Hypertrophic osteoarthropathy pathogenesis: a case highlighting the potential role for cyclo-oxygenase-2-derived prostaglandin E2

Background A 65-year-old woman presented with weakness, 9 kg weight loss, dysphagia, facial and bilateral upper-extremity swelling, and debilitating, bilateral lower-extremity pain. The

patient had undergone a right upper lobectomy for a 5 mm, poorly differentiated adenocarcinoma of the lung 4 years previously. Medical history included chronic obstructive pulmonary disease

(emphysema), hypertension, cerebrovascular disease and multinodular goiter. Surgical history included a right carotid endarterectomy. The patient's history was remarkable for 50+ pack-years

of smoking.

Investigations Physical examination, comprehensive metabolic panel and complete blood counts, CT, bone scintigraphy, quantification of urinary

11a-hydroxy-9,15-dioxo-2,3,4,5-tetranor-prostane-1,20-dioic acid (also known as PGE-M).

Diagnosis Recurrent non-small-cell lung cancer with adrenal metastasis, hypertrophic osteoarthropathy associated with non-small-cell lung cancer, and hyperprostaglandinuria.

Management Rofecoxib 25 mg daily for hypertrophic osteoarthropathy, palliative external-beam radiation (44 Gy in 22 fractions) for mediastinal mass, palliative external-beam radiation (30 Gy

in 12 fractions), followed 2 years later with radiofrequency ablation, for left adrenal metastasis.

The authors thank Timothy P Padera and Torunn I Yock for advice and critical review of the manuscript. This study was supported by NIH grants DK48831, GM15431, CA77839 and RR00095 (JDM).

Physician at the Harvard Radiation Oncology Program at Massachusetts General Hospital, Boston, MA

Professor of Medicine and Pharmacology at Vanderbilt University Medical Center, Nashville, TN

Attending Medical Oncologist and Hematologist at Brockton Hospital, Brockton, MA, USA

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