A very rare presentation of lung cancer

Abstract

Rationale: Acrometastases of the hand are an unusual sign of lung cancer onset and may often be mistaken for other benign disorders, thus delaying diagnosis and treatment. Patient concerns: A 58-year-old man presented at the Rheumatology Clinic with a lump in the distal phalanx of the right index finger associated with intense pain, swelling, rib pain, and hemoptysis. Diagnoses: Given the clinical manifestations, an x-ray of the right hand was performed, and it revealed an osteolytic lesion in the distal phalanx of the right index finger. The subsequent CT of the thorax and abdomen showed a lung tumor, osteolytic lesions in the ribs, sternum, and the thoracic spine. Interventions: Amputation of the phalanx was decided on account of intense pain refractory to NSAIDs and opioids. Pathology assessment established the diagnosis of bone metastases secondary to lung adenocarcinoma. The patient underwent 6 cycles of first-line palliative chemotherapy with cisplatin and gemcitabine with partial response according to the RECIST 1.1. criteria. EGFR and ALK testing were not available at the time. A year later, the patient presented with progressive disease, which lead to 6 more cycles of chemotherapy with docetaxel. The disease progressed during chemotherapy and the patient was switched to erlotinib. Outcomes: After 7 months of anti-EGFR treatment, the patient passed away due to disease progression, thus having an overall survival of 25 months. Lessons: On rare occasions, acrometastases of the hand may be the first manifestation of a lung cancer and, as such, they must be taken into consideration in the differential diagnosis of rheumatologic disorders. They are a poor prognosis marker, but some cases like this one can have a better survival than reported in the literature, most likely due to that particular cancer's biology.

Tumor Type Agnostic Therapy Carrying BRAF Mutation: Case Reports and Review of Literature

“…To overcome this resistance, BRAF inhibitors are used in combination with MEK inhibitors which mediate the blockade of MAPK kinase (MEK), downstream of BRAF in the MAPK pathway [24]. Beside melanoma, thyroid cancers [25] and colon cancers [26], the prevalence of a BRAF V600E mutation in other cancers is less than 5% [27]. The relatively low frequency of this mutation accounts for the lack of randomized controlled studies looking at the use of specific anti-BRAF targeted therapies in other cancers.…”

Infections of Deep Hand and Wrist Compartments

“…An initially superficial but expanding infection most commonly tracks and rapidly reaches the functionally important structures of the flexor compartments, including the mid-palmar space and the space of Parona through the carpal tunnel in the volar aspect of distal forearm. A similar pathogenesis characterizes abscess formation into the webs, the thenar, and hypothenar spaces [4,6,7] (Figures 2 and 3). Deep infection at the thenar and the mid-palmar spaces, one week after a penetrating injury at the palmar aspect of the 1 st phalanx of the thumb.…”

“…When the septic material and exudates reach the synovial sheaths of mobile structures that serve as "pathways", infection can be spread far and widely. The destruction of local anatomy further disseminates the infection into adjacent anatomical compartments and the deep spaces of the hand and forearm [4,5]. The infection may also spread through the lymphatic pathway to more proximal soft tissue compartments.…”

“…The unique anatomy of the hand, with its numerous enclosed spaces and compartments, warrants special considerations. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout, injection injuries, algodystrophy, metastases, and rheumatological disorders [4,7]. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation or life-threatening complications can result from missed diagnoses or delayed treatment.…”