[Shoulder arthritis as a lung metastatic carcinoma revealer. A case report.]
ABSTRACT Joint metastasis is very rare. It usually presents as a monoarthritis. It is generally located in the knee and secondary to lung cancer. Prognosis is poor, with a mean survival term of less than six months. We report the case of a right shoulder joint metastasis from a bronchopulmonary squamous cell carcinoma in a 55-year-old male smoker. The patient presented with an atypical chronic post-traumatic arthritis, not improved by symptomatic treatment. The diagnosis was based on synovial biopsy performed during open surgery. The primitive lung cancer was confirmed by chest CT scan and bronchial biopsy.
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ABSTRACT: A case in which a post-traumatic shoulder impairment revealed the presence of the joint involvement by a metastatic localization of lung adenocarcinoma is presented. The patient was a 60-year-old white man, a smoker, in apparent healthy condition complaining of pain and stiffness from a 1-year-old traumatic accident to the right shoulder sustained during a tennis match. He had been unsuccessfully treated for 6 months with physical therapy. Because of the negativity of the usual imaging studies, a diagnostic arthroscopy was performed. It revealed the presence of a traumatic rupture of the glenoid labrum and of an atypical gelatinous synovial formation in the medial wall of the joint; it was histologically and immunohistochemically diagnosed as adenocarcinoma, probably originating in the lung or in the gastrointestinal tract. The pulmonary origin of the neoplasm was confirmed by computed tomography. The patient underwent chemotherapy and eventually died with contralateral lung and femur metastases 8 months after the diagnosis. The clinical importance of this rare observation is discussed.Arthroscopy The Journal of Arthroscopic and Related Surgery 01/1998; 14(5):508-11. · 3.10 Impact Factor
- Scandinavian Journal of Rheumatology 02/1989; 18(3):169-70. · 2.22 Impact Factor
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ABSTRACT: Synovial metastases are rare events. Only 37 cases diagnosed by synovial fluid cytologic examination and/or by microscopic investigation of synovial biopsies have been previously reported in the literature. We report another case of shoulder chronic arthritis due to a recurrence of rectal adenocarcinoma and review previous published observations. Generally, this condition carries a poor prognosis with average patients survival of less than 5 months. The possibility of metastatic disease should be considered when an elderly person or patient with a history of previous malignancy presents with a chronic arthritis.Clinical Rheumatology 02/2007; 26(1):60-3. · 2.04 Impact Factor
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 451—453
Shoulder arthritis as a lung metastatic carcinoma
revealer. A case report
I. Alouia,∗, L. Njimb, A. Moussab, M.F. Hamdia, A. Abida, A. Zakhamab
aDepartment of Orthopedic Surgery, Fattouma Bourguiba Hospital, 1er Juin street, 5000 Monastir, Tunisie
bDepartment of Pathology, Fattouma Bourguiba Hospital, 1er Juin street, 5000 Monastir, Tunisie
Accepted: 31 March 2009
located in the knee and secondary to lung cancer. Prognosis is poor, with a mean survival term of
less than six months. We report the case of a right shoulder joint metastasis from a bronchopul-
monary squamous cell carcinoma in a 55-year-old male smoker. The patient presented with an
atypical chronic post-traumatic arthritis, not improved by symptomatic treatment. The diag-
nosis was based on synovial biopsy performed during open surgery. The primitive lung cancer
was confirmed by chest CT scan and bronchial biopsy.
© 2009 Elsevier Masson SAS. All rights reserved.
Joint metastasis is very rare. It usually presents as a monoarthritis. It is generally
Joint metastasis is very rare. In the few reported cases [1,2],
the primitive cancer was most frequently lung adenocarci-
The primitive cancer is usually diagnosed before the
sometimes reveal it. Diagnosis is generally based on joint
fluid cytology or more rarely on biopsy material.
We here report a new case.
A 55-year-old male smoker (40 packets per year) had
received a direct shock to the right shoulder by a heavy
E-mail address: aloui email@example.com (I. Aloui).
object in a work accident, causing painful right upper limb
impotence. Shoulder contusion was diagnosed, and managed
by symptomatic treatment associated to rehabilitation.
swelling of the shoulder. X-ray assessment found subchon-
dral cysts in the proximal part of the humerus and inferior
subluxation of the humeral head (Fig. 1).
The presence of an infectious syndrome (SR 62/95, CRP
23mg/ml, WC 16,500elts/mm3), shoulder skin scarification
and intra- and extra-articular effusion on ultrasound sug-
gested septic osteoarthritis.
Surgical drainage of the shoulder joint found only extra-
articular effusion in the form of an infected hematoma. The
shoulder joint contained a very small quantity of liquid. The
cartilage was healthy and the synovial membrane slightly
hyperemic. Several biopsies were taken from the capsule
and synovial membrane.
Serendipitously, chest X-ray revealed a left parahilar
opacity with an irregular contour, strongly suspected to be
malignant (Fig. 2).
1877-0568/$ – see front matter © 2009 Elsevier Masson SAS. All rights reserved.
452I. Aloui et al.
humeral upper extremity, inferior subluxation of the shoulder
Plain shoulder X-ray: subchondral cysts of the
Peroperative findings and the sterility of the joint liquid
ruled out infectious origin of the arthritis. A thoraco-
abdominal CT scan, to explore the suspicious lung image,
found a 4cm-diameter parenchymal mass of the lingula, sug-
gestive of bronchial cancer. The liver and adrenal glands
were of normal aspect.
Histologically, synovial biopsies showed massive infil-
tration of the synovial membrane by a carcinomatous
proliferation with distinct squamous cell differentiation
(Fig. 3), confirming the metastatic origin of the joint pathol-
Currently, the patient was undergoing chemo- and radio-
therapy, with no local improvement and deterioration of his
Plainchest X-ray: ill-definedleft parahilar
membrane by carcinomatous tumoral elements (Hematoxylin-
formation of an keratinous pearl (×400).
Synovial biopsy showing infiltration of the synovial
Inset: typicalsquamous differentiationwith
Metastatic carcinomatous arthritis is rare but can reveal an
overlooked primitive cancer [1—4]. Symptomatology varies,
mimicking rheumatoid, inflammatory or even septic arthri-
tis, as in the present case . However, in the absence
of history of oncology, exploration secondary to trauma
may incidentally reveal hitherto asymptomatic metastasis
Joint metastases are mainly located in the knee, the
shoulder being involved in only one case in ten .
The primitive carcinoma should be sought first in the
lungs and then in the gastro-intestinal tract. Exception-
ally, the primitive cancer may be located in the kidneys,
pancreas or breast . The present case is histologically
original: squamous cell carcinoma, unlike adenocarcinoma,
rarely gives rise to bone metastases .
Bone involvement in carcinomatous arthritis is usual,
but the mechanism of synovial invasion remains controver-
sial. Unlike other richly vascularized tissue, the synovial
membrane is, paradoxically, an extremely rare location
for metastasis. In 1996, Thompson et al.  reported 30
cases described as synovial metastases, although many of
them had concomitant periarticular bone metastases. In
1997, Hatem et al.  found, in addition to their per-
sonal observation, only three reported cases of true synovial
metastasis. The synovium is exceptionally affected in the
absence of periarticular involvement, in particular pre-
existing subchondral bone metastasis [1,3], although the
order of events cannot be determined [1,3,6,8]. In the
present case, the lytic humeral head lesion was probably
related to subchondral metastasis accompanying synovial
The diagnosis is based on cytologic examination of
synovial fluid  or, better, on histological analysis of
a fine needle biopsy ], samples being taken during
arthroscopy or arthrotomy . The absence of neoplastic
cells in cytological or histological material does not rule
out localized synovial invasion. The synovial fluid tends to
Shoulder arthritis as a lung metastatic carcinoma revealer. A case report453
be hemorrhagic, but can be inflammatory or even puru-
lent [2,7,9]; some authors advise assaying tumor markers
such as carcinoembryonic antigen (CEA) in the synovial fluid
CT scan and MRI may be useful for diagnosis. They reveal,
respectively, infra-radiological bone lesions and incipient
synovial invasion [6,8].
Arthroscopy is of particular diagnostic interest when
there is no joint effusion, and can guide the choice of biopsy
site in localized involvement [2,6,10].
With its whole-body mode and the use of qualitative
methods, fluoro-2-dexoy-d-glucose (FDG) positron emission
tomography (PET) can contribute not only to diagnosis but
also to the assessment of both local and general extension
These lesions are managed by treating the primitive
tumor. Local treatment is rarely recommended, given the
advanced stage of the cancer and the low life-expectancy,
of less than six months [1,6].
However rare, carcinomatous arthritis should be considered,
even in the absence of any history of cancer, when the clin-
ical history is long, symptomatology is atypical, response to
treatment is lacking and X-ray suggests a destructive pro-
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