Blame A.

Keigley, MD2 Allan

#{149} M. Haggar, MD Arthur
#{149} Gaba, MD Burton
#{149} I. Ellis, MD
Jerry W. Froelich, MD3 Kent
#{149} K. Wu, MD

Primary Tumors of the Foot: MR Imaging’

The findings at magnetic resonance T HE precise definition of local tu- age planes, the repetition
the echo time (TE) varied
time (TR), and
according to the
(MR) imaging of eight patients with mom extent is crucial in planning
primary tumors of the foot were surgery for suspected tumors of the needs of the case. In seven of the eight
compared with those at gross patho- foot (1). In addition, the relatively me- cases, Ti-weighted SE images were ob-
tamed with a TR of 600-800 msec and a
logic examination. In all cases, there cent development of adjuvant che-
TE of 25 msec (TR/TE 600-800/25), and
was excellent correlation between motherapy and local radiation thera-
12-weighted images were obtained with a
the two studies. When compared py regimens has made conservative TR of 2,500 msec and a TE of 25-100 msec.
with computed tomography (CT), resection of foot malignancies feasi- Comparative CT examinations were
MR imaging was superior in defin- ble (2-5). The paucity of fat in the performed in four cases with the use of a
ing the presence and extent of local foot may make delineation of tumor fourth-generation 1200 SX scanner (Pick-
disease. While the appearances of margins with plain radiography or em International, Highland Heights.
various foot neoplasms are nonspe- computed tomography (CT) difficult. Ohio) or a fourth-generation 144OHPS
cific, the ease of multiplanar imag- To our knowledge, no report in the scanner (GE Medical Systems). The stud-

ing, the superior contrast resolution, literature has dealt with the value of ies were performed without the intnave-
nous administration of contrast material.
and the sensitivity to marrow ab- magnetic resonance (MR) imaging in
Plain radiogmaphs of the foot were ob-
normalities are major advantages of the assessment of patients with tu- tamed in seven of eight cases.
MR imaging over CT in staging foot moms of the foot. For this reason, we The MR findings were compared with
neoplasms. These advantages are undertook a review of the data on the findings at pathologic examination
crucial when foot-sparing curative eight patients to determine the value and/on surgery in all cases.
resection of a malignancy is con- of MR imaging in patients with foot
templated. The combination of neoplasms, both benign and mabig-
plain radiography and MR imaging nant. RESULTS
may be all that is necessary for opti-
mal preoperative detection and local Of the eight patients examined,
PATIENTS AND METHODS three had synovial sarcoma (cases 1,
staging of tumors of the foot.
We retrospectively identified all pa- 3, 4), one had multiple enchondro-
tients who had undergone MR imaging mas (case 2), one had osteosarcoma
Index terms: Foot, 46.1214 Foot,
#{149} MR studies,
for evaluation of masses of the foot at our (case 5), one had a cavernous heman-
46.12i4 #{149}
Foot, neoplasms, 46.3
institution from November 1985 to De- gioma of the plantam aspect of the
Radiology 1989; 171:755-759
cembem 1987. Four female and four male foot (case 6), one had osteoblastoma
patients were ultimately shown to have (case 7), and one had osteochon-
primary tumors of the foot. The patients’
droma (case 8). CT examinations
ages ranged from 3 to 73 years (mean, 34
were performed on four patients
years). The MR studies were reviewed by
(cases 3-5, 7). Conventional radio-
the MR fellow (B.A.K.) and a senior staff
radiologist experienced in MR diagnosis graphs were obtained in all cases.
(A.M.H. or J.W.F.) and were compared Pathologic follow-up data were avail-
with other available imaging studies and able in all cases.
the pathologic findings. All plain radio- Synovial sarcomas (cases 1, 3, 4)
graphs had been originally interpreted by were variable in location. In case 1,
a skeletal radiologist (B.I.E.). Special at- the mass was isointense to skeletal
tention was paid to the relative value of muscle on SE 600/25 images (the
From the Departments of Diagnostic Radi-
MR imaging compared with plain nadiog-
1 only sequence obtainable in this
ology and Medical Imaging (B.A.K., A.M.H., naphy and CT in the detection of the pres-
case), with the lesion involving the
B.I.E., J.W.F.), Anatomic Pathology (AG.), and ence and extent of disease.
intermediate plantam compartment
Orthopedic Surgery (K.K.W.), Henry Ford Hos- MR studies were performed with a su-
pital. 2799 W Grand Blvd. Detroit, MI 48202. pemconducting magnet operating at 1.51 and the calcaneus. Multiple metatar-
Received August 15, 1988; revision requested and 63 MHz (GE Medical Systems, Mil- sals were invaded and abutted by tu-
October 6; revision received January 13, 1989; waukee). Patients were examined with a mom. The lesions in cases 3 and 4
accepted January 24. Address reprint requests
transmit-receive extremity surface coil. were best demonstrated with the use
to A.M.H.
All images were obtained with the use of
2 Current address: Department of Radiology,
Toledo Hospital, Toledo, Ohio.
a spin-echo (SE) pulse sequence and a
3 Current address: Department of Radiology. two-dimensional Fourier transform imag-
Massachusetts General Hospital, Boston. ing technique. The number of images ob- Abbreviations: SE spin echo, TE echo
© RSNA, 1989 tamed, the nominal thickness of the im- time, TR = repetition time.

755
of long TR/TE sequences. In case 3 tensity compatible with shortened 12 second metatarsal. Pathologic exam-
there was tumomal involvement of effects. A soft-tissue mass was seen to ination showed the tumor to be
the distal tendon sheaths in the me- involve the distal talus and the navic- bounded by spicubated subpemiosteal
dial portion of the plantar aspect of ubam bone. Tumor extension to the in- bone. The CT scans showed only
the distal foot extending to the first fenion surface and the calcaneocuboid pemiosteal elevation without cortical
tamsometatarsal joint. In case 4 a 5 X 5 joint was demonstrated. The diagno- disruption. Diffuse soft-tissue swell-
x 10-cm mass in the medial portion sis of osteosarcoma was confirmed at ing was evident.
of the plantar aspect extended from pathologic examination. Osteochondroma (case 8) was seen
the hindfoot to the forefoot with ex- Cavernous hemangioma (6,7) of as a 3 X 2-cm mass in the plantar as-
tensions between the first and sec- the plantar aspect of the foot (case 6) pect of the left foot adjacent to the
ond metatarsals and between the was seen as a 2 X 2 X 3-cm well-de- third and fourth metatarsophaban-
fourth and fifth metatarsals; tumor fined mass (Fig 1). The flexor muscu- geal joints. Long TR/TE images
was also seen intendigitating be- lature of the fourth and fifth digits showed mixed high and intermediate
tween the cuneiform bones. There demonstrated infiltration, and there
was no MR evidence of bone inva- was MR evidence of involvement of
sion. When the findings obtained at the plantar aponeurosis. No bone in-
MR imaging were compared with vasion was demonstrated. At patho-
those obtained at pathologic exami- logic examination, fibroadipose tis-
nation, MR imaging was found to be sue containing numerous thin-
accurate in predicting gross invasion walled, dilated blood vessels was
of bone and in defining compart- found without evidence of calcifica-
mental extent of the lesion. tion or bone invasion.
Radiognaphs in case 2 (multiple en- Osteoblastoma (case 7) involving
chondmomas) showed a cystic expan- the midshaft of the second metatarsal
sile lesion of the fifth metatarsal, showed intermediate signal intensity
both phalanges of the fifth digit, and with both short TRITE and long TR/
the middle phalanx of the fourth dig- TE sequences. With both sequences,
it with areas of central calcification diminished signal intensity involv-
compatible with enchondroma. MR ing the soft-tissue component of the
images (SE 2,500/25-100) demon- mass suggested the presence of ossifi-
strated a focal high-signal-intensity cation, in keeping with the plain-ma-
lesion of the fifth metatarsal, with tu- diogmaphic findings of abundant
mon involvement of the proximal 2 periosteal new-bone formatjon in the a.
cm of the bone. There was no exten-
sion seen proximal to the tarsometa-
tarsal joint, and the lesion was best
noted on long TRITE images. Figure 1. Case 6. Cavernous hemangioma
of the plantam surface of the foot. (a) SE 600/
Plain radiographs in case 5 showed
25 MR image shows a well-defined mass of
deformity and lytic changes in the
intermediate signal intensity occupying the
lateral portion of the navicular bone plantar aspect of the foot. Mass arises from
and what was thought to be cartilagi- the plantan fascia with infiltration into the
nous matrix. CT showed fragmenta- plantar flexor tendons (arrows). (b) SE
tion of the anterolateral portion of 2,500/75 MR image shows mass of uniform-
the naviculan bone with soft-tissue ly high signal intensity with posterior ex-
tension into plantar structures (arrowheads).
thickening over the lateral dorsum of
Appearance of somewhat striated mass of
the foot and generalized osteopenia. high signal intensity is in keeping with de-
Long TRITE (SE 2,500/25-100) MR scription of soft-tissue hemangiomas at oth-
images showed decreased signal in- en sites. Lesion was treated by local excision.
b.

a. b. C.

Figure 2. Case 4. Synovial sarcoma of the right foot in a 28-year-old man. (a) Non-contrast-enhanced CT scan shows soft-tissue thickening
of the forefoot. Mass extends from the plantar aspect of the metatarsals to the plantar surface. No obvious evidence of extension between
metatarsals is seen on either soft-tissue or bone windows. Axial (b) and sagittal (c) MR images (SE 2,500/75) of the foot show high-signal-in-
tensity tumor involving the midfoot and forefoot. High-signal-intensity areas within the tumor represent areas of necrosis. Note extension
of tumor between the fourth and fifth metatansals toward the dorsum of the foot. Because of extension toward the hindfoot, below-knee am-
putation was performed.

756 Radiology
#{149} June 1989
signal intensity with areas of low sig- teosarcoma), the MR images showed DISCUSSION
nab intensity within the lesion, sug- tumor abutting the talus, the calcane-
gesting ossification. The mass ex- us, the cuboid bone, and the second Recent advances in diagnostic im-
tended to the subcutaneous tissues metatarsal; microscopic invasion was aging have proved of particular ben-
and insinuated between the third detected in these bones after resec- efit in staging musculoskeletal neo-
and fourth metatamsals. The flexor tion (Fig 3). Similar results were seen plasms. While various imaging stud-
tendons of the foot appeared sun- in the other cases (Fig 4). ies are valuable in the assessment of
rounded by the mass, but there was Enchondroma displayed homoge- muscuboskeletal tumors (1), each par-
no evidence of other involvement of neous high signal intensity on 12- ticular case must be evaluated in a
bone. A discrete cartilaginous cap weighted images, and there was ex- tailored and cost-effective manner,
was not visible. At pathologic exami- cellent delineation of the extent of depending on the history, physical
nation, a thin layer of cartilage was the lesion within the shaft of the examination, and other clinical data.
seen covering the tumor. metatarsal (Fig 5). Our cases of syno- While plain-radiographic examina-
Correlative CT examinations were vial sarcoma of the foot were mani- tion remains the cornerstone of diag-
available in four of the eight cases. In fested as bulky areas of disease in the nosis of disease of the musculoskele-
general, the extent of soft-tissue dis- plantar aspect of the foot. The prime tal system (especially in the case of
ease was more clearly defined on MR contribution of MR imaging in these osseous neoplasms), its role in the lo-
images than on CT scans. In case 4 cases was definition of tumor mar- cal staging of tumors is limited, par-
(synovial sarcoma), tumor conspicu- gins, since no specific signal charac- ticularly in the case of soft-tissue tu-
ity was greater at MR imaging than at tenistics could be attributed to these moms. MR imaging has emerged as
CT because the extensions of the lesions. the modality of choice for the assess-
mass dorsally between the metatar- one might
As expect, plain radiog- ment of soft-tissue tumors of the
sals and the cuneiform bones were raphy of bone-forming lesions or le- musculoskeletal system (8). In this
not identified at CT (Fig 2). In case 5, sions suspected of containing calci- study, MR imaging was excellent in
involvement of the talus was not sus- fied cartilaginous matrix was the defining tumor margins and extent
pected on the CT study but was sug- most useful modality in initial analy- of disease regardless of its location
gested by the MR findings (Fig 3). sis and differential diagnosis. The within the foot.
The extent of tumor demonstrated principal contribution of MR imag- Foot tumors are rare. A number of
at MR imaging correlated well with ing in these cases was definition of articles regarding cross-sectional
the pathologic findings. In case 5 (os- tumor extent within the foot. evaluation of normal anatomy and

a. b.

c. d.
Figure 3. Case 5. Osteosancoma of the navicular bone. (a) Plain radiograph shows a blastic lesion involving the navicular bone (arrows).
(b, c) No significant soft-tissue component of the tumor is seen at CT. Bone windows show osteoblastic lesion of bone. (d) Sagittal SE 800/25
MR image shows soft-tissue component of tumor with involvement of cuboid bone, cuneiform bones, and talus. MR findings were con-
firmed at pathologic examination.

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#{149} 3 Radiology 757
#{149}
 traumatic and acquired lesions of the The relative paucity of fat between
foot have been published, but our the deep structures of the foot limits
search of the radiology literature me- contrast for the delineation of soft-
veabed no articles dealing with stag- tissue extension of tumor at CT. Our
ing of primary foot tumors. preliminary experience suggests that
CT, with its excellent anatomic de- MR imaging is superior to CT with
tail, has been used with great success regard to local staging of tumors of
to detect and stage muscuboskeletal the foot. Similar observations have
tumors in most of the body (9,10). been made regarding muscuboskebe-
tal tumors elsewhere in the body, al-
though CT and plain radiography are
Figure 4. Case 3. Synovial sarcoma.
considered superior for assessment of
(a) Conventional radiograph shows soft-tis-
sue mass of midfoot and forefoot without
bone involvement (8,11-13). In case
definite radiographic evidence of bone inva- 4, CT failed to show the portion of
sion. (b) Bone window on CT scan shows the soft-tissue mass that extended
a. sesamoid erosion and involvement of the dorsally between the bones of the
first metatarsal. (c) Sagitta! SE 600/25 MR foot, which would have resulted in
image shows fungating mass of plantam sum-
significant underestimation of the
face involving deep plantar structures with
involvement of the first metatarsal. Precise extent of disease; the MR images,
proximal-distal extent of tumor is displayed. however, demonstrated this finding
(d) Sagittal pathologic specimen shows de- well. A definitive judgment of the
struction of the first metatarsal and distor- superiority of MR imaging over CT
tion of plantar tissues by the tumor. Syme
cannot be made on the basis of these
b. amputation was performed.
cases alone, since CT was performed
without the administration of con-
trast material in this study. However,
when one considers the ease of mul-
tiplanam imaging, the superior con-
trast resolution, and the increased
sensitivity to bone marrow abnor-
malities, MR imaging appears to be
the cross-sectional modality of choice
in the evaluation of foot tumors.
In cases of suspected musculoskele-
tal tumor, the radiologist is faced
with three questions. First, is there a
mass? Second, if tumor is present,

C. d.

a. b. c.
Figure 5. Case 2. Enchondroma of fifth metatarsal. (a) Conventional radiograph shows lytic expansile lesions with intact cortical margins
and slight osseous septations involving fifth ray and middle phalanx of fourth toe. Dense calcification is seen in the proximal aspect of the
lesion in the fifth metatarsal. Destructive change in the proximal phalanx of the fifth toe is postoperative. SE 600/25 (b) and 2.500/75 (c) MR
images show intraosseous extent of the lesion. No soft-tissue component is identified. Soft-tissue high-signal-intensity area (c, arrow) is due
to effects of biopsy. MR imaging findings are otherwise nonspecific.

758 Radiology
#{149} June 1989
can the tumor be histologically char- aging technology. Our experience in 8. Pettensson H, Gillespy T III, Hamlin DJ, et
acterized? While tumors arising in imaging tumors of the foot strongly al. Primary musculoskeletal tumors: ex-
amination with MR imaging compared
bone often have a characteristic ra- suggests that MR imaging will play a
with conventional modalities. Radiology
diographic appearance that allows a principal role in local preoperative 1987; 164:237-241.
histologic diagnosis to be made, most staging of muscuboskeletal tumors of 9. Weekes RG, McLeod RA, Reiman HM,
soft-tissue tumors are much less spe- the foot, in many cases obviating oth- Pritchard DJ. CT of soft tissue neoplasms.
AJR 1985; 144:355-360.
cific in their appearance. Third, if tu- en imaging studies. The combination
10. Levine E. Computed tomography of mus-
mom is present, what is its extent? of conventional radiography and MR culoskeletal tumors. CRC Cnit Rev Diagn
This question is important not only imaging may ultimately prove all Imaging 1981; 16:279-309.
in cases in which excisional biopsy is that is necessary for preoperative as- 11. Petasnick JP, Turner DA, Charters JR.
to be performed (ie, where a benign Soft-tissue masses of the locomotor sys-
sessment of the foot. U
tem: comparison of MR imaging with CT.
lesion is suspected and the entire be- Radiology 1986; 160:125-133.
sion is to be removed) but also in References
12. Totty WG, Murphy WA, Lee JKT. Soft-
1. Simon MA. Diagnostic and staging strat-
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J. Extremity preservation by combined
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