Metastatic Carcinoma Presenting as Soft Tissue Infection in the Hand
Alaa A. Alibrahim, MD1; Maria Cipollone, MD2; Emran S. Sheikh, MD1; Renata V. Weber, MD1
1Multi Disciplinary Specialists, Rutherford, NJ; 2Mount Sinai Beth Israel, New York, NY
Metastatic tumors in the hand are rare, accounting for approximately 0.1% of all metastatic tumors. Of these tumors, the majority present as bony lesions rather than as cutaneous or soft tissue lesions. When the soft tissue is affected, it is usually misdiagnosed as benign condition such as infection or inflammatory conditions. When recognized, it signifies an advanced stage. Occasionally, it may be the first presentation of a previously undiagnosed primary malignancy elsewhere. We present two patients who had metastatic tumors present as soft tissue infections in the hand.
Patient 1 was in remission after being treated with chemotherapy for squamous cell nasopharyngeal carcinoma who presented with a swollen first webspace and no evidence of bony erosion on radiograph. Patient 2, who had metastatic hepatocellular carcinoma, presented with a swollen and erythematous left thumb with some skin necrosis but no bony destruction of the distal phalanx. While Patient 2 had known bony metastasis in the spine, Patient 1's mass was the first indication of metastatic disease.
Both nasopharyngeal and hepatocellular carcinomas usually metastasis to the lungs, bones, and regional lymph nodes. The mechanism of soft tissue metastases to the hand is still unclear; possible theory includes the "Seed and Soil" hypothesis and "Immune escape" theory. Hand dominance and intravenous insertion of chemotherapy may play a role. Since metastasis represents a progression of tumor staging, early awareness of unusual metastatic presentations may lead to a change in intervention options for the primary tumor and may affect patient survival.
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