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  Table of Contents    
LETTER TO EDITOR  
Year : 2022  |  Volume : 65  |  Issue : 4  |  Page : 953-955
Acral metastasis as the primary presentation of colon carcinoma


1 Department of Pathology, IPGME&R, Kolkata, West Bengal, India
2 Department of Radiotherapy, NRS Medical College, Kolkata, West Bengal, India

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Date of Submission12-Mar-2021
Date of Acceptance05-Dec-2021
Date of Web Publication26-May-2022
 

How to cite this article:
Basu T, Das M, Bandyopadyay A, Chatterjee U. Acral metastasis as the primary presentation of colon carcinoma. Indian J Pathol Microbiol 2022;65:953-5

How to cite this URL:
Basu T, Das M, Bandyopadyay A, Chatterjee U. Acral metastasis as the primary presentation of colon carcinoma. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Dec 7];65:953-5. Available from: https://www.ijpmonline.org/text.asp?2022/65/4/953/345864




Dear Editor,

Skeletal spread of colorectal carcinoma is rare and if it does so, it happens in conjunction with other distant metastasis.[1] Common sites for skeletal metastasis following a colorectal primary are the vertebral column, pelvic or hip bones, and long bones.[2]

Metastasis to the fingers and toe bones, so-called Acrometastasis is derived from the Greek word akros, which means “extreme.” It is a rare form of skeletal spread where reported incidence is as low as 0.1% including primaries other than colorectal carcinoma.[3] Additionally, acrometastasis as the presenting feature of colonic carcinoma has not been reported so far in our population.

A 62-year-old man presented with a 3 months' history of gradually worsening pain and swelling in the dorsum of his left foot without a history of trauma or associated fever. Clinical examination showed pallor. Local examination revealed firm to hard swelling of 5 × 3 × 2 cm over the dorsum of left foot. Magnetic resonance imaging (MRI) suggested a heterogeneous swelling with signal from the underlying metatarsal bone and edema of the neurovascular planes. Impression was of a sarcomatous lesion. The mass was excised and it consisted of multiple irregular pieces of gray-white gelatinous material. Haematoxylin and eosin stain revealed glandular structures lined by atypical columnar cells with cytoplasmic mucin and pools of extracellular mucinous material; thus, a diagnosis of mucin secreting adenocarcinoma was made. A panel of immunohistochemical markers were used considering a possible pulmonary or colonic primary. The results revealed positivity for CDX2 and CK20 and negative for TTF1 and Napsin A [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. Test for serum prostate specific antigen (PSA) was normal but carcinoembryonic anitigen (CEA) was raised. The subsequent investigations revealed a primary neoplastic lesion in the ascending colon on colonoscopy. Surgery was being planned but the patient's condition deteriorated and he expired within 8 weeks of the diagnosis.
Figure 1: (a) X-ray of lateral and AP views of left foot. Note the soft tissue shadow indicating an infiltrative tumor mass. (b) MRI sagittal view of left foot showing a heterogenous lesion involving the left foot. (c) MRI coronal view of left foot showing the same. (d) HPE 4 × showing features of mucin secreting adenocarcinoma and pools of extracellular mucin. (e) HPE 10× (400 × inset) showing features of mucin secreting adenocarcinoma. (f) IHC (CDX2) 10 × showing strong nuclear positivity of the neoplastic glands

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Osseous metastasis from colorectal carcinomas is a rare phenomenon found in only 5.5% patients at the time of initial diagnosis and is seen usually in the setting of synchronous metastatic disease to other organ sites.[4] Metastases to the hands are three times more common than in the feet and men are more likely to develop acrometastasis than women.[5] A literature review of reported cases of acrometastasis by Stomeo et al.[6] found that lung cancer was the foremost malignancy associated with acrometastasis, followed by renal cell carcinoma, breast carcinoma, and lastly colonic carcinoma.

The pathophysiology of acrometastasis is poorly understood. It is hypothesized that Batson's venous complexes communicate with the vessels of the lower extremities facilitating metastasis to the feet.[3] More recently, it has been suggested that the chemotactic factors (prostaglandins) released following a traumatic experience may be responsible for cell migration and adherence to osseous material.[6] The various hypotheses indicate hematological spread of tumor cells as opposed to lymphatic spread.[6] Bone metastases usually develop in areas rich with red marrow and bones of the hand have red marrow, while those in the feet do not and this may explain the increased frequency of acrometastasis in the hands.

Acrometastases can be mistaken for other more common conditions including gout, rheumatoid arthritis, osteomyelitis, and ligament sprains frequently delaying diagnosis and leading to inappropriate treatment.[7] Therefore, history, radiological findings, and biopsy are helpful in making the diagnosis.

The common primary for bone metastasis in males are lung, kidneys, prostate, and bladder. Colorectal origin is rare. Mucinous tumors are known to occur in all the above locations and hence the search for a primary was a challenge. With raised serum CEA and normal PSA levels, the possibility of a malignant prostatic primary was ruled out. Immunohistochemistry showed negative TTF1 and napsin A. Further, CDX2 and CK20 positivity of the tumor cells was useful to establish colorectal origin.

The prognosis of colorectal carcinoma patients with skeletal metastases is worse than other primary cancers with bony metastases.[1] Further, a review of existing literature reveals a few cases reported worldwide but none of these presented as an acral mass [Table 1]. We can expect that a better understanding of the pathogenesis of this phenomenon may pave way for future management and therapy in such cases and may reveal clinically and biologically distinct forms of primary colorectal carcinoma.
Table 1: Summary of previously reported cases of acrometastasis to the foot following colorectal carcinoma

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The mainstay of treatment for such metastatic colorectal carcinoma case is palliative chemotherapy with the option of local radiotherapy to alleviate pain. However, the prognosis is always dismal.

Acrometastasis is usually a late manifestation of a disseminated disease but sometimes it can also be the primary manifestation of occult cancer. Here, we take the opportunity to report a rare case of colorectal carcinoma presenting initially as acrometastasis. Histopathological features and immunohistochemistry were useful in making a definitive diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[11]



 
   References Top

1.
Assi R, Mukherji D, Haydar A, Saroufim M, Temraz S, Shamseddine A. Metastatic colorectal cancer presenting with bone marrow metastasis: A case series and review of literature. J Gastrointest Oncol 2016;7:284-97.  Back to cited text no. 1
    
2.
Santini D, Tampellini M, Vincenzi B, Ibrahim T, Ortega C, Virzi V, et al. Natural history of bone metastasis in colorectal cancer: Final results of a large Italian bone metastases study. Ann Oncol 2012;23:2072-7.  Back to cited text no. 2
    
3.
Agha K, Akbari K, Abbas SH, Middleton S, McGrath D. Acrometastasis following colorectal cancer: A case report and review of literature. Int J Surg Case Rep 2016;29:158-61.  Back to cited text no. 3
    
4.
Kanthan R, Loewy J, Kanthan SC. Skeletal metastases in colorectal carcinomas: A Saskatchewan profile. Dis Colon Rectum 1999;42:1592-7.  Back to cited text no. 4
    
5.
Flynn CJ, Danjoux C, Wong J, Christakis M, Rubenstein J, Yee A, et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008;15:51-8.  Back to cited text no. 5
    
6.
Stomeo D, Tulli A, Ziranu A, Perisano C, De Santis V, Maccauro G. Acrometastasis: A literature review. Eur Rev Med Pharmacol Sci 2015;19:2906-15.  Back to cited text no. 6
    
7.
Schmidt RG, Cecchini AJ, Mayer DP, Kabbani Y. Magnetic resonance diagnosis of an occult metastatic colon carcinoma of the calcaneus. Foot Ankle Int 1994;15:334-9.  Back to cited text no. 7
    
8.
Härkönen M, Olin PE. Rectal carcinoma metastasizing to a toe. Acta Med Scand 1980;207:235-6.  Back to cited text no. 8
    
9.
Sebag-Montefiore DJ, Lam KS, Arnott SJ. Tarsal metastases in a patient with rectal cancer. Br J Radiol 1997;70:862-4.  Back to cited text no. 9
    
10.
Tuteja A, Owings M, Pulliam J, Elzinga L. Adenocarcinoma of the colon metastasizing to the foot masquerading as osteomyelitis. J Am Podiatr Med Assoc 1998;88:84-6.  Back to cited text no. 10
    
11.
Ellington JK, Kneisl JS. Acrometastasis to the foot: Three case reports with primary colon cancer. Foot Ankle Spec 2009;2:140-5.  Back to cited text no. 11
    

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Correspondence Address:
Mou Das
Department of Pathology, IPGME&R, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_276_21

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