Review
Malignant tumours of the foot and ankle

https://doi.org/10.1016/j.fas.2019.05.005Get rights and content

Highlights

  • Malignant tumours of the foot and ankle are rare and frequently diagnosed late.

  • Features suspect of malignancy should lead to patient referral to a designated tumour centre.

  • Biopsy must follow strict oncosurgical guidelines and should be performed at the same centre.

  • Systemic chemotherapy and/or radiation therapy, isolated limb perfusion and hyperthermia are discussed individually within a multidisciplinary tumour board.

  • Limb-sparing techniques have increasingly replaced primary amputations without compromising on the principles of oncologic resection.

Abstract

Tumours of the foot and ankle constitute about 4–5% of all musculoskeletal tumours with the majority of them being benign. Diagnosis of malignant soft tissue or bone tumours is frequently delayed because of the relatively low prevalence and uncommon presentation at the foot and ankle. Suspicious lesions or lumps should be subjected to CT, MRI and biopsy. Subfascial location, lump size more than 5 cm, increase in size, painful and recurrent tumours should raise the suspicion of malignancy and lead to patient referral to a designated tumour centre. Neoadjuvant and adjuvant systemic chemotherapy and/or radiation therapy, isolated limb perfusion (ILP) and hyperthermia for malignant tumours have to be discussed in a multidisciplinary tumour board. With the advances in local and free tissue transfer, limb-sparing techniques have increasingly replaced primary amputations thus preserving lower limb function as much as possible without compromising on the principles of oncologic resection.

Section snippets

General principles

The foot has a particular anatomy with multiple small muscular compartments, the terminal neurovascular branches, and a delicate soft tissue cover including a uniquely structured sole that cannot be replaced by adequate tissue in case of loss. Surgical treatment of foot and ankle tumours, therefore, represents a true challenge. Like infections and compartment pressures, tumours may spread along the tendons which pass through fascial defects between the foot compartments and between the foot and

Sarcomas

Soft tissue sarcomas have distinct age peaks in children and middle to old aged patients [19,40]. Rhabdomyosarcoma is the most common sarcoma in the pediatric foot and ankle [28]. The need for neoadjuvant systemic chemotherapy and sentinel lymph node biopsy depends on the histological subtype of the sarcoma. Lymphatic spread is relatively rare, but must be considered in cases of synovial sarcoma, epitheloid sarcoma, and clear cell sarcoma [41].

Synovial sarcoma is the most frequent malignant

Malignant bone tumours

Because of the low prevalence and the nonspecific symptoms like pain and a hard mass, malignant tumours of the foot and ankle are often diagnosed late. Chondrosarcoma is the commonest among them, affecting predominately patients in their 40 s–50 s [11,40]. It is seen more frequently in the hindfoot than in the forefoot (Fig. 3). Radiographs show an irregular osseous lesion with central destruction and marginal calcification. MRI reveals the intramedullary extent and soft tissue involvement of

Metastatic disease

Metastases in the foot and ankle have an overall prevalence of less than 1% [16,20]. Acrometastatic lesions are generally believed to occur rather rare, and if so, then late in the course of the disseminated disease and therefore are associated with a poor prognosis [70]. The presentation is nonspecific with diffuse pain, swelling and sometimes ulceration [11]. Radiographs reveal osteolysis and sometimes a pathological fracture. Among the primary tumours squamous cell lung carcinoma, renal cell

Conclusions

Malignant tumours of the foot and ankle are frequently diagnosed late because of the relatively low prevalence and non-specific symptoms. Workup of suspicious lesions includes CT, MRI, and biopsy following strict oncosurgical guidelines. Subfascial location, lump size more than 5 cm, increase in size, painful and recurrent tumours should raise the suspicion of malignancy and lead to patient referral to a designated tumour centre. Neoadjuvant and adjuvant systemic chemotherapy and/or radiation

Confict of interest

The authors report no conflict of interest.

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