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CASE REPORT
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 599-601

First case of acrometastases to the wrist reported from penile cancer


1 Department of Nuclear Medicine, Greater Poland Cancer Centre, Poznan, Poland
2 Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
3 Department of Radiotherapy, Greater Poland Cancer Centre, Poznan, Poland
4 Department of Electroradiology, Medical University; Department of Nuclear Medicine, Greater Poland Cancer Centre, Poznan, Poland
5 Department of Electroradiology, Medical University; Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland

Date of Submission09-Jul-2019
Date of Decision13-Jul-2020
Date of Acceptance12-Aug-2020
Date of Web Publication11-Jun-2021

Correspondence Address:
Paulina Cegla
Department of Nuclear Medicine, Greater Poland Cancer Centre, Garbary 15, Poznan 61-866
Poland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_476_19

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 > Abstract 


Penile cancer is a rarely diagnosed cancer that affects 0.4%–0.6% of all male population. Metastases to the bones from various human cancers are common; however, acrometastases are extremely rare with the most common primary tumor from lung, kidney, and breast. We report the first case of a patient with acrometastases to the left wrist reported from penile cancer.

Keywords: Acrometastases, 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography, penile cancer, radiotherapy


How to cite this article:
Cegla P, Konstanty E, Fundowicz M, Pietrasz K, Matuszewski K, Heydrych A, Piotrowski T. First case of acrometastases to the wrist reported from penile cancer. J Can Res Ther 2021;17:599-601

How to cite this URL:
Cegla P, Konstanty E, Fundowicz M, Pietrasz K, Matuszewski K, Heydrych A, Piotrowski T. First case of acrometastases to the wrist reported from penile cancer. J Can Res Ther [serial online] 2021 [cited 2021 Sep 23];17:599-601. Available from: https://www.cancerjournal.net/text.asp?2021/17/2/599/318111




 > Introduction Top


Penile cancer is a rare, challenging urological cancer, and according to the newest data from GLOBOCAN in 2018, there was 34,475 new incidences and 15,138 deaths worldwide.[1] The 5-year survival rate in penile carcinoma is about 50%; however, only 27% of patients with metastatic lymph nodes survive the first 5 years after diagnosis.[2] Acrometastases to the hand and feet are usually the sign of disseminated disease, representing 0.1% of all metastatic lesions in bones and associated with poor prognosis.[3],[4] The importance of proper diagnosis of acrometastases in penile cancer patients might help improve the treatment options for patient and patient's quality of life.


 > Case Report Top


A 71-year-old man with histopathologically confirmed keratinizing squamous cell carcinoma (SCC) moderately differentiated (G2) penile cancer, after total panectomy with perineal urethrostomy, underwent a positron emission tomography/computed tomography (PET/CT) labelled with 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) imaging in the Nuclear Medicine Department to determine to severity of the disease in March 2015. Due to of swelling in the left hand in June 2014, the patient underwent whole body scintigraphy (WBS) – in different Nuclear Medicine Department – with99mTc-labeled methylene diphosphonate ([99mTc]Tc-MDP), which revealed increased uptake in the left wrist suggesting local tumor growth or a wrist injury. [18F]-FDG PET/CT study performed in authors' institution department revealed a hypermetabolic mass destroying the bones of the left wrist with maximum standardized uptake value (SUVmax) up to 10.9 [Figure 1], lymph nodes in the left axillary with SUVmax up to 3.7, and mesenteric lymph node at the superior mesenteric vein (SMV) with SUVmax up to 2.7, which were suggested as metastatic lymph nodes.
Figure 1: 2-deoxy-2-[18F]fluoro-D-glucose-positron emission tomography/computed tomography with increased uptake in the left wrist

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The patient underwent the biopsy of the left wrist which revealed a metastasis from keratinizing SCC; he was referred to the Oncology and Radiotherapy Clinic for a palliative radiotherapy of the left wrist. Physical examination findings showed a Karnofsky score of 80, irregular heartbeat (around 80 for min), with significant swelling of the fingers of the left hand and no other findings (liver and spleen nonenlarged). He received a dose of 6 MV photons to the wrist and left distal forearm bone. A month after treatment, the patient underwent chemotherapy according to the monotherapy bleomycin scheme and the second radiotherapy palliative treatment to the wrist to dose of 8 Gy [Figure 2].
Figure 2: Dose distribution during palliative radiotherapy of the left wrist

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After 5 months, he underwent another [18F]-FDG PET/CT imaging which showed a progression of the disease [Figure 3] which SUVmax in the left wrist bones up to 13.9.
Figure 3: Progression of the disease showed in the second 2-deoxy-2-[18F]fluoro-D-glucose-positron emission tomography/computed tomography study

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Amputation at the level of the distal end of the left humerus was performed in November 2015, because of the dissemination of the disease, and due to nonrecovery of the surgical wound, the patient was not qualified for continuation of chemotherapy treatment. He also complained of weakness and phantom pain. The last data about this patient were noted in December 2015, and because of the progression of the disease, the patient died a few months later.


 > Discussion Top


Penile cancer represents about 0.5% of all men cancers,[5] with distant metastases seen only in advanced stages. Although distant metastases to the lymph nodes are common, involvement of lungs, liver, or bones is rare, affecting <3%–5% of patients.[6] Bone metastases in penile cancer are very rare and usually are localized in the axial skeleton. Regional lymph nodes are usually first demonstration of dissemination of the disease. In our case, the patient did not have any inguinal or regional lymph nodes, only in the left axillary and mesenteric lymph node at the SMV.

Metastases localized below the elbow or knee account around 4.1% of all bone metastases, while metastases to the hand are extremely rare accounting for only 0.1% of all metastatic lesions.[7] Based on the literature review, Stomeo et al. performed a meta-analysis where they revised new cases of acrometastates and added them to the previous database available in literature, and according to them, since 1987, no acrometastases have been reported from penile cancer, but only two new cases from urothelial cancers.[4] Other authors suggest that acrometastases are more common in men than in female and less common are reported in colon, stomach, liver, prostate, and rectum cancer. In the same review, authors noted that right hand was more often affected by metastatic lesions and almost 10% of patients had metastases to both hands.[8] In our case, the patient represented acrometastases in the left capital bone and no other metastatic lesions in bones were noted. According to the analysis performed by Afshar et al., hand metastases was the first manifestation of an occult diagnosis and only 26% of patients had isolated metastases to their hands as in our case. The most commonly involvement was distal phalanx and no penile cancer was reported as a primary tumor in analysis of 221 cases.[9]

PET/CT is a useful tool for imaging and staging various malignant disease; however, in penile cancer, the role of this method is limited due to the urinary [18F]-FDG excretion and spatial resolution (even if most of primary penile cancers are [18F]-FDG-avid).[10] However, it should be remembered that acrometastases might be missed in standard [18F]-FDG imaging because hands and feet are usually located outside the imaging area. In our case, because the patient complained for a pain and swelling of the left hand, examination was performed in “hands down” position. If there is tumor cell dissemination, the patient should have metastases located in the axial skeleton, which in our case were not diagnosed either with WBS or in [18F]-FDG. In addition to metastasis to the lymph nodes, no other in the skeletal system was noted. Because penile cancer is a rare cancer and treatment options are limited, the median survival is around 6 months. In our case, the patient survived 18 months since acrometastases to the left wrist were diagnosed which could have been caused by two courses of palliative radiotherapy to the wrist area and courses of chemotherapy that slowed the progression of the disease.


 > Conclusion Top


This case shows the importance of proper diagnosis of acrometastases in penile cancer patients, which might help improve the treatment options for patient and patient's quality of life. Further, to the best of our knowledge, we report the first case of acrometastases to the wrist from penile cancer patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 1
    
2.
Barski D, Georgas E, Gerullis H, Ecke T. Metastatic penile carcinoma-An update on the current diagnosis and treatment options. Cent European J Urol 2014;67:126-32.  Back to cited text no. 2
    
3.
Khosla D, Rai B, Patel FD, Sapkota S, Srinvasan R, Sharma SC. Acrometastasis to hand in vaginal carcinoma: A rare entity. J Cancer Res Ther 2012;8:430-2.  Back to cited text no. 3
    
4.
Stomeo D, Tulli A, Ziranu A, Perisano C, De Santis V, Maccauro G. Acrometastasis: A literature review. Eur Rev Med Pharmacol Sci 2015;19:2906-15.  Back to cited text no. 4
    
5.
Barnholtz-Sloan JS, Maldonado JL, Pow-sang J, Giuliano AR. Incidence trends in primary malignant penile cancer. Urol Oncol 2007;25:361-7.  Back to cited text no. 5
    
6.
Sonpavde G, Pagliaro LC, Buonerba C, Dorff TB, Lee RJ, Di Lorenzo G. Penile cancer: current therapy and future directions. Ann Oncol 2013;24:1179-89.  Back to cited text no. 6
    
7.
Kerin R. Metastatic tumors of the hand. A review of the literature. J Bone Joint Surg Am 1983;65:1331-5.  Back to cited text no. 7
    
8.
Flynn CJ, Danjoux C, Wong J, Christakis M, Rubenstein J, Yee A, et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008;15:51-8.  Back to cited text no. 8
    
9.
Afshar A, Farhadnia P, Khalkhali H. Metastases to the hand and wrist: An analysis of 221 cases. J Hand Surg Am 2014;39:923-3.  Back to cited text no. 9
    
10.
Ottenhof SR, Vegt E. The role of PET/CT imaging in penile cancer. Transl Androl Urol 2017;6:833-8.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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