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Indian Journal of Cancer
Medknow Publications on behalf of Indian Cancer Society
ISSN: 0019-509X EISSN: 1998-4774
Vol. 48, Num. 1, 2011, pp. 112-113

Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 112-113

Letter to Editor

Carcinoma esophagus with isolated metatarsal metastasis

A Mohanty1, D Dutta2, S Das1, DR Samanta1, S Senapati1

1 Department of Radiation Oncology, AHRCC, Cuttack, India
2 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India

Correspondence Address:
D Dutta
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai
India
duttadeb07@gmail.com


Code Number: cn11020

 

Sir,

Carcinoma esophagus usually presents in advanced stage with loco-regional node and visceral (liver) involvement. [1] Bone metastasis is uncommon and usually denotes terminal stage as a part of multiple systemic involvements. [1] Isolated skeletal metastasis is rare (1.2%) and usually seen in long bones. We report a rare case of carcinoma esophagus with isolated small bone (metatarsal) metastasis.

A 53-year-old male patient presented with dysphagia to solid foods and intermittent episodes of vomiting for 2 months. Upper GI endoscopy revealed ulcerative lesion involving full circumference at 28 cm from incisors teeth and biopsy was invasive squamous cell carcinoma (SCC). Contrast-enhanced CT scan thorax showed thickened esophageal walls involving middle third of esophagus with enlarged subcarinal nodes. Metastatic work up (chest X-ray, USG abdomen, liver function test) was normal. Patient received three cycles of neoadjuvant chemotherapy (cisplatin and flurouracil) followed by radical intent radiotherapy (RT) [44 Gy/22 # in AP-PA portal with Co60 followed by 22 Gy/11# boost with oblique fields] and had significant clinical and radiological response. At 1½ year post-treatment patient presented with hard mass fixed to the underlying bone on lateral aspect of right foot. X-ray revealed osteolytic lesion at the base of right fifth metatarsal bone [Figure - 1] and biopsy revealed SCC. Barium swallow showed residual constricting lesion in mid esophagus [Figure - 2] and bone scan showed increased uptake only at base of right fifth metatarsal, while other metastatic work up (Chest X-ray, USG) was normal. The patient was diagnosed to have persistent invasive SCC of middle third esophagus with isolated metastasis to right fifth metatarsal bone. He was treated with symptomatic and supportive care.

Small bones of extremities are relatively spared from metastasis. Lesser blood supply or ′soil and seed′ hypothesis is thought to be the reason for this rare incidence. [1],[2] Renal cell carcinoma commonly presents with small bone metastasis and calcanium is most commonly involved. Five to eight percent of esophageal cancer patients present with bone metastasis and long bones are commonest site. [1] In systematic review of 1909 carcinoma esophagus patients, only 5.2% had metastasis to bones and only one patient presented with small bone (metatarsal) metastasis.[3] Survival in patients with solitary bone metastasis is also dismal and thus treated with palliative intent. Several prospective studies had shown excellent pain relief and restoration of function after palliative RT to long or flat bone metastasis. [2],[3] However, there are no consensuses in solitary bone metastasis involving only small extremity bones. Solitary small bone metastasis may be excised, treated symptomatically, or treated with RT. On the other hand, RT to small extremity bones, which has end arterial supply is challenging. There are speculations that RT in small bones may induce ′radiation-induce vasculitis′ and necrosis [4],[5] Prognosis of this solitary small bone metastasis is also not known, speculated to have favorable prognosis, and thus, may be considered for aggressive treatment.[6],[7] Solitary metatarsal bone metastasis is a rare manifestation of carcinoma esophagus with unknown natural history, management option thus merit further investigation and reporting. [6],[7]

References

1.Dormanns E, Ackerman LV, Regato JA. St. Louis: Mosby Company; 1963. p. 160.  Back to cited text no. 1    
2.Bricout BB. Acrometastases. J Natl Med Assoc 1981;73:325-9.  Back to cited text no. 2    
3.Goodner JT, Turnbull A. Bone metastases in cancer of the esophagus Am J Radiology 1971;2:365-7.  Back to cited text no. 3    
4.Toubiana CG, Proux C. Les metastases osseus destale. Am Radiol 1965;8:217-28.  Back to cited text no. 4    
5.Gall RJ, Sim FH, Pritchard DJ. Metastatic tumors to the bones of the foot. Cancer 1976;37:1492-5.  Back to cited text no. 5    
6.Hsieh CY, Bai LY, Lo WC, Huang HH, Chiu CF. Esophageal squamous cell carcinoma with a solitary phalangeal metastasis. South Med J 2008;101:1159-60.   Back to cited text no. 6    
7.Aguiar Bujanda D, Bohn Sarmiento U, Aguiar Morales J. Some unusual paraneoplastic syndromes. Case 1. Metastatic squamous cell esophageal cancer to the thumb. J Clin Oncol 2003;21:2620.  Back to cited text no. 7    

Copyright 2011 - Indian Journal of Cancer

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[cn11020f1.jpg] [cn11020f2.jpg]
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