Bone metastasis as the presenting complaint in ovarian carcinoma

Abstract

Shoulder pain is a common presenting complaint in our orthopedic service. Most cases with the clinical features of rotator cuff tendinitis respond to intra-articular injection of corticosteroids and local anesthetic. In the case described below, a patient whose pain persisted despite injection was investigated further and found to have advanced ovarian cancer with a metastasis in the humeral head. This is a rare pattern of spread Fig. 1. Anteroposterior view of the right shoulder showing a lytic area in the humeral head.C Acta Obstet Gynecol Scand 80 (2001) and a previously unreported mode of presentation of ovarian cancer. Case reportA 52-year-old mother of three was referred to the orthopedic service with a four-month history of right shoulder pain. The pain was moderate, constant, exacerbated by movement, and kept her awake at night. There was no antecedent injury. She was otherwise well with no systemic complaints or weight loss, and was a non-smoker. On examination all shoulder movements were limited by pain. The provisional diagnosis was rotator cuff tendinitis. The shoulder was injected with lidocaine (Xylocaine) and methylprednisolone (Depo-Medrone) without symptomatic relief, and so she was admitted for further investigation.Plain X-ray of the right shoulder showed a lytic area in the humeral head ( Fig. 1). MRI revealed a lesion in the head of the humerus (Fig. 2), and no rotator cuff pathology. 99 Tc bone scan showed increased uptake in both humeral heads. Chest X-ray revealed a mass lesion in the right midzone. CT of the thorax Fig. 2. Axial T1-weighted MRI image showing a destructive low-attenuation mass in the humeral head.Fig. 3. CT showing multiple low-attenuation liver lesions and a peritoneal nodule (arrowed).