Skeletal Radiol (1987) 16 : 387-392
Radiology
Metastatic tumours of bones of the hand and foot
A comparative review and report of 43 additional cases
Eugene Libson, M.D. 1, Ronald A. Bloom, M.D. 1, Janet E. Husband, M.D./, and Dennis J. Stoker, M.D. 3
Departments of Radiology, ~ Hadassah University Hospital, Jerusalem, Israel, 2 Royal Marsden Hospital, Sutton, U.K.,
3 Royal National Orthopaedic Hospital, London, U.K.
Abstract. Metastases in the bones of the hands and
feet are rare. The literature relating to these tu-
mours has been reviewed, and 43 new cases are
reported. In the cumulative total of cases, metas-
tases to the hand outnumber those to the foot 2:1
(196 cases as against 94). Bronchial carcinoma is
the most common neoplasm metastasising to the
hand. Subdiaphragmatic neoplasms such as gas-
trointestinal, vesical, renal and uterine malignan-
cies, metastasise more frequently to the foot. A
possible explanation for this latter finding is the
retrograde spread of tumour emboli from the ver-
tebral venous plexus down incompetent leg veins.
Key words: H a n d - Foot - Carcinoma - Metastasis
- Bone tumour
Metastases to the bones of the hand and feet are
rare, the incidence of involvement of the hand be-
ing in the region of 0.1% of all metastases [17].
Wu and Guise found only seven such cases in
41,833 cancer patients treated at Henry Ford Hos-
pital [24, 25]. The enormous prevalence of cancer
in the general population has, however, resulted
in a considerable body of literature on the subject
of such turnouts. The great majority of reports
of metastases to the bones of the hands and feet
have been single case reports or small series, not
exceeding three cases. Kerin [16, 17] reviewed the
literature on metastases in the hand up to 1983,
collecting 146 cases; Zindrick et al. in 1982 [26]
performed a similar service in respect of the foot,
finding 72 cases in the literature. A further review
of the literature has revealed 37 additional cases
Address reprint requests to: Dr. R.A. Bloom, Department of
Radiology, Hadassah University Hospital, Ein Karem, Jerusa-
lem, Israel
Skeletal
of such metastases in which the metastatic site and
primary focus is recorded [6, 8, 11, 12, 14, 15,
18-20, 22, 24].
The teaching collections of the authors' institu-
tions have yielded an additional 43 cases. This
study, in addition to tabulating these new cases,
reviews the literature on this subject and contrasts
the sites of origin and radiological appearances of
metastatic tumours of the extremities.
Materials and methods
All metastases affecting the extremities found in the teaching
collections of the Department of Radiology, Institute of Ortho-
paedics, London, U.K., the Royal Marsden Hospital, Sutton
Surrey, U.K., and the Hadassah University Hospital, Jerusa-
lem, Israel, have been reviewed. These comprise 43 cases, 21
of the hand and 22 of the foot. The salient features of these
cases are shown in Tables 1 and 2.
These cases have been added to those previously recorded
in the literature. Table 3 records the 196 cases of metastases
to the hand by site of origin. Table 4 deals similarly with the
94 cases of pedal metastases.
Discussion
The earliest mention of a metastasis to the bones
of the hand was made by Handley in 1906 [12].
An elderly woman presented with pathological
fractures of the metacarpus due to metastatic
breast carcinoma. Bloodgood in 1920 reported the
first case of metastatic disease involving bones of
the foot [3]. Until the late 1940s metastases to the
bones of the foot were thought to be encountered
more frequently than to those o f the hand [9]. This
belief is not confirmed by the number of cases re-
ported to date, which seems to indicate that hand
metastases are approximately twice as common as
foot metastases (Tables 3 and 4). This preponder-
ance may, however, be due to selective reporting,
hand surgery being a recognised subspeciality [20].
9 1987 International Skeletal Society
388 Libson et al. : Metastatic hand and foot tnmours

Table 1. Metastases to the hand Table 3. Metastases to the hand with site of primary neoplasm

Site of Sex Age Affected bones Site of origin Number Percentage

origin (years) of whole

1) Breast F 63 Phalanges, Metacarpals, Lung 91 47

Carpal bones Breast 25 12.5
2) Lung F 71 Phalanx Kidney 21 11
3) Lung M 74 Distal phalanx Colorectum 10 5
4) Lung M 63 Metacarpal Leukaemia and lymphoma 4 2
5) Lung M 70 Distal phalanx Chondrosarcoma 4 2
6) Lung M 65 Distal phalanx Osteogenic sarcoma 4 2
7) Breast F 59 Phalanges Prostate 4 2
8) Lung M 66 Distal phalanx thumb Uterus 4 2
9) Lung M 42 Middle phalanx index Larynx 3 1.5
10) Breast F Not given Middle and terminal Unknown 4 2
phalanx ringfinger
11) Breast F Not given Phalanx, metacarpal, Oesophagus, larynx, pharynx, buccal cavity, thyroid, melanoma
carpal 2 (1%) each salivary gland, tongue, stomach, testis, brain, blad-
12) Lung M Not given Distal phalanx index der, rhabdomyosarcoma, epidermoid sarcoma, liver, neuroblas-
finger toma 1 (0.5%) each
13) Lung M Not given Middle phalanx middle total 196 100
finger
14) Kidney F 65 Distal phalanx thumb
15) Lung M 40 Proximal phalanx index Table 4. Metastases to the foot with site of primary neoplasm
16) Lung M 70 Third metacarpal
17) Lung M Not given Distal phalanx thumb Site of origin Number Percentage of whole
18) Prostate M Not given Proximal phalanx thumb
19) Colon F 79 Metacarpal Colorectum 16 17
20) Unknown M 47 Scaphoid Kidney 16 17
21) Lung F 70 Metacarpal Lung 14 15
Bladder 9 10
Breast 9 10
Table 2. Metastases to the foot Uterus 6 6
Prostate 4 4
Site of origin Sex Age (years) Affected bones Ovary 2 2
Leukaemia 2 2
1) Breast F 61 Cuboid Unknown 8 9
2) Lung M 70 Fifth metatarsal Salivary gland, larynx, stomach, vagina, rhabdomyosarcoma,
3) Lung M 66 Fifth metatarsal osteosarcoma, multiple myeloma, reticulum cell sarcoma 1
4) Bladder F 66 Tarsals and meta
(1%) each
tarsals
5) Kidney F 64 Fourth metatarsal total 94 100
6) Colon F 60 Third metatarsal
7) Cervix F 55 Second metatarsal
8) Bladder F 59 Calcaneus In the few series in which metastases to both
9) Uterus F 50 Calcaneus hand and foot were recorded, the incidence in each
10) Breast F 65 Calcaneus extremity appears approximately equal. Of the me-
11) Uterus F 65 Tarsal bones tastases reported by Wu and Guise, three were in
12) Bladder Not Not given Multiple bones
given the hand and four in the foot [24, 25]. A further
13) Breast F Not given Tarsal and meta- report of 41 metastatic lesions of the hand and
tarsals foot showed 21 to the hand and 20 to the foot
14) Prostate M Not given Tarsal and meta- [13]. In the present series 21 subjects had metas-
tarsal (lytic)
Not given Navicular
tases of the hand and 20 of the foot (Tables I and
15) Reticulumcell Not
carcinoma given 2). Metastases to bones of the hand and foot in
16) Uterus F 65 Tarsal bones the same patient would appear to be excessively
17) Kidney F 52 Talus rare, only six cases being recorded [6, 18].
18) Not given F 80 Terminal phalanx Metastases have been recorded in every bone
great toe
19) Bladder M Not given Cuboid and fourth of each hand. The phalanges are affected most
metatarsal commonly, particularly the distal phalanges [17].
20) Kidney M Not given Calcaneus The carpus has been stated to be a most uncom-
21) Colon F 56 Calcaneus (sclerotic) mon site of metastases, even in recent papers [8,
22) Not given F 67 Calcaneus
15]. The literature review of Kerin [17] contradicts
Libson et al. : Metastatic hand and foot tumours
this thesis as approximately 20% of upper extremi-
ty lesions are found in this site. Carpal lesions were
present in 3 of our 21 cases (14%). The involve-
ment of left and right hands is approximately equal
[17].
Metastases to the foot show a quite different
distribution. The review by Zindrick et al. showed
that about half the metastatic foci affected the tar-
sus, a quarter being localised to the calcaneus [26].
This tarsal predilection was even more pronounced
in our series with 16 out of 22 (73%) tarsal lesions;
the calcaneus was the only bone involved in 6 cases
(27%). Nevertheless, involvement of several bones
occurs quite frequently in an extremity and in our
series of 43 cases, this occurred on 10 occasions
(23%) (7/22 foot and 3/21 hand). The site of origin
of the primary tumour appears to influence the
likelihood of either hand or foot involvement and
the tendency for multiple bone involvement.
Carcinoma of the lung
Metastases from bronchial carcinoma comprise al-
most half the recorded secondary turnouts to the
bones of the hand (Table 3) (Fig. 1). This reflects
both the prevalence of bronchial carcinoma and
its predilection for the skeleton in metastatic
spread. Bony metastases are found in as many as
33% of autopsy cases of bronchogenic carcinoma
[7]. Metastases to the foot are much less common.
Tables 3 and 4 show only 14 cases of metastases
of the foot as against 91 of the hand. As with
other bone metastases from a bronchial carcinoma
peripheral metastases are virtually always osteo-
lytic (Figs. 1, 2). A metastasis to a single bone of
an affected extremity is the common finding, and
this occurred in each of our 13 cases (Tables 3 and
4); multiple bony involvement may, however, oc-
cur [17].
Carcinoma of the breast
Carcinomatous metastases to the extremities from
the breast show an almost equal predilection for
the hand and foot (Tables 3 and 4). Multiple bony
involvement is characteristic with this turnout, be-
ing present in all four cases of metastases to the
hand and one of three cases to the foot (Tables 1
and 2). The metastases may be sclerotic, lytic, or
mixed; gross infiltration of the whole hand or foot
may be shown (Fig. 3).
Gastrointestinal carcinoma
Metastases from carcinoma of the large bowel
show a tendency to involve the foot, where they
389
Fig. 1. Typical lytic metastasis of terminal phalanx of little
finger from carcinoma of the lung
are the most commonly occurring metastases
(17%), sharing that position with secondary renal
tumours. Metastases to the hand are much less
frequent, the 10 cases so far reported representing
only 5% of all hand metastases (Tables 3 and 4).
Gastric tumours rarely metastasise to the extremi-
ties; only two cases have been recorded and a simi-
lar number have been secondary to oesophageal
carcinoma (Tables 3 and 4).
Genitourinary tumours
Bunkis and Carter in 1981 reviewed 948 cases with
carcinoma of the kidney, bladder, prostate and tes-
tis, and found only one patient with peripheral me-
tastasis [5], suggesting that such a metastasis is ex-
tremely rare. Examination of Tables 3 and 4 shows,
however, that metastases from renal carcinoma are
the most common pedal metastases (17%), equal
in incidence to deposits from carcinoma of the
large bowel. Renal carcinomatous metastases are
also the third most common cause of metastases
to the hand, constituting 11% of the total.
Peripheral metastases from a primary carcino-
ma of bladder show a remarkable tendency to fa-
vour the foot. The nine cases reported constitute
10% of pedal metastases (Table 4). Four of these
are derived from our series (Table 2). In three of
our cases metastases to multiple bones occurred,
in the fourth there was a single metastasis to the
calcaneus. In contradistinction the literature con-
tains only one report of vesical carcinoma metas-
tasising to the hand [7].
390 Libson et al. : Metastatic hand and foot tumours

Fig. 2. Lytic metastasis in the base of the second metacarpal from carcinoma of the lung (Table 1, case 4)
Fig. 3. Diffuse mixed osteolytic and osteoblastic metastases to the hand from breast carcinoma (Table 1, case 1)
Fig. 4. Expanding osteolytic metastasis to the calcaneus from an endometrial carcinoma (Table 2, case 9)
Fig. 5. Destructive lesion with gross periosteal reaction in the proximal phalanx of the ring finger. Metastasis from a carcinoma
of the lung (Table 1, case 2)
Fig. 6. Expanding osteolytic metastasis to the fifth metatarsal of the foot from bronchogenic carcinoma
Fig. 7. Diffuse osteolytic metastases to the tarsal and metatarsal bones from breast carcinoma with destruction of articular margins
(Table 2, case 13)

Peripheral metastases f r o m uterine c a r c i n o m a (Fig. 4). F o u r cases o f metastases to the h a n d are

are rare. T w o previous studies r e p o r t metastases recorded [16, 17]. All other t u m o u r s metastasising
to the foot f r o m this p r i m a r y and we r e p o r t an to the h a n d or f o o t are very rare. O u r record o f
additional f o u r cases (Table 4). In two o f these a reticulum cell c a r c i n o m a metastasising to the na-
cases osteolytic expanding lesions were present vicular b o n e o f the foot is the first reference to
Libson et al. : Metastatic hand and foot tumours
a peripheral metastasis from a primary tumour of
this type.
A number of hypotheses have been proposed
to explain the occurrence of peripheral metastases.
In those organs drained by the systemic venous
system, metastases first tend to appear in the lung.
Venous invasion by a pulmonary neoplasm will
allow tumour emboli to be carried to the left side
of the heart, thereby reaching the systemic arterial
circulation. It has been shown experimentally that
the number of metastases, and hence the number
of turnout emboli to that organ, occurring in a
particular organ is proportional to the blood flow.
According to Mulvey [21] this would explain the
tendency for metastases to the hand to occur in
the distal phalanges, where arterial flow is greatest.
In those organs drained by the portal system, me-
tastases first arise in the liver, then pass to the
lungs and hence to the systemic arterial system.
The direct spread of prostatic, mammary, and
gastrointestinal carcinomata to the vertebral ve-
nous plexus of Batson explains the high frequency
of vertebral bony metastases in these primary tu-
mours [2]. The pelvis and shoulder girdle are the
upper limits of this pathway, but the vertebral
veins communicate by innumerable channels with
the ascending lumbar veins and the internal and
common iliac veins. According to Batson, the en-
tire system of epidural and vertebral veins has a
free and rich anastamosis at each spinal segment
with the veins of the thoracoabdominal cavity [2].
The communications between the spinal veins in
the lumbar region with the iliofemoral venous sys-
tem may indicate that colonic and rectal neo-
plasms, as well as vesical tumours seed to the feet
in a retrograde fashion. In cases where there is
venous valvar incompetence, tumoral emboli could
descend on a gravitational basis.
The exact mechanism by which turnouts devel-
op in the extremities is, however, unclear. Trauma,
thermal differences, hormonal influence, local hae-
modynamic factors, and host immune response
have all been implicated as affecting the chances
of tumour emboli arriving at a particular site [26].
In practical terms, the diaphragm provides a
rough and ready division between tumoral spread
to the hand or foot. Neoplasms arising from the
supradiaphragmatic lung tend to metastasise to the
hand, while subdiaphragmatic tumours of the co-
lon, rectum, bladder, and to a lesser extent the
kidney, uterus and prostate tend to metastasise to
the foot. Superficial organs such as the breasts
show no particular predilection (Tables 2 and 4).
The radiological features of peripheral metas-
tases are usually those of purely osteolytic destruc-
391
tive lesions; this appearance occurs in approxi-
mately 80% of cases [8]. Metastases from the pros-
tate are generally sclerotic, while those from breast,
bladder, and gastrointestinal primaries may show
lytic, mixed, or purely sclerotic appearances
(Fig. 3). A periosteal reaction is unusual [26] and
was present in only one of our 43 cases (Fig. 4).
Joints are rarely involved or crossed by lesions.
A thin margin of subchondral bone remains even
in the presence of marked destruction. The neo-
plasm may expand the cortical shell as it enlarges
(Figs. 4-6). In the tarsus or carpus, almost total
destruction of many bones, with destruction of ar-
ticular cartilage, may occur in the late stages of
the disease [11] (Fig. 7).
While the presence of a destructive bony lesion
in an extremity of a patient with widespread meta-
static disease may produce no difficulty in diagno-
sis, as the first indication of an occult process the
appearances may be deceptive. The lesion may re-
semble a pulp-space infection, ostomyelitis, septic
arthritis, acute monoarticular rheumatoid arthritis,
tenosynovitis, or sympathetic algodystrophy, Clin-
ically, the signs of inflammation are often present.
Pain, tenderness, swelling, and loss of function ap-
pear, but often with a lack of heat; pain may pre-
cede any radiological signs [1, 10, 15, 16, 23, 24].
When signs of inflammation are not present,
the radiological differential diagnosis must be wi-
dened to include such benign lesions as enchon-
droma, epidermoid cyst, osteoid osteoma, giant
cell turnout, and gout. Primary malignant tumours
of the skeleton of the hand are extremely rare,
but even osteosarcomata have been reported, usu-
ally showing a mixed osteolytic and osteoblastic
appearance. Periosteal new bone is a prominent
feature, but has also been seen, unusually, in me-
tastases of the extremities [16, 26] (Fig. 5).
In an individual over the age of 45 years, any
skeletal lesion with a radiological appearance even
remotely suggesting malignancy must always ar-
ouse suspicion of a metastatic deposit. Scintigra-
phy or a skeletal survey may confirm a widespread
metastatic process. In cases of a solitary lesion,
biopsy usually will be required.
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