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ankle and foot, leg

A 57-year-old woman who has a lesion in the talus bone

Case Identification
Case ID Number: 
20091105MK
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a very pleasant 57-year-old woman who has pain and a lesion in the talus bone. She was initially seen by a variety of practitioners, including one who gave her an injection for gout or for arthritis. The patient is generally healthy.

Radiological findings:: 
The patient has had tonsillectomy, and a benign tumor removed from the right breast. She does not smoke. In the family there is high blood pressure in the brother and diabetes and a brother. There is no other contributory history. Examination of the left ankle shows diffuse swelling. The range of motion is preserved. There is diffuse tenderness, but no definite mass is palpable. There is a faint mild lesion in the neck of the talus, that was visible on the original xrays taken months ago. MRI films show a mass in the neck of the talus which appears to have arisen in bone or adjacent to bone. A bone scan shows there are two areas of increased uptake, one in the talus and one in the hip. A CT scan of the abdomen is shown.
Differential Diagnosis: 
Possibilities include pigmented villonodular synovitis, giant cell tumor of bone, and malignancy, among others.
Further Work Up Needed:: 
Clearly biopsy is going to be necessary in order to decide on the appropriate course of treatment. I do not believe that biopsy and removal in one stage is an appropriate choice.
Pathology results:: 
See images.
Special Features of this Case:: 
Lesions in the foot may arise from pathology elsewhere. The clinician needs to maintain a broad perspective.
Image Reference: 

A 90 year old woman with 3 weeks of foot pain

Case Identification
Case ID Number: 
20110512FP
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

This delightful 90-year-old woman has pain in the right foot, in the midfoot at the base of the second and third metatarsals. There is a lesion on the x-rays and on the MRI in that area. The patient has a history of nephrectomy for renal cell carcinoma 6 years ago.

Radiological findings:: 
On the plain radiographs, there is a lytic, destructive, completely lucent lesion in the base of the second metatarsal, that seems to extend in into the base of the third metatarsal. There may be very faint mineralization of the lesion. Deletion has a relatively aggressive appearance. There is no periosteal reaction present. There is diffuse demineralization of the nearby bones. An MRI shows a T1 dark, T2 intermediate lesion extending across the second and third metatarsal base, into the base of the cuneiforms. It has a slightly lobular outline that extends outside the contour of the bones themselves.
Laboratory results:: 
no laboratory examinations are requested
Differential Diagnosis: 
The working diagnosis would be metastasis from renal cell carcinoma. Other metastasis such as from lung and breast carcinoma is possible. Although metastatic deposits in the bones of the foot are rare, they definitely can occur, and should be at the top of the differential in a patient with a prior history of cancer with propensity to metastasize to bone and the new onset of foot pain with a bone lesion.
Further Work Up Needed:: 
The patient needs a complete assessment of the skeleton, including a whole body bone scan, and a CT scan of the chest, abdomen, and pelvis with oral and intravenous contrast. This workup combined with the x-rays and MRI of the foot, will complete the radiological examinations necessary to stage the patient. The biopsy will provide the histological information necessary to confirm the local lesion, and the slides and blocks from the original nephrectomy should be reexamined to compare these with the cells from the foot. Together, this series of procedures will confirm the diagnosis, the stage of the disease, and these two pieces of information lead directly to the preferred treatment.
Pathology results:: 
See the images from the frozen section that are shown. Findings include abundant foamy and in some areas clear cytoplasm, round nuclei with prominent nucleoli, and prominent small blood vessels in the tumor. Final analysis is pending.
Treatment Options:: 
Patients with metastatic lesions in the foot require surgical treatment for biopsy only. It is uncommon that reconstructive surgical intervention is necessary. Radiation treatment is mandatory, and bisphosphonate medication such as Zometa should be given as soon as the patient can receive them to prevent further bone damage as much as possible. In most of these cases, the patient is immobilized in a removable walking boot and allow to be partially weightbearing.
Special Features of this Case:: 
Although uncommon, a presentation of metastatic carcinoma with deposits in the skeleton of the foot can occur. A number of case reports of presentation of renal cell carcinoma with metastasis to the foot have been published. Foot Ankle Spec. 2008 Dec;1(6):338-43. Epub 2008 Oct 21. Metastases to bones of the foot: a case series, review of the literature, and a systematic approach to diagnosis. El Ghazaly SA, DeGroot H 3rd.

A banker with a mass in the foot

Case Identification
Case ID Number: 
20090722BM
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

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

Radiological findings:: 
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. 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.

A Cartilage Mass in the mid foot

Case Identification
Case ID Number: 
20100810CM
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 78 year old man has a slowly growing, slightly painful, palpable nodular mass in the TMT joint of the 1st ray.

Radiological findings:: 
The mass is dark on T1, bright on T2. It surrounds the joint on all sides.
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