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unknown tumor - soft tissue

A 25-year-old man with persistent swelling after an ankle sprain.

Case Identification
Case ID Number: 
20091117AG
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a 25-year-old male who has a history of an ankle sprain some months ago. He has had persistent swelling in the ankle. He is working as a painter. There is pain in the ankle in the mornings and after workouts.

Radiological findings:: 
The patient is generally healthy and takes no prescription medicines or supplements. He has no allergies to medicines. He gives no history of previous surgery or illnesses. The rest of the review of systems is negative in detail. There is no significant family history. Examination of the foot shows there is a soft, slightly mobile, soft tissue mass in the anteromedial portion of the right ankle that measures approximately five by 3 cm and appears to be about 1 cm thick. It is nontender. There is synovitis and swelling in the ankle generally. There is pain and tenderness along the course of the posterior tendon behind the medial malleolus. The range of motion of the ankle is slightly reduced. The overall alignment and arch of the foot is preserved. The neurovascular status is normal. There is no skin lesion and no cafe au lait spots are seen. No popliteal or inguinal lymphadenopathy is palpated.

A lawyer with a mass on the leg for 18 months

Case Identification
Case ID Number: 
20090813LM
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 61 year old attorney has noticed a superficial mass on the left left for about 18 months. It was totally painless but sometimes caused itching. The mass was initially thought to be a varicose vein, but slowly and progressively increased is size. On examination, a definite mass can be seen and felt.

Radiological findings:: 
The MRI shows a multilobular lesion apposed to the cortex of the anterior distal tibia, without obvious bony involvement, with "indeterminate" signal characteristics (low signal on T1, high signal on T2). The signal intensity is somewhat variegated within the mass, and is not consistent with a fluid-filled process such as a cyst.
Differential Diagnosis: 
This mass is "indeterminate" on MRI. However, the clinical and radiological features allow the potential for malignancy to be assessed in a qualitative way. What factors have a bearing on the potential for malignancy of this lesion?

A man with multiple skin tumors and a thigh mass

Case Identification
Case ID Number: 
20131212TM
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This man has multiple skin lesions as shown. A large, deep, painless, progressively growing soft mass is present in the left posterior thigh. Sensation is normal in the left leg and foot. What is the likely diagnosis? Given the diagnosis you suspect, what treatment is required?

Radiological findings:: 
A T1 dark and T2 variegated mass is seen in the left posterior compartment of the thigh, approximately 10 x 15 cm. Note the relationship to the neurovascular elements.
Differential Diagnosis: 
Soft tissue sarcoma, other mesenchymal neoplasm.
Further Work Up Needed:: 
Biopsy pending
Treatment Options:: 
This lesion will require removal. Outline your recommended surgical treatment given three scenarios: 1) The lesion is benign 2) The lesion is a low grade sarcoma 3) The lesion is a high grade sarcoma.
Special Features of this Case:: 
This is a real case but the details have been left out to increase the teaching value of the case and challenge the reader. The association of the skin lesions and the mass in the thigh - discuss.

A mass on the big toe for more than 10 years

Case Identification
Case ID Number: 
20110901TY
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 69 year old male has a mass on the lateral aspect of the great toe for at least 10 years. The mass has now gotten large enough to be troublesome. The lesion is not painful. It is fleshly, and moderately soft.

Radiological findings:: 
The lesion is completely radiolucent. There is no calcification. The density appears to be higher than that of lipid. MRI findings show a well circumscribed mass, T1 dark, T2 intermediate signal intensity. There appears to have a normal tissue plane between the Mass and the adjacent first distal phalanx.
Laboratory results:: 
none ordered
Differential Diagnosis: 
There are a large number of benign soft tissue lesions. Lipoma and variants of lipoma, fibrous lesions, tumors that arise from nerve cells or nerve sheath cells, and tumors of vascular origin are among the possibilities.
Further Work Up Needed:: 
The concerns here are the potential for cancer, which exist despite the very slow growth, and the skin loss that will result from excision. Although local coverage may be possible, a split thickness skin graft should be considered. It does not appear that a local flap or rotational flap will be necessary.
Treatment Options:: 
Excision with local or split thickness skin graft coverage is planned.
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