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CASE REPORT
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Metastatic adenocarcinoma presenting as monoarticular arthritis of the knee: A case report with review of literature


1 Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Orthopaedics, Indira Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Radiology, Indira Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission01-Jul-2019
Date of Decision20-Oct-2019
Date of Acceptance01-Dec-2019
Date of Web Publication05-Nov-2020

Correspondence Address:
Banushree C Srinivasamurthy,
Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry - 605 009
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_469_19

 > Abstract 


Patients who develop metastatic arthritis secondary to solid tumors are rare. It is even more uncommon to be a presenting symptom. We present a case where a known case of osteoarthritic patient presented with complaints of knee swelling secondary to primary colonic carcinoma with lung metastasis. It was initially diagnosed on histopathology examination as metastatic adenocarcinoma from excised synovial mass and further investigated for primary carcinoma. Later, computed tomography was done and found out the primary colonic carcinoma arising from transverse colon along with lung metastasis.

Keywords: Immunohistochemistry, lung secondaries, osteoarthritis, transverse colon carcinoma



How to cite this URL:
Subhashini R, Srinivasamurthy BC, Bhat RV, Kaliaperumal A, Sivagurunathan GM. Metastatic adenocarcinoma presenting as monoarticular arthritis of the knee: A case report with review of literature. J Can Res Ther [Epub ahead of print] [cited 2020 Dec 2]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=300117




 > Introduction Top


The metastatic spread of cancer to the synovium is one of the rarest manifestations of malignant disease. It is even rare to be a presenting symptom of the disease. Adenocarcinoma has been the most common type of synovial metastasis encountered.[1] Primary lung cancer is the most common cancer to metastasize articular surfaces.[2] Malignant tumors of the knee joint occur most commonly secondary to metastasis. The malignant tumors which metastasize to the knee joint include lung, prostate, breast, thyroid, and gastrointestinal tract and bladder.[3] Most of these lesions are asymptomatic and clinically, the joint appears to be inflamed. The survival rate of patients was poor, with an average survival rate of fewer than 5 months.[4] Here, we report a rare case of colonic adenocarcinoma metastasizes to the knee joint and presenting as monoarticular arthritis.


 > Case Report Top


A 60-year-old diabetic and hypertensive female presented with sudden increase in swelling of the left knee joint with associated pain for the past 7 days. She was a known case of osteoarthritis of the left knee for the past 1 year on treatment and with a history of intra-articular steroid injection taken 1 month back. She had difficulty in moving the knee. The knee swelling was associated with pain and restriction of movement. There was no history of trauma or injury. On physical examination, diffuse, tender, warm swelling over the left prepatellar region associated with synovial thickening and fixed flexion deformity of 30°. Ultrasonography of the left knee was done and it suggested synovitis. Aspiration of the knee joint was done and it yielded a dry tap with only edema fluid. Magnetic resonance imaging (MRI) of the left knee suggested tubercular arthritis/pigmented villonodular synovitis [Figure 1]. Left knee synovectomy was done. Intraoperatively, necrotic areas were seen in the lower end of the femur, around the quadriceps tendon and medial aspect of the knee joint. A mass measuring 7 cm × 5 cm × 3 cm extending from the distal femur to the medial joint line was noted and it was excised [Figure 2] and sent for the histopathology examination. Gross examination revealed irregular gray-white soft-tissue mass measuring 7 cm × 5 cm × 4 cm. The external surface of the mass was gray yellow and capsulated at places. All surgical margins were painted. Cut surface was yellowish, soft to firm with necrotic and hemorrhagic areas [Figure 3]. Microscopic examination showed a joint capsule with an underlying tumor composed of irregular glands lined by pleomorphic cells with high N:C ratio, hyperchromatic nuclei surrounded by dense desmoplastic stroma with adjacent areas of hemorrhage and necrosis [Figure 4]a and b]. However, the focal area showed tumor infiltration into the adjacent adipose tissue. The skeletal muscle bundles and the painted margins were free from infiltration. Focal area of bony fragments, cartilage, and myxoid degeneration was also noted. Immunohistochemistry for pan-cytokeratin was done and it showed strong positivity [Figure 4]c. The final diagnosis of metastatic adenocarcinomatous deposits in the joint was given and advised to search for primary carcinoma. Then, computerized tomography of the thorax and abdomen was done and it revealed a primary tumor in the transverse colon with multiple lung metastases. Then, the patient was referred to the higher center for oncologist opinion and further management.
Figure 1: Magnetic resonance imaging showing multiple intra-articular synovial lesions with subarticular/subchondral extension, bony cortical defects of the patella, femoral condyles, and tibial plateau and joint effusion

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Figure 2: Intraoperative findings – After excision of the mass, necrotic area over the distal femur was identified and a cheesy material was scooped out

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Figure 3: Synovectomy specimen shows irregular gray-white soft-tissue mass measuring 7 cm × 5 cm × 4 cm. The external surface is gray yellow and capsulated at places. Cut surface is yellowish, soft to firm with necrotic and hemorrhagic areas

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Figure 4: Microphotograph showing tumor composed irregular glands (arrow), surrounded by robust desmoplastic stroma, with adjacent extensive areas of hemorrhage and necrosis (a, H and E, ×10). Microphotograph showing glands are lined by pleomorphic cells with high N:C ratio, hyperchromatic nuclei (b, H and E, ×40). Microphotograph showing immunohistochemistry positivity for pan-cytokeratin (c, PanCK +)

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 > Discussion Top


Patients who develop metastatic arthritis secondary to solid tumors are rare.[1] Skeletal metastasis from colorectal cancer is an uncommon event and when occurs, is usually a late manifestation of the disease, and is usually preceded by the liver or lung metastasis.[5] Adenocarcinoma has been the most common type of synovial metastasis encountered.[2] A review of the English language literature reveals that there have been 22 reported cases of malignant joint effusion associated with solid organ malignancy. Although there are number of malignancies that classically spread to the bone, over half of the reported cases with metastatic carcinomatous arthritis were associated with lung cancer.[6] Involvement is usually monoarticular with the knee being most commonly affected although the involvement of other joints has been reported.[3] The symptoms usually present in the joint sometime after the diagnosis of primary cancer has been made.[1] However, in our case, the patient was asymptomatic and she presented only with monoarticular arthritis. The mechanism by which primary cancer metastasizes to the synovium has been hypothesized to occur by one of the two mechanisms. The first mechanism is direct hematogenous spread to the synovium. The second is that the carcinoma first metastasizes to the bone and then further spreads to the synovium.[7] Aspiration may not always be reliable or diagnostic. In our case also, it yielded only dry tap. MRI may be informative and should be pursued in cases with a high index of suspicion. Synovial biopsy is needed for a definitive diagnosis. Ultimately, the prognosis of intrasynovial metastasis is poor, with an average survival of fewer than 5 months.[8] Roth et al. calculated an overall incidence of skeletal metastases from colorectal carcinoma was 5.5%. Among patients with skeletal metastases, 57% had concomitant liver involvement, whereas 71% had lung metastases.[9] In our study also, the patient had concomitant lung metastasis. There have been only three cases reported associated with colon cancer, and the average age of these patients was 72 years (the individual ages were 62, 73, and 83, respectively).[6] In a study by Ruparelia et al., a 28-year-old male presented with monoarticular arthritis, later the primary tumor was found in the sigmoid colon.[1] However, in our study, the patient was a 60-year-old female presented with monoarticular arthritis, and the primary was found in the transverse colon. The mass around the knee joint needs the expanded differential diagnosis, which includes pigmented villonodular synovitis, rheumatoid arthritis, gout, septic arthritis, hemarthrosis, lymphoma, amyloid arthropathy, and vascular malformations. The metastatic tumors have to be considered in the differential diagnosis once the patient crosses the age of ≥40 years.[10] The radiological and histopathological evaluation must be done for a definitive and final diagnosis.


 > Conclusion Top


After an extensive literature search, this is the first case of primary from transverse colon metastasizing to the knee and presenting as monoarticular arthritis. The diagnosis is difficult to reach and it is associated with a poor prognosis. This case illustrates the importance of thorough investigation in reaching this diagnosis and entertaining the possibility in individuals who do not respond to conventional management of acute monoarthritis and individuals who do not display any other symptoms of the disease.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge the patient and her family for allowing us to use her medical records in our case report and allowing this case to be published.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Ruparelia N, Ahmadi H, Cobiella C. Metastatic adenocarcinoma of the colon presenting as a monarthritis of the hip in a young patient. World J Surg Oncol 2006;4:95.  Back to cited text no. 1
    
2.
Levine HR, Tingle E, Carter B, Dockery D. Synovial metastasis from lung cancer. Proc (Bayl Univ Med Cent) 2013;26:25-7.  Back to cited text no. 2
    
3.
Devis P, Iwanik D, Aikens C. Metastatic adenocarcinoma presenting as monoarticular arthritis of the knee. AJR Am J Roentgenol 2005;184:S107-9.  Back to cited text no. 3
    
4.
Rothenberg AC, Henrikson AJ, Schiffmann SC, Goodman AC. Metastatic adenocarcinoma of hip and knee joints: A case series. J Cancer Ther 2014;5:323-30.  Back to cited text no. 4
    
5.
Aich RK, Suman G, Phalguni G, Jibak B, Diptimoy D. Bone metastasis. J Can Res Ther 2014;10:413-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Zissiadis Y. Acute arthritis as an unusual complication of malignancy. Australas Radiol 2000;44:474-7.  Back to cited text no. 6
    
7.
Murray GC, Persellin RH. Metastatic carcinoma presenting as monarticular arthritis: A case report and review of the literature. Arthritis Rheum 1980;23:95-100.  Back to cited text no. 7
    
8.
Capovilla M, Durlach A, Fourati E, Beucher AB, Eschard JP, Dehoux E, et al. Chronic monoarthritis and previous history of cancer: Think about synovial metastasis. Clin Rheumatol 2007;26:60-3.  Back to cited text no. 8
    
9.
Roth ES, Fetzer DT, Barron BJ, Joseph UA, Gayed IW, Wan DQ. Does colon cancer ever metastasize to bone first? A temporal analysis of colorectal cancer progression. BMC Cancer 2009;9:274.  Back to cited text no. 9
    
10.
Zabrzynski J, Jaworski L, Zabrzynska A. Adenocarcinoma of the lung versus synovial sarcoma – Metastatic tumor imitating primal tumor of the knee joint – Case report. Chir Narzadow Ruchu Ortop Pol 2016;81:1-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

 
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