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ankle and foot, leg

A mass in the foot for about 2 months

Case Identification
Case ID Number: 
20120307AM
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is 74, with pain and small area of swelling on the left foot for 2 months. The swelling has increased and a definite mass is present. The patient has prostate cancer treated years ago. He quit smoking 40 years ago.

Radiological findings:: 
Physical examination shows a definite visible and palpable mass, that is present on the dorsal extensor surface and in a more subtle way on the plantar surface of the lateral portion of the left foot as well (see photos). The mass is slightly tender, slightly warm, no evidence of infection. Very slight redness is seen. The patient prefers roomy slippers because his shoes are too painful (see photos). He is able to ambulate but he has pain that has required ongoing medication with Motrin or Tylenol for the past couple of weeks. The pain is present both day and night. The xrays show some subtle findings (see photos). There is slight loss of the cortex on the lateral side of the fourth and there is some change on the cortex on the medial side of the fifth. The mass itself does not have calcifications. The MRI shows a quite large mass, measuring five or 6 cm x 5 or 6 cm in the dorsal aspect of the foot, and about 7 x 7 or 8 x 8 cm in the plantar aspect of the foot, somewhat dumbbell shaped in overall appearance, extending through the fourth interspace (see photos). It is bright on T2, and dark on T1. Based on the MRI, it looks like this mass started as a soft tissue mass between the fourth and fifth metatarsals and gradually spread into the dorsal soft tissues, the plantar soft tissues, and gradually began to erode the nearby cortex of the fourth and fifth metatarsals. Chest x-ray shows three nodules, in the right upper lobe 12.7 mm, 17 mm in the left lower lobe, 26 mm near the lingula.
Laboratory results:: 
The patient's prostate specific antigen is normal. Complete blood count is normal. Kidney function tests are normal. Liver enzymes normal. Chest x-ray shows three nodules, in the right upper lobe 12.7 mm, 17 mm in the left lower lobe, 26 mm near the lingula.
Differential Diagnosis: 
This lesion appears to be a soft tissue mass. There are nodules in the lung which could represent metastasis. It is less likely that the nodules in the lung are a primary and the lesion the foot is a secondary or metastatic lesion. The history of prostate cancer is significant, but the PSA is low ruling out prostate cancer. Thyroid function is normal, effectively ruling out thyroid metastasis to the bone.
Further Work Up Needed:: 
Biopsy is necessary.
Pathology results:: 
pending

A mass in the right ankle of a 40 year old male

Case Identification
Case ID Number: 
20100629RA
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

A 40 year old male presents with a mass that was found on an MRI done 17+ months ago for peroneal tendon tendonitis. A new MRI showed that the mass had gotten much larger.

Radiological findings:: 
A 40 year old male presents with a mass that was found on an MRI done by another provider more than 17 months previous. According to the patient, the mass was not bothersome at that time. The patient presented for a recurring issue in the same ankle. Since the lesion had not been addressed, a new MRI was ordered, which showed the mass had increased significantly in size.
Laboratory results:: 
No labs were done. Lab exams do not normally add useful information in these cases.
Differential Diagnosis: 
This is an intra-arrticular process, which means there are only a small number of possible lesions. Intra-articular synovial sarcoma and PVNS are the top two choices.
Treatment Options:: 
Arthroscopy was performed, and the lesion had a brown / tan pigmented appearance, making it highly likely to be PVNS. Due to the size o fht lesion, a lateral arthrotomy was made, and the lesion was completely excised with a marrginal margin.

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.

A mysterious lesion in the tibia

Case Identification
Case ID Number: 
20110307ML
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This healthy and active 56 year old woman has a painless lesion in the distal tibia. The lesion was discovered on an MRI that was performed for unrelated foot pain. The lesion is totally invisible on the xray, but easily seen on the MRI.

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