-95. 12. Bej MD, Schwartzman RJ. Abnormalities of cutaneous blood flow regulation in patients with reflex sympathetic dystrophy as measured by laser doppler fluxmetry. Arch Neurol 1991;48:912-5. 13. Roberts WJ, Elardo SM. Sympathetic activation of unmyelinated mechanoreceptors in cat skin. Brain Res 1985;339:123-5. 14. Escobar PL. Reflex sympathetic dystrophy. Ortho Rev 1986; 15: 646-51. 15. Constantinesco A, Brunot B, Demangeat JL, Foucher G, Farcot JM. Three-phase bone scanning as an aid to early diagnosis in reflex sympathetic dystrophy of the hand: a study of eighty-nine cases. Ann Chir Main 1986;5:93-104. 16. Michaels RM, Sorber JA. Reflex sympathetic dystrophy as a probable paraneoplastic syndrome: case report and literature review. Arch Rheum 1984;27:1183-5. 17. Steinbrocker 0. The shoulder-hand syndrome: present perspective. Arch Phys Med Rehabil 1968;49:388-95. 18. Medsger TA, Dixon JA, Garwood VF. Palmar fasciitis and polyarthritis associated with ovarian carcinoma. Ann Intern Med 1982; 96:424-3 1. 19. Mandel S, Rothrock RW. Sympathetic dystrophies: recognizing and managing a puzzling group of syndromes. Postgrad Med 1990; 87: 213-8. 20. Amin R. Bilateral Pancoast’s syndrome in a patient with carcinoma of cervix. Gynecol Oncol 1986; 24: 126-8. 21. Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain, Homer’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;99:1391-6. 22. Derbekyan V, Novales-Diaz J, Lisbona R. Pancoast tumor as a cause of reflex sympathetic dystrophy. J Nucl Med 1993;34: 19924. 23. Dzwierzynski WW, Sanger JR. Reflex sympathetic dystrophy. Hand Clin 1994; 10:29&l. 24. Hinterbuchner C. Management of shoulder-hand syndrome. In: Ruskin AP, editor. Current therapy in physiatry: physical medicine and rehabilitation. Philadelphia: Saunders, 1984:263-5.
CLINICAL NOTES
Upper Limb Reflex Sympathetic Occult Malignancy Aubrey Ku, MD, Elisabeth Lachmann,
Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressivephysical therapy measures,the patients’ symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases,medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.
0 1996 by the American Congress ofRehabilitation Medicine and the American Academy ofPhysical Medicine and Rehabilitation
R
EFLEX SYMPATHETIC DYSTROPHY (RSD) is a syndrome of burning pain, swelling, vasomotor instability, and trophic changes in an extremity.’ RSD of the upper extremity often presents as a painful disability of the shoulder with swelling, stiffness, and pain of the hand and fingers.2,1 The most common precipitating factors of this syndrome include myocardial infarction, stroke, and trauma.4-6 We report two casesof RSD of the upper extremity in patients with a history of cancer. Despite aggressive physical therapy measures, the patients’ symptoms persisted. Workup of the first patient found recurrent breast cancer; in the second case, lymphoma, a second primary malignancy, was diagnosed. Appropriate treatment of the underlying malignancy in each case resulted in improved hand and shoulder function and decreased pain. In both cases,prolonged hospitalization and multiple procedures could have been avoided if malignancy had been suspected as a cause of RSD. CASE ONE A 68-year-old woman presented with a 4-month history of painful restriction of right shoulder movement with progressive From Rehabilitation Medicine, New York Hospital-Cornell Medical Center, New York, NY. Submitted for publication September 19, 1995. Accepted December 20. 1995. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Aubrey Ku, MD, 435 East 70th Street, 25 C, New York, NY 10021. 0 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Arch
Phys
Med Rehabil
Vol77,
July
1996
Associated With
MD, Richard Tunkel, MD, Willibald Nagler, MD
ABSTRACT. Ku A, Lachmann E, Tunkel R, Nagler W. Upper limb reflex sympathetic dystrophy associated with occult malignancy. Arch Phys Med Rehabil 1996;77:726-8.
0003.9993/96/7707-3700$3.M)IO
Dystrophy
swelling, stiffness, and burning pain of the ipsilateral hand and fingers. Her medical history was significant for breast cancer, treated 6 years before by left lumpectomy with axillary dissection and subsequent radiation therapy, which was in remission. There was no evidence of lymphedema. A left frontal lobe meningioma was removed 2 years before, leaving her with residual hand weakness without pain. Physical examination found 2+ pitting edema of the distal right upper extremity with shiny, pale skin over the hand and fingers. Sensation was intact, but painful dysesthesia was present. Range of motion of the shoulder, wrist, and fingers was decreasedto approximately 50% of normal. Reflexes were intact and laboratory values were within normal limits, with the exception of the alkaline phosphatase level, which was mildly elevated at 13lU/L (normal range, 30 to 1lOU/L). This patient’s upper extremity dysfunction was believed to be secondary to chronic right hemiparesis resulting from her left frontal lobe meningioma. Physical therapy consisted of contrast baths, paraffin baths, active assistedrange of motion exercises, and edema-controlling techniques, which included massage, arm elevation, and use of compressivegarments. A total of eight fluoroscopy-guided stellate ganglion blocks were performed by anesthesiologists, each with 5 to 1OmL of .25% bupivacaine without epinephrine at the C6 level. Reduced pain in the right arm and hand with increased range of motion lasted only a few hours after each block. Evaluation of the etiology of the patient’s RSD included a chest X-ray, which showed a right paratracheal mass. Computed tomography (CT) of the chest (fig 1A) showed this mass compressing the sympathetic ganglion chain. Biopsy of the mass revealed breast adenocarcinoma. Further workup for other sites of metastatic disease, including mammography, was negative. The patient received radiation therapy of 4,600cGy to the area of the mass, and administration of tamoxifen, 20mg each day, was begun. Complete amelioration of pain, normal right shoulder and hand range of motion, and resolution of edema was observed 6 months later on examination. Repeat CT 1 year later (Fig 1B) showed almost complete resolution of the right paratracheal mass. CASE TWO A 42-year-old woman presented with a 6-month history of presumed right axillary cellulitis unresponsive to antibiotics. She complained of increasing pain and decreasing range of motion of the right hand, fingers, and shoulder. Her medical history included medullary carcinoma of the thyroid 3 years earlier treated with thyroidectomy, without recurrence. Physical examination was significant for right axillary mass, 2+ pitting edema and erythema throughout the entire upper extremity, and atrophic changes of the integument. There was significant allodynia with light touch. Range of motion of the shoulder, wrist, and fingers was markedly limited, with significant pain at end-range. Laboratory values were significant for anemia, thrombocytosis, and an elevated erythrocyte sedimentation rate of 65mm/h (normal range, 0 to 2OmnVh).
RSD AND
MALIGNANCY,
727
Ku
Fig 1. IA) CT of the chest shows parsvertebbral mass (arrow) in the apical right lung. (6) CT 1 Year later shows residual scarring of the paravertebral mass (anowl.
During the medical workup physical therapy was begun, consisting of active assisted range of motion exercises, arm clevation, and systemic desensitization directed toward reducing the patient’s allodynia. CT showed a right axillary mass (fig 2) contiguous with the lower brachial plexus. Subsequent biopsy revealed pleomorphic lymphoma. Treatment with chemotherapy and radiation therapy was instituted, with marked improvement of shoulder, wrist, and finger range of motion and decreased complaints of pain.
DISCUSSION Mitchell and coworkers’ in 1864 described the syndrome of painful hands and feet in wounded soldiers of the American Civil War who wrapped their affected limbs in wet rags to “extinguish the fire.” Although RSD has been associated with many clinical conditions, its etiology is still poorly understood. There are many theories on the pathogenesis of RSD concerning both peripheral and central mechanisms.’ Sympathetic dysfunction is currently the presumed etiology of RSD.’ The clinician must bc aware of the clinical manifestation of RSD, because early recognition and aggressive treatment often produces the best clinical response.“ The clinical features of RSD include pain out of proportion to injury and progression in stages! Stage I is the acute stage, marked by burning or aching pain increased by dependency of the affected part of physical contact. Edema occurs in the affected part, and bony
Fig 2. CT of the chest
shows
mass
in the right
axilla
(arrow).
changes may be seen on X-rays.5 Stage 2 is the dystrophic stage in which pain is constant and the indurated tissue is cool and hypcrhydrotic. X-rays may show patchy osteoporosis.“’ Stage 3 is the atrophic stage. Pain spreads proximally, and irreversible tissue damage occurs. The skin is thin and shiny, and flexion contracturc may occur. X-rays show bony demineralization and ankylosis.“’ Each stage may last from 1 to 6 months or more.” RSD is a clinical diagnosis that may be supplemented by several diagnostic studies. Successful sympathetic blockade can bc both diagnostic and therapeutic.“,” Erythrocyte sedimentation rate is elevated in approximately 70% percent of RSD patients but is nonspecific.“’ Triple-phase bone scan may show increased uptake in the wrist, metacarpophalangeal, and interphalengeal joints, with a reported sensitivity of 96% and specificity of 86% for RSD.” Electrodiagnostic study results are usually normal. Thirty-eight cases of malignancies have been associated with RSD, primarily involving the upper extremity.16 RSD may represent a paraneoplastic syndrome in some cases, supported by the close temporal relationship with the development of malignancy. RSD of the upper extremity has been associated with meningiomas, primary and metastatic cerebral tumors, pancreatic carcinoma, and Pancoast tumors of the lung.“,‘“.” RSD has been reported in association with gynecologic malignancy. RSD of the lower extremity has been precipitated by cervical and vulvar carcinomas.” Ovarian carcinomas have been associated with shoulder-hand syndrome, possibly through paraneoplastic effects.‘x Radiation therapy in a patient with ovarian cancer resulted in regression of the neoplasm with improvemcnt in shoulder-hand syndrome.” Signs of RSD of the upper extremity have been found to precede the diagnosis of ovarian cancer by 2 years.” The two cases presented suggest a casual relationship between the malignancy and the RSD. In each case, RSD preceded the discovery of the neoplastic process by 4 to 6 months. Brcmer? described a similar history of RSD and subsequent diagnosis of cancer in 1966. Six months after the onset of RSD, ovarian cancer was diagnosed. The tumor regressed with radiation therapy, with coincident improvement in the RSD. Similarly, in our cases, treatment of the malignancy with radiation therapy or radiation therapy and chemotherapy resulted in tumor shrinkage and improved upper extremity functions.
Arch
Phys Med
Rehabil
Vol 77, July
1996
728
RSD AND
MALIGNANCY,
There are two likely etiologies of RSD in these two patients. Direct tumor effects may include mechanical irritation of the sympathetic ganglia or nerves. Space-occupying tumors may cause local ischemia to the sympathetic nervous tissue in the region. Macrometastatic invasion may also compromise sympathetic function. A second possible mechanism to explain RSD resulting from neoplasm is an immunologically mediated paraneoplastic effect. There are no established treatment protocols for RSD. The principle of treatment is to maintain range of motion and decreasepain and edema. To disrupt the destructive cycle of RSD, physical therapy and related modalities may be supplemented by sympathetic ganglion blockade or systemic corticosteroid if indicated.2’,24In our two patients, aggressive occupational and physical therapy in conjunction with the treatment of the underlying malignancy led to the resolution of RSD. CONCLUSION We presented two cases of occult malignancy preceded by RSD which resolved after successfultreatment of the neoplasia. A review of the literature found an infrequent association between RSD and malignancy. Onset of RSD without a clear precipitant or effective response to treatment may warrant a search for occult malignancy. References 1. Schutzer SF, Gossling HR. Current concept review: the treatment of reflex sympathetic dystrophy. J Bone Joint Surg Am 1989;66A: 625-9. 2. Bremer C. Shoulder-hand syndrome: a case of unusual aetiology. Ann Phys Med 1966;9:168-71. 3. Steinbrocker 0. The shoulder-hand syndrome: associated painful homolateral disability of the shoulder and hand with swelling and atrophy of the hand. Am J Med 1947; 3:402-7. 4. Lankford LL. Reflex sympathetic dystrophy. In: Hunter JM, editor. Rehabilitation of the hand: surgery and therapy. St. Louis: Mosby, 1990:763-86. 5. Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy: a review. Arch Neurol 1987;44:555-61. 6. Kozin F. The painful extremity-consider reflex sympathetic dystrophy. Diagnosis 1988; 10:86-91. 7. Mitchell SW, Morehouse GR, Keen WW. Gunshot wounds and other injuries of nerves. Philadelphia: Lippincott, 1864.
Arch
Phys Med Rehabil
Vol77,
July
1996
Ku
8. Dimitru D. Reflex sympathetic dystrophy. In: Walsh NE, editor. Physical medicine and rehabilitation: state of the art reviews. Philadelphia: Hanley & Belfus, 199 1; 5:89-l 02. 9. Philip PA, Philip M, Monga TN. Reflex sympathetic dystrophy in central cord syndrome: case report and review of the literature. Paraplegia 1990;28:48-54. 10. Hodges DL, McGuire TJ. Burning and pain after injury: is it causalgia or reflex sympathetic dystrophy? Postgrad Med 1988; 83: 18592. 11. Goldberg MI, Kennedy SF. Reflex sympathetic dystrophy-recognition and management in gynecologic oncology. Gynecol Oncol 1979; 8:288-95. 12. Bej MD, Schwartzman RJ. Abnormalities of cutaneous blood flow regulation in patients with reflex sympathetic dystrophy as measured by laser doppler fluxmetry. Arch Neurol 1991;48:912-5. 13. Roberts WJ, Elardo SM. Sympathetic activation of unmyelinated mechanoreceptors in cat skin. Brain Res 1985;339:123-5. 14. Escobar PL. Reflex sympathetic dystrophy. Ortho Rev 1986; 15: 646-51. 15. Constantinesco A, Brunot B, Demangeat JL, Foucher G, Farcot JM. Three-phase bone scanning as an aid to early diagnosis in reflex sympathetic dystrophy of the hand: a study of eighty-nine cases. Ann Chir Main 1986;5:93-104. 16. Michaels RM, Sorber JA. Reflex sympathetic dystrophy as a probable paraneoplastic syndrome: case report and literature review. Arch Rheum 1984;27:1183-5. 17. Steinbrocker 0. The shoulder-hand syndrome: present perspective. Arch Phys Med Rehabil 1968;49:388-95. 18. Medsger TA, Dixon JA, Garwood VF. Palmar fasciitis and polyarthritis associated with ovarian carcinoma. Ann Intern Med 1982; 96:424-3 1. 19. Mandel S, Rothrock RW. Sympathetic dystrophies: recognizing and managing a puzzling group of syndromes. Postgrad Med 1990; 87: 213-8. 20. Amin R. Bilateral Pancoast’s syndrome in a patient with carcinoma of cervix. Gynecol Oncol 1986; 24: 126-8. 21. Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain, Homer’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;99:1391-6. 22. Derbekyan V, Novales-Diaz J, Lisbona R. Pancoast tumor as a cause of reflex sympathetic dystrophy. J Nucl Med 1993;34: 19924. 23. Dzwierzynski WW, Sanger JR. Reflex sympathetic dystrophy. Hand Clin 1994; 10:29&l. 24. Hinterbuchner C. Management of shoulder-hand syndrome. In: Ruskin AP, editor. Current therapy in physiatry: physical medicine and rehabilitation. Philadelphia: Saunders, 1984:263-5.