Henry Ford Hospital Medical Journal Henry Ford Hospital Medical Journal

Volume 33 Number 1 Article 10

3-1985

Metastatic Bronchogenic Carcinoma Simulating Osteoarthritis Metastatic Bronchogenic Carcinoma Simulating Osteoarthritis

David Wendt

Paul Kvale

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Recommended Citation Recommended Citation Wendt, David and Kvale, Paul (1985) "Metastatic Bronchogenic Carcinoma Simulating Osteoarthritis," Henry Ford Hospital Medical Journal : Vol. 33 : No. 1 , 39-40. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol33/iss1/10

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.

Henry Ford Hosp Med J Vol 33, N o l , 1985

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Case Reports Metastatic Bronchogenic Carcinoma Simulating Osteoarthritis

David Wendt, MD* and Paul Kvale, MDt

Metastat ic bone disease is common among patients with bronchogenic carcinoma. Occasionally silent, such metastases wil l most often become symptomatic if untreated, provided the patient survives long enough to permit metastatic growth . Much less common is the patient wi th bronchogenic carcinoma who has a synovial e f fus ion that s imulates lower ex t remi ty osteoarthritis.

Case Report A 63-year-old woman who had osteoarthritis of long standing presented to the rheumatology clinic with a two-month his­tory of increased pain in both knees. Symptomatic treatment with nonsteroidal anti-inflammatory agents was only mar­ginally effective. Pain and tenderness of the medial aspect of the left knee continued, and she began to limp. Plain roent­genograms of the left knee showed early marginal osteophyte formation at the medial aspect of the tibial plateau (Figure A).

Five weeks later, the patient experienced blood-streaked spu­tum, dysphagia, hoarseness, and weight loss. She had a 40-pack-per-year smoking history. Abnormal physical findings included aS x2-cm mobile, nontender lymph node in the right supraclavicular fossa, wheezing and rhonchi over the left posterior chest, and fluid in the left knee joint. The joint was warm on palpation, and there was some tenderness over its medial aspect.

A chest roentgenogram obtained at this time revealed a 2.5 x 3.0-cm mass in the superior segment of the left lower lobe. Laboratory studies were normal except for alkaline phos­phatase of 138 U/L (normal:35 to 115 U/L) and SCOT of 46 U/L (normal:9 to 33 U/L). Bronchoscopy revealed a poorly differ­entiated large-cell carcinoma. A repeat roentgenogram of the left knee revealed a large lytic defect in the proximal tibia (Figure B). Radionuclide bone scan showed increased activity aboutthe left knee. (Although radionuclide bone scans can be abnormal in patients with osteoarthritis, the abnormalities are more often symmetrical and are not accompanied by lytic lesions on the plain films.) Needle biopsy of the synovium was negative for malignancy.

Radiation therapy to the left knee provided relief of pain, but the patient deteriorated and died 19 days later. Permission for autopsy examination could not be obtained.

Discussion Approximately 1 % to 2% of patients with bronchogenic carcinoma have bony metastases at the t ime of their initial diagnosis (1), most often in the axial skeleton o r i n proximal bones (2). The traditional explanation is the increased b lood f low to these bones through com­munications with the vertebral venous plexus (3). Distal bone metastases may occur when bronchogenic car­cinoma erodes in toa pulmonary vein (3). In such cases, a rapidly fatal course caused by tumor dissemination is the usual outcome. Synovial effusions are uncommon among patients with bony metastases f rom lung cancer, although effusions have been reported in the patellar region (4-7) and in the shoulder (7). In a series of three patients with synovial effusions (two of whom had pri­mary bone tumors), Lagier postulated that the malig­nant cells might liberate a substance wi th antigenic or enzymatic properties that would cause the synovitis (8). A l though hypertrophic osteoarthropathy can rarely cause a mild synovitis (9), pain and tenderness in the bone, rather than in the joint space, generally dominate the clinical f indings.

This case illustrates an unusual presentation of bron­chogenic carcinoma in a patient who was initially be­lieved to have degenerative joint disease. The presence o fan elevated alkaline phosphatase is distinctly unusual among patients with osteoarthritis. Such a laboratory f inding should cause the physician to search for meta­static carcinoma so that more appropriate and specific treatment can be given.

Submitted for publication: September 20, 1984

Accepted for publication: January 7, 1985

•Department of Internal Medicine, Henry Ford Hospital

^Department of Internal Medicine, Division of Pulmonary Medicine, Henry Ford Hospital

Address reprint requests to Dr Wendt, Departmentof Internal Medicine, Henry Ford Hospital, 2799 W Crand Blvd, Detroit, Ml 48202.

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Wendt and Kvale r Henry Fc Vol 33, N

Figure A. Left knee at time of original presentation. Note the early marginal osteophyte formation at the medial aspect of the

tibial plateau (arrows). B. Left knee five weeks later. Note the lytic metastasis (edges indicated by arrows).

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Dahlin DC. Bone tumors: General aspects and data on 6,221 cases. 3rd ed. Springfield, IL: Charles C Thomas, 1978:356.

Vaezy A, Budson DC. Phalangeal metastases from bronchogenic carcinoma. JAMA 1978;239:226-7.

Gall EP, Didizian NA, Park Y. Acute monarticular arthritis fol­lowing patellar metastasis. A manifestation of carcinoma of the lung. JAMA 1974;229:188-9.

Benedek TG. Arthritis rounds. Lysis of the patella due to meta­static carcinoma. Arthritis Rheum 1965;8:560-6.

6. Khan FA, Garterhouse W, Khan A. Metastatic bronchogenic car­cinoma: An unusual cause of localized arthritis. Chest 1975;l 67:738-9.

7. Fam AG, Kolin A, Lewis AJ. Metastatic carcinomatous arthritis and carcinoma of the lung. A report of two cases diagnosed by] synovial fluid cytology. J Rheumatol 1980;7:98-104.

8. Lagier R. Synovial reaction caused by adjacent malignant tumors; Anatomicopathological study of three cases. J Rheumatollj 1977;4:65-72.

9. Layfer LF, Jones JV. Arthritis with mass on chest x-ray. IM] 1979;156:120-1.

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