DOI:10.2214/AJR.04.0930
AJR 2006; 186:1797-1799
© American Roentgen Ray Society
Monomelic Spread of Metastatic Disease due to Proximal Deep Venous Thrombosis
Hans Van der Wall and
Amanda Palmer
Concord Hospital
Sydney, Australia
St. George Hospital
Sydney, Australia
Peripheral arterial tumor embolism is rare but has been reported in
association with bronchogenic carcinoma. In one such case, pathologic proof of
tumor in the lower limb was associated with a tumor in the left atrial
appendage [1]. Others have also
reported a handful of cases with compelling pathologic evidence of arterial
dissemination to the peripheral circulation
[2-4],
and even to the brain [5], from
primary lung tumors. We describe such a case that subsequently showed an
unusual and intriguing temporal sequence of events.
A 72-year-old man presented to his doctor with a painful swollen left foot.
Because he was a non-insulin-dependent diabetic, an infection was suspected.
Radiography of the left foot showed a destructive lesion of the left navicular
bone (Fig. 1A) that was thought
to be consistent with osteomyelitis. He was commenced on several courses of
antibiotics without a change in symptoms. After several weeks, a biopsy was
performed, and histology showed non-small cell carcinoma. Chest radiography at
that time showed a mass in the left lung, a biopsy of which also confirmed
non-small cell carcinoma of the lung. Bone scintigraphy at that time showed a
solitary focus of increased uptake in only the left navicular bone
(Fig. 1B).
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Fig. 1B —72-year-old man with bronchogenic carcinoma metastasis in left foot.
Bone scintigraphy study shows intense hyperemia and uptake in left navicular
bone but no other evidence of abnormal uptake to suggest metastatic disease. B
Pool = blood pool.
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Radiotherapy to the foot and left lung tumor was commenced. After several
courses, the patient experienced onset of acute pain in the left lower limb
from the knee downward. Doppler sonography studies were thought to show
occlusion of the distal superficial femoral artery with formation of popliteal
collaterals and reduced distal flow (Fig.
1C). Anticoagulation was commenced and resulted in symptomatic
improvement.
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Fig. 1C —72-year-old man with bronchogenic carcinoma metastasis in left foot.
Doppler study shows complete occlusion of superficial femoral artery
(arrowhead) with reconstitution of flow via collaterals and dampened
waveform in distal superficial femoral artery (arrow).
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Two months later, there was recurrence of the increasing pain and swelling
in the left leg below the knee. Deep venous thrombosis was suspected and
confirmed in the left thigh and popliteal fossa on Doppler studies.
Radiography at that time showed multiple lytic lesions involving the left
tibia and fibula (Fig. 1D),
indicative of further metastatic disease. Bone scintigraphy at this time
showed multiple sites of increased uptake below the left knee only
(Fig. 1E), without abnormal
uptake in the other skeletal structures. Further IV anticoagulation therapy
was commenced at this time. The patient's condition remains stable on
localized radiation therapy.
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Fig. 1D —72-year-old man with bronchogenic carcinoma metastasis in left foot.
Radiograph of left tibia and fibula. Multiple lytic lesions are apparent in
both bones, thought to be consistent with metastatic disease.
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Fig. 1E —72-year-old man with bronchogenic carcinoma metastasis in left foot.
Bone scintigraphy study, obtained 5 months after B, shows multiple
sites of increased uptake in left tibia and fibula in addition to navicular
bone. No evidence of abnormal uptake above left knee to suggest widespread
metastatic disease. Ant = anterior, Post = posterior.
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The case presented underlines a number of rare phenomena related to
metastatic disease from a primary non-small cell carcinoma of the lung. There
are only a handful of reports of presentation of the tumor as a solitary
metastasis in the foot
[6-8].
The most commonly reported peripheral metastases from primary lung tumors tend
to occur in the hands [8] and
very rarely in the feet. The most likely explanation is the growth of the
tumor into the pulmonary venous circulation and its subsequent embolization
through the left side of the heart and systemic arterial circulation to the
peripheral tissues. Researchers have theorized that there is streaming of the
arterial circulation to the upper limbs, hence the relatively more common
occurrence at this site.
The alternate hypothesis is that there is retrograde growth of the tumor
into the venous circulation and subsequent metastasis through incompetent
venous valves in the lower limb. There is little pathophysiologic evidence to
support either theory, although the simple mechanistic alternative of arterial
dissemination appears more likely.
The unique aspect of this case is related to the spread of metastatic
disease in just one limb. It is possible that the localized radiation therapy
to the left foot may have been compromised by relative ischemia due to
arterial occlusion above the left knee. This would have provided a shelter
site for further growth of the navicular bone tumor and its subsequent local
dissemination. The deep venous thrombosis above the knee would have presented
a mechanical block to the venous dissemination of the tumor beyond the knee
but would have enabled dissemination below this site. This was clearly evident
as a well-demarcated incidence of metastases in the bone scan, with radiologic
evidence of lytic lesions at corresponding sites in the tibia and fibula.
The possibility of simultaneous arterial micrometastases to other sites in
the same limb at the time of the navicular metastasis is another possibility.
However, the delay in appearance at other sites until after the occurrence of
deep venous thrombosis suggests a probable secondary spread from the initial
site in the navicular bone.
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