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Secondary Carcinoma of the Phalanges

1951; Radiological Society of North America; Volume: 57; Issue: 6 Linguagem: Inglês

10.1148/57.6.864

1527-1315

F. Wells Brason, Edward G. Eschner, S. Sanes, Gustave Milkey,

Bone Tumor Diagnosis and Treatments

Secondary carcinoma of the phalanges is uncommon. It may occur from pressure and direct invasion, or through metastasis. Each of these types of involvement is illustrated in the following cases, both of which possess special interest for the roentgenologist. Case I. Secondary Involvement of Distal Phalanx of the Right Thumb by Pressure and Direct Invasion from Carcinoma of the Nail Bed: W. P., a 35-year-old white man, was admitted to the hospital on Dec. 29, 1948, with pain and swelling of the right thumb. Four months prior to admission, the patient had crushed his thumb, and a hematoma had resulted. The pain and swelling were of one month duration. On admission, the distal part of the right thumb was swollen. A sinus at the tip discharged cheese-like material; similar material issued from a crusted area under the nail. The thumb was painful and tender. Epitrochlear and axillary nodes were not palpable. The clinical impression was “possible primary tumor; possible tuberculosis.” A roentgenogram of the right thumb showed a soft-tissue defect on the dorsal thenar aspect of the tip, with partial undermining and destruction of the nail. In this area there was some increase in the soft-tissue shadow, extending downward and backward to the phalanx. The bulbous portion of the phalanx was almost completely destroyed (Fig. 1); it presented a scaphoid defect with sharply demarcated border. Toward the basilar portion of the defect, the bone was irregular with decreased density streaking inward toward the joint. The roentgenologic impression was “osteolytic lesion, probably malignant.” Under local anesthesia (Jan. 4, 1949), the distal phalanx of the thumb was amputated by disarticulation. Following an uneventful postoperative course, the patient was discharged Jan. 17, 1949. Description of Surgical Specimen: Gross: The nail was missing in the dorsal thenar surface of the disarticulated phalanx over an area 1.4 × 0.5 cm. In this area and beneath the preserved nail, soft yellow granular material was present (Fig. 2). On sagittal section through the thumb, yellow nodular masses were found under the nail in the soft tissue, extending into the bone and destroying the terminal end of the phalanx (Fig. 3). Microscopically the lesion proved to be an infiltrating, highly mature, squamous-cell carcinoma with keratinization (Fig. 4) and with reactive inflammation in the stroma. It had its origin in the nail bed, which showed extensive ulceration. The carcinoma compressed and invaded bone. At its junction with the still remaining bone, there were chronic inflammation and fibrosis. Here loose fragments of bone were noted. New bone formation was not seen. Beyond this zone of carcinoma and preserved bone, the marrow was fibrous. Bony trabeculae were thick. Comment: In 1939, Levine and Lisa (1) collected 19 cases of carcinoma of the nail bed from the literature. In 1948, Ellis (2) reported 3 additional cases; Bayer (3) added 2 cases in 1949, and Russell (4) 1 in 1950.