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ankle and foot, leg

A subcutaneous tumor on the foot that has come back rapidly after surgery

Case Identification
Case ID Number: 
20121212ST
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 22 year old woman had a subcutaneous tumor removed from the top of her big toe 6 months ago. The tumor has already started to come back. A photo from before the surgery is shown.

Radiological findings:: 
A nonspecific, subcutaneous lesion is seen dorsal to the toe
Laboratory results:: 
The patient has no findings consistent with rheumatoid arthritis.
Differential Diagnosis: 
This is a tumor that podiatrists, orthopedic surgeons who treat foot and ankle conditions, and hand surgeons will see relatively frequently . Dermatologists and primary care MD's may also encounter this lesion. Students and practitioners of surgery of the foot should be aware of this lesion and include it in their differential when encountering skin and subcutaneous tumors in the foot.
Further Work Up Needed:: 
What is the best next step in managing this particular patient?
Pathology results:: 
The excision shows large areas of geographic necrobiosis with surrounding palisaded histiocytic inflammation and fibrosis. The areas of necrobiosis have a somewhat basophilic tint and are shown to contain degenerated collagen as well as mucin, highlighted on trichrome and Alcian blue stains respectively. The differential diagnosis for palisaded histiocytic inflammation in the deep soft tissues primarily includes rheumatoid nodule and subcutaneous granuloma annulare. Rheumatoid nodules are often seen in older patients in conjunction with a clinical diagnosis of rheumatoid arthritis. In addition, mucin deposition within the lesions is unusual, although it has been reported. Subcutaneous granuloma annulare is more common in children and young adults, and the areas of necrobiosis show more basophilia and often show mucin deposition. Unfortunately, there can be histologic overlap between these two diagnoses. In a young patient in the absence of coexisting rheumatoid arthritis and given the somewhat basophilic necrobiosis with positive mucin deposition, the findings are most consistent with subcutaneous granuloma annulare. However, if the patient has a known history of rheumatoid arthritis and the lesion is adjacent to an affected joint, these findings are best interpreted as rheumatoid nodule.
Treatment Options:: 
This lesion may require biopsy for conclusive diagnosis, but surgical excision is not needed and other treatments are better suited. Surgical treatment is frequently followed by recurrence. See the associated page on this site for complete information on this tumor.
Special Features of this Case:: 
The patient is a very pleasant 22-year-old woman who presents approximately 6 months after having had surgical treatment of a mass in the left great toe. She shows us a picture of multiple subcutaneous masses, adjacent to each other, on the dorsum of the left great toe, which blanch slightly with flexion of the toe, each may be six or 7 mm and roughly round, apparently projecting from the skin surface by a few millimeters. Overlying skin otherwise normal. These had gradually grown and increased in size over a period of two years.

A tumor in the fibula discovered by accident.

Case Identification
Case ID Number: 
20090624AC
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is 51 and in generally good health with severe leg pain. He was cutting trees in his yard when a falling limb struck his leg. An abnormality in the left mid distal fibula was noted.

Radiological findings:: 
On oncologic examination, the overall status, and regional status of the lesion is assessed. There is no local or regional lymphadenopathy, and no lymphadenopathy is noted in the draining lymph chain. 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. On musculoskeletal examination, the patient is ambulatory using two crutches because of pain in the left leg. There is noticeable swelling around the mid to distal fibula. Distally, the neurovascular status of the foot is normal. There is no popliteal or inguinal lymphadenopathy. No distinct masses palpable. There is point tenderness around the area of the impact from the accident the patient had one week ago. There is no visible bruising, no break in the skin, no ecchymosis. No skin changes whatsoever. The only findings are point tenderness and swelling. Xrays, a bone scan, and an MRI shows a small lesion in the fibula that has eroded the medial cortex, has a granular appearance, measures about 2 1/2 centimeters in length and about 2 cm in medial lateral size. It has a somewhat lobulated appearance. There is no periosteal reaction. There is no matrix calcification. It appears to be destroying the medial cortex of the fibula, and there is a soft tissue mass. A CT scan and the MRI show a lobulated, lytic, destructive process, having obliterated the medial cortex of the fibula, with no periosteal reaction, no matrix calcification. There is considerable perilesional edema. The lesion has low T1 signal and high T2 signal.
Laboratory results:: 
None relevant
Differential Diagnosis: 
This bone lesion has an active appearance. No definitive diagnosis is possible based on history and imaging studies.
Pathology results:: 
See images for pathological features.
Special Features of this Case:: 
This active lesion was discovered by a freak accident. Usually incidentally discovered lesions are latent.
Image Reference: 

A vascular mass on the front of the tibia

Case Identification
Case ID Number: 
20100628VM
Periosteal Reaction: 
absent
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

Patient has a mass he thinks might be a varicose vein on the anterior surface of his left leg for several years.

Radiological findings:: 
An x-ray shows that there is a lesion in the mid tibia which corresponds with the soft tissue abnormality noted. It appears that there is a series of openings in the tibial cortex at the location of the lesion, the largest of which is less than a centimeter in length and perhaps 0.5-cm in width. There are couple of smaller nearby openings as well. Overall the size of the lesion represents a little bit more than half the diameter of the shaft of the bone. There is no periosteal reaction. There is no matrix mineralization or other visible abnormality on x-ray. The MRI shows what appears to be a vascular anomaly. The lesion can be clearly seen crossing the tibial cortex, line both anterior and the tibial cortex perhaps underneath the periosteum, transgressing the cortex, and then lying within the intramedullary space. It has the globular appearance of a possible vein, and it connects to an elongated vascular appearing structure that exits proximally through a nutrient foramen in the posterior tibial cortex and joins the vascular elements in the soft tissues behind the tibia. The size of the vessel behind the tibia is slightly enlarged as well.
Differential Diagnosis: 
Vascular tumor vs vascular anomaly
Special Features of this Case:: 
The MRI appearance of this lesion appears to correspond exactly with the entity described as interosseous venous drainage anomaly. This has been described in the literature on a few occasions and a handful of cases have been reported. Reference: Intraosseous venous drainage anomaly of the tibia treated with imaging-guided sclerotherapy. Peh WC, Wong JW, Tso WK, Chien EP. Br J Radiol. 2000 Jan;73(865):80-2. Intraosseous venous drainage anomaly in patients with pretibial varices: imaging findings. Boutin RD, Sartoris DJ, Rose SC, Plecha EJ, Bundens WP, Haghighi P, Harter LP, Resnick D. Radiology. 1997 Mar;202(3):751-7.

A very large forefoot tumor in a 70 year old woman

Case Identification
Case ID Number: 
20150430VL
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 70 year old woman has a mildly painful right foot mass. The mass has forced the fourth and fifth metatarsals to bow outward and remodel.

Radiological findings:: 
The plain films show striking outward bowing of the fourth and fifth metatarsals due to the gradual enlargement of the mass. The fourth metatarsal also has an apex dorsal bowing deformity due to plantar pressure from the mass. The MRI shows a very large mass that extends from the plantar surface the foot up through the space between the fourth and fifth metatarsals and into the dorsal subcutaneous tissues.
Laboratory results:: 
No laboratory examinations were requested
Differential Diagnosis: 
This lesion has "indeterminate" features by MRI. This means that the diagnosis cannot be determined based on the MRI, as is possible with some soft tissue tumors such as lipoma and hemangioma. The differential diagnosis must be constructed from a set of soft tissue tumors that can cause this extensive growth, bone remodeling, and whose MRI features are strikingly heterogeneous such as seen on these MRI images.
Further Work Up Needed:: 
This patient needs staged biopsy followed by definitive surgical management, depending on the tumor type, grade, and stage.
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