AJR 2005; 184:S107-S109
© American Roentgen Ray Society
Metastatic Adenocarcinoma Presenting as Monoarticular Arthritis of the Knee
Paola Devis1,
Diana Iwanik2 and
Christopher Aikens1
1 Radiology Department, St Francis Hospital, 355 Ridge Ave., Evanston, IL
60602.
2 Radiology Department, Resurrection Medical Center, Chicago, IL 60631.
Received March 15, 2004;
accepted after revision August 17, 2004.
Address correspondence to P. Devis
(paoladevis{at}hotmail.com).
Introduction
Several possibilities should be considered when a patient with a
known history of malignancy presents with arthritis. The musculoskeletal
system may be either directly or indirectly involved with cancer or a
paraneoplastic syndrome such as hypertrophic osteoarthropathy, Sjögren's
syndrome, or carcinoma polyarthritis. Gout is a frequent complication of
patients undergoing chemotherapy. Lymphoma or leukemia may infiltrate the
synovium. Leukemia may also be complicated with hemarthrosis, crystal induced
synovitis, or synovial reaction to adjacent osseous lesions.
Case Report
A 70-year-old woman presented to her primary care doctor complaining of a
1-week history of progressive painful swelling of the right knee. On physical
examination the right knee was swollen, warm, and painful to the touch. Past
medical history was significant for adenocarcinoma of the rectum diagnosed 1
year earlier, which had been treated with resection and radiation therapy.
Workup at the time of diagnosis revealed no evidence of distant
metastasis.
Gouty arthritis was clinically suspected, and empiric medical treatment was
begun. The patient's symptoms were initially relieved. A joint aspiration
yielded approximately 5 mL of serosanguineous fluid. Analysis of the fluid was
negative for WBC and crystals; bacterial cultures were negative. After a week
of medical treatment, the symptoms recurred and worsened.
An additional diagnostic workup was performed and included unenhanced and
enhanced MRI of the right knee, followed by a CT-guided synovial biopsy.
Radiographs were not included in the workup.
Imaging Findings
MRI was performed by using two different MR systems: the EXP Edge 1.5T
(nonenhanced images, Philips Medical Systems) and the Signa LX 1.5T (enhanced
images, GE Healthcare). Nonenhanced images consisted of axial T1-weighted
field echo, sagittal proton density spin-echo, sagittal T2-weighted spin-echo,
and coronal T1-weighted fast spin-echo with fat saturation. Enhanced images
included coronal and sagittal T1-weighted fast spin-echo.
MRI revealed marked synovial thickening with the appearance of a complex
joint effusion. A heterogeneous high-signal-intensity mass is seen filling the
joint space in T1-weighted images, T2-weighted images, and T1-weighted fast
spin-echo with fat saturation images (Figs.
1A,
1B,
1C,
1D). After the administration
of contrast material, there is heterogeneous synovial enhancement. The
adjacent cortex of the bone and bone marrow shows a very small focus of high
signal intensity on noncontrast T2-weighted images that involves the medial
femoral condyle.
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Fig. 1A. —70-year-old woman presented to her primary care doctor
complaining of a 1-week history of progressive painful swelling of the right
knee. Axial T1-weighted image. Normal synovium has been replaced by thick
heterogeneous, predominantly high-signal-intensity mass, which is distending
the infrapatellar bursa and posterior aspect of joint capsule. (Images were
obtained using EXP Edge 1.5T: FE; TE/TR, 15.7/750; flip angle, 35°.)
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Fig. 1B. —70-year-old woman presented to her primary care doctor
complaining of a 1-week history of progressive painful swelling of the right
knee. Sagittal T2-weighted image. Heterogeneous, predominantly
high-signal-intensity mass is seen filling the joint space, distending
anterior and posterior aspects of joint capsule. (Images were obtained using
EXP Edge 1.5T: spinecho; SE; TE/TR, 80/2,500; flip angle, 90°.)
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Fig. 1C. —70-year-old woman presented to her primary care doctor
complaining of a 1-week history of progressive painful swelling of the right
knee. Coronal proton density-weighted fat-saturated image. There is a focus of
high signal intensity seen involving cortex and bone marrow of lateral femoral
condyle (not shown). (Images were obtained using EXP Edge 1.5T: fast
spin-echo; TE/TR, 26/2,000; flip angle, 90°.)
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Fig. 1D. —70-year-old woman presented to her primary care doctor
complaining of a 1-week history of progressive painful swelling of the right
knee. Sagittal enhanced T1-weighted fat-saturated image. There is intense
heterogeneous enhancement of synovial mass. (Images were obtained using Signa
LX 1.5-T: fast spin-echo; TE/TR, 9.4/516).
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A limited nonenhanced CT scan was performed on a HiSpeed CT/i (single
slice, GE Healthcare) for guiding a synovial biopsy
(Fig. 1E). After informed
consent was obtained, 5-mm-thick noncontrast images of the right knee were
obtained. The CT scan showed a heterogeneous soft-tissue mass filling the
articular space with a few small peripheral amorphous calcifications (the
calcifications were not apparent on MRI). The juxta-articular bones appeared
to be intact. A region of biopsy was selected in the suprapatellar area, and
markers were placed in the overlying skin. Using local anesthesia and CT
guidance, a 17-gauge coaxial biopsy system was inserted and advanced to the
lateral margin of the suprapatellar, soft-tissue mass. Five core biopsies were
obtained by using an 18-gauge cutting needle.
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Fig. 1E. —70-year-old woman presented to her primary care doctor
complaining of a 1-week history of progressive painful swelling of the right
knee. Nonenhanced CT image with bone windows. Soft-tissue density mass is seen
within synovial joint space, with faint amorphous peripheral calcifications
(not seen on MRI). Note that adjacent cortical bone is intact. (Images were
obtained using HiSpeed CT/i. scanner)
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Pathologic Diagnosis
The pathologic diagnosis was determined to be metastatic mucinous
adenocarcinoma consistent with the resected primary rectal carcinoma.
Discussion
Several possibilities should be considered when a patient with a known
history of malignancy presents with arthritis. The musculoskeletal system may
be either directly or indirectly involved with cancer or a paraneoplastic
syndrome such as hypertrophic osteoarthropathy, Sjögren's syndrome, or
carcinoma polyarthritis. Gout (crystal-induced synovitis) is a frequent
complication of patients undergoing chemotherapy. Lymphoma or leukemia may
infiltrate the synovium. Leukemia may also be complicated with hemarthrosis,
gout, or synovial reaction to adjacent osseous lesions.
Metastatic disease is the most common neoplasm found in the bones. The
skeleton (particularly the axial skeleton) is the third most common site for
metastasis after the liver and lung
[1,
2]. Roughly 80% of the primary
tumors are adenocarcinomas arising from the prostate, breast, lung, kidney,
thyroid, gastrointestinal tract, and bladder
[1]. Arthritis resulting from
metastatic carcinoma is rare. If there is synovial involvement, it is usually
related to direct extension of a metastatic lesion from juxta-articular bone
[1]. A 1980 review of the
literature summarized 19 case reports of arthritis resulting from metastatic
carcinoma [1].
Only a few reported cases of metastatic adenocarcinoma to the synovium,
without significant adjacent osseous disease, can be found in the literature.
We were only able to find four reported cases specifically identifying primary
involvement of the synovium
[1-4].
There are no reported descriptions of the MRI findings for this disease.
The most common primary tumor associated with metastatic carcinomatous
arthritis is bronchogenic carcinoma, followed by breast, melanoma, and
gastrointestinal carcinomas [5,
6]. Involvement is usually
monoarticular [6], with the
knee being most commonly affected, although the involvement of other joints
has been reported [5,
6]. Clinically, the joint
appears to be inflamed. Synovial fluid is usually sanguineous and not inflamed
[6]. Cytologic evaluation may
reveal malignant cells [2].
Synovial biopsy is needed for a definitive diagnosis
[1,
2].
The presence of synovial thickening, in the absence of an osseous lesion,
has a differential diagnosis that also includes localized nodular synovitis,
pigmented villonodular synovitis, synovial chondromatosis, rheumatoid
arthritis, and intraarticular synovial sarcoma
[7]. Imaging findings,
including MRI, are often nonspecific. Pigmented villonodular synovitis has
characteristic low signal intensity on all MRI pulse sequences, although it
may be heterogeneous. Synovial chondromatosis is characterized by multiple
calcifications within a soft-tissue mass of near fluid signal (high to
intermediate T2-weighted signal and low T1-weighted signal). Synovial sarcoma
is frequently associated with amorphous calcifications, which are often
peripheral, and up to 20% involve the adjacent bone with periosteal reaction,
bone remodeling, or invasion.
Metastatic synovial involvement is rare. With diagnostic imaging, it is
indistinguishable from synovial sarcoma and many times more difficult to
differentiate from the other causes of synovial thickening. It may be
considered as a diagnostic possibility when there is known history of a
primary adenocarcinoma. Biopsy is necessary for a definitive diagnosis.
References
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monoarticular arthritis: a case report and review of literature.
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Arthritis Rheum1975; 18:107
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- Meals RA, Hugerford DS, Stevens MB. Malignant disease mimicking
arthritis of the hip. JAMA1978; 293:1070
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- Stephen FH, Petersilge CA. Metastatic carcinomatous arthritis from
mucinous adenocarcinoma of the colon, MSK imaging case report. Roentgen Ray
1997:uhrad.com
(unpublished data). Accessed March 1, 2004
- Benhamou CL, Tourliere D, Brigant S, et al. Synovial metastasis of
an adenocarcinoma presenting as a shoulder monoarthritis. J
Rheumatol 1988;15:1031
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- Fam AG, Kolin A, Lewis AJ. Metastatic carcinomatous arthritis and
carcinoma of the lung: a report of two cases diagnosed by synovial fluid
cytology. J Rheumatol1980; 7:98
-104[Medline]
- Danhert W. Radiology review manual, 5th ed.
Philadelphia, PA: Lippincott Williams & Wilkins,2003
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Introduction
Case Report
