Octreotide for Control of Pain in Hypertrophic Pulmonary Osteoarthropathy

Abstract

Hypertrophic pulmonary osteoarthropathy (HPOA) is a paraneoplastic syndrome most often associated with pulmonary malignancies. It is characterized by digital clubbing, periosteal reaction and painful arthropathy (1,2). The etiology of HPOA is imprecise, but is thought to involve increased growth factors, in particular vascular endothelial growth factor [VEGF] (2). The mainstay of treatment for HPOA is treatment of the underlying malignancy, with resection þ/radiation being the most effective, although there have been reports of improvement with chemotherapy alone (3). CASE PRESENTATION:A 54-year-old male with 45 pack year smoking history, COPD and osteoarthritis was brought to the hospital by EMS after falling at home. He had 3 reported falls in the past 3 months, which were attributed to dizziness and mechanical etiologies. He reported worsening difficulty with ambulation due to pain and swelling in his right knee. Physical examination was notable for painful digital clubbing, and a tender right knee with effusion without warmth or erythema. Patient underwent CT scan of head and neck which revealed degenerative changes of the spine, and a partially imaged left apical lung mass. Dedicated CT chest revealed a 5.2 x 5.2 cm spiculated mass. Patient underwent CT guided transthoracic biopsy of mass with pathologic diagnosis of non-small cell lung cancer. Mediastinal staging revealed positive N2 subcarinal nodes and patient was staged as IIIB. The case was presented at tumor board and medical management with chemotherapy was the treatment recommendation.The patient continued to experience painful arthropathy in his hands and joints of the lower limbs. Plain films of the lower extremities revealed periosteal reaction of the long bones. Bone scintigraphy showed radiopharmaceutical tracer accumulation along the margins of the long bones, a pattern consistent with HPOA [Figure 1]. Patient was treated with NSAIDs with minimal improvement in his pain. He was subsequently treated with subcutaneous octreotide with improvement in subjective pain scores (from 9 to 4) as early as the following day. DISCUSSION:In patients where surgical resection is infeasible, and pain is refractory to standard of care analgesics alone, bisphosphonates or octreotide may provide symptomatic relief of the pain associated with HPOA. In our patient octreotide was pursued as patient's poor dentition disqualified him from receiving bisphosphonate therapy. Both octreotide and bisphosphonates have been shown in case reports to reduce the pain associated with HPOA (3). Bisphosphonates inhibit bone resorption and octreotide exhibits anti-angiogenic properties by reducing VEGF levels (3).CONCLUSIONS: This case highlights a classic presentation of HPOA in a patient with a primary lung tumor, and the successful use of less commonly used palliative therapies, namely octreotide, in patients who are not candidates for resection.