Copyright 989 by The Journal of Bone and Join: Surgery.

Incorporated

Soft-Tissue Tumors and Tumor-Like Lesions of the Foot

AN ANALYSIS OF EIGHTY-THREE CASES*

BY EDWARD J. KIRBY, M.D.t, MICHAEL J. SHEREFF, M.D.1, AND MICHAEL M. LEWIS, M.D.,
NEW YORK, N.Y.

From the Foot and Ankle Service and the Bone Tumor Service,
Hospital for Joint Diseases Orthopaedic Institute and Mount Sinai Medical Center, New York Cit’s

ABSTRACT: The cases of eighty-three patients who nodules, may closely mimic true soft-tissue tumors. The
had a soft-tissue tumor or tumor-like lesion in the foot large number of different histiogenic types, coupled with
or ankle were retrospectively analyzed to determine the the low incidence, makes it difficult for a single physician
relative frequency of the lesions and which factors, if or institution to gain a large clinical experience with tumors
any, could be used to identify them preoperatively. Sev- and tumor-like lesions of the foot and ankle.
enty-two (87 per cent) of the lesions were benign, with It is well known that the initial treatment for a neo-
ganglion cysts and plantar fibromatoses being the most plasm, including management of the biopsy, greatly influ-
common, and eleven (13 per cent) were malignant tu- ences the final outcome of the patient. Therefore, the
mors, five (45 per cent) of which were synovial sarcomas. possibility, however remote, that a tumor is malignant must
The age of the patient and the location of the lesion always be considered. In an effort to identify distinguishing
were the two most important factors that characterized clinical characteristics of soft-tissue tumors of the foot, we
the malignant tumors. For eight patients (12 per cent), analyzed the cases of all patients having a tumor or tumor-
radiographs were helpful in identifying the nature of the like lesion that had recently been biopsied at our institution.
lesion. The sex of the patient, a history of trauma, the
duration of the symptoms, the size of the lesion, and the Materials and Methods
presence of pain or of neurological symptoms were not All patients who were seen at the Hospital for Joint
useful in discriminating a benign lesion from a malignant Diseases Orthopaedic Institute between 1979 and 1984 who
tumor. had a biopsy of a lesion of the foot or ankle were included
in the study. The age and sex of the patient, location and
While the majority of soft-tissue lesions about the foot size of the lesion, history of trauma, duration of the symp-
or ankle are reactive or inflammatory in nature, some are toms, presence or absence of pain and of neurological symp-
true neoplasms. Even though primary sarcomas arising dis- toms, and final pathological diagnosis were obtained from
tal to the knee comprise only 8 per cent of the estimated the patient’s hospital records for retrospective analysis. The
4,500 sarcomas that are discovered each year’9, and meta- available radiographs were reviewed for evidence of a soft-
static tumors at that location are rare, concern always exists
as to whether or not a given lesion is a malignant process.
Numerous types of soft-tissue lesions are encountered
in the foot. The World Health Organization classification 1
system, as modified by Enzinger and Weiss, recognizes
eighty-two distinct benign and malignant soft-tissue lesions
and tumors of ten major histiogenic types that can arise in
the distal part of the leg. Some of these, however, such as
ganglion cysts and xanthomas, are generally not considered
to be true neoplasms. In addition, several non-neoplastic
lesions, such as epidermal inclusion cysts or rheumatoid

* No benefits in any form have been received or will be received from FIG. I
a commercial party related directly or indirectly to the subject ofthis article. The zones of the foot that were used to analyze the data. The anatomical
No funds were received in support of this study. positions of the lines correspond to an oblique coronal plane. drawn from
t 1024 Daisy Avenue, Carlsbad, California 92009. the mid-tarsal joint to the posterior margin of the longitudinal arch; a
1: Foot and Ankle Service, Hospital for Joint Diseases Orthopaedic transverse plane. drawn from the mid-point of the metatarsal heads to the
Institute, 301 East 17th Street, New York, N.Y. 10003. Please address level of insertion of the Achilles tendon into the calcaneus; and a coronal
requests for reprints to Dr. Shereff. plane, drawn through the metatarsophalangeal joints. These regions were
§ Department of Orthopaedics, Mount Sinai School of Medicine, 1 numbered I through 5, to correspond to the ankle, heel, dorsum of the
Gustav Levy Place, New York. N.Y. 10029-6574. foot, plantar surface of the foot, and toes.

VOL. 71-A, NO. 4. APRIL 1989 621

622 E. J. KIRBY, M. J. SHEREFF, AND M. M. LEWIS

TABLE I
DISTRIBUTION OF LESIONS BY HISTIOGENIC TYPE*

Tissue Benign Lesions Malignant Tumors

Precursor (n = 72) (n = 11)

Fibrous Fibroma (I)

Infantile digital tibroma (I)
Plantar fibromatosis ( I I)
Unspecified fibromatosis (2)
Fibrohistiocytic Benign fibrous Dermatofibrosarcoma ( 1)
histiocytoma ( I)
Adipose Lipoma (6)
Lipoblastoma (1)
Smoch muscle Leiomyoma (2)
Angiomyoma (2)
Vascular Hemangioma (I) Kaposi sarcoma ( I)
Synovial Pigmented villonodular Synovial sarcoma (5)
synovitis(l)
Giant-cell tumor of
tendon sheath (3)
Neural Neurofibroma ( I)
Cartilage/bone Extraosseous chondroma ( 1) Extraosseous myxoid
Metaplastic cartilage! chondrosarcoma (2)
bone (2)
Miscellaneous Ganglion cyst (24) Unspecified sarcoma (2)
Myxoma ( I)
Tumor-like Epidermal inclusion cyst (7)
Rheumatoid nodule (3)
Synovial cyst ( I)

* Numbers of lesions are given in parentheses.

tissue mass, abnormal densities, calcification of the lesion, malignant tumors and 6 per cent of the total of eighty-three
or secondary osseous involvement. lesions. The remaining malignant tumors were represented
For the purpose of this study. the foot was divided into by only four histiogenic types.
five regions, or zones (Fig. 1). Data on the site of the lesion
were analyzed according to these regions. Age (Fig. 2)
The average age of the patients, size of the lesions, The average ages ofthe patients who had benign lesions
and duration of the symptoms; the female-to-male ratio; and and malignant tumors were not significantly different, but
the percentages of patients who had pain, neurological the benign lesions tended to occur in the middle decades;
symptoms, and a history of trauma were calculated for both forty-seven (65 percent) ofthe patients were between twenty
the benign-lesion and malignant-tumor groups. The mci- and sixty years old. The malignant tumors occurred either
dence of the lesions by site and by age of the patients also between the ages of ten and forty years or after the age of
was calculated. A table of the radiographic findings was sixty years. Although there were too few malignant tumors
prepared for each patient, taking care to note abnormal tissue in this series to permit drawing any valid conclusions, the
densities, the presence of calcification, and any evidence of distribution of malignant tumors parallels that found by Si-
secondary osseous involvement. mon and Enneking, indicating that sarcomas are very rare
in the middle decades of life.
Results
Type ofLesion (Table I) Sex

Seventy-two (87 per cent) of the lesions were benign, The female-to-male ratio of the patients was 1 .6 to 1
and eleven (13 per cent) were malignant tumors. Thus, the for the benign lesions and 1 .8 to 1 for the malignant tumors.
ratio of benign lesions to malignant tumors was 6.5 to I. Although some studies’6’9 found a slight male predominance
Ganglion cysts were the most commonly encountered for soft-tissue sarcoma, the sex of the patient was of no use
benign lesions, accounting for nearly one-third of all of the in predicting the nature of the lesion in our series.
total, followed in order of frequency by plantar fibroma-
toses, epidermal inclusion cysts, lipomas, rheumatoid nod- Clinical Findings (Table II)
ules, and giant-cell tumors oftendon sheath. The remaining Antecedent trauma was reported by approximately 20
benign lesions were of many types. representing nearly all per cent of the patients; it was therefore a common (and
classes of histiogenic precursors. often misleading) part of the history. Although pain was
Synovial sarcoma was the most frequent type of ma- most common in the patients who had a malignant tumor,
lignant tumor, comprising five (45 per cent) of the eleven it was only slightly less common in those who had a benign

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 SOFT-TISSUE TUMORS AND TUMOR-LIKE LESIONS OF THE FOOT 623

15

14

13

12

11

10

U) U)
9
0 0

D 8

0 0 7

w ‘U 8

D 5
z 2

0 I 0 2#{149}0
30 40 50 60 70 80

AGE (years) AGE (years)

Figure 2(a) (b)

FIG. 2
Histograms showing the number of lesions relative to the ages of the patients (in decades). a represents the benign lesions and b, the malignant
tumors.

lesion and was not a useful discriminator between the two. fourteen lesions in the sole of the foot (Zone 4). Ganglion
Similarly, the sizes of the lesions fell mostly within an cysts were seen throughout the foot, accounting for nearly
average range of one to three centimeters and were of no one-half, or sixteen (48 per cent) of the lesions in Zone 3
diagnostic importance. and for six (32 per cent) of those in Zone 1 . Synovial
Perhaps somewhat surprising was the duration of the sarcomas tended to aggregate about the ankle in Zones I,
symptoms. While it might be expected that a malignant 2, and 3, although one of these lesions developed in the
tumor would be evident sooner because of rapid growth or sole of the foot. Epidermal inclusion cysts were found
other progressive symptoms, the patients who had a malig- mainly in the weight-bearing surfaces of the foot (Zones 2,
nant tumor could trace the onset of the symptoms for an 4, and 5), which is not remarkable, as these surfaces are
average of nearly one and one-half years. This duration did the most susceptible to the penetrating injury that causes
not differ significantly from that in the patients who had a this lesion.
benign lesion.
Neurological symptoms were exceedingly rare, being Radiographic Findings

found in only one patient, who had a synovial sarcoma of For sixty-nine patients, the radiographs were available
the medial aspect of the hind part of the foot and symptoms for review. Twenty-four (35 per cent) of these patients had
of tarsal tunnel compression. a visible soft-tissue mass, and eight (12 per cent) had other
findings. Of the patients who had a benign lesion, one had
Zones of the Foot (Table III)
an unspecified fibromatosis with calcification; one, a lipoma
Thirty-three (40 per cent) of the eighty-three lesions with a lucent fat density; one, pigmented villonodular syn-
were in Zone 3; nineteen (23 per cent), in Zone 1 ; fourteen
TABLE II
(17 per cent), in Zone 4; and twelve (14 per cent), in Zone
CLINICAL CHARACTER.IST1CS
5. Only five (6 per cent) of the lesions arose in Zone 2. On
examining the distribution of the malignant tumors, how- Benign Malignant
ever, it was found that two (40 per cent) of the lesions in Lesions Tumors

Zone 2 were malignant, followed by three (16 per cent) in History of 17 22

Zone 1 , four (12 per cent) in Zone 3 , one (8 per cent) in trauma (per cent)
Zone 5, and one (7 per cent) in Zone 4. Thus, lesions in Pain (per cent) 52 89
Duration of 23 19
the heel (Zone 2) were more likely to be malignant, while
symptoms (mos.) (1 to 144) (1 to 108)
those about the ankle (Zone 1) or on the dorsum of the foot Neurological 0 9
(Zone 3) had a rate of malignancy approximating that of symptoms (per cent)
the group as a whole. Alternatively, lesions in the sole of Size of lesion (cm) 2.0 3.0
the foot or in the toes were only occasionally malignant. (1.0 to 5.0) (1.0 to 4.0)

Some lesions had a predilection for a specific zone. * Numbers in parentheses indicate ranges. No statistical differences
Plantar fibromatoses accounted for ten (7 1 per cent) of the were found between the two groups.

VOL. 71-A, NO. 4, APRIL 1989

624 E. J. KIRBY, M. J. SHEREFF, AND M. M. LEWIS

TABLE III TABLE IV

- DISTRIBUTIoN OF LESIONS BY ZON ES OF THE FooT* DATA USED IN THE BAYES-RULE ANALYSIS
OF FREQUENCY OF TYPES OF MALIGNANT TUMORS IN THE FooT
Benign Lesions Malignant Tumors
Zone (N = 72) (N = 11) Percentage
Percentage Percentage of All
I Ganglion cyst (6) Kaposi sarcoma (1) of All Occurring Sarcomas in
Lipoma (4) Synovial sarcoma (I) Sarcomas in the Foot* the Foot
Angiomyoma (2) Unspecified sarcoma (1)
Epidermal inclusion cyst (I) Fibrosarcoma 16 2.4’ 10
Fibroma (1) Liposarcoma 15 1 #{176} 4
Hemangioma (1) 8
Malignant fibrous 14 2.4023
Synovial cyst (1)
histiocytoma
2 Epidermal inclusion cyst ( 1) Synovial sarcoma (2)
Rhabdomyosarcoma I3 2’ ‘ 6
Leiomyoma (I)
Synovial sarcoma 9 2527 56
Metaplastic bone/cartilage ( I)
3 Ganglion cyst (16) Extraosseous myxoid *When multiple sources were referenced, an average of the cited
Rheumatoid nodule (3) chondrosarcoma (2)
figures was used.
Fibromatosis (unspecified) (2) Synovial sarcoma (I)
Giant-cell tumor of tendon Unspecified sarcoma ( 1)
symptoms, and the size of the lesion were not useful dis-
sheath (2)
Lipoma (2) criminators between malignant tumors and benign lesions.
Benign fibrous histiocytoma (1) On the contrary, the five synovial sarcomas were in patients
Chondroma (1)
whose symptoms had ranged in duration from months to
Leiomyoma (1)
Myxoma (1) many years before medical treatment had been sought. One
4 Plantar fibromatosis ( 10) Synovial sarcoma ( 1) patient had a nine-year history of pain in the ankle and a
Epidermal inclusion cyst (2) diagnosis based on a biopsy that was performed during
Lipoblastoma (1)
arthroscopy of the joint. It is not unusual for a synovial
5 Epidermal inclusion cyst (3) Dermatofibrosarcoma ( I)
Ganglion cyst (3) sarcoma to remain relatively quiescent for a long period of
Giant-cell tumor of tendon time. Anderson and Wildermuth found an average duration
sheath (1)
of symptoms of thirty-five months in their patients, one of
Infantile digital fibro-
matosis (1) whom had had symptoms for thirty years before seeking
Metaplastic bone/cartilage ( 1) treatment. Therefore, malignancy should not be ruled out
Pigmented villonodular
on the basis of chronicity.
synovitis (1)
Rheumatoid nodule (1) It is of interest that all seven epidermal inclusion cysts
and sixteen of the twenty-four ganglion cysts were in
* The zones are defined in the text and in Figure 1 . The numbers of
women. Also, six of the eleven patients who had a plantar
tumors in each zone are given in parentheses.

ovitis with subchondral bone cysts; and two, metaplastic TABLE V

bone and cartilage with calcification. Of the patients who RADIOGRAPHIC FINDINGS THAT HAVE BEEN
DOCUMENTED IN THE LITERATURE FOR SOFT-TISSUE LESIONS
had a malignant tumor, two who had a synovial sarcoma
and one who had an extraosseous myxoid chondrosarcoma Soft-Tissue Secondary
also had evidence of invasion and destruction of bone sec- Density (Other Osseous
Tumor than Water) Calcification Involvement
ondary to extrinsic pressure.
Very little computerized tomography and no magnetic Juvenile aponeurotic Usual”
resonance imaging had been done on these patients. We fibromatosis
Fibrosarcoma Occasional’ Yes’7
chose instead to concentrate on factors that could easily be
Malignant fibrous Yes’#{176}
evaluated in an office setting. histiocytoma
Lipoma Radiolucency
Discussion
Liposarcoma Mixed lucency Yes’8
The optimum treatment of a patient who has a soft- and density

tissue sarcoma begins with a proper work-up and a correctly Leiomyoma Yes4
Rhabdomyosarcoma Yes’3
performed biopsy that does not limit further definitive pro-
Hemangioma Yes’4 Yes’4
cedures. Because of the rarity of primary soft-tissue sarcoma
Hemangiopericytoma Rare’
in the foot, often the diagnosis is made only after the surgical
Glomus tumor Tuft-scalloping of
excision of a tumor that had been thought to be benign. terminal phalanx
There have been several reports on soft-tissue tumors arising Giant-cell tumor Yes5’
in the hand and wrist, but very little has been written about of tendon sheath

tumors in the foot and ankle to aid the clinician in making Pigmented villo- Subchondral
nodular synovitis cysts
this determination.
Synovial sarcoma Abundant’7 ‘ Yes6’’5
The sex ofthe patient, a history oftrauma, the duration
Neurilemoma Yes’
of the symptoms, the presence of pain or of neurological

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 SOFT-TISSUE TUMORS AND TUMOR-LIKE LESIONS OF THE FOOT 625

fibromatosis were women. Stoyle commented on the rarity each type of tumor in the foot or ankle was calculated on
ofthis lesion in women, but Allen et al. reported that twenty- the basis of earlier reports2367”#{176}”3’7”23 (Table IV). No
six of their sixty-nine patients were women. true value for the proportion of all sarcomas arising in the
The benign lesions were fairly normally distributed foot was found, but an estimate of approximately 4 per cent
with respect to age, most having occurred in patients be- was made on the basis of the statement by Russell et al.
tween the ages of twenty and sixty years. In contrast, no that 8 per cent of soft-tissue sarcomas arise distal to the
sarcomas were seen in the sixth decade of life; they occurred knee. The resulting distribution of soft-tissue sarcomas in
instead in the younger and older age-groups. This is due to the foot was then calculated. When this method was used,
the high frequency of synovial sarcoma in younger people, synovial sarcomas were found to account for 56 per cent of
with a peak incidence between the second and fifth sarcomas in the foot, a figure that is in reasonably good
decades267”, and to the increased incidence of sarcoma in agreement with our incidence of45 per cent. The remaining
general after the age of fifty-five years9. There were too few malignant tumors had an incidence of 10 per cent or less.
sarcomas to permit any conclusions related to the patient’s While the figures that were used to arrive at this conclusion
age, but their distribution was in agreement with that re- were not exact, the relative frequency of sarcomas indicates
ported by Simon and Enneking. that synovial sarcoma should be the most frequently en-
Analysis of the lesions by site revealed that most of countered malignant soft-tissue tumor in the foot and ankle.
the malignant tumors, especially the synovial sarcomas, had Radiographic abnormalities can sometimes be useful
a predilection for the ankle, heel, or dorsum of the foot; the in formulating a differential diagnosis of a soft-tissue lesion
sole of the foot was rarely involved. In contrast, 90 per cent in the foot or ankle. In our series, twenty-four (35 per cent)
of all lesions in the sole in patients between the ages of of the sixty-nine patients whose radiographs we reviewed
thirty and seventy years were plantar fibromatoses. This is had a visible soft-tissue mass, and eight (12 per cent) had
in agreement with the study of Allen et al., who found that other abnormalities. Table V lists the radiographic findings
sixty-nine of seventy-eight lesions in the sole of the foot that have been documented in the literature4’ 1.14.15.17 The
were plantar fibromatoses, although eight of the remaining most diagnostic of these findings is the presence of an ab-
nine were synovial sarcomas. Ganglion cysts also tended to normal fat density associated with lipoma. The presence of
show a preference by site, accounting for 32 per cent of the a tumor containing mixed areas of fat and soft-tissue den-
lesions about the ankle and 48 per cent ofthose in the dorsum sities should alert the physician to the possibility of lipo-
of the foot. sarcoma. Several types of tumors, both benign and ma-
The relatively large number of synovial sarcomas lignant, may exhibit either abnormal calcification or sec-
(five), which accounted for 45 per cent of the malignant ondary erosion or destruction of bone. The presence of a
tumors in our series, was surprising. To test the significance subchondral cyst should signal the possibility of pigmented
ofthis finding, an analysis was performed using the theorem villonodular synovitis. Scalloping of the terminal phalanx
of Bayes22. According to Bayes’ rule, the probability of a of a toe is characteristic of a glomus tumor or an epidermal
sarcoma in the foot being of a given tissue-type equals the inclusion cyst. Most importantly, extensive calcification of
frequency of that type of tumor among all sarcomas, mul- a lesion, associated with secondary destruction of the sur-
tiplied by the probability of finding that tumor in the foot, rounding bone, should suggest a diagnosis of synovial sar-
and divided by the frequency of sarcomas arising in the coma. While calcification was notably absent in our five
foot. To obtain an estimate of the distribution of sarcomas patients who had a synovial sarcoma, it has been reported
by type, the results of four recent large series of soft-tissue in as many as 40 per cent of patients, and it may be so
sarcomas’2’6”2#{176} were combined. The probability of finding exuberant that it mimics osteogenic sarcoma67’5.

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ThE JOURNAL OF BONE AND JOINT SURGERY