Acrometastasis to the Hand in Renal Cell Carcinoma
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IMAGES IN SURGERY
Acrometastasis to the Hand in Renal Cell Carcinoma Sridhar Panaiyadiyan 1 & Prabhjot Singh 1
&
Brusabhanu Nayak 1
Received: 25 August 2020 / Accepted: 18 September 2020 # Association of Surgeons of India 2020
Abstract Acrometastasis to the hand is an unusual presentation in renal cell carcinoma. We describe a patient with left renal mass with left metacarpal acrometastasis besides adrenal and lung metastases. The patient had cytoreductive nephrectomy with adrenalectomy and palliative radiotherapy to the hand metastasis. Keywords Acrometastasis . Renal cell carcinoma . Prognosis . Survival
Case presentation A 47-year-old gentleman presented with 4 months history of left flank pain and gross haematuria. He also complained of gradually increasing painful left hand swelling of 3 months duration. He denied any fever, lower urinary tract symptoms or haemoptysis. Physical examination revealed a 8 × 7-cm swelling on the dorsum of left hand (Fig. 1a) and a palpable left renal mass. His blood investigations were normal except for a haemoglobin of 8.2 g/dl. A radiograph of the hand showed a complete destruction of the left second metacarpal bone (Fig. 1b). Further, a contrast-enhanced computed tomography of the chest, abdomen and pelvis revealed an enhancing 16 × 16 × 14-cm left renal mass (Fig. 2a), a 9.7 × 2.8 × 9-cm left adrenal mass (Fig. 2b) and bilateral lung nodules (Fig. 2 c and d). A 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography scan showed metabolically active lesions in the left kidney, in the left adrenal, in the bilateral pulmonary lesion and in the left hand. He was categorized to intermediate risk as per International Metastatic
* Prabhjot Singh [email protected] Sridhar Panaiyadiyan [email protected] Brusabhanu Nayak [email protected] 1
Department of Urology, All India Institute of Medical Sciences, New Delhi 110029, India
Renal Cancer Database Consortium model [1]. After two units of blood transfusion, cytoreductive nephrectomy with adrenalectomy was done in view of persistent hematuria. The final histopathology showed clear cell renal cell carcinoma (RCC). He was started on adjuvant pazopanib 800 mg once daily and received palliative radiotherapy to the left hand. At 12-month follow-up, the patient is alive, asymptomatic with completely resolved hand swelling (Fig. 3).
Discussion Acrometastases denote secondary deposits of the hands and/or feet in malignancies. Particluarly, hand acrometastases are uncommon with an incidence of 0.1% of all skeletal metastases [2]. While the most common primary tumour is lung cancer, hand acrometastasis in RCC is extremely rare [3]. Prostaglandins with chemotactic properties of cell migration and adhesions are proposed as possible mechanism. Hand being prone to repeated trauma is hypothesized to cause traumainduced acrometastasis by increased blood flow enabling tumour emboli to lodge and grow [3]. The most common site of hand metastasis is distal phalanx, followed by metacarpal bones, proximal and mid
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