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CASE HISTORY

Case history: When fate plays a hand

PUBLISHED : Tuesday, 08 January, 2013, 12:00am
UPDATED : Tuesday, 08 January, 2013, 2:48pm
 

Matteo Russo's left thumb hurt every time he tried to move it. He assumed that, because he was 74, the problem might be age related.

He consulted a rheumatologist who diagnosed tendonitis, or inflammation of the tendon. He gave Russo (whose name has been changed for reasons of patient confidentiality) anti-inflammatory medication. Although the medication initially helped reduce the pain, the condition of his hand worsened over the next month to the point where Russo was in pain even when his hand was at rest.

Having lost confidence in the rheumatologist, Russo turned to the orthopaedic department at the University of Perugia, Italy. Radiographs showed that the bones in his hand were more porous than normal, with signs of cartilage wear and tear in his thumb joint. Russo was diagnosed with carpometacarpal osteoarthritis, and prescribed a hand splint to rest the joint, keep it in position and reduce pain.

Two months later, Russo lost his appetite. A heavy drinker and smoker, he had also been losing weight. His left hand was increasingly swollen and painful. The pain was so excruciating that Russo could not even lift it without pain, much less use it.

Despite the agony and the obvious distortion of his hand, Russo endured the pain, refusing to seek medical help.

The following month, he was admitted to hospital with respiratory distress and severe weakness. The mass on his left hand was so large his hand looked like an inflated rubber glove. The slightest touch would inflict excruciating pain.

Dr Giuseppe Rinonapoli, associate professor of orthopaedics and traumatology at the University of Perugia's orthopaedic department, was called in.

When he saw the condition of the hand, he suspected that a cancerous tumour had taken root but he needed to be sure.

An X-ray showed that the bones at the thumb joint had nearly disappeared - they had been dissolved by the body. The rest of the hand was osteoporotic, meaning the bones had become porous.

Rinonapoli tried to have Russo undergo a magnetic resonance imaging (MRI) scan but severe pain meant he couldn't keep his hand still long enough to complete the scan.

Given his respiratory symptoms, severe weakness and heavy smoking habit, internal medicine doctors gave him a chest X-ray. A lesion was found at the top of his left lung. A computed tomography (CT) scan showed a huge mass in his chest.

Further tests confirmed that Russo had large cell lung carcinoma, or lung cancer. This form of lung cancer makes up 9 per cent of lung cancers and metastasises to the brain in half of the cases.

Biopsy of his hand tissue showed that the cancer had metastasised to his hand, which is unusual. Other scans showed that it had only spread to the hand so far, making it the first location of metastases, which is an extremely rare occurrence.

Cancer cells break away from the tumour and travel in the bloodstream or lymphatic system to the bone marrow. Scientists think protein molecules in the bone marrow called cytokines may attract cancer cells. But metastases usually take place in parts of bone that are rich in marrow, says Rinonapoli. Metastases to the extremities are not common. Only 10 per cent to 15 per cent of bone metastases occur in the upper limbs, and only 4.1 per cent take place below the elbow or the knee.

The metastasis meant that Russo had stage IV lung cancer, with little hope of a cure. The goal was to extend and improve the quality of his life.

Given the extreme erosion of the bones in the hand, and to prevent the cancer from spreading further, Rinonapoli amputated Russo's hand from above the wrist. Six months later, Rinonapoli examined Russo's forearm, which was healing perfectly.

Unfortunately, Russo continued to deteriorate rapidly despite chemotherapy. The cancer eventually metastasised to his brain. A few weeks after that discovery, Russo died.

Rinonapoli says that the rarity of the hand for bone metastasis might have delayed an accurate diagnosis.

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