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ORIGINAL ARTICLE
Year : 2012  |  Volume : 27  |  Issue : 4  |  Page : 249-251  

Association of non-traumatic complex regional pain syndrome with adenocarcinoma lung on 99mTc-MDP bone scan


1 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication23-Jul-2013

Correspondence Address:
Nishikant A Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.115397

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   Abstract 

Complex regional pain syndrome (CRPS) is usually associated with trauma. Rarely, it may be seen in association with malignancies. We present here the bone scan and X-ray findings in the case of a 56-year-male-patient with adenocarcinoma lung who also had non-traumatic CRPS without involvement of the stellate ganglion. The case highlights the fact that spontaneous development of reflex sympathetic dystrophy may be associated with a neoplastic etiology.

Keywords: Adenocarcinoma lung, bone scan, complex regional pain syndrome


How to cite this article:
Damle NA, Tripathi M, Singhal A, Bal C, Kumar P, Kandasamy D, Jana M. Association of non-traumatic complex regional pain syndrome with adenocarcinoma lung on 99mTc-MDP bone scan. Indian J Nucl Med 2012;27:249-51

How to cite this URL:
Damle NA, Tripathi M, Singhal A, Bal C, Kumar P, Kandasamy D, Jana M. Association of non-traumatic complex regional pain syndrome with adenocarcinoma lung on 99mTc-MDP bone scan. Indian J Nucl Med [serial online] 2012 [cited 2019 Dec 8];27:249-51. Available from: http://www.ijnm.in/text.asp?2012/27/4/249/115397


   Introduction Top


Complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD) is an excessive or exaggerated response to an injury of an extremity manifested by (a) intense/unduly prolonged pain (b) vasomotor disturbances (c) delayed functional recovery (d) associated trophic changes. [1] CRPS typically occurs after an inciting event like trauma, surgery etc., However, in 10-26% cases no identifiable cause can be found. Other suspected inciting factors include cerebrovascular accidents, myocardial infarction, medicines including anticonvulsants, barbiturates, diseases of cervical spine, neuromuscular disorders etc. [2] Criteria have been set by Kozin et al. [3] and Mackinnon and Holder [4],[5] for interpretation of bone scan findings and are widely followed.


   Case Report Top


A 56-year-old male, smoker since last 30 years presented to the physician with complaints of cough and hemoptysis since 3 weeks. A chest radiograph showed a right lung upper zone mass with surrounding consolidation [Figure 1]. There was no bone destruction. Non-contrast computed tomography scan of the chest showed a homogeneous mass with lobulated margins and surrounding consolidation in the right upper lobe. There was no calcification or cavitation seen in the mass. Mass showed a broad area of contact with the anterior chest wall, superior vena cava, and right brachiocephalic vein. No rib destruction or brachial plexus involvement were noted. Mass was not extending in to the paravertebral location where the stellate ganglion is located. There was no significant mediastinal adenopathy or lung metastasis seen [Figure 2]. A tru-cut biopsy revealed adenocarcinoma lung. The patient was referred for a bone scan to rule out metastases. The Nuclear Medicine physician observed swelling and redness in the right hand of the patient. The patient underwent a three phase 99mTc-MDP bone scan with intravenous administration of 20 mCi (740 MBq) radiotracer. Flow and pool phase study revealed diffusely increased tracer activity in the right hand and elbow [Figure 3]. Whole body anterior and posterior views taken 3 h later showed no evidence of metastases but right wrist joint and hand showed diffusely increased juxta-articular uptake consistent with CRPS. Also noted was increased uptake along long bones of the lower limbs especially in the tibiae, consistent with hypertrophic osteoarthropathy (HPOA) [Figure 4]. A radiograph of bilateral hands showed juxta-articular osteopenia consistent with CRPS and there was increased soft-tissue shadow in the right hand suggestive of subcutaneous edema. There was also periosteal reaction seen in the distal radius and ulna suggestive of HPOA [Figure 5]. Seven days after the diagnosis on bone scan, the patient developed pain in the affected hand. He was prescribed NSAIDS for these symptoms which did not relieve his symptoms appreciably. The patient was referred to the pain clinic of our institution for further management in addition to his oncologic treatment.
Figure 1: Chest radiograph PA view shows a mass lesion (thick arrow) seen in the right upper zone with surrounding consolidation. No obvious bone destruction seen. There are no other nodules seen in bilateral lung fields. Bilateral cardiophrenic angles are free

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Figure 2: (a,b) Non-contrast computed tomography scan of thorax in mediastinal (a) and lung window (b) show homogeneous lobulated mass lesion seen in right upper lobe with wide area of contact with chest wall and mediastinal vessels. No calcification or cavitation seen in the mass. The location of stellate ganglion in the paravertebral location (thick arrow) is free from the mass. There is surrounding consolidation (*) seen in the right upper lobe

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Figure 3: (a,b) PA radiograph of bilateral hands with wrists (a) and cropped image of distal radius and ulna (b) show juxta-articular osteopenia (thick arrow) in bilateral hands along with increased soft-tissue in the right hand. There is also periosteal reaction seen in the distal shaft of right radius and ulna (thin arrow). These findings along with clinical features are suggestive of reflex sympathetic dystrophy with hypertrophic osteoarthropathy

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Figure 4:

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Figure 5:

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   Discussion Top


Since CRPS/RSD lacks specific histopathologic or biochemical markers, a clear and accurate definition is necessary. The diagnosis of CRPS is often by exclusion depending heavily on clinical examination, corroborated by bone scan. There are many published reports of cases of the RSD syndrome [3],[6] in association with malignancy, including carcinoma of bowel, ovary, pancreas, lung, and chronic myelogenous leukaemia. In most of these CRPS was the presenting feature with the tumor being detected subsequently, with substantial time gap between the two. [7] This case highlights the association of CRPS with underlying malignancy. We did not find reports where the RSD syndrome reversed completely after successful tumor removal, therefore a direct cause-effect relationship is difficult to establish. Although, the etiology of CRPS is unknown, its occasional association with an apparently distant neoplastic process suggests that as yet unidentified circulating humoral factors may be responsible. It is possible that the tumor produces humoral factor(s) that may act at either the internuncial pool of the spinal cord to lower fiber threshold with increased activity spreading to sympathetic efferents or at a peripheral site to stimulate sympathetic fibers. There is an evidence to suggest that noradrenaline lowers the threshold of peripheral mechanoreceptors [8],[9],[10] thus, enhancing abnormal firing in peripheral sensory nerves, which may account for the spontaneous pain and hyperaesthesia seen clinically. The case highlights the need for a thorough search for underlying malignancy in patients presenting with the so called 'idiopathic' CRPS.

This case also shows that CRPS can be associated with lung cancer and a keen observation on part of the imaging physician may help in its diagnosis and therapy. Spontaneous development of CRPS should alert the physician to the possibility of an underlying malignancy.

 
   References Top

1.Schutzer SF, Gossling HR. The treatment of reflex sympathetic dystrophy syndrome. J Bone Joint Surg Am 1984;66:625-9.  Back to cited text no. 1
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2.Acquaviva P, Schiano A, Harnden P, Cros D, Serratrice G. Algodystrophy: Predisposition and pathogenic factors. Results of a multicentric survey concerning 765 cases. Rev Rhum Mal Osteoartic 1982;49:761-6.  Back to cited text no. 2
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3.Kozin F, Soin JS, Ryan LM, Carrera GF, Wortmann RL. Bone scintigraphy in the reflex sympathetic dystrophy syndrome. Radiology 1981;138:437-43.  Back to cited text no. 3
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4.Mackinnon SE, Holder LE. The use of three-phase radionuclide bone scanning in the diagnosis of reflex sympathetic dystrophy. J Hand Surg Am 1984;9:556-63.  Back to cited text no. 4
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5.Holder LE, Mackinnon SE. Reflex sympathetic dystrophy in the hands: Clinical and scintigraphic criteria. Radiology 1984;152:517-22.  Back to cited text no. 5
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6.Medsger TA, Dixon JA, Garwood VF. Palmar fasciitis and polyarthritis associated with ovarian carcinoma. Ann Intern Med 1982;96:424-31.  Back to cited text no. 6
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7.Michaels RM, Sorber JA. Reflex sympathetic dystrophy as a probable paraneoplastic syndrome: Case report and literature review. Arthritis Rheum 1984;27:1183-5.  Back to cited text no. 7
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8.Goldberg E, Dobransky R, Gill R. Reflex sympathetic dystrophy associated with malignancy. Arthritis Rheum 1985;28:1079-80.  Back to cited text no. 8
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9.De Takats G. Causalgia status in peace and war. JAMA 1945;78:699-704.  Back to cited text no. 9
    
10.Devor M. Nerve pathophysiology and mechanisms of pain in causalgia. J Auton Nerv Syst 1983;7:371-84.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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