Calcaneal acrometastasis from urothelial carcinoma of the ureter: a case report and literature review

Abstract

Purpose: Ureteral cancer is a rare entity. Typical symptoms are painless hematuria as well as flank pain. Bone metastasis of ureteral cancer can occur in nearby bone structures, such as the spine, pelvis, and hip bone. Distal bone metastasis, such as that in the calcaneus bone, however, is rare.

Case report: An 82-year-old woman presented to the orthopedic clinic at the university hospital with a 3-month history of left heel pain. A magnetic resonance imaging (MRI) of her foot demonstrated a calcaneal lytic lesion. A biopsy of the lytic lesion showed urothelial carcinoma with squamous differentiation. A computed tomography (CT) scan of the abdomen and pelvis showed left hydronephrosis and an obstructive mass in the left ureter, at the iliac crossing. The patient received combined therapy that included local radiation, bisphosphonate, and chemotherapy, with complete resolution of her cancer-related symptoms. However, she eventually died from the progressive disease, 20 months after the initial diagnosis.

Conclusion: This case highlights the rare presentation of ureter cancer with an initial presentation of foot pain, secondary to calcaneal metastasis. Multimodality therapy provides effective palliation of symptoms and improved quality of life. We also reviewed the literature and discuss the clinical benefits of multidisciplinary cancer care in elderly patients.

Keywords: calcaneal acrometastasis; chemotherapy; elderly; multimodality therapy; radiation; urothelial carcinoma.

Figure 1

Radiograph of the left foot, demonstrating a large lytic lesion and destruction of the calcaneus, the cuboid, and the fifth metatarsal.

Figure 2

Left calcaneal biopsy specimen showing urothelial carcinoma with squamous differentiation. Notes: Hematoxylin and eosin; magnification 100×.

Figure 3

Abdominal and pelvic CT scan revealing a left hydronephrosis with renal cortical atrophy and an obstructing mass at the iliac crossing of the left ureter. Abbreviation: CT, computed tomography.

Figure 4

Technetium-99m MDP whole body bone scan displaying intense increased radioactive uptake in the left calcaneus with mild increased radioactive uptake in the proximal and distal left fibula with some extension into the shaft. Abbreviation: MDP, methylene-diphosphonate.