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CASE REPORT
Year : 2015  |  Volume : 31  |  Issue : 4  |  Page : 363-365
 

Solitary second metatarsal metastasis as the first site of distant spread in TCC urinary bladder: A case report


Department of Urology, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication1-Oct-2015

Correspondence Address:
Rajeev Kumar
Department of Urology, All Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.163312

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   Abstract 


Metastasis to the skeleton is uncommon in muscle-invasive carcinoma of the urinary bladder. When present, it most commonly involves the axial and proximal appendicular skeleton, and acrometastasis (metastasis to hand and foot) is very rare. We report a patient who developed a solitary metastatic lesion of the left metatarsal 2 weeks after radical cystectomy. The lack of suspicion and magnetic resonance imaging findings suggestive of inflammation led to a diagnosis of tubercular osteomyelitis and antitubercular therapy was started. The patient developed nodal metastasis and, because the foot lesion did not respond to treatment, fine needle aspiration cytology from it revealed poorly differentiated metastatic cancer.



How to cite this article:
Yadav S, Kumar R. Solitary second metatarsal metastasis as the first site of distant spread in TCC urinary bladder: A case report. Indian J Urol 2015;31:363-5

How to cite this URL:
Yadav S, Kumar R. Solitary second metatarsal metastasis as the first site of distant spread in TCC urinary bladder: A case report. Indian J Urol [serial online] 2015 [cited 2019 Nov 22];31:363-5. Available from: http://www.indianjurol.com/text.asp?2015/31/4/363/163312





   Introduction Top


Bone metastasis from any malignant tumor usually occurs in the axial and proximal appendicular skeleton, and spread to distal bones (distal to knees and elbows) is unusual. Acrometastasis to the hands and feet is rare, with a 1.7% incidence of foot metastasis in all types of metastatic cancers.[1] Metastasis to hands usually originates from malignancies above the diaphragm (lungs, head and neck) and to the foot arise from subdiaphragmatic primaries (gastrointestinal, genitourinary and uterine).[2] Pedal metastasis most commonly originates from the colon and kidneys and usually involves the tarsal bones (50–73%), with calcaneum being the most common site.[2],[3] These metastatic lesions usually produce non-specific symptoms and are osteolytic in nature. Their rarity, combined with a lack of suspicion, may lead to a delay in diagnosis. We report a patient of muscle-invasive bladder cancer who developed tarsal metastasis as thefirst site of spread and in whom the diagnosis could not be made until additional metastasis appeared.


   Case Report Top


A 54-year-old non-smoking male underwent radical cystectomy with extended pelvic lymphnode dissection and ileal conduit urinary diversion for muscle-invasive high-grade urothelial carcinoma. The tumor had lymphovascular emboli with microscopic extension into the perivesical fat. All lymph nodes, prostate, seminal vesicle and distal uretric margins were free from tumor (pT3aN0M0). About 2 weeks after surgery, he complained of mild pain, associated with weight bearing, in the left mid foot. This gradually increased in duration and severity and was associated with swelling, redness and tenderness of the left foot. Magnetic resonance imaging revealed altered marrow signal intensity of 2nd metatarsal and T2/STIR sequence suggested osteomyelitis [Figure 1]. His serum uric acid levels were 8.6 mg% and alkaline phosphatase was 193 IU/L. A contrast-enhanced computed tomography scan of the abdomen and pelvis revealed mild left hydrouretronephrosis till aortic bifurcation. In view of localized disease, raised serum uric acid levels and the typical location of pain, anti-gout treatment was started. His symptoms persisted with increased pain, swelling and restriction of mobility. The size of the osteolytic lesion also increased on X-ray [Figure 2]a]. A clinical review suggested the possibility of tuberculosis due to its high prevalence, radiological features and immuno-suppressed status in view of malignancy. He was started on antitubercular therapy empirically. Three months later, he developed enlarged left inguinal, retroperitoneal, pelvic and supraclavicular lymphnodes along with a mass in the left pelvic wall, causing sigmoid colon obstruction that necessitated a diverting transverse colostomy. The foot lesion also progressed with extensive lytic lesions of the 1st, 2nd and 3rd metatarsals [Figure 2]b]. No other skeletal sites showed increase uptake on the Fluoro Deoxy d-Glucose –Positron Emission T omography scan. Fine needle aspiration cytology of the 2nd metatarsal and left supraclavicular lymph node revealed high-grade metastatic carcinoma and he was started on chemotherapy (gemcitabine and carboplatin) with palliative radiotherapy to the left foot. After palliative radiotherapy and the 1st cycle of chemotherapy, the swelling and pain in the foot and inguinal nodes reduced.
Figure 1: A magnetic resonance imaging scan of the left foot. (a) Axial T1-weighted image of the left mid-foot showing low signal intensity in the 2nd metatarsal base. (b) Axial T2/STIR image showing increased signal intensity inthe 2nd metatarsal and adjoining muscles

Click here to view
Figure 2: (a) Antero-posterior X-ray of the left foot showing a lytic lesion involving
the base of the 2nd metatarsal. (b) Saggital image of non-contrast computed
tomography scan of the left foot showing a necrotic area in the base of the 2nd
metatarsal


Click here to view



   Discussion Top


Invasion of lamina propria by transitional cell cancer gives it access to the lymphovascular system, and the pelvic lymph nodes are usually thefirst sites of spread. Bones, the spine in particular, are the most common site of metastasis outside the pelvis, with multiple lesions being the norm.[4] Our patient developed a symptomatic left foot lesion 2 weeks after surgery as possibly thefirst sign of metastatic disease. The absence of metastatic disease on imaging, negative nodes on histology, low incidence of foot metastasis and radiological diagnosis of infection contributed to a lack of suspicion of metastasis in this case.

Acrometastasis usually presents with insidious-onset pain, especially on weight bearing, and swelling. A strong clinical suspicion in patients with previous or current advanced malignancies with early histologic diagnosis is required to make a definite diagnosis. Confusion with osteomyelitis, gout, rheumatoid arthritis and ligament strains are well documented.[5] A solitary destructive lesion of bone at sites distal to the knee, as in our case, suggests inflammatory cause because metastasis to these sites is rare. Tuberculosis is a common cause of such destructive lesions of the metatarsal in this part of the world and presents as altered signal intensity of marrow with inflammatory edema of the surrounding muscles. Although abscess formation would have been confirmatory, in the phlegmonous stage, only soft tissue edema is seen. The only feature suggesting a metastasis was previous history of transitional cell cancer of the bladder.

Acrometastasis usually responds well to palliative radiotherapy and chemotherapy. Our patient received carboplatin and gemcitabine-based chemotherapy and 20 Gy of radiation to the left foot. After the palliative radiotherapy and the 1st cycle of chemotherapy, there was a significant decrease in pain and swelling in the foot and inguinal lymph node disease.


   Conclusion Top


This report is a testament to the adage that multiple pathologies are less common than multiple manifestations of a single pathology. Acrometastasis, although rare, can be thefirst sign of metastatic disease. Strong clinical suspicion and early histologic diagnosis may facilitate early diagnosis.

Financial support and sponsorship

Nil

Conflicts of interest

None declared.



 
   References Top

1.
Leeson MC, Makley JT, Carter JR. Metastatic skeletal disease distal to the elbow and knee. Clin Orthop Relat Res 1986;206:94-9.  Back to cited text no. 1
    
2.
Lisbon E, Bloom RA, Husband JE, Stoker DJ. Metastatic tumors of the bones of the hand and foot. A comprehensive review and report of 43 additional cases. Skeletal Radiol 1987;16:387-92.  Back to cited text no. 2
    
3.
Zindrick MR, Young MP, Daley RJ, Light TR. Metastatic tumors of the foot: Case report and literature review. Clin Orthop Relat Res 1982;170:219-25.  Back to cited text no. 3
    
4.
Petkovic M, Muhvic D, Zamolo G, Jonjic N, Mustac E, Mrakovcic-Sutic I, et al. Metatarsal metastasis from transitional cell cancer of the urinary bladder. Coll Antropol 2004;28:337-41.  Back to cited text no. 4
    
5.
Harrtup SJ, Amadio PC, Sim FH, Lombard FH. Metastatic tumors of the foot and ankle. Foot Ankle 1988;8:243-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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    Abstract
     Introduction
     Case Report
     Discussion
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