J o s e R o d rig u e s P e re ira , J o s e R ib e iro A g u ia r N e to , F lq ra K a z u m i Ik a ri, S u e ly M a y u m i N ik a e d o
Pulm onary cancer and hypertrophic osteoarthropathy
Brief recurrence of the osteoarticular sym ptom s after surgical ressection
Instituto do Cancer Arnaldo Vieira de Carvalho - Siio Paulo, Brazil
A ca se o f a d e n o ca rcin o m a o f th e lu n g in a 5 7 ye a rs o ld p a tie n t a sso cia te d w ith h yp e rtro p h ic o ste a rth ro p a th y is re p o rte d b y th e a u th o rs. T h e p a ra n e o p la stic m a n ife sta tio n o ccu rre d a fte r th e p u lm o n a ry sym p to m s a n d re ce d e d sp o n ta n e o u sly a fte r a rig h t in fe rio r
lo b e cto m y w a s p e rfo rm e d . O ste o a rticu la r sym p to m s re tu rn e d n e a r a fte r a tu m o ra l re cu rre n ce . A rticu la r p a in s d isa p p e a re d 4 8 h o u rs a fte r th e tu m o ra l re cu rre n ce re sse ctio n o f th e ch e st w a ll a n d clu b b in g d isa p p e a re d co m p le te ly a fte r th e 3 rd . w e e k.
U N IT E R M S : P u lm o n a ry ca n ce r. A d e n o ca rcin o m a . H yp e rth ro p h ic. O ste o a rth ro p a th y.
IN T R O D U C T IO N
D
osteoarthropathyescribed for the first tim e in 1868, hypertrophic(O A R ) can be defined as asyndrom e characterized by proliferative chronic
periostitis of the long bones, digital clubbing, artritis,
A d d re s s fo r c o rre s p o n d e n c e :
J o s e R o d rig u e s P e re ira
R . D r. M a rtin ic o P ra d o , 2 6 -C j. 1 0 2 S a o P a u lo - S P - B ra s il- C E P 0 1 2 2 4 -0 1 0
synovitis and arthralgia and, m any tim es, causing
incapacity.
W ithin the neoplastic diseases related to O A R ,
pulm onary cancer is a prom inent one. O steoarticular
m anifestations m ay precede the pulm onary in several
m onths and, as the clinic condition is invariably
subestim ated and understood as being a rheum atic disease,
w e can frequently observe a delay in the bronchial cancer
diagnosis (6).
L iterature describes the frequent association of this
syndrom e to the bronchial adenocarcinom a and considers
as very unusual the concom itance w ith indisctinct
carcinom a of little cells (1).
T he case presented illustrates clearly the O A R shades
and the interference in the treatm ent of the osteoarticular
sym ptom s developm ent.
PRESENTATION
C B R , 5 7 y e a rs , w h ite , a c to r, s in c e th e e n d o f J u ly
1 9 9 1 , b e g a n to c la im o n in s id io u s a n d p ro g re s s iv e p a in s
a t th e d o rs a l re g io n o f th e rig h t h e m ith o ra x . S o m e w e e k s
a fte r, h e n o tic e d d ig ita l c lu b b in g o f th e h a n d s a n d le g s ,
b e s id e s a rtic u la r a n k le p a in s a n d a s lig h t lo c a l e d e m a .
P e rs is te n c e o f th e th o ra c ic p a in s c a u s e d h is v is it to a
p h y s /ic ia n w h o id e n tifie d , ra d io lo g ic a lly , a s m a ll m a s s
p ro je c te d in d ire c tio n to th e a p ic a l s e g m e n t o f th e rig h t
in fe rio r lo b u le , u n d e rs to o d a s b e in g a c o n s e q u e n c e o f s o m e
s p e c ific p ro c e s s . In th e n e x t ra d io lo g ic a l c o n tro l
p ro c e d u re s , a p ro g re s s iv e in c re a s e o f th e in ju ry w a s
o b s e rv e d , fo llo w e d b y m o re in te n s iv e th o ra c ic p a in s a n d
a rth ra lg ia . T h e b ro n c h o s c o p y a n d tra n s p a rie ta l p u lm o n a ry
b io p s y d o n e w e re n o t c o n c lu s iv e . D u e to th e d ia g n o s e
in d e fin itio n , in J a n u a ry 1 4 , 1 9 9 2 , a e x p lo rin g th o ra c o to m y
w a s d o n e . T h e p re s e n c e o f a n a d e n o c a rc in o m a in th e rig h t
in fe rio r lo b u le w a s id e n tifie d . In fe rio r lo b e c to m y w ith
re s s e c tio n o f th e c o s ta l a rc h e s in b lo c k s w a s d o n e (s u rg ic a l
d u ra tio n
=
T 2 N O ). A c o m p le te d is a p p e a rin g o f O A Hw a s o b s e rv e d 3 0 d a y s a fte r s u rg e ry .
O c to b e r, 1 9 9 2 o n , p a tie n t o b s e rv e d a g a in th o ra c ic
p a in s in th e s a m e lo c a l p re v io u s ly d e s c rib e d a n d in c re a s in g
p ro g re s s iv e ly . H e a ls o o b s e rv e d th e re tu rn o f th e c lu b b in g
o f th e e x tre m itie s , p a in in a x le s a n d k n e e s , fo llo w e d b y a
lo c a l e d e m a a n d p h lo g y s tic m a n ife s ta tio n , b e s id e s
d iffic u lty in m o v e m e n ts a s a c o n s e q u e n c e o f th e a rth ra lg ia .
T u m o r re c u rre n c e o n th e p o s te rio r rig h t w a ll o f th e c h e s t
w a s c o n firm e d in M a y , 1 9 9 3 . P a tie n t w a s s u b m itte d to a
re s s e c tio n o f th e s e g m e n t o f th e th o ra c ic .w a ll in v o lv in g
th re e c o s ta l a rc h e s a n d c o m p ris in g in its to ta lity th e tu m o r
re c u rre d in J u ly 1 9 , 1 9 9 3 . T w o d a y s a fte r s u rg e ry th e
p a tie n t in fo rm e d a c o m p le te d is a p p e a rin g o f th e a rth ra lg ia
a n d th e p h lo g y s tic m a n ife s ta tio n . D ig ita l c lu b b in g
d is a p p e a re d c o m p le te ly a fte r th re e w e e k s .
COMMENTS
T h e c a s e a b o v e is q u ite illu s tra ti v e in w h a t re fe rs to
d e la y in th e p u lm o n a ry n e o p la s ia d ia g n o s e w h e n
m a n ife s ta tio n s a n d s y m p to m s o f rh e u m a tic d is e a s e s a re
a s s o c ia te d to it. T u m o r re c u rre n c e c o n firm a tio n w a s
d iffic u lt a s w e ll, a lth o u g h p a ra n e o p la s tic s y n d ro m e h a s
a c te d a s a re a l b io lo g ic a l m a rk e r.
L ite ra tu re d e s c rib e s re c u rre n c e o f th e o s te o a rtic u la r
s y m p to m s e v e n fo u r tim e s a fte r th e n e o p la s ia tre a tm e n t.
C o m p le te d is a p p e a rin g o f th e a rth ra lg ia w ith in th e firs t
4 8 h o u rs a fte r re s s e c tio n o f tu m o r c a lle d th e a tte n tio n . T h is
s h o u ld p ro b a b ly b e a re s u lt o f th e s u d d e n re d u c tio n o f th e
s e ru m le v e ls o f s u b s ta n c e s w ith c h e m ic a l s tru c tu re s im ila r
to th e h o rm o n e s p ro d u c e d b y n e o p la s ia . In O A H
m a n ife s ta tio n s , in c re a s e in th e s e ru m le v e ls o f th e
fo llo w in g h o rm o n e s is m a d e re fe re n c e : g ro w th (3 ) a n d
e s tro g e n (4 ). M o re re c e n tly , p re s e n c e o f a s u b s ta n c e in
th e g ra n u le p la q u e s h a s b e e n id e n tifie d a s c a p a b le o f
c h a n g in g th e c h a ra c te ris tic s o f th e e n d o th e liu m -p la q u e
u n ity , c a u s in g m o d ific a tio n ~ in th e m ic ro v a s c u la r s y s te m
o f th e e x tre m itie s . T h is s u b s ta n c e is n o m in a te d a s th e
g ro w th fa c to r d e riv e d fro m p la q u e s (P D G F )(7 ).
A lth o u g h s u rg e ry in w h a t re fe rs to o n c o lo g ic te rm s
is m o re a d e q u a te a n d e ffic ie n t in th e c o n tro l o f n e u ro p la s tic
d is e a s e s a n d c o n s e q u e n tly o f th e O A H , re c u rre n c e o f th e
s y n d ro m e is e x p e rie n c e d in b o th c h e m o th e ra p y (5 ) a n d in
ra d io th e ra p y , tu m o r e v e n n o t b e in g c o m p le te ly
e x te rm in a te d (2 ). In th is c irc u m s ta n c e , it is p ro b a b le th a t
th e ra p y c h a n g e s th e b io lo g ic a l. b e h a v io r o f th e re m a in in g
tu m o r. S o , e v e n in p a tie n ts w h e re n e o p la s ia c a n n o t b e
fa c e d s u rg ic a lly , o th e r tre a tin g m a n n e rs s h o u ld b e trie d ,
e v e n if o n ly w ith p a llia tiv e p u rp o s e , w ith th e o b je c tiv e o f
m in im iz in g th e s y m p to m s c a u s e d b y th e .p a ra n e o p la s ia
s y n d ro m e .
REFERENCES
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&
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&
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