|Year : 2012 | Volume
| Issue : 3 | Page : 430-432
Acrometastasis to hand in vaginal carcinoma: A rare entity
Divya Khosla1, Bhavana Rai1, Firuza D Patel1, Simit Sapkota1, Radhika Srinvasan2, Suresh C Sharma1
1 Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cytology and Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||17-Nov-2012|
Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, U.T - 160012
Although metastases to bones from solid tumors are very common, involvement of small bones of the hands is extremely rare. We report the first case of acrometastasis in vaginal carcinoma. We present a 65-year-old multiparous woman with FIGO Stage II vaginal carcinoma. The patient received treatment with external beam radiotherapy followed by brachytherapy. She had complete response to above treatment. Eleven months later, she presented with swelling on dorsum of hand. Investigations revealed metastasis to 4th metacarpal bone with lung metastasis. Hence, we present a patient with metastasis of carcinoma vagina to the 4 th metacarpal to draw the attention for the potential of such lesions to be developed in this region. It should be remembered that bone metastasis at unusual sites might be seen in vaginal carcinoma. We present this case because of its rarity and for documentation and discussion.
Keywords: Acrometastasis, bone metastasis, metacarpal, vaginal carcinoma
|How to cite this article:|
Khosla D, Rai B, Patel FD, Sapkota S, Srinvasan R, Sharma SC. Acrometastasis to hand in vaginal carcinoma: A rare entity. J Can Res Ther 2012;8:430-2
| > Introduction|| |
Primary vaginal cancer is a rare entity, representing only 3% of all malignant neoplasms of the female genital tract. Acrometastasis to the hands is not common, accounting for approximately 0.1% of all metastatic osseous involvement.  Acrometastasis is usually a late manifestation of disseminated disease or it can also be the primary manifestation of an occult cancer. Consequently, its manifestation often connotes a poor prognosis. The terminal phalanges are the most frequent site of metastasis, followed by the metacarpals and the proximal phalanges. , The most frequent site of hematogenous metastasis is the lung. Less frequently, vaginal cancers may metastasize to liver, bone, or other sites.  Metastatic bone involvement in vaginal carcinoma is rare. To the best of our knowledge, there is no case report of acrometastasis in vaginal carcinoma. We report a rare presentation of metacarpal bone metastasis with lung metastasis in patient of carcinoma vagina with controlled primary disease.
| > Case Report|| |
A 65-year-old female presented with 7-month history of bleeding per vaginum, vaginal discharge, and pain lower abdomen. On examination, she had no palpable nodes and her abdomen was soft and non-tender with no mass palpable. On local examination, cervix was atrophied with posterior lip partially flushed and polypoidal nodular growth was palpable arising from the junction of upper and middle third of posterior vagina which was reaching up to introitus and extending to bilateral vaginal walls. On rectal examination, disease was felt in bilateral paracolpos but not reaching up to the lateral pelvic wall. Examination under anesthesia was done which confirmed above findings. Chest roentgenography, complete blood cell count, biochemical profile, and proctoscopy were within normal limits. Contrast-enhanced computed tomography (CECT) of abdomen and pelvis was also done which was suggestive of thickened and irregular vaginal walls with preserved fat planes with rectum and bladder with no evidence of pelvic and inguinal lymphadenopathy. Histopathological diagnosis of vaginal growth was squamous cell carcinoma. Thus, the patient was diagnosed with carcinoma of the vagina FIGO stage II. She was treated with external beam radiotherapy of 46 Gy/23#/4.3 weeks followed by low dose rate (LDR) intracavitary brachytherapy with the Delcos vaginal cylinder (30 Gy LDR). The patient completed treatment without interruption and had a complete clinical response. However, at 11 months follow-up, she presented with a firm swelling over dorsum of left hand [Figure 1]. X-ray of the hand showed an osteolytic lesion with destruction of 4th left metacarpal bone [Figure 2]. A biopsy revealed metastatic moderately differentiated squamous cell carcinoma [Figure 3]. Bone scan showed an isolated area of increased tracer uptake in 4th metacarpal with no other evidence of bony metastasis. Positron emission tomography (PET) scan revealed multiple FDG avid pulmonary nodules, multiple mediastinal nodes, right hilar nodes with a FDG avid lytic expansile lesion with complete bone destruction of 4 th left metacarpal. Thus, the patient was diagnosed with carcinoma of vagina with metastasis to lungs and 4th metacarpal bone with controlled primary disease. She was treated with palliative radiotherapy (30 Gy in 10 fractions) to hand followed by palliative chemotherapy with paclitaxel, ifosfamide, and carboplatin. There was a significant reduction in size with improvement in symptoms after treatment and the patient remains under observation.
|Figure 2: X-ray of the hand showing an osteolytic lesion with destruction of 4th left metacarpal bone|
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|Figure 3: Microphotograph of the biopsy showing a moderately differentiated squamous cell carcinoma. [H&E stain ×400]|
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| > Discussion|| |
In patients with gynecologic malignancies, bone metastases are unusual and generally occur in a more advanced stage of the disease with extended local invasion of the primary site and parenchymal metastasis. In a study by Abdul-Karim et al.,  autopsies were performed on 305 patients with primary carcinomas of the cervix, endometrium, ovaries, fallopian tubes, vulva, and vagina. Skeletal metastases were detected premortem and at autopsy in 49 cases (16.1%): cervix, 20 (40.8%); endometrium, 17 (34.7%); ovary, 7 (14.3%); vulva, 4 (8.2%); fallopian tube, 1 (2%). There were no cases of osseous metastasis from vaginal carcinoma.
The pattern of spread from carcinoma of vagina has been well studied. The most frequent sites of hematogenous metastasis in vaginal carcinoma are lung and liver. Bone metastasis is very rare. In a study by Chyle et al.,  51 sites of metastasis were documented in the 44 patients of vaginal carcinoma who developed disease dissemination: lung in 25, paraaortic in 9, liver in 8, bone in 5, peritoneal in 3 and brain in 1. In a retrospective review of 28 patients of vaginal carcinoma by Gallup et al.,  the most common metastatic site was lung followed by liver. Tjalma et al.  reported a rare case of metastasis to fibula as the presenting feature of vaginal cancer in a 74-year-old woman who was then treated with palliative bone resection and radiotherapy. This case highlighted the unique presentation of a vaginal cancer by pain in the lower leg secondary to a metastasis in the fibula and the importance of aggressive treatment of a solitary bone metastasis in order to provide effective palliation. To the best of our knowledge, there is no case report of acrometastasis from vaginal carcinoma.
Acrometastasis to the hands is a rare occurrence. The distal phalanges are the most frequent site of metastatic deposition although involvement in all bones of the hand has been described. The incidence of metastasis to the metacarpals is 17%, phalanges 66%, and carpal bones 17%.  The lung is the most common source with 42% followed by the breast and kidney each of which account for 11%. , Other sources include colon, prostate, thyroid, esophageal, and bone cancers. 
Metastases typically involve the osseous structures of the hand although soft tissue lesions can occur as a result of tumor erosion or direct seeding. The mechanism by which tumors metastasize to the hand remains obscure. A variety of factors including trauma, tissue thermal differences, hormonal influence, hemodynamics, and host immune responses have all been implicated. , Hematogenous dissemination of tumor emboli is the presumed mechanism in the majority of cases. Bone metastases usually develop in areas rich in red marrow.  The scarce quantity of this tissue within the bones of the hand supports findings in the literature suggesting that secondary lesions arising in the terminal regions of the extremities are quite remarkable.  The lung can spread metastases into the systemic circulation and origin of hand metastases is usually the lung. ,
The patient usually presents with a painful, swollen, erythematous, and warm hand. The x-rays show lytic bony lesion. The differential diagnosis includes gout, pulp space infection, osteomyelitis, septic arthritis, rheumatoid arthritis, tenosynovitis, and reflex sympathic dystrophy.
Because acrometastasis generally accompany widespread disease, the prognosis of patients with acrometastasis is poor. Upon presentation of a metastatic hand lesion, patients are anticipated to survive merely 6 months. , This should be taken in account in the management of these patients. Due to poor prognosis, patients should be treated with the aim to improve quality of life and palliate symptoms. Radiotherapy and chemotherapy may be appropriate and amputation could be an option for lesions at the distal phalanx. We treated our patient using palliative radiotherapy to the metastatic site and chemotherapy. Following the treatment, there was a definitive improvement in the patient's symptoms and quality of life.
| > Conclusion|| |
Acrometastasis to the hands is a rare occurrence. It has never been documented in vaginal cancer. It should be remembered that bone metastasis at unusual sites might be seen in vaginal carcinoma. The present report serves to emphasize the importance of properly diagnosing acrometastasis. Although acrometastasis is rare, a high clinical suspicion must exist. Diagnosing such lesions can be difficult and challenging. Management of such cases should be multifactorial, due to the rarity and the poor prognosis.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3]