Case Presentation

The patient is a very pleasant 45-year-old gentleman who has noticed a mass in the right foot for approximately 6 months.

The patient is generally healthy. There is no history of high blood pressure, diabetes, strokes, shortness of breath.

The patient has completed a history and physical form which is examined and discussed, as well as entered into the chart. The past medical history, surgical history, medications, allergies, family and social history are reviewed.

On oncologic examination, the overall status, and regional status of the lesion is assessed. There is a palpable lymph node in the right inguinal ligament area, and no lymphadenopathy in the right popliteal fossa. No central lymphadenopathy is noted. There is no café au lait spot, or other unusual skin lesion. The patient does not appear chronically ill or cachectic.

In the foot, there is a firm, somewhat tender, deep, fairly sizable mass that surrounds the neck of the distal portion of the fifth metatarsal, spreading into the interspace between the fourth and the fifth metatarsal. The dorsal side of the foot is slightly swollen. There is slight lifting up of the lateral border of the foot because of the bulk of the mass. The overlying skin circulation as well as the neurologic findings are normal. There is no definite Tinel's sign but the mass is quite tender and percussing the mass does cause pain.

The plain radiographs of the foot show a few foci of calcification within the mass. Click on the images to see larger views.

The MRI shows a multiloculated mass surrounding the fifth metatarsal shaft near the distal end. It has grown between the fourth and fifth up into the dorsal portion of the foot and is apparent between the fourth and fifth toes and in the tendinous interspace of the fifth. Click on the images to see larger views.

CT scan of the chest, abdomen and pelvis shows bilateral inquinal adenopathy, with multiple small bilateral nodes, but no other finding of concern.

What is the differential diagnosis? What is the next step in the management of this patient?

Click on an image to enlarge