*Asterios Dramis, +Adesgun Abudu

*Senior House Officer, Department of Orthopaedic Oncology, Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham B31 2AP, UK
+Consultant Orthopaedic Oncologist, Department of Orthopaedic Oncology, Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham B31 2AP, UK

Address for Correspondence

Mr Asterios Dramis
38 Pakenham Road, Edgbaston, Birmingham
B15 2NE, UK.
E-mail: ad199@doctors.org.uk

Solitary metastatic renal cell carcinoma to the radius is uncommon. We present such a case treated with surgery and reconstruction with non-vascularised fibula graft. Postoperatively there was progression of the disease with involvement of the proximal radius. Eventually the disease was controlled with adjuvant treatment.
Key words: metastatic lesion; renal cell carcinoma

J.Orthopaedics 2006;3(3)e7

Introduction:

Bone metastases of renal cell carcinoma is believed to be somewhere near 50 per cent (6). The metastatic deposits are rather multiple than solitary ones. Reconstruction after excision of the distal radius with non-vascularised fibula graft is one of the current methods of treatment. It is anticipated that clear surgical margins are achieved to prevent recurrence of the disease. In our case, despite the clear bone margins achieved with surgery and reconstruction with non-vascularised fibula graft, there was an unusual progressive metastatic disease in the proximal radius.

Case Report

A 45 year old, right hand dominant male presented to our department with a six-week history of right wrist pain. Examination revealed a diffuse swelling and tenderness over the right distal radius, without infiltration of the skin and no distal neurovascular deficit. No regional lymph nodes were palpable. Wrist movements were limited by pain. An X-ray showed an aggressive lytic lesion involving the distal radial metaphysis and styloid process. A subsequent whole bone scintigraphy and CT scan of the chest did not reveal any other lesions. A CT scan of the abdomen and pelvis revealed a left renal mass suggestive of renal carcinoma. MRI of the forearm showed a large expansile lesion of the distal radius (fig 1). A biopsy of the lesion confirmed a metastatic renal cell carcinoma. He underwent excision of the right distal radius and reconstruction with non-vascularised proximal right fibula graft (fig 2).

The incision was planned in order to incorporate the biopsy tract. The tumour-bearing portion of the radius along with healthy bone margins was excised en bloc. The proximal fibula from the ipsilateral leg was used to replace the excised radius and fixed with six hole DC plate with compression. The renewed radial carpal and radial ulna joints were stabilised with Kirscher wires. An above-the-elbow plaster cast was applied which was retained for 6 weeks. It was then replaced by an above-the-elbow removable cast after removal of the Kirscher wires.Histology of the excised specimen confirmed clear cell carcinoma with clear bone resection margins.  

An X-ray of his right forearm taken six weeks postoperatively showed rapid progression of metastasis in the whole radius with extensive destruction of the remnant radius and multiple destructive foci in the ulna and wrist joint (fig 3a,b). Following that he had a nephrectomy and was then referred to the oncologists who offered him palliative radiotherapy and interferon alpha treatment (IFN-a).  He received irradiation, 35Gy in ten fractions to his right forearm, and started on IFN-a treatment, 10 mega units three times a week. About a year after initial presentation he was reviewed in the outpatient department. An X-ray taken then, showed that there was regeneration of the radius and ulna bones.

He was pain free; he had a fixed deformity of 45 degrees at the elbow with deformed and curved forearm with no movement at the wrist, no rotation of the forearm and stiff MCP joints.

He was still being treated with interferon and a year later he was reviewed in the clinic again. He was pain free and examination of his right upper limb showed loss of extension at the elbow with elbow flexion from 70 degrees to 130 degrees of flexion. His wrist joint and finger joints were very stiff but improving with physiotherapy.  X-rays of his radius and ulna showed remarkable consolidation of the radius, which had previously been almost completely destroyed by the tumour (fig 4). The graft had healed fully.

Discussion :

The fact that renal cell carcinoma (RCC) metastasises to the skeleton is well known. The metastatic deposits are generally multiple, and only occasionally solitary, and they generally involve the axial skeleton or the proximal parts of the long bones (particularly the femur and humerus) or both (1). Metastatic renal cell carcinoma remains a disease that is highly resistant to systemic therapy and difficult to treat. In the last few years, randomised studies have demonstrated a survival advantage for patients receiving immunotherapies such as Interferon alpha (IFN-a) although this advantage is marginal (5).

The use of autografts in reconstruction of skeletal defects following tumour surgery has been well documented (3). Al-Zahrani et al (2) and Mack et al (5) have showed that the non-vascularised single fibular graft is still valid to bridge bone defects.Aggarwal et al (1) reported a case of solitary metastasis to the radius of renal cell carcinoma treated successfully with excision and fibula bone grafting only. There was no recurrence of the disease in that case.To our knowledge this unusual behaviour of a metastatic renal cell carcinoma of distal radius treated with surgery and autologous non-vascularised fibula graft has not been reported in the medical literature.

The case we report here is of interest in that: (a) it was a solitary metastasis, (b) it involved the distal radius, (c) there was progression of the disease after treatment by excision and reconstruction with non-vascularised fibula graft. Recurrence of the metastatic renal cell carcinoma at the fibula graft site and progression of the disease to the proximal radius despite clear bone margins was very unusual. In our patient, surgery alone failed to control the disease, which responded though very well to adjuvant radiotherapy and immunotherapy with IFN-a.

Reference :

1. Aggarwal ND, Mittal RL, Bhalla R. Delayed solitary metastasis to the radius of renal cell carcinoma. J Bone Joint Surg 1972 ; 54(6)-A : 1314-1316.

2. Al-Zahrani S, Harding MGB, Khan FA, Ikram A, Takroni T. Free fibular graft still has a place in the treatment of bone defects. Injury 1993; 24(8) : 551-554.

3. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg 1980; 62-A : 1039.

4. Mack GR, Lichtman DM, MacDonald RI. Fibular autografts for distal defects of the radius. J Hand Surg 1979; 4 : 576-583.

5. Nanus DM. New treatment approaches for metastatic renal cell carcinoma. Curr Oncol Rep 2000; 2(5) : 417-422.

6. Willis RA. The Spread of Tumour in the Human Body. Butterworth and Co, London, 1952, 233-235.

This is a peer reviewed paper 

Please cite as : Asterios Dramis: Solitary Metastasis To The Radius Of Renal-Cell Carcinoma. An Unusual Case

J.Orthopaedics 2006;3(3)e7

URL: http://www.jortho.org/2006/3/3/e7

ANNOUNCEMENTS

Arthrocon 2011


Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044

E-Mail:
anwarmh@gmail.com

Powered by
VirtualMedOnline