(Image #1), (Image #2) and (Image #3) [close up view]

(Image #4), (Image #5 [close up view]), (Image #6)

Findings: Image #1 is a PA chest x-ray demonstrating a large left upper lobe lung mass.

Images # 2 through 6 demonstrate diffuse periostitis involving the left humerus, femur and tibia.

Diagnosis: Hypertrophic osteoarthropathy secondary to bronchogenic CA.

Discussion: Hypertrophic osteoarthropathy secondary to an underlying etiology such as bronchogenic carcinoma is a rare condition of uncertain etiology. There are multiple potential causes of secondary hypertrophic osteoarthropathy including bronchogenic carcinoma (as was demonstrated in this case), pulmonary abscess, Hodgkin's disease, metastasis, and cystic fibrosis. Pulmonary metastatic disease from extrapulmonary malignancy is a rare cause of hypertrophic osteoarthropathy. In addition, hypertrophic osteoarthropathy has been associated with mesothelioma, cyanotic congenital heart disease, as well as inflammatory bowel disease. Of these, the most common association is with bronchogenic carcinoma, in which it is estimated that between 1 and 12% of these patients will develop hypertrophic osteoarthropathy. The disease is characterized by digital clubbing and articular pain as well as diffuse periostitis.

Radiographic abnormalities include periosteal new bone deposition appearing primarily in the diaphysis of the tibia, fibula, radii, ulna, and less frequently the femora, humeri, metacarpals, metatarsals, and phalanges. With progression of disease, the periosteal new bone formation will progress from the diaphysis to the metaphysis, but generally does not extend into the epiphysis. The periosteal new bone formation may take various forms such as a single layer of new bone, laminated or "onion skin" or irregular areas of periosteal elevation. On bone scans, images will demonstrate diffusely increased uptake in the diaphysis and metaphysis of affected long bones. The scintigraphic findings often appear prior to the radiographic abnormalities. The differential diagnosis would include primary hypertrophic osteoarthropathy (pachydermoperiostosis) and thyroid acropachy. In contradistinction to secondary hypertrophic osteoarthropathy associated with bronchogenic CA, the periosteal new bone formation seen in thyroid acropachy has a predilection for the small bones of the hands and feet.

Reference:
Resnick D. Bone and Joint Imaging 2nd edition. W. B. Saunders,
1996;1218-1223.

Ali Amjed. Distribution of Hypertrophic Pulmonary Osteoarthropathy.
AJR 1980;134:771.780.

Davies RA, Darby M., Richards MA. Hypertrophic Pulmonary Osteoarthropathy
in Pulmonary Metastatic Disease. A Case Report and Review of the Literature.

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