M E D iC A L
'O U R N A L
S ao P aulo M edical Journal/R P M 113(1):726-728,1995
Pulmonary cancer and hypertrophic osteoarthropathy
Brief relief of the osteoarticular symptoms after surgical ressection
Jose Rodrigues Pereira, Jose Ribeiro Aguiar Neto, Flora Kazumi Ikarl, Sueli Mayumi Nikaedo
Instituto
do Cancer Arnaldo
Vieira de Carvalho - sao Paulo, Brazil
a r c h e s a n d c o m p r i s i n g i n i t s t o t a l i t y t h e t u -m o r r e c u r r e d i n J u l y 1 9 , 1 9 9 3 . T w o d a y s a f t e r s u r g e r y t h e p a t i e n t i n f o r m e d a c o m p l e t e d i s a p p e a r i n g o f t h e a r t h r a l g i a a n d t h e p h l o g y s t i c m a n i f e s t a t i o n . D i g i t a l c l u b b i n g d i s a p p e a r e d c o m p l e t e l y a f t e r t h r e e w e e k s .
U N ITE R M S : P ulm onary cancer. A denocarcinom a. H yperthrophic osteoarhropathy.
A case of adenocarcinom a of the lung in a 57 year-old patient associated w ith hypertrophic ostearthropathy is reported by the authors. The paraneoplastic m anifestation occurred after the pulm onary sym ptom s and receded spontaneously after a right inferior lobectom y w as perform ed. O steoarticular sym ptom s returned near after a tum oral recurrence. A rticular pains disappeared 48 hours after the tum oral recurrence ressection of the chest w all and clubbing disappeared com pletely
after the 3rd. w eek. .
IN TR O D U C TIO N
D
e s c r i b e dh y p e r t r o p h i cf o r t h e f i r s t t i m eo s t e o a r t h r o p a t h yi n 1 8 6 8 , ( H O A ) c a n b e d e f i n e d a s a s y n d r o m e c h a r a c t e r i z e d b y p r o l i f e r a t i v e c h r o n i c p e r i o s t i t i s o f t h e l o n g b o n e s , d i g i t a l c l u b b i n g , a r t r i t i s , s y n o v i t i s a n d a r t h r a l g i a a n d , m a n y t i m e s , c a u s i n g i n c a p a c i t y .W i t h i n t h e n e o p l a s t i c d i s e a s e s r e l a t e d t o H O A , p u l m o n a r y c a n c e r i s a p r o m i n e n t o n e . O s t e o a r t i c u l a r m a n i f e s t a t i o n s m a y p r e -c e d e t h e p u l m o n a r y i n s e v e r a l m o n t h s a n d , a s t h e c l i n i c c o n d i t i o n i s i n v a r i a b l y s u b e s -t i m a -t e d a n d u n d e r s -t o o d a s b e i n g a r h e u m a t i c d i s e a s e , w e c a n f r e q u e n t l y o b s e r v e a d e l a y i n t h e b r o n c h i a l c a n c e r d i a g n o s i s ( 6 ) .
L i t e r a t u r e d e s c r i b e s t h e f r e q u e n t a s s o c i a t i o n o f t h i s s y n d r o m e t o t h e b r o n c h i a l a d e n o c a r c i n o m a a n d c o n s i d e r s a s v e r y u n u s u a l t h e , c o n c o m i t a n c e w i t h s m a l l c e l l c a r c i n o m a ( 1 ) .
T h e c a s e p r e s e n t e d i l l u s t r a t e s c l e a r l y t h e H O A s h a d e s a n d t h e i n t e r f e r e n c e i n t h e t r e a t m e n t o f t h e o s t e o a r t i c u l a r s y m p t o m s d e v e l o p m e n t .
P R E S E N TA TIO N
C B R , 5 7 y e a r - o l d , w h i t e , a c t o r , s i n c e t h e e n d o f J u l y 1 9 9 1 , b e g a n t o c l a i m o n i n s i d i o u s a n d p r o g r e s s i v e p a i n s a t t h e d o r s a l r e g i o n o f t h e r i g h t h e m i t h o r a x . S o m e w e e k s
a f t e r , h e n o t i c e d d i g i t a l c l u b b i n g o f t h e h a n d s a n d l e g s , b e s i d e s a r t i c u l a r a n k l e p a i n s a n d a s l i g h t l o c a l e d e m a . P e r s i s t e n c e o f t h e t h o r a c i c p a i n s c a u s e d h i s v i s i t t o a p h y s i c i a n w h o i d e n t i f i e d , r a d i o l o g i c a l l y , a s m a l l m a s s p r o j e c t e d i n d i r e c t i o n t o t h e a p i c a l s e g m e n t o f t h e r i g h t i n f e r i o r l o b e , u n d e r s t o o d a s b e i n g a c o n s e q u e n c e o f t u b e r c u l o s i s . I n t h e n e x t r a d i o l o g i c a l c o n t r o l p r o c e d u r e s , a p r o g r e s s i v e i n c r e a s e o f t h e i n j u r y w a s o b s e r v e d , f o l l o w e d b y m o r e i n t e n s i v e t h o r a c i c p a i n s a n d a r t h r a l g i a . T h e b r o n c h o s c o p y a n d t r a n s p a r i e t a l p u l m o n a r y b i o p s y d o n e w e r e n o t c o n c l u s i v e . D u e t o t h e d i a g n o s e i n d e f i n i t i o n , i n J a n u a r y 1 4 , 1 9 9 2 , a e x p l o r i n g t h o r a c o t o m y w a s d o n e . T h e p r e s e n c e o f a n a d e n o c a r c i n o m a i n t h e r i g h t i n f e r i o r l o b e w a s i d e n t i f i e d . I n f e r i o r l o b e c t o m y w i t h r e s s e c t i o n o f t h e c o s t a l a r c h e s i n b l o c k s w a s d o n e ( s u r g i c a l s t a g e
=
T 2 N O ) . A c o m p l e t e d i s a p p e a r i n g o f H O A w a s o b s e r v e d 3 0 d a y s a f t e r s u r g e r y .O c t o b e r , 1 9 9 2 o n , p a t i e n t o b s e r v e d a g a i n t h o r a c i c p a i n s i n t h e s a m e l o c a l p r e v i o u s l y d e s c r i b e d a n d i n c r e a s i n g p r o g r e s s i v e l y . H e a l s o o b s e r v e d t h e r e t u r n o f t h e c l u b b i n g o f t h e e x t r e m i t i e s , p a i n i n a x l e s a n d k n e e s , f o l l o w e d b y a l o c a l e d e m a a n d p h l o g y s t i c m a n i f e s t a t i o n , b e s i d e s d i f f i c u l t y i n m o v e m e n t s a s a c o n s e q u e n c e o f t h e a r t h r a l g i a . T u m o r r e c u r r e n c e o n t h e p o s t e r i o r r i g h t w a l l o f t h e c h e s t w a s c o n f i r m e d i n M a y , 1 9 9 3 . P a t i e n t w a s s u b m i t t e d t o a r e s s e c t i o n o f t h e s e g m e n t o f t h e t h o r a c i c w a l l i n v o l v i n g t h r e e c o s t a l
C O M M E N TS
T h e c a s e a b o v e i s q u i t e i l l u s t r a t i v e i n w h a t r e f e r s t o d e l a y i n t h e p u l m o n a r y n e o p l a s i a d i a g n o s e w h e n m a n i f e s t a t i o n s a n d s y m p t o m s o f r h e u m a t i c d i s e a s e s a r e a s s o c i a t e d t o i t . T u m o r r e c u r r e n c e c o n f i r m a t i o n w a s d i f f i c u l t a s w e l l , a l t h o u g h p a r a n e o p l a s t i c s y n d r o m e h a s a c t e d a s a r e a l b i o l o g i c a l m a r k e r .
L i t e r a t u r e d e s c r i b e s r e l i e f o f t h e o s t e o a r t i c u l a r s y m p t o m s e v e n f o u r m o n t h s a f t e r t h e n e o p l a s t i c t r e a t m e n t . C o m p l e t e d i s a p p e a r i n g o f t h e a r t h r a l g i a w i t h i n t h e f i r s t 4 8 h o u r s a f t e r r e s s e c t i o n o f t u m o r c a l l e d t h e a t t e n t i o n . T h i s s h o u l d p r o b a b l y b e a r e s u l t o f t h e s u d d e n r e d u c t i o n o f t h e s e r u m l e v e l s o f s u b s t a n c e s w i t h c h e m i c a l s t r u c t u r e s i m i -l a r t o t h e h o r m o n e s p r o d u c e d b y n e o p l a s i a . I n H O A m a n i f e s t a t i o n s , i n c r e a s e i n t h e s e r u m l e v e l s o f t h e f o l l o w i n g h o r m o n e s i s m a d e r e f e r e n c e : g r o w t h ( 3 ) a n d e s t r o g e n ( 4 ) . M o r e r e c e n t l y , p r e s e n c e o f a s u b s t a n c e i n t h e g r a n u l e p l a t e l e t s h a s b e e n i d e n t i f i e d a s c a p a b l e o f c h a n g i n g t h e c h a r a c t e r i s t i c s o f t h e e n d o t h e l i u m - p l a t e l e t u n i t , c a u s i n g m o d i f i c a t i o n s i n t h e m i c r o v a s c u l a r s y s t e m o f t h e e x t r e m i t i e s . T h i s s u b s t a n c e i s n o m i n a t e d a s t h e p l a t e l e t d e r i v e d g r o w t h f a c t o r ( P D G F ) ( 7 ) .
A l t h o u g h s u r g e r y i n w h a t r e f e r s t o o n c o l o g i c t e r m s i s m o r e a d e q u a t e a n d e f f i c i e n t i n t h e c o n t r o l o f p a r a n e o p l a s t i c d i s e a s e s a n d c o n s e q u e n t l y o f t h e H O A , r e l i e f o f t h e s y n d r o m e i s e x p e r i e n c e d i n b o t h c h e m o t h e r a p y ( 5 ) a n d i n r a d i o t h e r a p y , t u -m o r e v e n n o t b e i n g c o -m p l e t e l y e x t e r m i n a t e d ( 2 ) . I n t h i s c i r c u m s t a n c e , i t i s p r o b a b l e t h a t t h e r a p y c h a n g e s t h e b i o l o g i c a l b e h a v i o r o f t h e r e m a i n i n g t u m o r . S o , e v e n i n p a t i e n t s w h e r e n e o p l a s i a c a n n o t b e f a c e d s u r g i c a l l y , o t h e r t r e a t i n g m a n n e r s s h o u l d b e t r i e d , e v e n i f o n l y w i t h p a l l i a t i v e p u r p o s e , w i t h t h e o b j e c t i v e o f m i n i m i z i n g t h e s y m p t o m s c a u s e d b y t h e p a r a n e o p l a s t i c s y n d r o m e .
923
Sao Paulo Medical Journal/RPM 113(1):734-735,1995
Marcos Brasilino de Carvalho, Abrao Rapoport
Head and Neck Service of the Heliopolis Complex. Slio Paulo, Brazil
Neck dissection: classification and nomenclature
N
e c kd is s e c tio n is a s u rg e ry w h o s e p rim a ry o b je c tiv e is th e c o n tro l o fth e re g io n a l ly m p h a tic m e ta s ta s is o f
p rim a ry c a n c e r in th e re g io n o f th e h e a d a n d
n e c k . T h e m o s t im p o rta n t h is to ric a l
re fe re n c e c o m e s fro m C R IL E (J A m M e d A s s o c 4 7 : 1 7 8 0 -8 8 , 1 9 0 6 ) w h o p ro p o s e th e
s a m e a p p ro a c h fo r c a n c e r o f th e h e a d a n d
n e c k re g io n a s th a t p ro p o s e d b y H a ls te a d
fo r b re a s t c a n c e r, th a t is , th e p rim a ry le s io n
s h o u ld b e re m o v e d to g e th e r w ith th e lo c a l
ly m p h n o d e s . T h is s u rg e ry is k n o w n e v e n
n o w a d a y s a s ra d ic a l n e c k d is s e c tio n in
a n a lo g y w ith ra d ic a l m a s te c to m y w h ic h
in c lu d e s re m o v a l o f a b re a s t w ith th e tu m o r
a n d th e lo c a l ly m p h n o d e s .
T a k in g th e s u rg e ry o f C rile a s a
re fe re n c e , m a n y v a ria tio n s h a v e b e e n
p ro p o s e d a s m u c h to re d u c e th e m o rb id ity
(th ro u g h re d u c tio n o f th e n u m b e r o f n o n
-ly m p h a tic s tru c tu re s re m o v e d ) a s to c h a n g e
n e c k d is s e c tio n in to m in o r s u rg e ry (b y
s e le c tin g s o m e ly m p h a tic c h a in s to b e
re m o v e d ). In th is d ire c tio n th e p a p e rs o f
S U A R E Z (R e v O to rin o 1 a rin g o I2 3 :9 3 -9 9 ,
1 9 6 3 ), B O C C A (.1 L a ry n g o l 8 0 :8 3 1
-3 8 ,1 9 6 6 ) e J E S S E , B A L L A N T Y N E
&
a n d L A R S O N (A m .1 S u rg 1 3 6 :5 1 6 -1 9 , 1 9 7 8 )a n d B A L L A N T Y N E (C u rr P ro b l C a n c e r
9 :3 -3 4 , 1 9 8 5 ) a re fu n d a m e n ta l. T h e firs t tw o
e x c is e d th e s a m e ly m p h a tic c h a in s a s
tra d itio n a l d is s e c tio n b u t p re s e rv e d th e
s u b m a n d ib u la r g la n d , th e
s te rn o c le id o m a s to id m u s c le , th e in te rn a l
ju g u la r v e in a n d th e a c c e s s o ry s p in a l n e rv e .
T h is s u rg e ry w a s c a lle d fu n c tio n a l c e rv ic a l
d is s e c tio n . B A L L A N T Y N E a ls o s p a re d
th o s e n o n -ly m p h a tic s tru c tu re s b u t h is
s u rg e ry d id n o t e x te n d to th e in fe rio r 2 /3 o f
th e s p in a l n e rv e c h a in n o r to th e e x te rn a l
th ird o f th e s u p ra c la v ic u la r re g io n . T h is
s u rg e ry re c e iv e d th e n a m e o f m o d ifie d n e c k
d is s e c tio n . L IN G E M A N a n d c o lle a g u e s
(A n n O to l 8 6 :7 3 7 -4 4 , 1 9 7 7 ) d e s c rib e a
te c h n iq u e o f n e c k d is s e c tio n s im ila r to th a t
o f S U A R E Z a n d th a t o f B O C C A b u t th e y
c a ll it c o n s e rv a tiv e n e c k d is s e c tio n . T h is
te c h n iq u e c o n tra s ts its e lf w ith th e s o -c a lle d
ra d ic a l n e c k d is s e c tio n . T h e te rm ra d ic a l h a s
b e e n e m p lo y e d in v a ria b le w a y s b y v a rio u s
a u th o rs ; ra n g in g fro m a s y n o n y m fo r s u rg e ry
th a t re m o v e s a ll th e n e o p la s ia ( a s o p p o s e d
to th e p a llia tiv e ) to th e id e a o f to ta l, o r c o m
-p le te (a s o p p o s e d to p a rtia l o r s e le c tiv e ).
B e c a u s e it m a k e s c o m p re h e n s io n o f th is
c la s s ific a tio n m o re c o m p lic a te d , th e w o rd
ra d ic a l s h o u ld b e a v o id e d w h e n d e s ig n a tin g
a d e te rm in e d ty p e o f s u rg e ry .
T h e c la s s ific a tio n o f d iffe re n t ty p e s o f
n e c k d is s e c tio n h a s re c e n tly d e s e rv e d th e
a tte n tio n o f a u th o rs re s p o n s ib le fo r
im p o rta n t re g is tra tio n o f c lin ic a l d a ta , b u t
th e y h a v e n o t a rriv e d a t a c o n s e n s u s m a in ly
b e c a u s e th e y p ro p o s e th a t th e d e n o m in a tio n
o f th e s u rg e ry in c lu d e to o m u c h d e ta il a s to
w h ic h s tru c tu re s a re c o n s e rv e d o r n o t
(B Y E R S : A m
J
S u rg 1 5 0 :2 1 5 -2 2 , 1 9 8 5 : O 'B R IE N a n d c o l.: A mJ
S u rg 1 5 3 :3 1 0 -1 6 , -1 9 8 7 ; S U E N&
G O E P F E R T , 9 :7 5 -7 7 , 1 9 8 7 ; R O B B IN S a n d c o l.: A rc hO to la ry n g o U H e a d
&
N e c k S u rg 1 1 7 :6 0 1 -0 5 ,1 9 9 1 ).A fu n d a m e n ta l ru le b y w h ic h a
c la s s ific a tio n s h o u ld b e a d o p te d is th a t it b e
b a s e d o n lo g ic a l p rin c ip a ls a n d b e e a s ily
u n d e rs to o d . W ith re s p e c t to n e c k d is s e c tio n
th e m o s t re a s o n a b le a p p ro a c h w o u ld b e to
u s e a s a p o in t o f re fe re n c e th e ly m p h a tic a n d
n o n -ly m p h a tic s tru c tu re s in v o lv e d in th e
s u rg e ry . In th is w a y , w ith re s p e c t to th e
re m o v e d ly m p h a tic c h a in s , th e d is s e c tio n
w o u ld b e c o m p le te (o r to ta l) o r p a rtia l (o r
s e le c tiv e ). T h e p a rtia l d is s e c tio n h a v e b e e n
c la s s ifie d a c c o rd in g w ith re g a rd to th e
in c lu d e d c h a in s , a n d h a s n o t b e e n a s o u rc e
o f c o n tro v e rs y . W ith re g a rd to n o n -ly m p h a tic
e le m e n ts , w h e th e r c o n s e rv e d o r n o t, in th e
d e n o m in a tio n o f c o m p le te o r p a rtia l c e rv ic a l
d is s e c tio n th e s tru c tu re s th a t w e re s p a re d
w o u ld b e m e n tio n e d , fo r e x .: " c o m p le te n e c k
d is s e c tio n w ith c o n s e rv a tio n o f th e
s te rn o c le id o m a s to id m u s c le a n d th e
a c c e s s o ry s p in a l n e rv e " ; " c o m p le te b ila te
-ra l n e c k d is s e c tio n w ith c o n s e rv a tio n o f th e
rig h t in te rn a l ju g u la r v e in a n d th e a c c e s s o ry
s p in a l n e rv e s " .
T h e q u a lify in g te rm s
conservative,
functional,
classic,
modified
a n dradical
s h o u ld b e a b a n d o n e d , a s th e ir u s a g e
d e m a n d s a n a c c o m p a n y in g e x p la n a tio n a s
to th e in te n d e d m e a n in g in te rp re te d b y th e
a u th o r, w h ic h m a k e s s ta n d a rd iz a tio n
d iffic u lt.
F in a lly , s o m e w o rd s a b o u t th e te rm
" ly m p h a d e n e c to m y " . U n d e r th is
d e n o m in a tio n th e a u th o rs h a v e re fe rre d to
th e s m a lle s t s u rg e ry p o s s ib le o n th e
ly m p h a tic s y s te m w h ic h is th e e x tra c tio n o f
o n e ly m p h n o d e . E v e n to d a y w e c a n fin d
re fe re n c e s in th e In d e x M e d ic u s to
ly m p h a d e n o p a th y a n d to ly m p h a d e n e c to m y .
T h e N o m in a A n a to m ic a o f 1 8 9 5 (B a s ile ia )
s u b s titu te d th e G re e k te rm g a n g lio n (w h ic h
m e a n s g la n d ) fo r th e d e n o m in a tio n o f ly m p h
g la n d . In 1 9 3 5 , in le n a th e N o m in a
A n a to m ic a d e fin itiv e ly a d o p te d th e te rm
ly m p h n o d e a s th e m o s t a p p ro p ria te a n d a s
o n e o f a lm o s t u n a n im o u s a c c e p ta n c e a m o n g
d iffe re n t a u th o rs .
In e x p lic a b ly th e id e a o f a ly m p h g la n d
p e rs is ts in th e te rm in o lo g y re la te d to s u rg e ry
a n d ly m p h n o d e p a th o lo g y . T h e e x p re s s io n s
lymphadenitis,
ly m p h a d e n e c to m y a n dlymphadenopathy
a re c o m m o n ly s e e n in s c ie n tific p u b lic a tio n s . E v e ry o n e k n o w s th a tth e c o m p o s itio n e le m e n t
aden
is fro m th e o rig in a l G re e k w o rd a d e n w h ic h m e a n sg la n d , a n d fro m th e re w e h a v e a d e n o m a a n d
a d e n o c a rc in o m a to d e s ig n a te b e n ig n a n d
m a lig n a n t tu m o rs d e riv e d fro m th e g la n d u
-la r tis s u e . T h e re fo re , if w e h a v e a b a n d o n e d
th e e x p re s s io n ly m p h g la n d a n d p re fe r th e
te rm ly m p h n o d e , th e n fo r e ty m o lo g ic a l
c o h e re n c e w e s h o u ld u s e th e te rm s
ly m p h o n o d itis , ly m p h o n o d o p a th y a n d
ly m p h o n o d e c to m y w h e n re fe rrin g to ,
re s p e c tiv e ly , a n in fla m m a tio n , a p a th o lo g y ,
a n d ly m p h n o d e s u rg e ry .
