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Aggressive digital papillary adenoma / adenocarcinoma - Foot and Ankle

Aggressive digital papillary adenocarcinoma is a rare cutaneous tumor of eccrine sweat gland origin that occurs on the plantar surfaces of the digits in the hand and foot.
This tumor affects men more than women, with a mean age at presentation of 52 yrs (range: 19-83 yrs).
It can have an indolent clinical course without symptoms or change for years. The average tumor size is 1.7 cm and the mas may be present from 2 months to 15 years. Pain is a frequent presenting complaint.
Aggressive surgical re-resection or amputation if necessary to avoid local recurrence.

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A 22 year old woman with a large tibial mass

Case Identification
Case ID Number: 
03252009a
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

A case sent for consulation. A 22 year old woman presents with a 1-year history of leg pain. No other clinical data are available.

Radiological findings:: 
A large surface based lesion projects from the posterior and proximal tibia. There is a gradual and mature looking expansion of the posterior cortex of the tibia, which appears to be of long standing. From this cortex projects the mass, very heavily calcified, with a somewhat varigated pattern of calcification, with some ring or round shaped lucent areas.
Laboratory results:: 
None available
Differential Diagnosis: 
Exostosis, exostosis with associated low-grade chondrosarcoma, periosteal osteosarcoma, parosteal osteosarcoma.
Further Work Up Needed:: 
I would recommend a CT scan, and if possible an MRI. The CT scan will show the relationship of the lesion to the bone, and as you may know, the specific appearance of the junction between the lesion and the bone will allow the diagnosis to be made with a high degree of certainty.
Pathology results:: 
None available
Treatment Options:: 
Clearly, removal is needed. This is a very difficult place to operate, and a very large tumor, I recommend this patient be operated by a very experienced surgeon or team of surgeons, if that is possible.
Special Features of this Case:: 
A lesion of exceptionally large size.

A 49 year old woman with an enlarging calcaneal mass

Case Identification
Case ID Number: 
20120112EC
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient reports an enlarging mass in the left foot for 2 years. Apparently it was small 2 years ago and now is quite substantial. It is painful, she cannot put on a regular shoe, and it is starting to significantly interfere with function

Radiological findings:: 
There is a bony mass that projects from the plantar lateral surface of the calcaneus. The mass appears to be arising from the surface of the calcaneus, almost directly plantar. The portion adjacent to the calcaneus is ossified, the more superficial and lateral portion is lucent, with scattered calcifications. It appears that the cortex of the calcaneus and the cortex of the lesion are confluent at the base of the lesion. The normal trabecular bone of the medullary portion of the calcaneus appears to continues out into the base of the lesion. There is cap of tissue covering the surface of the lesion and projecting from its lateral border, that is more than 2 cm thick in some areas, lobular, with very bright T2 signal on MRI suggestive of cartilage.
Laboratory results:: 
No laboratory examinations were requested.
Differential Diagnosis: 
This lesion has a bony base and a cartilaginous cap. It is a surface lesion. However, the cartilaginous cap is quite thick, and there has been progressive growth. Differential diagnosis includes osteochondroma, secondary chondrosarcoma.
Further Work Up Needed:: 
For biopsy purposes, large wedge shaped sections of the thick cartilaginous cap were excised and sent for pathologic examination.
Special Features of this Case:: 
Several authors have reported that benign osteochondroma can be distinguished from secondary chondrosarcoma based on the thickness of the cartilage cap. A recent report shows that cap thickness of 2 cm or greater strongly indicated secondary chondrosarcomas. Radiology. 2010 Jun;255(3):857-65. Epub 2010 Apr 14. Improved differentiation of benign osteochondromas from secondary chondrosarcomas with standardized measurement of cartilage cap at CT and MR imaging. Bernard SA, Murphey MD, Flemming DJ, Kransdorf MJ.

A 49 year old woman with an enlarging calcaneal mass - 2

Case Identification
Case ID Number: 
20120116AA
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient reports an enlarging mass in the left foot for 2 years. Apparently it was small 2 years ago and now is quite substantial. An open biopsy was done, and resection is now planned.

Radiological findings:: 
There is a bony and cartilagenous mass on the plantar lateral surface of the calcaneus. Once the surrounding tissues are freed, the mass measures more than 8 cm. from base to the most distal point (arrows). At the base is a stalk at its base where the cortex of the bone and the lesion are confluent. The normal trabecular bone of the medullary portion of the calcaneus continues into the lesion. There is thick cap with several large lobules of cartiagenous tissue at the furthest extent definitely more than 2 cms thick (see images). Osteotomy is carried out through normal bone within the body of the calcaneus, resecting the entire stalk of the lesion and its cap en bloc.
Differential Diagnosis: 
chondrosarcoma vs osteochondroma
Special Features of this Case:: 
Lingering concerns about the nature of this lesion necessitated an ample incision for complete exposure and an aggressive resection.However, the peroneal tendons (arrows), a portion of the plantar fascia (arrow), and the tuberosity of the calcaneus were spared, and primary closure was achieved without difficulty.
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