Journal of the Louisiana State Medical Society
Elbow Synovium as the Initial Site of Colon Adenocarcinoma Metastasis: Diagnosis by Arthroscopic Biopsy
David H. Ballard, MS; Brett M. Cascio, MD
An acutely painful and swollen isolated joint has a broad differential. We present the case of an elderly male with four-month progressive, painful swelling of the right elbow. After an initial workup for inflammatory arthropathies was nondiagnostic and a trial of conservativemanagement failed to relieve his pain, a diagnostic arthroscopy was performed. Biopsy revealedmetastatic colon adenocarcinoma isolated to the synovial tissue of the elbow. This case provides an example of the presentation and progression of synovial metastasis from a visceral cancer and can potentially guide physicians in the diagnosis and management of similar cases.
INTRODUCTION Unilateral joint pain has many potential etiologies, rare- ly including metastatic cancer. Metastasis to the joint may involve bone, cartilage, or synovial tissue. Synovial metasta- sis is often unilateral to a single joint andmaymimic the pre- sentation of inflammatory or autoimmune arthropathies. 1-3 Imaging usually reveals nonspecific signs such as synovitis. Definitive diagnosis requires histopathologic examination of synovial fluid or tissue, and this can be accomplished by joint aspiration or arthroscopic biopsy. 4,5 Even with prompt diagnosis and aggressive surgical or anti-neoplastic therapy, the prognosis of synovial metastasis is poor with an average survival of less than six months. 1-3 We present a rare case of colon adenocarcinoma metastasis to the synovium of the right elbow that may serve as an example for diagnosis and management of suspected synovial metastasis. CASE REPORT A 79-year-old white male presented with a four-month history of progressive right elbow pain and swelling. The patient denied trauma, and the pain was not relieved by nonsteroidal anti-inflammatories (NSAIDs). Pertinent history included surgical resection of the sigmoid colon for Stage IIA (T3N0M0) adenocarcinoma 19 months prior. The patient refused postsurgical chemotherapy. Physical examination revealed a swollen and erythematous right elbow with pitting edema. Range of motion (ROM) was limited by pain. Flexion-extension was 60 to 90 degrees, and pronation-supination was very limited. Sensory and motor nerves were intact.
Radiographs showed early arthritic change with a small olecranon spur. Magnetic resonance imaging (MRI) showed hypertrophic synovitis (approximately 2 cm thickness), humeral and ulnar erosions, inflammation of the common extensor tendon, and edema in both the olecranon bursa and synovial capsule. This imaging was suggestive of an inflammatory arthropathy. Hematologic workup showed no evidence of systemic inflammation – complete blood count, C-reactive protein, and erythrocyte sedimentation rate were all within normal limits. Serum was negative for rheumatoid factor. Elbow aspiration yielded sanguineous, nonpurulent fluid with no evidence of crystals, organisms, or atypical cytology. Initial management included compres- sion wrapping, posterior splint immobilization, physical therapy, and analgesic medication. The patient responded well to the immobilization and frequent physical therapy sessions (five days/week) – his pain decreased, and range of motion increased. However, four weeks post-presentation, he experienced spontaneous recurrence of severe elbow pain. MRI revealed ulnar nerve compression with worsening hypertrophic synovitis and bursitis (Figure 1). Arthroscopy was recommended and scheduled. Arthroscopy revealed diffuse synovitis and intra- articular nodular tissue. The synovium and olecranon bursa were biopsied. Intra-articular synovial adenocarcinoma was found and confirmed to be of colorectal origin being posi- tive for both CDX-2 and CK20. Surgery was halted upon discovery of metastasis. Following uncomplicated postop- erative recovery, imaging for metastasis revealed localized synovial involvement with no other local tissue or systemic involvement. Mutation analysis of the metastatic tumor
50 J La State Med Soc VOL 166 March/April 2014
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