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ankle and foot, leg

A 36 year old woman with metatarsal lesion

Case Identification
Case ID Number: 
20091110FP
Periosteal Reaction: 
absent
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is a very pleasant 36 year old woman who has noticed a pain in the foot since approximately one month ago.

Radiological findings:: 
Plain radiographs, a bone scan, and MRI are assessed. A lytic, slightly multilocular lesion in the midportion of the second ray is seen. The dimensions are approximately 2 0.5 cm x 1 cm. It seems to extend through one cortex. It does not have any matrix mineralization. It is non-expansile and there is no periosteal reaction.The bone scan shows that the lesion has abnormally increased uptake. The MRI shows a lesion in the above-named location that has bright signal on T2 weighted images. There is destruction of one cortex. There is some surrounding edema.
Further Work Up Needed:: 
This lesion needs to be characterized by biopsy. Possible choices include chondromyxoid fibroma, or other benign lesion. It does not have malignant appearance. Nevertheless, malignancy is still a possibility.

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.

A 55 year old Greek woman with foot pain and a bone lesion

Case Identification
Case ID Number: 
20110329GW
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is a 55 y.o female with pain on the base of the 1st metatarsal. She has difficulty on weight bearing leading to an antalgic gait.

Radiological findings:: 
The patient is a 55 y.o female with pain on the base of the 1st metatarsal (in the medial part of the midfoot). She has difficulty on weight bearing leading to an antalgic gait. There was a good response to NSAID medication, but the pain recurs as soon as she stops the medication. Symptoms have been going on for 3 months.
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