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 Table of Contents     
LETTER TO THE EDITOR
Year : 2017  |  Volume : 32  |  Issue : 3  |  Page : 248-249  

An interesting case of unknown primary presenting as heel pain


1 Department of Nuclear Medicine, Sri Ram Murti Smarak Functional Imaging Centre, Lucknow, Uttar Pradesh, India
2 Department of Radiation Oncology, Sri Ram Murti Smarak Functional Imaging Centre, Lucknow, Uttar Pradesh, India

Date of Web Publication13-Jun-2017

Correspondence Address:
Mudalsha Ravina
DNB Nuclear Medicine, SRMS Functional Imaging and Medical Centre, CP 2/3 Vishwas Khand-2, Bypass Road, Gomti Nagar, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_16_17

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How to cite this article:
Ravina M, Tripathi VD, Mishra A, Ahmad SO, Agarwal S. An interesting case of unknown primary presenting as heel pain. Indian J Nucl Med 2017;32:248-9

How to cite this URL:
Ravina M, Tripathi VD, Mishra A, Ahmad SO, Agarwal S. An interesting case of unknown primary presenting as heel pain. Indian J Nucl Med [serial online] 2017 [cited 2017 Sep 25];32:248-9. Available from: http://www.ijnm.in/text.asp?2017/32/3/248/207876

Sir,

A 64-year-old male presented with heel pain that had been present for past 3 months. An excision of the calcaneal lesion with bone cementing was performed which on histopathology revealed metastatic squamous cell carcinoma. Subsequent F-18fluorodeoxyglucose positron emission tomography/computerized tomography revealed increased tracer uptake in the left hemithorax, mediastinum on the right side, right scapula, right clavicle, pelvis and left distal extremity [Figure 1]A maximum intensity projection images]. Fused PET-CT with sagittal reformats [Figure 1]B of the left distal extremity reveals FDG avid skeletal lesions involving the remaining unexcised calcaneum, talus, navicular, cuneiform and proximal end of the metatarsals, distal end of femur and along the entire length of the tibia. Multiple skeletal lesions noted elsewhere in the body [Figure 1]C. Fused PET CT images [Figure 2]A, [Figure 2]B revealed a tracer avid lesion in the lingular segment of the left lung with right lower paratracheal [Figure 2]C and contralateral lung metastasis [Figure 2]D, suggesting primary in the left lung. CT-guided biopsy of the mass confirmed the squamous cell carcinoma lung.
Figure 1: Fused PET-CT with sagittal reformats (B) of the left distal extremity reveals FDG avid skeletal lesions involving the remaining unexcised calcaneum, talus, navicular, cuneiform and proximal end of the metatarsals, distal end of femur and along the entire length of the tibia. Multiple skeletal lesions noted elsewhere in the body (C)

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Figure 2: Fused PET CT images (A, B) revealed a tracer avid lesion in the lingular segment of the left lung with right lower paratracheal (C) and contralateral lung metastasis (D)

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Plantar heel pain is a common complaint in this age group. In general, patients with bone metastases become symptomatic earlier in the clinical course than patients with liver and lung metastases. Obviously local symptoms alert clinicians to consider metastases. However, in some circumstances, they may have bizarre presentation.[1],[2],[3] Just like in this case, the patient presented with heel pain. There have been case reports of calcaneal metastasis in lung, gastric, urothelial and lung malignancies.[4],[5],[6] Thus, we need to ponder over the fact of acquiring vertex to toe images in certain clinical situations instead of the usual protocol. Also, the heel pain not responding to conservative therapy must be evaluated further.[Figure 1]: Fused PET-CT with sagittal reformats (B) of the left distal extremity reveals FDG avid skeletal lesions involving the remaining unexcised calcaneum, talus, navicular, cuneiform and proximal end of the metatarsals, distal end of femur and along the entire length of the tibia. Multiple skeletal lesions noted elsewhere in the body (C)[Figure 2]: Fused PET CT images (A, B) revealed a tracer avid lesion in the lingular segment of the left lung with right lower paratracheal (C) and contralateral lung metastasis (D)

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   References Top

1.
McGarry RC. Images in clinical medicine. Lung cancer presenting as ankle metastasis. N Engl J Med 2000;343:268.  Back to cited text no. 1
    
2.
Dai H, Qiang M, Chen Y, Zhai K. Lung cancer presenting as heel pain. A case report. Oncol Lett 2014;8:736-8.  Back to cited text no. 2
    
3.
Tsuya A, Kurata T, Tamura K, Fukuoka M. Skeletal metastases in non small lung cancer: A retrospective study. Lung Cancer 2007;57:229-32.  Back to cited text no. 3
    
4.
Maheshwari AV, Chiapetta G, Kugler CD, Pitcher JD Jr, Temple HT. Metastatic skeletal disease of the foot: Case reports and literature review. Foot ankle Int 2008;29:699-10.  Back to cited text no. 4
    
5.
Agrawal S, Irvine A, Money-Kyrle J, et al. Isolated calcaneal metastasis from prostate cancer. Ann R Coll Surg Engl 2008;90:W7-W9.  Back to cited text no. 5
    
6.
Grumbrecht C, Täger F. Calcaneal metastasis in cervix carcinoma. Zentralbl Gynakol 1972;94:702-3.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2]



 

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