Isolated Metastatic Carcinoma to the Hamate Bone: The First Manifestation of an Occult Malignancy

Abstract

A 60-year-old man presented with swelling, pain, and tenderness at the ulnar side of his left wrist. Imaging studies demonstrated an osseous lesion in the left hamate bone. Histopathology study of the lesion revealed that the lesion was an isolated osseous metastatic carcinoma. The metastasis was the first presentation of this occult malignancy. The patient was treated with radiotherapy and chemotherapy; however, he expired 20 months after the diagnosis. This is a level IV study.

Introduction

Osseous metastasis distal to the elbow and knee (acrometastasis) is a rare complication of malignancies. It is estimated that acrometastasis occurs in 1% of all metastases. 1 2 3 4 The diagnosis of acrometastases may be delayed because of their rarity, and they often masquerade as infection, gout, osteomyelitis, tenosynovitis, arthritis, chronic regional pain syndrome, and other inflammatory disorders. 1 2 3 4 A delay in diagnosis affects appropriate management and patient's survival. There are limited reports of metastases to the wrist region and particularly to the hamate bone. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 This case report presents a case of metastatic carcinoma to the hamate bone.

Case Report

A 60-year-old man presented with swelling, pain, and tenderness at the ulnar side of his left wrist since 4 weeks. He did not have weight loss. He was not a smoker or alcohol consumer. His symptoms were not related to his job. He did not have any obvious disease and any problem with his wrist in the past.

Anteroposterior radiographs of the left wrist demonstrated a lytic lesion in the hamate bone ( Fig. 1 ). Isotope whole-body bone scan demonstrated an isolated increased uptake on the hamate bone ( Fig. 2 ). T1 and T2 magnetic resonance imaging scans (MRI) demonstrated that the lesion had engulfed the hamate bone ( Figs. 3 4 ). His chest radiograph was normal. Preoperative blood laboratory tests were normal. The patient was scheduled for biopsy from the lesion.

Fig. 1.

Anteroposterior radiograph of the left wrist demonstrates a hazy lytic lesion (arrow) with destruction of the bone trabeculae in the hamate bone.

Fig. 2.

Isotope bone scan demonstrates an isolated increased uptake at the ulnar side of the left wrist.

Fig. 3.

T1 magnetic resonance imaging demonstrates the lesion with low signal intensity in the hamate.

Fig. 4.

T2 magnetic resonance imaging demonstrates the lesion with high signal intensity in the hamate.

At surgery multiple fragments of gray-colored tissue measuring 1.5 × 1.5 × 1.5 cm were removed for pathologic evaluation ( Fig. 5 ). Histopathologic study of the hamate lesion demonstrated fragments of bone trabeculae and fibrotic tissue infiltrated by nests of tumoral cells. The neoblastic cells contained oval nuclei with some irregularity of nuclear membranes and single prominent nucleoli. Cytoplasm were clear to moderate pale eosinophilic ( Fig. 6 ). Immunohistochemistry (IHC) staining was positive for CK7, CK20, EMA, Kr, and TTF1. IHC staining was focally positive for CD10 and thyroglobulin, weakly positive for vimentin, and focally and weakly positive for carcinoembryonic antigen (CEA), but negative for prostate-specific antigen (PSA), CDX2, Heppar, and HMB45. According to IHC staining results, a metastatic carcinoma from urothelial, upper gastrointestinal tract, and lung and thyroid origins should be considered.

Fig. 5.

At surgery multiple fragments of gray-colored tissue measuring 1.5 × 1.5 × 1.5 cm removed for pathologic evaluation.

Fig. 6.

The neoplastic cells contain oval nuclei with some irregularity of nuclear membranes and single prominent nucleoli, with moderate amounts of clear to pale eosinophilic cytoplasm (hematoxylin-eosin, original magnification ×400).

Further workups failed to demonstrate a lesion in the thyroid, gastrointestinal, and urinary tracts. An initial computed tomography (CT) scan of the chest at the time of the histopathology diagnosis failed to demonstrate any lesion in the lungs; however, it demonstrated extensive lymphadenopathy in anterior, middle, and posterior mediastinal compartments, which was highly suggestive of an occult lung malignancy. A second CT scan performed 2 weeks later demonstrated a lesion at the right upper lung; however, the patient refused bronchoscopy examination to obtain a biopsy sample from the right lung lesion for diagnosis.

Four weeks after his hand biopsy, the patient complained of headache. MRI of the brain demonstrated a 19- × 19-mm mass in the right cerebellum hemisphere. Radiotherapy with a dose of 40 Gy in 20 fractions was administered for his right hamate and 20 Gy in 10 fractions for the brain lesion. His wrist was supported by a splint. The patient was treated with chemotherapy, and paclitaxel and cisplatin were administered for six periods with 3-week intervals. The left wrist complaints resolved; however, we advised the patient to continue to support his wrist with a splint. His general health continuously deteriorated. He expired 20 months after the diagnosis because of multiple organ failure.

Discussion

Metastasis to the hand, wrist region, and hamate is a rare occurrence. 24 During a 43-year experience, Amadio and Lambordi treated only three cases of wrist metastases that were located in the capitate, scaphoid, and lunate bones. 1 In an analysis of 163 reported metastases to the hand and wrist region between 1907 and 1986, Kerin found five reported metastases to the hamate bones in four patients among the 48 reported wrist metastases. 2 In an analysis of the 221 reported metastasis to the hand and wrist region from 1986 till 2013, there were 9 reported patients (8 males and 1 female) with metastases to their hamate bones among the 27 reported patients with metastases to their wrists. 3

Table 1 demonstrates a concise review of the available English literature about the reported metastases to the wrist region and hamate bone. Metastases to the wrist region and hamate have been reported from bronchogenic adenocarcinoma, bronchogenic small cell carcinoma, bronchogenic large cell carcinoma, hepatocellular carcinoma, gastric adenocarcinoma, esophageal squamous cell carcinoma, renal cell carcinoma, and B-cell lymphoma. The treatments were varied, including pain management, radiotherapy, chemotherapy, excision of the hamate, partial excision of carpus, and amputation. However, the average survival among the seven patients with identified survivals was 8.6 months. Although in this case the metastasis was isolated to one carpal bone, involvement of multiple carpal bones may occur. 3 13

Table 1. Characteristics of 20 patients with the wrist and hamate metastases including the current case and from the English literature.

	Authors	Year	Age/Sex	Metastasis location	Primary tumor	Known history of malignancy	Presence of other metastasis	Metastatic treatment	Survival (mo)
Abbreviations: F, female; M, male.
1	Abrahams 5	1995	59/F	Left lunate	Bronchogenic squamous cell carcinoma	Negative	Not identified	Not identified	Not identified
2	Ahlmann et al 6	2008	65/M	Right hamate	Bronchogenic adenocarcinoma	Negative	Yes	Excision of the hamate	12
3	Borgohain et al 7	2012	70/M	Right second metacarpal bone, trapezium, and trapezoid	Renal cell carcinoma	Negative	Yes	No treatment	Not identified
4	Buckley and Peebles Brown 8	1987	78/F	Left trapezium and trapezoid	Sigmoid colon adenocarcinoma	4 y	Yes	Chemotherapy	Not identified
5	Caglar and Ceylan 9	2001	51/M	Right capitate	Bronchogenic squamous cell carcinoma	Negative	No	Not identified	Not identified
6	Craigen and Chesney 10	1988	37/M	Right hamate	Gastric adenocarcinoma	3 y	Yes	Not identified	Not identified
7	Esther and Bos 11	2000	58/F	Right capitate	Parotid mucoepidermoid carcinoma	5 y	Yes	Radiotherapy	Not identified
8	Gaston et al 12	2008	Mid-40s/F	Right trapezium	Bronchogenic non–small cell carcinoma	Positive	No	Excision of the trapezium	Not identified
9	Keramidas and Brotherston 13	2005	66/F	Right middle, ring, little metacarpal bones, capitates, and hamate	Bronchogenic adenocarcinoma	Negative	No	Biopsy	3
10	Park et al 14	2006	39/F	Right trapezium, left capitates bones	Gastric adenocarcinoma	Positive	Yes	Radiotherapy and chemotherapy	Not identified
11	Reichert et al 15	2001	29/M	Left capitate	Foot clear cell sarcoma	2 mo	Yes	Partial excision of carpus	10
12	Rinonapoli et al 16	2012	74/M	Left trapezium, trapezoid, and Scaphoid	Bronchogenic undifferentiated large cell carcinoma	Negative	No	Bellow-elbow amputation	Not identified
13	Roushdi et al 17	2012	66/F	Left hamate	B-cell lymphoma	Negative	Yes	Chemotherapy	Not identified
14	Song and Yao 18	2012	70/M	Right trapezium	Bronchogenic non–small cell carcinoma	Negative	No	Trapezium ectomy	Not identified
15	Stahl et al 19	2012	46/F	Left scaphoid	Lower leg melanoma	8 y	Yes	Excision	13
16	Stanković et al 20	2017	56/M	Right scaphoid, lunate, and capitate	Bronchogenic adenocarcinoma	Negative	No	Upper arm amputation	Not identified
17	Strooker et al 21	2015	83/M	Lunate	Bronchogenic large cell carcinoma	Negative	No	Proximal row carpectomy	2
18	Tolo et al 22	2002	63/M	Left triquetrum	Renal cell carcinoma	13 y	Yes	En block resection of ulnar side of the wrist	13
19	Tomas et al 23	2005	25/F	Right capitate	Skin malignant melanoma (interscapular)	20 mo	Yes	Chemotherapy	Not identified
20	Wurapa et al 24	2010	80/F	Left scaphoid, trapezium, and trapezoid	Esophageal adenocarcinoma	3 y	Yes	Below-elbow amputation	7
21	Present study	2018	60/M	Left hamate	Bronchogenic carcinoma	Negative	No	Chemotherapy	20

Acrometastases, as occurred in this case, may be the first manifestation of an occult malignancy. 1 2 3 4 In the Kerin's study, 16% of the patients did not have a known malignancy in their history. 2 The hand and wrist metastasis denotes a widespread dissemination of the malignancy and implies a poor prognosis. 1 2 3 4 There may be some difficulties in finding the primary tumor when the metastatic bone disease as well as hand and wrist metastasis occurs as the first manifestation of an occult malignancy; however, the most common sites are from the lung, breast, prostate, and gastrointestinal tract. The primary malignancy may not be even identified in 30% of the patients with an unknown history of malignancies. 25 26 The source of the hand and wrist metastasis may be secondary to the other metastatic sites rather than the primary tumor. 2 3 4 Sometime the histology of metastatic site may be different from primary tumor because of previous chemotherapy. 27

This case report presents the fate of a case of metastatic carcinoma to the hamate bone. Each reported case may hopefully bring more insight to early diagnosis and management of the hand and wrist metastasis.