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Tumors of Foot and Ankle


KEY FACTS

  • Foot and ankle tumors are relatively rare entities but must be kept in the differential diagnosis of musculoskeletal complaints in that area.

  • The overwhelming majority of bone and soft tissue tumors in the foot and ankle are benign, but occasionally, a primary sarcoma will be present. Acral metastases (i.e., below the knee) are uncommon, although they can occur most commonly from breast, lung, thyroid, renal, and prostate primary tumors.

    • Ganglion cysts are likely the most common "tumor" seen in an adult outpatient foot and ankle practice.

  • It is imperative that all caregivers be knowledgeable of the common foot and ankle neoplasms, both bone and soft tissue in nature, such that accurate diagnoses, proper treatment, and patient education regarding expected prognosis can occur.

  • With that being said, if there is any concern for a malignant tumor, the most appropriate treatment once that reality is recognized is swift transfer of care to a musculoskeletal oncologist.

AP radiograph of the foot shows a giant cell tumor of the distal 2nd metatarsal. The destructive nature of the lesion is readily seen here.

The expansile nature of the giant cell tumor is seen in this T1 MR. Resection of the distal metatarsal is often the most appropriate treatment in this setting.

Clinical Evaluation

History and Physical Examination

  • Retrospective analysis of missed or improperly diagnosed malignant lesions often uncovers significant clues in both the clinical history and physical examination.

  • A complete physical examination must be undertaken with special attention paid to nodules, adenopathy, masses, skin changes, and local tenderness.

  • Although most malignant musculoskeletal tumors metastasize to the lung, some soft tissue sarcomas go to the draining lymph nodes. A careful physical examination of both regional and systemic lymph nodes is required.

  • Malignant neoplasms of the soft tissues are ~ 3-4 times more common than malignant tumors of the bone, but both are rare with soft tissue sarcoma comprising < 2% of all malignancies.

Biopsy and Surgical Excision

  • If a diagnosis cannot be made with imaging studies, then biopsies can be performed via needle or open approach. If an open biopsy is performed, which may be preferable in the foot so as not to contaminate normal structures, a frozen section analysis should be performed to ensure that diagnostic tissue has been obtained.

  • For bone tumors with a soft tissue mass, the soft tissue component is often diagnostic.

  • Additional principles for performing a biopsy are as follows.

    • Use longitudinal as opposed to transverse incisions. Keep soft tissue dissection and development of tissue planes at a minimum. Avoid neurovascular planes. Close wound in layers.

    • Use the most direct approach to the lesion through, not between, compartments/muscle.

    • Submit all biopsy samples for bacteriologic analysis should frozen section fail to reveal a neoplasm.

    • Maintain meticulous hemostasis with use of a drain brought out in line with the wound if necessary.

    • Use the smallest biopsy incision that will allow adequate tissue sampling and that can be incorporated into the definitive resection.

    • Do not use Esmarch to exsanguinate if a tourniquet is used.

    • Do not biopsy Codman triangle (new subperiosteal bone that forms when a lesion, such as a tumor, lifts the periosteum away from the bone).

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