Estimated that 10% of acrometastasis become symptomatic before a primary tumor is discovered,8 it was the initial presentation of occult tumors in 10 of the 29 (34%) reported cases since 2008. Patients were misdiagnosed with osteoarthritis or infection based on presentation.9,10 Radiographic osteolytic changes prompted a malignancy work-up after histological confirmation. However, Bhandari and Brown11 reported one case of persistent pain 3 months before radiographic changes increasing the need for high suspicion of acrometastasis in persistent pain refractory to nonsteroidal anti-inflammatory drugs or antibiotics.
Not limited to bone, acrometastasis to the skin and soft tissues without skeletal involvement can also occur. Aydin et al12 reported a laryngeal carcinoma metastasizing to skin overlying the palmar surface of the left fifth metacarpal joint, and Afshar et al13 reported a gestational choriocarcinoma metastasizing to the junction of the hyponychium and nail bed of the small finger of the dominant hand.
The mechanism of acrometastasis remains poorly understood. The phalangeal absence of bone marrow has led to alternative theories for hematologic spread14 including increased blood flow and trauma. The release of prostaglandins and local chemotactic factors can promote cell migration and adherence to bone.8 Observation that dominant hand metastasis occurs more commonly supports this theory as that hand receives more blood flow and is more prone to trauma than the nondominant hand.15
Given the advanced stage of disease upon presentation with a mean survival of 6 months, the goal of treatment is palliation.3 Although zoledronic acid and denosumab are often indicated to treat bone metastasis of primary solid tumors, their primary mechanism of action is the inhibition of osteoclasts from resorbing bone, limiting their use in acrometastasis where osteolysis has already occurred.16 Early detection, as in the case of Bhandari and Brown,11 may benefit from these medications to prevent progression.
Unfortunately, acrometastasis is usually detected late, making aggressive modalities such as curettage, wide excision, chemotherapy, radiation, and amputation necessary to achieve palliation.6 The lesion site also contributes to the treatment approach. Proximal and thumb lesions are best managed conservatively with radiation providing immediate pain relief while maintaining normal function.17,18 Distal lesions or lesions unresponsive to radiation require palliative amputation to provide comfort in the patient’s end of life.3 Acrometastasis represents a poor prognosis with a survival rate of approximately 1 year with therapy19; therefore, reconstruction is not typically considered unless the patient remains tumor free for 2 to 3 years.20
Acrometastasis from a primary RCC or HCC is a rare condition carrying grave prognostic indicators. It is important for plastic hand surgeons treating patients to understand implications of discovering such a lesion; although curative resection is unlikely, palliative resection should be considered.
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