gms | German Medical Science

Objectives/Interrogation: Metastatic cancer is the most common reason for a destructive bone lesion in adults. The hand and wrist are less commonly affected than the axial skeleton, and acrometastasis develop in less than 0.3% of patients with cancer.

Methods: A 69-year-old white male patient presented with a 2 days history of pain, edema, and decreased right wrist ROM. The patient denied any history of trauma, recent illness or fever. On physical examination there was mild swelling over the distal forearm and no warmth increase or erythema was identified, as well as no mass was palpable. The neurovascular structures were intact. An x-ray revealed a lytic lesion of the radius metaphysis with an associated pathological fracture. A renal cell carcinoma was diagnosed, with lung metastasis and one single bone metastasis in the right wrist. The patient underwent right total nephrectomy and started chemotherapy treatment. MRI confirmed a bone lesion at the distal end of the right radius 3 cm from the radio-carpal joint with 25 mm of longitudinal extension, destruction of the cortical bone, a small extra-osseous extension of the lesion and associated reactive edema of adjacent soft tissues. The decision was to treat this metastasis with a wide, local en bloc resection of the lytic lesion excision and fill the defect with iliac autograft (tricortical) plus fixation with a palmar distal plate of the radius. In the postoperative period, a splint was maintained for 4 weeks. Radiographs confirmed bone integration of the graft at 9 months. At follow-up the patient scored a VAS of 2/10 with mobilization of the wrist and almost normal ROM. Recurrence control with annual MRI was done, with no further diseaase at 5 years follow-up. The systemic disease also presented good response to the treatment instituted and seams to be estabilized.

Results and Conclusions: Acrometastasis can appear in patients of any age, with men being twice as likely as women to be affected. Rarely, they may be the first presentation of an occult silent cancer, mimicking a benign condition.

In cases of RCC metastasis, one must aware that this type of carcinoma has an extremely unpredictable clinical course. But, a bone metastasis may be the first sign of the disease. Patients may present with pathologic fractures because the lesions weaken the integrity of the osseous matrix. Such lesions can be misdiagnosed. Our case describes an unusual presentation of metastatic RCC where a pathological fracture was the first sign of the disease that led to all the subsequent study made and the final diagnosis.