Don’t Spread This Around

By Peter Galvin, MD

The terms metastasis, metastasize, etc. refer to the spread, usually hematogenous (via the bloodstream), of cancer. As a rule, the presence of metastatic disease is not a good sign. Today’s case is from the Peter MacCallum Cancer Center in Melbourne, Australia. A 55-year-old man was being treated there for metastatic squamous-cell lung cancer when he presented to the hospital with a six-week history of pain and swelling of the right great toe and tip of the right middle finger. He denied having gout, trauma, or a fever. On physical examination, there was swelling and erythema (redness) of the distal phalanx (outermost small bone in a finger or toe) of the right middle finger (Panel A) and right great toe (panel B). An area of ulceration adjacent to the toenail of the toe was also present (as seen in Panel B). The lesions were firm and tender on palpation.

Radiographs (X Rays) of the hands and feet showed destructive lytic lesions that had completely replaced bone in the distal phalanx of the middle finger (Panel C) and great toe (Panel D). A diagnosis of acrometastases was made. Acrometastases are a rare type of bony metastases that are found distal to (outward of) the elbow or knee. Although acrometastases may mimic acute gout, osteomyelitis (bone infection), or a paronychia (ingrown nail), in patients with known cancer plain radiographs aid in making the diagnosis and will help differentiate the correct diagnosis from osteomyelitis, which also destroys bone.

In this case palliative radiation was begun, but unfortunately the patient died three weeks later from complications of his lung cancer.

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