Case Reports

Bronchogenic Squamous Cell Carcinoma With Soft-Tissue Metastasis to the Hand: An Unusual Case Presentation and Review of the Literature

Am J Orthop. 2014 December;43(12):E324-E327

References

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Acrometastasis

Metastatic disease distal to the elbow and knee is very rare; specifically, metastatic disease of the hands or feet accounts for approximately 0.1% of all metastases.⁴ Carcinoma of the lung accounts for 44% to 47% of all acrometastasis.^11,12 When hand acrometastasis is considered, the right hand accounts for 55% of bony cases, likely because of hand dominance, although approximately 10% of patients had bilateral acral metastatic disease.¹² The underlying mechanism of acrometastasis remains unclear; however, some authors have postulated that it may result from an increase in vascularity or a trauma to the affected extremity.^12,13 Flynn and colleagues¹² reviewed the literature and reported a total of 257 cases of acral metastasis to the hand; they found that the median age at presentation was 58 years. Men were more than twice as likely to be affected when compared with women. Most commonly, the primary malignancies were in the lung (44%), kidney (12%), and breast (10%). The authors also reported less common cases of acral metastasis with primary malignancies located in the stomach, liver, rectum, prostate, and colon. Most commonly, these metastases were found in the distal phalynx, followed by the metacarpals, proximal phalynx, and middle phalynx.¹²

Soft-Tissue Metastasis

Skeletal muscle metastasis occurs in 0.8% to 17.5% of metastatic neoplasms.^14-17 Studies in lung cancer patients have also revealed a low prevalence of muscular metastasis (0% to 0.8%).¹⁶ The rarity of muscular metastatic disease has been attributed to local inhibition of tumor survival secondary to muscle contraction, increased diffusing capacity of enzymes and immune cells, and extreme variability in blood flow and pH, lactate, and oxygen concentration. Skeletal muscular metastases most commonly arise from the lung, kidneys, colon, or melanoma.¹⁶ In a recent large series of more than 1400 patients imaged for soft-tissue masses, 2.5% were metastatic.¹⁸ There are only 2 reports of soft-tissue metastatic disease involving the hand: one from a patient with a thyroid carcinoma and the other from a patient with a lung adenocarcinoma.¹⁸ Soft-tissue metastatic disease from squamous cell carcinoma distal to the wrist has never been reported in the literature.

Acral Soft-Tissue Metastasis

A review from 2012 found 264 cases of skeletal muscle metastasis from 151 articles.⁶ Only 2 (0.75%) of these patients, as reported above, had a soft-tissue metastasis distal to the wrist.^6,17

Conclusion

We report the first known case of a soft-tissue metastasis distal to the wrist from a primary bronchogenic squamous cell carcinoma. This report highlights the extremely uncommon presentation of soft-tissue acral metastatic disease of a bronchogenic squamous cell carcinoma of the lung. Although exceedingly rare, oncologists and physicians who manage pathology of the hand should consider metastatic disease when evaluating a patient with complaints of hand pain and a soft-tissue mass, especially in a patient with a known primary malignancy.