Spontaneous sacral fracture with associated acrometastasis of the hand

Background: Acrometastases, secondary tumors affecting oncological patients with systemic metastases, are associated with a poor prognosis. In rare cases, acrometastases may precede establishing the primary tumor diagnosis. Case Description: A 72-year-old female heavy smoker presented with low back pain, and right lower extremity sciatica/radiculopathy. X-rays, CT, MR, and PET-CT scans documented primary lung cancer with multi-organ metastases and accompanying pathological fractures involving the sacrum (S1) and right 4th digit. She underwent a S1 laminectomy and amputation of the distal phalanx of the right fourth finger. The histological examination documented a poorly differentiated pulmonary adenocarcinoma infiltrating bone and soft tissues in the respective locations. The patient was treated with a course of systemic immunotherapy (i.e. pembrolizumab). At 6-month follow-up, the patient is doing well and can stand and walk without pain. Conclusion: Spontaneous sacral fractures may be readily misdiagnosed as osteoporotic and/or traumatic lesions. However, in this case, the additional simultaneous presence of a lytic finger lesion raised the suspicion that these were both metastatic tumors. Such acrometastases, as in this case attributed to a lung primary, may indeed involve the spine.