Tumors and Tumor-Like Lesions

of the Foot and Ankle: Diagnosis 44

and Treatment

Hans Gollwitzer, Andreas K. Toepfer,

Ludger Gerdesmeyer, Reiner Gradinger,
and Hans Rechl

44.1 Introduction 44.3 Diagnosis

Bone and soft tissue tumors of the foot and ankle are not Benign and indolent soft tissue masses are common
rare in the foot specialist’s practice. Although masses are at the foot, and failure of suspicion can substantially
usually seen early with early symptoms due to compact delay diagnosis of neoplasia. Patient age and location
anatomy with thin soft tissue coverage (e.g., pain on of tumor can be useful in determining possible diagno-
weight-bearing), diagnosis is often delayed. Diagnostic ses. A detailed history of risk factors, prior malignancy,
errors are more common than in other regions, since neo- and metastatic disease especially in patients older than
plasia is often not considered. Tumor size is a major prog- 50 years (e.g., lung or genitourinary tract) should raise
nostic factor for recurrence-free survival, and delayed the index of suspicion toward malignancy. Furthermore,
diagnosis finally results in undertreatment or overtreat- especially preexisting painless masses that suddenly
ment with serious consequences. Thus, if early diagnosis start growing should be followed by further diagnostic
is compelled, prognosis is generally improved. measures to rule out neoplasia. Fractures mandate the
question for adequate trauma. Hence, fractures follow-
ing inadequate trauma should not be accepted without
44.2 Epidemiology ruling out underlying bone disease.

Suspicion is warranted in investigating any foot mass,

44.3.1 Physical Exam
including especially those with an apparently indolent
course. Several investigations have shown that malig- Physical exam confirming the presence of a mass must
nancy rates are much higher at the foot and ankle than analyze whether the tumor is fixed to or can be moved
previously thought. The foot and ankle, which repre- against the underlying tissue. Pain is generally unspe-
sents approximately 3% total body mass, is also the site cific; however, sharp electrifying pain or tingling at
of 3% of osseous neoplasms.1 Even more important, 5% palpation with positive Hofmann-Tinel sign can point
of malignant and 8% of all benign soft-tissue tumors toward nerve entrapment by the mass or peripheral
occur at the foot and ankle region.2 In larger case series, nerve tumors. Thorough diagnostics should be initi-
3.4–12.8% of the treated foot and ankle tumors in referral ated with pigmented lesions of the skin, since malig-
centers have been reported as malignant.3-5 nant melanoma is quite common in the foot and ankle
region.6 In any case of suspicion, a biopsy is manda-
tory to confirm or rule out melanoma. Transillumination
H. Gollwitzer ( ) is still helpful to confirm the presence of a cystic lesion,
Klinik für Orthopädie und Sportorthopädie,
although further diagnostic measures have to be taken
Klinikum rechts der Isar, Technische Universität München,
Ismaninger Str. 22, Munich 81675, Germany if there is any doubt of a completely cystic mass or if
e-mail: gollwitzer@[Link] therapeutic measures are to be taken.

A. Saxena (ed.), International Advances in Foot and Ankle Surgery, 489

DOI: 10.1007/978-0-85729-609-2_44, © Springer-Verlag London Limited 2012
490 H. Gollwitzer et al.

44.3.2 Ultrasound consequent history taking for adequate trauma can point
toward underlying metabolic or neoplastic disease.9
Ultrasound is an appropriate tool for differentiation of
solid and cystic tumors (e.g., ganglion). Additionally,
ultrasound can be used to guide needle aspiration or 44.3.4 Computed Tomography
biopsy.7 However, specific diagnosis based on ultra-
sound alone is generally not sufficiently accurate, Compared to conventional X-rays, computed tomogra-
which commonly results in further diagnostic steps phy (CT) scans can provide additional information on
like magnetic resonance imaging (MRI) and biopsy.8 bony detail after MRI and are commonly used to differen-
tiate matrix calcifications from real ossification as well as
assessment of cortex integrity (Fig. 44.1). Furthermore,
44.3.3 X-Rays analysis of Hounsfield units allows assessment of tissue
density, especially in comparison with subcutaneous fatty
Radiographic workup is initiated to differentiate tissue for specific diagnosis of (intraosseous) lipoma. In
bone tumors with soft tissue masses from soft tissue the case of a metal implant, CT scan is the imaging
tumors. High-quality dorsoplantar, oblique, and lat- method of choice to describe tumor expansion and rule
eral radiographs should be taken so as not to miss out or confirm tumor recurrence.10
subtle osseous lesions. X-rays should especially be Finally, CT scan of the thorax is the method of
analyzed for localization of the tumor (epiphyseal, choice in the staging of most malignant tumors of the
metaphyseal, or diaphyseal), morphology of the lesion, skeletal system, which commonly metastasize into the
and its margins (bony arrosions, cortical thinning, lungs.
periosteal reactions, sclerotic margins, and tumor
matrix like calcification or ossification). The Lodwick
classification is very helpful to obtain a first grading 44.3.5 Magnetic Resonance Imaging
of bone tumors (Table 44.1). Although it is some-
times difficult to differentiate Grade II and III MRI is the standard imaging method for bone and soft
lesions, the precise grading is not that relevant since tissue tumors.11 Certain entities – both benign and
both describe aggressive growth that requires fur- malignant – can be definitely diagnosed by MRI due to
ther evaluation. specific resonance characteristics.8,12,13 Standard proto-
Certain radiographic characteristics can give diag- cols have been established, and most commonly native
nostic clues, like extensive punctuate calcifications T1, T1 plus intravenous gadolinium, and native T2
being typical, e.g., for enchondroma, whereas small sequences in the same orientation are recommended to
intralesional calcifications are commonly observed in evaluate the tumor and uptake of contrast medium
synovial sarcoma. (Fig. 44.2). Additionally, transverse images of the
Furthermore, especially in the case of a fracture, total tumor expansion are obtained to define the mar-
subtle analysis of the adjacent bone for osteolysis and gins of the tumor with regard to major nerves and

Table 44.1 Lodwick classification of bone tumors

Grade Destruction Margin Cortex penetration Sclerotic rim Expanded cortical
shell
IA Mandatory Regular, lobulated, None or partial Thick Optional, d1 cm
geographic or multicentric
IB Mandatory Regular, lobulated, None or partial Optional Optional, >1 cm
geographic or multicentric
IC Mandatory Regular, lobulated, Mandatory total Optional Optional
geographic or multicentric
II Moth-eaten Irregular, poorly Total Optional but unlikely Optional but unlikely
or geographic defined
III Mandatory Any edge Total Optional but unlikely Optional but unlikely
permeated
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 491

a b

c d

Fig. 44.1 X-ray (a), MRI (b), and CT (c, d) scan of a 16-year- sion and penetration into adjacent joints. (e) Postoperative radio-
old patient with unicameral bone cyst of the calcaneus. CT scan graph after curettage and filling with autologous bone
is the most reliable method to confirm or rule out cortical ero-
492 H. Gollwitzer et al.

Fig. 44.1 (continued)

a b

Fig. 44.2 A 48-year-old patient with a chondrosarcoma of the complete tumor extension to define the relation to neurovascular
midfoot. Standard MRI with (a) native T1-weighted sequence structures; (e) postoperative X-ray at 2 months after midfoot
(b) T1-weighted sequence with contrast (c) T2-weighted amputation and fusion of the tilted calcaneus to the distal tibia
sequence, all in the same orientation; (d) axial sequence of the (Boyd’s amputation)
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 493

c e

Fig. 44.2 (continued)

494 H. Gollwitzer et al.

Table 44.2 Typical MRI features of soft tissue tumors with corresponding signals
T1+, T2+ T1+, T2+/− T1−, T2− T1−, T2+
Hemangioma Lipoma Desmoid Various sarcomas
Lymphangioma Liposarcoma Fibromatoses Neurogenic tumors
Hematoma Hamartoma PVNS Cysts
Small AVM Elastofibroma Morton neuroma Ganglion
Mineralizations Clear cell sarcoma Xanthoma Myxoma
Melanoma High-flow AVM Chondrogenic tumors
Scar tissue Myxoid liposarcoma
Mineralized tumors Synovial sarcoma
Amyloid tumors
T1+ = high signal on T1-weighted MRI images; T1+/− = intermediate signal intensity; T1− = low signal intensity; T2+ = high signal
on T2-weighted images; T2+/− = intermediate signal intensity; T2− = low signal intensity; PVNS pigmented villonodular synovialitis;
AVM arteriovenous malformation

blood vessels.13 Depending on the suspected tumor Since biopsies can be associated with major com-
entity, additional sequences can be obtained as neces- plications that might significantly impair prognosis,15
sary (e.g., hem sequences for pigmented villonodular early referral to a center experienced in musculoskel-
synovitis). Typical MRI features of soft tissue tumors etal tumors is strongly recommended – even before
have been summarized in Table 44.2.6 biopsy! In this context, the Musculoskeletal Tumor
There are various diagnostic challenges that require Society demonstrated much higher incidence of
a high level of specialization and experience. For this biopsy-related complications when biopsies were not
reason, we recommend regular interdisciplinary con- performed at centers experienced in musculoskeletal
ferences with radiologists specialized in musculoskel- tumors.15,16 Mankin and co-workers demonstrated that
etal tumors. Soft tissue tumors with bone infiltration out of 17.5% of complications related to biopsy, nearly
can often be distinguished from bone tumors with soft 10% had negative impact on prognosis; 77.2% of these
tissue masses by the use of MRI. However, accuracy of biopsies with complications had not been performed in
MRI to distinguish bone marrow edema from tumor oncologic centers.15,16
infiltration and postoperative scarring from recurrent Several important issues have to be regarded when
tumor is limited. tissue is harvested for histologic workup. Since the
Vascular infiltration on MRI is defined by encase- tissue that is penetrated during biopsy is potentially
ment of blood vessels by the tumor mass above 180°. contaminated with tumor cells, the biopsy approach
Nerves and blood vessels with less contact to the tumor has to be excised during final surgery. Thus, the differ-
can often be preserved. ent options and approaches for definitive tumor resec-
Entities that can be specifically diagnosed by MRI tion have to be considered already at the time of biopsy!
alone include hemangioma/lymphangioma, lipoma/ The biopsy approach should be defined by or in accor-
low-grade liposarcoma, chondrogenic tumors, benign dance with the surgeon who will perform the later
neurogenic tumors, and various intra-articular tumors.14 definitive tumor resection.
If a specific diagnosis cannot be established by imag- Closed biopsy techniques, such as CT-guided or
ing techniques, every tumor has to be regarded “poten- ultrasound-guided needle biopsies, are especially
tially malignant” and a specific diagnosis has to be suitable in deep and larger lesions with homogeneous
enforced by biopsy and histopathologic workup. matrix and in the case of suspected tumor recurrence.
Fine needle biopsy has the lowest risk of complica-
44.3.6 Biopsy tion but is limited to cytology, since small size of
tissue samples does not allow accurate histologic
In any mass with suspected malignancy, indeterminate workup. Core-needle biopsy is appropriate for histol-
behavior, or if the diagnosis cannot be specified to one ogy, but has a higher risk of hematoma.17 Multiple
single entity, a biopsy must be obtained (possible dif- samples should be taken to improve diagnostic accu-
ferentiation of benign and malignant is not enough!). racy (75–90%).
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 495

Table 44.3 Surgical stages for benign musculoskeletal tumors

Stage Grade Site Metastases Definition Behavior
1 G0 T0 M0 Latent or inactive Remains static or heals spontaneously
2 G0 T1 M0 Active Progressive growth but limited by natural barriers
3 G0 T2 M0 Aggressive Progressive growth, not limited by natural barriers

Open and incision biopsy on the other hand have a tures which is again associated with tumor cell spread-
higher diagnostic value and allow harvesting of suffi- ing. Thus, all relevant measures such as splint or cast
cient tissue for histology, immunostaining, and molec- as well as limited weight-bearing have to be addressed
ular workup. Radical biopsy is appropriate for certain postoperatively. Finally, use of non-resorbable sutures
benign lesions and has the advantage that no second helps to mark the biopsy incision. Drains are used
surgical intervention is necessary. Areas of vital tumor whenever necessary to avoid hematoma, and drains
should be addressed in fast-growing and heteroge- should pass through the skin close to the incision’s distal
neous masses, and margins to healthy tissue as well as margin in line with the skin incision.
cystic membranes are most representative and should If the diagnosis is not straightforward after defini-
also be sent for histopathologic analysis. tive histopathology, cases should be discussed in inter-
Good surgical technique is necessary to avoid com- disciplinary conferences with pathology consultant,
plications that can have negative influence on the prog- radiologist, and orthopedic surgeon.
nosis for tumor resection and survival. A longitudinal
incision facilitates later resection. The skin should not
be mobilized to allow complete resection of the biopsy 44.3.7 Staging
canal at final surgery. A direct approach should be cho-
sen, and additional compartments must not be opened. Special considerations have to be used in the staging of
Neurovascular structures and joints have to be avoided. foot tumors,18 because of the special anatomic situa-
Bony lesions should be addressed from the dorsum of tion. No real compartments are present at the midfoot,
the foot, whereas a direct approach is appropriate for hindfoot, and ankle. Moreover, only thin fascial bor-
soft tissue lesions. ders exist along single rays, and thin cortex and perios-
Several samples of viable tissue as well as tissue sam- teum of the tarsals allow early perforation of both bone
ples for microbiological culture are taken and transported and soft tissue tumors. In oncologic surgery, the hind-
on ice to the pathology department to allow for immuno- foot and the midfoot are considered single anatomic
logical and molecular analyses. Intraoperative frozen sec- compartments by the staging system of MSTS.9,18
tions are helpful in certain tumors with non-mineralized Tables 44.3 and 44.4 summarize the classic staging
tissue to make sure that representative tumor tissue has systems for musculoskeletal tumors.10,11
been taken, to check the resection margins for remaining
tumor cells, or to verify the diagnosis in case of suspected
tumor recurrence. Frozen sections may provide a diagno- 44.4 Treatment
sis, but often definitive histopathological workup includ-
ing immunohistochemistry is necessary. If definitive 44.4.1 Surgical Treatment
diagnosis is not obtained, discontinue case and perform
definitive surgery in a second procedure. Adequate resection of any tumor is the sine qua non
In nonhomogeneous masses, tissue should be taken for local tumor control and survival. “Life before
from different locations within the tumor. Meticulous limb!” No compromise in resection margins should be
hemostasis (e.g., with bone wax, acrylic cement, or tolerated in tumors in which recurrence is associated
collagen sponges) is of utmost importance, since with decreased survival. Hence, resection has to be
hematoma is associated with local uncontrolled tumor adapted to the dignity of the tumor. Reoperations have
cell contamination. In this context, bony biopsies are a statistically worse prognosis, since the extension of
of special interest because weakening of the bone by the original tumor cannot be determined by the sur-
tumor and biopsy increase the risk of pathologic frac- geon who is doing the revision. Four general types of
496 H. Gollwitzer et al.

Table 44.4 Surgical stages for malignant musculoskeletal tumors

Stage Grade Site Metastases
IA Low (G1 and G2) Intracompartmental (T1) None (M0)
IB Low (G1 and G2) Extracompartmental (T2) None (M0)
IIA High (G3 and G4) Intracompartmental (T1) None (M0)
IIB High (G3 and G4) Extracompartmental (T2) None (M0)
IIIA Low (G1 and G2) Intracompartmental or Extracompartmental (T1–T2) Regional or distant (M1)
IIIB High (G3 and G4) Intracompartmental or Extracompartmental (T1–T2) Regional or distant (M1)
G is the grade of the tumor as defined by histology. G0 is benign tumor. G1 and G2 are low-grade malignant tumors, and G3 and G4
are high-grade malignant tumors
T is the anatomic extension of the tumor. T0 means a benign tumor contained by a true capsule (intracapsular). T1 is a benign tumor
or malignant tumor that is confined inside an anatomical compartment without a true capsule. T2 is a benign or malignant tumor that
is originating in an extracompartmental space or expanded extracompartmentally by penetrating the natural barriers
M are the metastases, either regional (skip or lymph nodes) or distant. M0 means absence, M1 means presence of metastases

tumor resection have been defined: intralesional, should not be opened during surgery for macroscopic
marginal, wide, and radical. inspection to avoid spreading of tumor cells. After resec-
Intralesional resection, such as curettage, is appro- tion, the tumor mass is immediately transported on ice
priate for some benign lesions with none to very low to the pathology department. Similarly to septic surgery,
risk of recurrence or good healing potential. Marginal all instruments as well as drapings and gloves should be
resection is the excision through the reactive zone, and changed after removal of the tumor mass. Finally, the
is appropriate for most benign lesions that show a cer- defect is appropriately reconstructed.
tain potential for recurrence or do not heal spontane-
ously. Wide resection is defined as removal of tumor [Link] Adjuvant Therapy Accompanying
surrounded on all sides with healthy tissue, and this Intralesional Procedures
type of resection is adequate for most malignant As pointed out before, latent or active benign tumors
tumors. Finally, radical resection includes resection of or tumor-like lesions of the bone, referring to the clas-
the entire anatomic compartment (metatarsals are the sification of Enneking,18 can be treated sufficiently by
only compartmental boundaries). Since recurrence- intralesional curettage in a majority of cases. It is to be
free survival after wide and radical resection is similar noted that the assignment into the three-group classifi-
for most malignant cases, but radical resection is often cation of latent, active, and aggressive lesions might
associated with severe functional impairment, wide differ not only from entity to entity but by localization,
resection is the resection of choice in most malignant radiographic appearance, and severeness of symptoms.
tumors. However, due to the smaller anatomic situation at Optional therapeutical means besides intralesional or
the foot with only limited boundaries, radical resection – marginal resection and the employment of a high-
which is often equivalent with (ray) amputation – is speed burr to clean the cavity in bone tumors might be
more common at the foot than at other areas. necessary for successful treatment. Local recurrence
Again, at the time of definitive surgery for a bone or after surgical intralesional procedures may be reduced
soft tissue tumor at the foot and ankle, the scar and by additional use of local adjuvants, either chemical or
underlying tissue that has been contaminated during thermal. Phenol and alcohol repeatedly have shown to
biopsy has to be excised. A tourniquet should be used decrease the recurrence rate in the treatment of various
after exsanguinations by elevation instead of Esmarch to bone tumors.19 Effectivity of phenol on cartilaginous
reduce the risk of traumatizing a potentially malignant tumor tissue is discussed controversially, though. Lack
lesion and possibly promoting metastases. Thereafter, et al. found no effect of phenol on chondromatous
the tumor is excised with appropriate resection margins tumor tissue in his studies.20 Adjuvant thermal proce-
as described above. If local resection involves sacrific- dures include cryotherapy (use of liquid nitrogen) and
ing of plantar nerves, (partial) amputation of the foot the use of polymethylmetacrylate (PMMA) by filling
may be considered. Resection borders are then unequiv- the lesion with bone cement. Both methods are widely
ocally marked with sutures, and the marked borders are used and aim at the necrotizing effects of cytotoxical
documented on the pathology protocol. The tumor hypo- and hyperthermia.21 In contrast to liquid nitrogen,
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 497

the tumoricidal capacity of PMMA is not well investi- Boyd, Syme, or transtibial amputation. Figure 44.2
gated. An advantage of bone cement is the stabilizing illustrates the case of a 48-year-old patient in whom a
effect on the curetted cavity and a well-defined and vis- Boyd’s amputation became necessary due to chondro-
ible demarcation to biological tissue (bone healing, sarcoma of the midfoot. With good functional result, the
tumor recurrence) on imaging during follow-up. patient was able to go downhill skiing 6 months later.

[Link] Radiofrequency Ablation

In contrast to traditional surgical tumor therapy with 44.4.2 Nonsurgical Adjuvant Treatment
different ways of open tumor resection, radiofrequency
thermal ablation allows for a less invasive treatment Treatment of musculoskeletal tumors requires a multidis-
for a limited number of bone lesions. Image-guided ciplinary approach. Best results have been reported for
radiofrequency thermal ablation is used in interven- specialized surgeons and tumor centers. Each patient
tional oncology to coagulate and destroy tumor tissue should be discussed in interdisciplinary tumor board
by the direct application of radiofrequency-generated (with participation of specialized musculoskeletal tumor
heat,22 mainly in metastases. surgeon, oncologic radiologist, pathologist, radiother-
Radiofrequency thermal ablation is well described for apy specialist, oncology specialist, and plastic sur-
the successful treatment of osteoidosteoma and bone geon). Neoadjuvant and adjuvant treatment modalities
metastases for many years, and commonly is guided by like radiotherapy and chemotherapy have had a major
CT.23,24 Osteoidosteoma is characterized by a distinct impact on healing rates and long-term survival, espe-
radiographic appearance, a small tumor volume, superfi- cially in primary bone tumors like osteosarcoma and
cial localization within the bone, and a latent tumoral Ewing’s sarcoma. In general, neoadjuvant radiother-
behavior and is therefore predestined for minimal-inva- apy and brachytherapy is indicated in high-grade
sive ablation. More active or even aggressive benign bone malignant tumors with limited resection margins or with
lesions such as aneurysmatic bone cysts or giant cell close contact to neurovascular structures. Preoperative
tumors and a curative therapeutic concept in singular radiation of soft tissue masses that are in direct contact to
metastatic bone disease are not suitable for this kind of nerves and blood vessels or that penetrate compartment
treatment. Although there have been limited reports of borders might allow “downgrading” and help to preserve
successful radiofrequency therapy of osteoblastoma24 and important structures at definitive surgery. Lower doses of
chondroblastoma,25,26 long-term results and larger num- radiotherapy are used in the foot because of increased
ber of cases are yet to be critically awaited. An obvious risks of side effects like fibrosis and stress fracture.
disadvantage of this procedure is the lack of adequate
sample gathering and subsequent histological verification
as well as differentiation of the tumor. Moreover, large 44.5 Most Common Entities
tumor formations are less likely to be removed completely
by minimal-invasive procedures and higher rates of recur- 44.5.1 Bone Tumors
rence thus have to be expected.27
[Link] Benign
[Link] Amputations Benign bone tumors are much more common than
Amputations are more common in malignant tumors of malignant tumors of the foot and ankle with a rate of
the foot compared to other anatomical sites because approximately 84% vs. 16% in specialized centers.28
functional impairment is less the more distal the ampu- Slowly growing benign bone lesions are often recog-
tation is done. Although good results have been reported nized first after the occurrence of a pathologic fracture,
in limb salvage surgery, compromise in resection mar- after pain due to weakening of the bone with an
gins should not be accepted in foot and ankle tumors, impending fracture, or by chance. In addition to osteo-
especially, since many different amputation techniques chondroma, which is the most common bone tumor,
are associated with acceptable functional outcome. common foot and ankle lesions are giant cell tumors
Ray amputation of up to three lateral or medial rays and intraosseous lipoma of the calcaneus. The most
leads to good functional results. Other amputation common benign bone tumors have been summarized
options include transmetatarsal, Lisfranc, Chopart, in Table 44.5.
Table 44.5 Important benign bone tumors and tumor-like lesions of the foot and ankle
498

Tumor Decade/age Localization X-ray CT, MRIa Resection Recurrence/ Important differential
spreading diagnoses
Giant cell tumor 2nd–5th Distal tibia and fibula, Intramedullary T1−, T2+ Curettage and High risk of Aneurysmal bone cyst,
tarsal bones osteolytic grafting; consider recurrence (~10%); giant cell reparative
changes, thin bone cement and rarely pulmonary granuloma, metastasis,
sclerotic margin, secondary replace- metastases osteosarcoma, clear cell
cortical thinning, ment by bone graft chondrosarcoma, multiple
pathologic myeloma
fracture
Giant cell reparative 2nd Metaphysis of small Osteolytic, no T1−, T2+ Curettage and Heals with Osteosarcoma, aneurysmal
granuloma/solid bones perilesional grafting; radiation thorough curettage bone cyst, giant cell tumor
aneurysmal bone sclerosis, therapy in recurrence
cyst well-defined
margins, cortical
thinning
Aneurysmal bone 2nd–3rd Tubular and tarsal Osteolytic, Curettage and
Internal septation, High risk of Chondroblastoma, giant
cyst bones, eccentric cortical thinning gadolinium grafting; consider recurrence; often cell tumor, simple bone
or destruction, no enhancement of bone cement and secondary to other cyst, osteosarcoma,
or thin sclerosis septa, fluid levelssecondary replace- tumors; send all malignancies
ment by bone graft tissues to pathology
Osteochondroma/ 1st–2nd Tubular bones; not in Cancellous bone Cartilage cap In cases with Consider multiple Chondrosarcoma,
osteocartilaginous tarsal bones of exostosis (>2 cm in mechanical irritation: hereditary osteosarcoma, parosteal
exostosis blends with thickness Marginal excision of exostoses with reactive ossifications
cancellous bone suspicious for the exostosis at the higher risk of
of metaphysis, malignancy); T1−, base; complete malignant
thin outer cortex; T2+ removal of cartilage transformation; risk
pedunculated or component! of recurrence if
broad base; exostosis is
bowing of resected in child
adjacent bones age
Chondroma/ 2nd–6th Tubular bones and Pathologic CT for cortical Rarely required; Transformation in a Diagnosis doubtful if
enchondroma tarsals fracture; perforation; curettage and bone chondrosarcoma is calcifications are missing;
expansion of cartilage (T1−, grafting controversial giant cell reparative
affected bone, T2+) and granuloma, giant cell
cortical scallop- calcifications tumor, aneurysmal bone
ing, central lysis (T1−, T2−) cyst, chondrosarcoma
with well-defined
margins and
calcifications
H. Gollwitzer et al.
 44

Chondroblastoma 2nd–3rd Tarsals >> metatar- Epiphyseal or Parenchimatous, Curettage and bone Send all tissues for Clear cell chondrosarcoma,
sals, distal tibia small bones; occasionally grafting or cement, histology; ~10% giant cell tumor, chon-
eccentric, cystic; T1−, T2+ avoid opening joint risk of recurrence droma, Brodie’s abscess
well-defined (especially if joint
margins, is contaminated)
lobulated, thin
sclerosis
Osteoid osteoma 1st–3rd Neck of talus, tarsals, Eccentric, in or CT with thin Removal of nidus or Pain resolves Typical pain at night and
phalanges, near cortex sections (1 mm) to percutaneous immediately with early morning, relieve with
metatarsals define characteris- radiofrequency removal of nidus; aspirin or NSARs;
tic nidus with (histology rarely no recurrence if osteoblastoma, sclerosing
surrounding necessary) nidus is removed osteoperiostitis
sclerosis;
characteristic bone
scan; highly
vascular nidus in
CT arteriography
Unicameral bone 1st–2nd Calcaneus, tubular Pathologic Liquid or fatty Curettage, bone Aneurysmal bone cyst,
cyst bones, metaphyseal fracture, central content, unicam- grafting fibrous dysplasia
osteolysis, eral, sometimes
cortical thinning few fibrous septa
and expansion,
sclerosis
a
T1+ = high signal on T1-weighted MRI images; T1+/− = intermediate signal intensity; T1− = low signal intensity; T2+ = high signal on T2-weighted images; T2+/− = intermediate
signal intensity; T2− = low signal intensity; contrast+ = signal enhancement on gadolinium-enhanced MRI; contrast− = no signal enhancement after gadolinium
Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment
499
Table 44.6 Most common malignant bone tumors of the foot and ankle
500

Tumor Decade/age Localization X-ray MRIa Resection Adjuvant Spreading Differential

therapy diagnoses
Osteosarcoma 2nd–4th Tarsals, exceptional Intramedullary, T1−, T2+, best to Radical Neoadjuvant Pulmonary MFH (malignant
in tubular bones and breaching cortex, show intramedullary and adjuvant metastases fibrous histiocy-
metatarsals; 0.2–2% faded edges, tumor extension chemother- toma), giant cell
of all osteosarcomas periosteal reactions, apy tumor, Ewing’s
both radiolucencies sarcoma, lymphoma
and osseous
radiodensity
Chondrosarcoma 4th–7th Tarsals and Central osteolysis Cartilage cap Wide resection or Ineffective, Pulmonary Osteochondroma,
metatarsals with signs of slow >20 mm, lobular amputation radical metastases, high synovial chondro-
but permeative pattern of the tumor, resection is rate of local matosis, chondro-
growth, “popcorn- T1−, T2+ key recurrence blastic osteosarcoma
like” granular
radiodensities due to
calcifications and
ossifications,
scalloping of inner
cortex
Ewing’s sarcoma 1st–3rd Rare in the foot, Permeative, poorly T1−, T2+, best to Radical resection Neoadjuvant Pulmonary , Osteosarcoma,
(PNET) localization defined “moth- study intramedullary and adjuvant skeletal and lymphoma,
anywhere possible eaten” and tumor extension chemother- lymphatic mesenchymal
“rotten-wood” apy, (lymph nodes) chondrosarcoma,
osteolysis, often radiation metastases osteomyelitis,
prominent extra- metastatic neuro-
osseous mass in flat blastoma, eosino-
bones philic granuloma
Metastases > 5th Rare in foot and Osteolytic (e.g., T1−, T2+, contrast+ Intralesional, wide Radiation, Hematogeneous, Multiple myeloma,
ankle, incidence kidney, lung, or radical chemother- dissemination to osteolytic sarcomas,
decreases from thyroid), osteoblastic apy multiple skeletal lymphoma
proximally to (e.g., prostate & and extraskeletal
distally bronchial carci- sites possible
noma) or mixed
(breast).
Indistinct borders,
permeated or eroded
cortex with little or
no periosteal
reaction
PNET Peripheral neuroendothelial tumor
a
T1+ = high signal on T1-weighted MRI images, T1+/− = intermediate signal intensity, T1− = low signal intensity; T2+ = high signal on T2-weighted images, T2+/− = intermediate
signal intensity, T2− = low signal intensity; contrast+ = signal enhancement on gadolinium-enhanced MRI; contrast− = no signal enhancement after gadolinium
H. Gollwitzer et al.
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 501

[Link] Malignant might become necessary – to reduce the risk of recur-

Table 44.6 displays typical malignant bone tumors that rence associated with the close contact of fibromatosis
occur in the foot and ankle. Osteosarcoma29 and and skin.
Ewing’s sarcoma,30 which are the most common
primary malignant tumors are often misdiagnosed or [Link] Malignant
delayed, since both represent highly variable lesions. Synovial sarcoma is the most common malignant
Osteosarcomas of the foot occur in a slightly older age soft tissue tumor of the foot and ankle (Table 44.8).
group than do osteosarcomas elsewhere. Metastases Diagnosis is often delayed, with an average of 21 months
are the most common malignant lesions in bone. between the onset of symptoms and the final diagno-
However, metastases of the foot are far less frequent, sis.34 The peak incidence of synovial sarcoma is
with foot lesions accounting for less than 1% of bony observed in the second to fifth decade. Diagnosis is
metastases, and lung tumors being the most common31 often challenging since synovial sarcoma can mimic
(Fig. 44.3). other entities and clinical features are unspecific, with
a slowly or rapidly growing, indolent or painful, firm
and fixed mass.35 Risk of pulmonary metastases as well
44.5.2 Soft Tissue Tumors as lymphatic spread is high.
Although generally considered a very rare condi-
[Link] Benign tion with only 1% of all soft tissue sarcomas, clear
A soft tissue tumor of the foot and ankle (Table 44.7) cell sarcoma demonstrated a special predilection for
has to be considered malignant until proved other- the foot with 43% of all clear cell sarcomas involv-
wise, since most malignant soft tissue masses can ing the foot.36,37 Similarly, approximately 31% of all
mimic benign lesions. Clinical characteristics like malignant melanomas have been reported to occur at
pain, size of the lesion, and symptom duration are not the foot and deserve special consideration in clinical
reliable parameters to distinguish benign and malig- practice.
nant tumors.32 Squamous cell carcinomas (SCC) of sinus tracts
The ganglion is the most common mass in the foot (Marjolin’s ulcers) are rare malignant tumors that
and ankle and represents a mucoid cystic degeneration occur in patients with chronic infections (e.g., osteo-
of a joint capsule or a tendon sheath rather than a true myelitis), and represent malignant degeneration of
neoplasm. Clinically, ganglia are palpable as a firm epithelial cells within the sinus tracts.38 SCC may
mass with predisposition to areas of increased mechan- metastasize rapidly and should be considered particu-
ical stress. Transillumination is a helpful tool to con- larly if chronic drainage changes to a blood-tinged
firm the presence of a cystic lesion, although further character. Radical excision or amputation becomes
diagnostic measures should be taken if there is any necessary.
doubt. Diagnosis can be confirmed by needle aspira-
tion, and approximately 50% of ganglia can be ade-
quately treated with the aspiration technique, but MRI 44.6 Summary
is the imaging method of choice. Recurrence of the
cyst or failure to aspirate thick fluid may require surgi- Although tumors of the foot and ankle are considered
cal excision of the ganglion, and all resected tissue uncommon, previous studies have shown an inci-
should be sent for histopathological workup. dence that is consistent with the amount of body mass
Plantar fibromatosis is the most common real neo- of the foot and ankle region. In spite of early notice
plasm of the foot, and bilateral occurrence is com- of masses in the foot and ankle due to the confined
mon.33 Clinically, firm cords of small nodules can be anatomic areas, diagnosis is often delayed due to
palpated in the plantar surface of the foot. Since the late presentation of patients and initial misdiagnosis
neoplasm is in firm contact with the plantar fascia, sig- or neglect. High vigilance to recognize suspicious
nificant pain can be present with weight-bearing. In masses is necessary for the general foot and ankle
symptomatic patients with extensive fibromatosis, surgeon. Further diagnostic procedures have to be
resection of the nodules together with the overlying taken to definitively determine a specific diagnosis.
skin and fascia is recommended – even if skin grafting In addition to radiography, MRI represents the method
502 H. Gollwitzer et al.

Fig. 44.3 Palliative a b

treatment of a painful and
immobilizing metastasis of a
lung cancer in the cuboid of
an 81-year-old patient with
disseminated metastatic
disease. Therapy by
intralesional resection and
filling with bone cement.
Postoperative radiotherapy
was done to control local
tumor recurrence

c d
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 503

f g

Fig. 44.3 (continued)

Table 44.7 Most common benign soft tissue tumors of the foot and ankle
504

Tumor Decade/age Clinical presentation X-ray MRIa Resection Recurrence/ Differential

spreading diagnoses
Ganglion (= mucous All, preferably adult Swelling, possible Not visible on plain Rounded & sharply Aspiration Recurrence after Synovial cyst,
cyst) age fluctuation, firm on x-rays defined, homogenous technique, aspiration intramuscular
palpation; positive and sometimes marginal myxoma
transillumination multilobulated lesion; resection
T1−, T2+, no contrast
enhancement
Lipoma All, 5th–7th Painless, soft Roundish mass, Signal intensity of Marginal Rare Well-differentiated
swelling homogeneous normal fat, no excision liposarcoma, myxoid
translucency contrast enhance- liposarcoma
ment, thin fibromus-
cular traversing septa
Fibromatosis Any age, more Diffuse or nodular Angiography shows a Highly variable MR Observation; Common if not May be accompanied
frequent from mass, sometimes persistent tumor imaging pattern, complete completely excised by Dupuytren
2nd–3rd decade painful, muscular blush depending on amount resection of contractures and
retraction, limitations of cellular and plantar fascia, Peyronie’s disease;
in joint function, collagen tissue. if necessary fibrosarcoma
poorly defined Common heteroge- with skin
borders neous pattern, with
intermediate signal
intensity; T1+ and
T2+ in hypercellular
areas, T1− and T2−
in hypocellular areas.
Pigmented 3rd–6th, exceptional Soft to firm on Bony erosions and Heterogeneous Complete Common if not Synovial heman-
villonodular in children palpation, indolent subchondral cysts, lobulated masses with synovectomy completely excised gioma, traumatic
synovitis (PVNS) growth, diffuse or sharp-edged cortical contrast enhancement hemarthros, synovial
villonodular scalloping on T1, low signal sarcoma
manifestation; intensity on both T1
macroscopically and T2 due to
yellowish-brown hemosiderin deposits
synovium
Giant cell tumor of 3rd–5th Moderate pain, Typical shell of T1−, T2+ Marginal Rare Solid aneurysmal
the tendon sheath swelling, tenderness radiodensity due to bone cyst, bone
reactive ossification metastases, brown
at the periphery of tumor of primary
the lesion hyperparathyroidism
H. Gollwitzer et al.
 44

Fibroma (FTS) 3rd–5th Firm, painless, Usually not visible on T1−, T2+/−, Marginal Rare Giant cell tumor of
well-circumscribed plain x-rays peripheral contrast tendon sheaths,
and sometimes enhancement on nodular fasciitis,
lobulated, size gadolinium-enhanced tendosynovial
between 1-2 cm, MRI chondromatosis
attached to a tendon
or tendon sheath
Benign schwan- 3rd–6th Sharp pain on Small neurilemomas Homogeneous and Longitudinal Rare Neurofibroma,
noma percussion, radiating are not visible on isointense to muscle intracapsular neurofibrosarcoma,
(neurilemoma) distally, slow tumor plain x-rays, large on T1, T2+, moderate resectionb hamartoma
growth enhancement on
lesions may appear as
radiopaque contrast; large
formations neurilemomas can
show inhomogeneous
consistency due to
hemorrhage, necrosis,
and calcification
Hemangioma 3rd–6th Deep-seated mass, Calcifications on Fatty and vascular Wide margins Common in Sarcoma NOS;
firm on palpation and plain x-rays possible; content; T1+, T2+, as size seems infiltrating lesions synovial sarcoma,
painless; changing in angiography shows strong enhancement to correlate mesenchymal
size, intermittent pain high vascularity, after gadolinium with chondrosarcoma
diffuse capillary malignancy
blush in the mass,
and arteriovenous
shunting
a
T1+ = high signal on T1-weighted MRI images, T1+/− = intermediate signal intensity, T1− = low signal intensity; T2+ = high signal on T2-weighted images, T2+/− = intermediate
signal intensity, T2− = low signal intensity; contrast+ = signal enhancement on gadolinium-enhanced MRI; contrast– = no signal enhancement after gadolinium
b
Longitudinal intracapsular resection with preservation of surrounding nerve fibers (one fiber is always attached to the tumor and has to be excised)
Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment
505
 506

Table 44.8 Most common malignant soft tissue sarcomas of the foot and ankle
Tumor Decade/age Clinical presentation X-ray MRIa Resection Adjuvant Spreading Differential
therapy diagnoses
Synovial 2nd–5th Deep-seated tumor, Calcifications and Inhomogeneous, Wide or radical Radiotherapy Lymphatic, Ganglion, synovial
sarcoma mostly para-articu- ossifications may be T1+/−, T2+, hematoge- cyst, PVNS,
lar, slowly growing present contrast+, triple- neous synovial chondro-
within years, pain (25%);superficial signal pattern on T2 matosis, clear cell
and tenderness bone erosions, sarcoma, myositis
periosteal reaction ossificans
Malignant 2nd–4th Growth of lesion, Negative T1+, T2+/− Wide resection and Chemotherapy, Mainly Nevi
melanoma deepening pigmen- skin grafting, immunotherapy lymphatic
tation and ulceration sentinel lymph
of nevi node biopsy
Clear cell 2nd–3rd Deep-seated tumor Radiopaque density T1+/−, T2+/−, Wide or radical Chemotherapy, Mainly Synovial sarcoma,
sarcoma without involvement in case of a large contrast+ with regional radiotherapy in lymphatic giant cell tumor of
of the overlying tumor lymph node case of positive the tendon sheaths,
skin; unspecific slow dissectionb lymph nodes metastasis of a
growth melanoma,
malignant peripheral
nerve sheath tumor,
spindle cell
melanoma
Epitheloid 3rd–4th Superficial or deeply Rarely erosion of Poorly defined Wide or radical Radiotherapy Lymphatic and Chronic inflamma-
sarcoma seated nodule, adjacent bone and/or limits, central hematogenous tory process,
indolent course, stippling necrosis nodular fasciitis,
ulcerated skin calcifications synovial sarcoma
Fibrosarcoma 3rd–8th Deep soft tissue Rarely calcifications T1−, T2+, contrast+ Wide or radical Radio- and Pulmonary, Sarcoma NOS,
single roundish and/or erosion of chemotherapy skeletal, and malignant peripheral
mass, firm adjacent bone with moderate hepatic nerve sheaths tumor,
constancy, usually effectiveness metastases leiomyosarcoma,
slow growth common; aggressive
rarely fibromatosis
lymphatic
metastases
a
T1+ = high signal on T1-weighted MRI images, T1+/− = intermediate signal intensity, T1− = low signal intensity; T2+ = high signal on T2-weighted images, T2+/− = intermediate
signal intensity, T2− = low signal intensity; contrast+ = signal enhancement on gadolinium-enhanced MRI; contrast− = no signal enhancement after gadolinium
b
Sentinel lymph node biopsy for clear cell sarcoma is currently under investigation
H. Gollwitzer et al.
44 Tumors and Tumor-Like Lesions of the Foot and Ankle: Diagnosis and Treatment 507

of choice in evaluation of foot tumors. Unfortunately, 12. Rhee JH, Lewis RB, Murphey MD. Primary osseous tumors
malignant tumors can also arise with nonaggressive of the foot and ankle. Magn Reson Imaging Clin N Am.
2008;16(1):71-91.
imaging features. Diagnostic errors can be avoided 13. Waldt S, Rechl H, Rummeny EJ, Woertler K. Imaging of
if any lesion that cannot be specifically diagnosed benign and malignant soft tissue masses of the foot. Eur
is regarded as potentially malignant until proved Radiol. 2003;13(5):1125-1136.
otherwise. Biopsies and further treatment should be 14. Woertler K. Soft tissue masses in the foot and ankle: charac-
teristics on MR Imaging. Semin Musculoskelet Radiol.
planned or performed by specialized centers since 2005;9(3):227-242.
errors in biopsies often negatively influence outcome 15. Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in
and prognosis. Treatment is done after tumor grading patients with malignant primary bone and soft-tissue tumors.
and staging with wide resection being the appropriate J Bone Joint Surg Am. 1982;64:1121-1127.
16. Mankin HJ, Mankin CJ, Simon MA. The hazards of the
form of resection in most malignant tumors. No com- biopsy, revisited. Members of the Musculoskeletal Tumor
promise should be accepted in surgical margins, and Society. J Bone Joint Surg Am. 1996;78:656-663.
amputation should be performed if adequate local 17. Huch K, Röderer G, Ulmar B, Reichel H. CT-guided inter-
resection is not possible. Neoadjuvant and adjuvant ventions in orthopedics. Arch Orthop Trauma Surg.
2007;127:677-683.
treatment options like radiotherapy and chemother- 18. Enneking WF. A system of staging musculoskeletal neo-
apy have significantly improved function and survival plasms. Clin Orthop Relat Res. 1986;204:9-24.
after treatment of malignant tumors. Every patient 19. Capanna R, Sudanese A, Baldini N, Campanacci M. Phenol
with a musculoskeletal tumor should first be dis- as an adjuvant in the control of local recurrence of benign
neoplasms of bone treated by curettage. Ital J Orthop
cussed in an interdisciplinary tumor board.13 Traumatol. 1985;11(3):381-388.
20. Lack W, Lang S, Brand G. Necrotizing effect of phenol
on normal tissues and on tumors. A study on postopera-
tive and cadaver specimens. Acta Orthop Scand.
References 1994;65(3):351-354.
21. Malawer MM, Dunham W. Cryosurgery and acrylic
1. Dahlin DC, Unni KK, eds. Bone Tumors: General Aspects cementation as surgical adjuncts in the treatment of aggres-
and Data on 8,542 Cases. 4th ed. Springfield: Charles C. sive (benign) bone tumors. Clin Orthop Relat Res.
Thomas; 1986. 1991;262:42-57.
2. Kransdorf MJ. Benign soft-tissue tumors in a large referral 22. Ruiz Santiago F, Del Mar Castellano García M, Guzmán
population: distribution of specific diagnoses by age, sex, Álvarez L, Martínez Montes JL, Ruiz García M, Tristán
and location. AJR Am J Roentgenol. 1995;164:395-402. Fernández JM. Percutaneous treatment of bone tumors by
3. Gerrand CH, Wunder JS, Kandel RA, et al. The Influence of radiofrequency thermal ablation. Curr Rev Musculoskelet
anatomic location on functional outcome in lower-extremity Med. 2009;2(1):43-50.
soft-tissue sarcoma. Ann Surg Oncol. 2005;11:476-482. 23. Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency
4. Chou LB, Ho YY, Malawer MM. Tumors of the foot and ablation in the treatment of musculoskeletal tumors. J Am
ankle: experience with 153 cases. Foot Ankle Int. Acad Orthop Surg. 2009;17(12):737-743.
2009;30:836-841. 24. Simon CJ, Dupuy DE. Percutaneous minimally invasive
5. Ozdemir MH, Yildiz Y, Yilmaz C, Saglik Y. Tumors of the therapies in the treatment of bone tumors: thermal ablation.
foot and ankle: analysis of 196 cases. J Foot Ankle Surg. Semin Musculoskelet Radiol. 2006;10(2):137-144. Epub
1997;36:403-408. 2006 Apr 5.
6. Albreski D, Sloan SB. Melanoma of the feet: misdiagnosed 25. Erickson JK, Rosenthal DI, Zaleske DJ, Gebhardt MC,
and misunderstood. Clin Dermatol. 2009;27(6):556-563. Cates JM. Primary treatment of chondroblastoma with
7. Bancroft LW, Peterson JJ, Kransdorf MJ. Imaging of soft percutaneous radio-frequency heat ablation: report of
tissue lesions of the foot and ankle. Radiol Clin North Am. three cases. Radiology. 2001;221(2):463-468.
2008;46(6):1093-1103. 26. Rybak LD, Rosenthal DI, Wittig JC. Chondroblastoma:
8. Llauger J, Palmer J, Monill JM, Franquet T, Bagué S, Rosón radiofrequency ablation – alternative to surgical resection in
N. MR imaging of benign soft-tissue masses of the foot and selected cases. Radiology. 2009;251(2):599-604.
ankle. Radiographics. 1998;18(6):1481-1498. 27. Ahrar K. The role and limitations of radiofrequency ablation
9. Campanacci M, ed. Bone and Soft Tissue Tumors. 2nd ed. in treatment of bone and soft tissue tumors. Curr Oncol Rep.
Padova: Piccin Nuova Libraria and Wien, New York: 2004;6(4):315-320.
Springer; 1999. 28. Murari TM, Callaghan JJ, Berrey BH Jr, Sweet DE. Primary
10. Johnson PT, Fayad LM, Frassica FJ, Fishman EK. Computed benign and malignant osseous neoplasms of the foot. Foot
tomography of the bones of the foot: neoplastic disease. Ankle. 1989;10:68-80.
J Comput Assist Tomogr. 2009;33(3):436-443. 29. Fox C, Husain ZS, Shah MB, Lucas DR, Saleh HA.
11. De Schepper AM, De Beuckeleer L, Vandevenne J, Somville Chondroblastic osteosarcoma of the cuboid: a literature
J. Magnetic resonance imaging of soft tissue tumors. Eur review and report of a rare case. J Foot Ankle Surg.
Radiol. 2000;10:213-222. 2009;48(3):388-393.
508 H. Gollwitzer et al.

30. Berliner RA, Guadara J, Adelman H, Conforti J, Uhm K. 34. Brewster MB, Power D, Sumathi VP. Delayed diagnosis of
Extraosseous Ewing’s sarcoma in the foot. J Foot Ankle synovial sarcoma of the foot. Orthopedics. 2008;31(2):175.
Surg. 1995;34(3):301-304. 35. Scully SP, Temple HT, Harrelson JM. Synovial sarcoma of the
31. El Ghazaly SA, DeGroot H III. Metastases to bones of the foot and ankle. Clin Orthop Relat Res. 1999;364:220-226.
foot: a case series, review of the literature, and a systematic 36. Malchau SS, Hayden J, Hornicek F, Mankin HJ. Clear
approach to diagnosis. Foot Ankle Spec. 2008;1(6):338-343. cell sarcoma of soft tissues. J Surg Oncol. 2007;95(6):
32. Kirby EJ, Shereff MJ, Lewis MM. Soft-tissue tumors and 519-522.
tumor-like lesions of the foot. An analysis of eighty-three 37. Sara AS, Evans HL, Benjamin RS. Malignant melanoma of
cases. J Bone Joint Surg Am. 1989;71:621-626. soft parts (clear cell sarcoma). A study of 17 cases, with
33. Robbin MR, Murphey MD, Temple HT, Kransdorf MJ, Choi emphasis on prognostic factors. Cancer. 1990;65(2):367-374.
JJ. Imaging of musculoskeletal fibromatosis. Radiographics. 38. Potter BK, Pitcher JD Jr, Adams SC, Temple HT. Squamous
2001;21(3):585-600. cell carcinoma of the foot. Foot Ankle Int. 2009;30:517-523.