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ankle and foot, leg

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 lawyer with a mass on the leg for 18 months - treatment

Case Identification
Case ID Number: 
20090825LM
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

The patient had an incisional biopsy, and the findings are shown. The initial treatment is shown.

A lesion in the talus of an 88 year old woman with 2 previous tumors

Case Identification
Case ID Number: 
20110208LT
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 88 year old woman has dementia, left ankle pain, and a lesion in the left talus. There was treatment for two different tumors approximately 10 years ago, but further details are not available. The local exam shows swelling and tenderness, but no redness, no old incisions or scars,and moderate tenderness generalized around the ankle. The patient is afebrile.

Radiological findings:: 
A destructive, permeative lesion is seen in the body, neck and head of the talus, with no matrix mineralization, no periosteal reaction, and a slightly displaced fracture of the talar neck. The lesion also appears to involve the calcaneus near the sinus tarsi. The articular spaces and cortical surfaces are largely preserved. There is generalized osteopenia. A CT scan shows how permeative the lesion is. No MRI or other imaging was deemed necessary prior to biopsy. An ultrasound was performed to rule out blood clots, which notes an enlarged node in the ipsilateral groin.
Laboratory results:: 
WBC normal, no left shift. CRP 0.6
Differential Diagnosis: 
Primary bone tumor Metastatic bone tumor from previous tumors? Atypical infection
Further Work Up Needed:: 
Treatment plan needed.
Pathology results:: 
See the images shown. 1- 100x © 2011 bonetumor.org courtesy M. Misialek 2- 200x © 2011 bonetumor.org courtesy M. Misialek 3- 400x © 2011 bonetumor.org courtesy M. Misialek 4- 200x, immunohistochemical stain for CD20 © 2011 bonetumor.org courtesy M. Misialek
Treatment Options:: 
As an additional challenge, given the diagnosis, what orthopedic treatment is required?

A man who has to wear size12EEEEEE shoes

Case Identification
Case ID Number: 
20130628EE
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 54-year-old man has a medial and a lateral mass on the foot. Both have been growing steadily for years. He must wear EEEEEE width shoes. The diagnosis is evident from the xray and the photo of the mass.

Radiological findings:: 
There are findings on the first metatarsal medial side, as well as in the second and third metatarsal heads.
Laboratory results:: 
No laboratory data is necessary.
Differential Diagnosis: 
This lesion is predominantly in the soft tissues but several bones are affected as shown.
Further Work Up Needed:: 
The mass was removed as shown.
Pathology results:: 
Pathology is pending.
Special Features of this Case:: 
The combination of the appearance of the mass and the radiographic findings indicated by the arrows are unique to this lesion.
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