Symptoms in cancer patients and an unusual tumor: Case 1. Regression of hypertrophic pulmonary osteoarthropathy following chemotherapy for lung metastases of a nasopharyngeal carcinoma.

A 20-year-old woman presented with bone and joint pain for 2 months. She had a history of localized nasopharyngeal carcinoma treated with radiotherapy 1 year earlier. Physical examination was normal with the exception of digital clubbing of the hands and feet. The computed tomography (CT) scan of the thorax revealed multiple pulmonary opacities suggesting metastatic lesions (Fig 1A). The technetium-99m (Tc) bone scan showed a typical uptake for a periosteal reaction of the long bones corresponding to the hypertrophic pulmonary osteoarthropathy (HPO; Fig 2A). The patient received eight cycles of chemotherapy that repeated every 3 weeks and consisted of paclitaxel, carboplatin, fluorouracil, and leucovorin. Following the first chemotherapy course, the patient’s analgesic consumption for bone and joint pain decreased considerably. The CT scan performed after the eighth cycle of chemotherapy showed a complete antitumor response (Fig 1B). At that time, the patient had no more bone or joint pain, and the digital clubbing had noticeably regressed (Fig 3). The Tc bone scan was also normal (Fig 2B). Periosteal new bone formation is a characteristic of the HPO. This uncommon condition may be associated with intrathoracic primary or metastatic malignant tumors, chronic pulmonary infections, congenital cyanotic heart disease, cirrhosis of the liver, and other disorders. HPO with an underlying neoplasm has been reported in various tumors. A pediatric case of nasopharyngeal carcinoma devoid of pulmonary metastasis was also reported to have HPO. It is believed that continuous bone remodeling is the cause of the clinical picture and this hypothesis is seemed to be supported by the data showing the benefit from bisphosphonates in terms of symptomatic control of the disease. Recently, vascular endothelial growth factor and platelet-derived growth factor were suggested for their role in the pathogenesis of digital clubbing which is a frequent condition associated with HPO. In patients with primary or metastatic pulmonary lesions, HPO regresses with effective treatment of the malignancy. The major antitumor response to the chemotherapy was correlated with the clinical improvement and later disappearance of HPO in our patient.