0198-0211 /89/1002-0068$02.
00/0
FOOT8 ANKLE
Copyright 0 1989 by the American Orthopaedic Foot and Ankle Society, Inc
Primary Benign and Malignant Osseous Neoplasms of the Foot
Timeri Mahinder Murari, M.D., MAJ, MC, USAR,*John J. Callaghan, M.D., MAJ, MC, USAR,t
B. Hudson Berrey, Jr., M.D., LTC, MC, USA,* and Donald E. Sweet, M.D.5
INTRODUCTION
Small series and case reports of benign and malig-
nant neoplasms of the foot have been reported in the
literature.’, 4 . 8 . 9 . 1 1 . 1 7 . 1 8 However, other than reports on
specific neoplasms3, 6* 7* 16, l7 no large series of
53
benign and malignant primary neoplasms of the os-
seous structures of the foot have been reported. The
purpose of this paper is to retrospectively review the
primary benign and malignant osseous neoplasms of
the foot referred to the Orthopaedic Pathology Depart-
ment of the Armed Forces Institute of Pathology be-
tween 1970 and 1986. No attempt has been made to
define treatment alternatives or long-term prognosis in
this study.
MATERIAL AND METHODS
Each record was reviewed to determine the diagno-
sis, patient’s age and sex, availability of x-ray, and bone
involved. Pathologic material (glass microscopic slides)
reviewed at the time of submission to the Department
of Orthopedic Pathology, and correlated with the radio-
graphic and clinical findings formed the basis for diag-
nosis. The diagnosis was morphologically confirmed or
abandoned in selected cases; including those with un-
usual, controversial, or questionable diagnoses based
on established histologic and radiologic criteria. Of the
297 cases reviewed, 255 were selected for inclusion in
this study. Forty-two cases were discarded because of
failure to fulfill exact morphologic criteria, specify bone
involved, or because of nonavailability of radiographs.
Primary soft tissue tumors with secondary bone in-
volvement were also excluded.
From the Armed Forces Institute of Pathology and Orthopedic
Service, Walter Reed Army Medical Center.
* To whom all correspondence should be addressed; Orthopedic
Surgeon, Dewitt U S . Army Hospital Fort Belvoir, VA 22060.
$ Orthopedic Surgeon, Armed Forces Institute of Pathology.
t Present address: Assistant Professor, Division of Orthopedic
Surgery, Duke University, Durham, NC 27707.
9 Orthopedic Pathologist, Walter Reed Army Medical Center.
68
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RESULTS
The 255 cases of primary bone tumors of the foot
reviewed in this study revealed 213 benign (83.5%)
(Tables 1 and 2) and 42 malignant (16.5%) (Tables 3
and 4) neoplasms. Patient age ranged from 21 months
(bone cyst of the 0s calcis) to 94 years (chondrosar-
coma of the 0s calcis) with a mean age of 32.6 years.
Males outnumbered females by a ratio of 1.6:l. No
cases of bilateral foot involvement were identified. The
metatarsals were the most commonly involved bones
by both benign and malignant neoplasms, followed by
the 0s calcis.
CASE ILLUSTRATIONS OF BENIGN LESIONS
Case 1
A 35-year-old male presented with foot pain. Radio-
graph of a giant cell tumor shows a well-defined, “ex-
pansile” lytic defect involving the distal end of the first
metatarsal. The lesion extends from the metadiaphysis
to the subchondral plate (Fig. 1). Photomicrograph
(16Ox/H&E) of the lesion demonstrates a giant cell
tumor characterized by numerous, densely packed,
uniform appearing osteoclastic giant cells within a
slightly spindled to mononuclear stromal background
(Fig. 2).
Case 2
A 28-year-old male presented with right foot pain.
Radiograph reveals a well-defined lytic defect with a
thin reinforced sclerotic margin in the distal end of the
right first metatarsal (Fig. 3). Photomicrograph (80x/
H&E) reveals a moderately cellular myxocartilagenous
pattern characterized by stellate appearing cartilage
cells demonstrating modest cellular variability. The ill-
defined lobular architecture is focally separated by in-
complete elongated islands of giant cells and delicate
vascular bed, diagnostic of chondromyxoid fibroma
(Fig. 4).
Foot & Ankle/Vol. 10, No. 210ctober 1989 OSSEOUS NEOPLASMS 69
TABLE 1
Distribution of Benign Primary Osseous Neoplasms of the Foot
Benign neoplasms
(total no. of cases)
Metatarsals 0s calcis Talus Navicular Cuneiform Cuboid Phalanges

Giant cell tumor (43) 18 9 1 3 5

Chondromyxoid fibroma (41) 17 9 2 1 -
Osteoblastoma (34) 8 5 10 1 1
Bone cyst (21) 4 16 1 - -
Chondroblastoma(20) 2 15 2 - -
Osteochondroma(1 3) 10 2 - - -
Osteoid osteoma (12) 2 1 1 - -
Enchondroma (8) 3 3 - - -
Ossifying lipoma (7) 1 6 - - -
Chondroma (4) 3 - - 1 -
Hemangioma (3) 2 1 - - -
Ossifying fibroma (3) 2 - - 1 -
Echondrornatous giant cell tumor (2) 2 - - - -
Vascular leiomyoma (1) 1 - - - -
Lipoblastoma (1) - - - - -
Total 213 75 (35.2%) 67 (31.4%) 17 (8.0%) 7 (3.3%) 6 (2.8%)

TABLE 2 Case 4
Benign Primary Neoplasms of the Foot-Age and Sex Incidence
in 213 Cases A 25-year-old male presentedwith heel pain following
Mean age of a fall. Radiograph demonstrates a well-defined lytic
Benign neoplasms defect involving the anterior aspect of the calcaneus.
involvement in years Male:female
(total no. of cases)
and aae ranae Note the slightly reinforced margins and single thick-
Giant cell tumor (43) 26.7(4-77years) 2518 ened internal supporting trabeculae (Fig. 7). Photomi-
Chondromyxoidfibroma 28.3 (9-38years) 24:17 crograph (6Ox/H&E) demonstrates a bone cyst char-
(411 acterized by several segments of the thin fibrous cyst
Osteoblastoma (34) 25.5(7-77years) 20:14
13:8
wall and lining. Note the elongated cholesterol clefts
Bone cyst (21) 21.7(21months-58 years)
Chondroblastorna (20) 20.4(12-28 years) 18:2 (crystals)within the cyst wall, lining the trabecular bone
Osteochondroma (13) 34.7(12-75years) 7:6 (Fig. 8).
Osteoid osteoma (12) 22.3 (16-33years) 10:2
Enchondroma(8) 26.0(6-55years) 4:4 Case 5
Ossifying lipoma (7) 38.5(15-65 years) 4:3
Chondroma (4) 43.4(13-72years) 1 :3 A 19-year-old female presented with heel pain follow-
Hemangioma (3) 29.0 (1 8-45 years) 3:O ing trauma. Radiograph of a chondroblastoma is char-
Ossifying fibroma (3) 32.6(1 2-55 years) 3:O acterized by a well-defined lytic defect, involving the
Enchondromatous giant 15.0(14-16years) 1 :1 posterior aspect of the calcaneus with sharp, slightly
cell tumor (2) reinforced margins and focal cortical thinning. There
Vascular leiomyoma (1) 8.0 F
Lipoblastoma (1) 77 M appears to be partial cortical avulsion in the area of the
Achilles tendon attachment (Fig. 9). Photomicrograph
(16Ox/H&E) demonstrates a chondroblastoma with
sheets of chondroblastic cells separated from each
Case 3
other by a thin rim of chondroid matrix. Note the
A 28-year-old male presented with chronic ankle pain sparsely scattered giant cells and rare foci of cartilage
and swelling. Radiograph reveals an expansile lytic differentiation (Fig. 10).
lesion in the anterior superior talus with mineralization
of matrix (Fig. 5). Photomicrograph (240x/H&E) dem- CASE ILLUSTRATIONS OF MALIGNANT LESIONS
onstrates numerous small, irregular, interconnecting
Case 1
spicules of partially mineralized osteoid matrix, rimmed
by large numbers of homogenous, plump and bland A 65-year-old male presented with chronic pain and
appearing osteoblasts, diagnostic of osteoblastorna. swelling of the heel. Radiograph demonstrates a large
Note the congested, delicate, sinusoidal vascular bed lytic defect arising in the posterior, inferior calcaneus.
in the background (Fig. 6). Note the degree of trabecular loss and partially rein-

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70 MURARI ET AL. Foot & Ankle/Vol. 10, No. 210ctober 1989

TABLE 3
Distributionof Malignant Primary Osseous Neoplasms of the Foot
Malignant neoplasms
(total no. of cases)
Metatarsals 0s calcis
Chondrosarcoma (22) 9
Osteosarcoma (7) 5
Ewing’s Sarcoma (5) 3
Malignant giant cell tumor (4)” 3
Malignant hemangioendothelioma (1) 1
Plasmacytoma (1) -
Fibrosarcoma (1) -
Liposarcoma (1) -
Total 42 21 (50%) 15 (35.7%) - - 1 (2.4%) 3 (7.1%) 2 (4.8%)

Two classified as atypical.

TABLE 4
Malignant Primary Osseous Neoplasms of the Foot-Age and Sex Incidence in 42 Cases
Mean age of
Malignant neoplasms
involvement in years Ma1e:female
(total no. of cases)
and age range
Chondrosarcoma (22) 43.0 (14-94 years) 13:9
Osteosarcoma(7) 30.5 (23-66 years) 25
Ewing’s Sarcoma (5) 21.2 (9-38 years) 3:2
Malignant giant cell tumors (4)” 26.2 (20-33 years) 3:l
Malignant hemangioendothelioma (1) 37.0 F
Plasmacytoma (1) 56.0 M
Fibrosarcoma (1) 63.0 M
Liposarcoma(1) 25.0 F
a Two classified as atypical.

forced and focally permeative margin (Fig. 11). Photo-
micrograph (1 6Ox/H&E) reveals a moderately cellular
admixture of hyaline and myxocartilage with focal
atypia, loose matrix and rare binucleate cells diagnostic
of a low grade chondrosarcoma (Fig. 12).
Case 2
A 22-year-old male presented with foot pain. Pa-
tient’s radiograph reveals a lesion involving the poste-
rior aspect of the calcaneus which is characterized by
an ill-defined, lytic defect with permeative margins and
cortical destruction. Note the patchy areas of increased
density within the defect (Fig. 13). Gross photograph
of the amputation specimen in sagittal plane reveals
the extent of calcaneal destruction and violation of the
cortex by infiltrating tumor (Fig. 14). Photomicrograph
(6Ox/H&E) demonstrates an osteosarcoma with large
numbers of atypical malignant osteoblasts generating
an irregular pattern of tumor osteoid (Fig. 15).
Case 3
An 18-year-oldfemale presented with foot pain when
weightbearing and when wearing shoes. Radiograph of
the right second metatarsal reveals a poorly-defined
lytic defect involving its proximal end. Note the layered
periosteal reaction creating the illusion of a widened
bone contour (Fig. 16). Photomicrograph (1GOx/H&E)
reveals an undifferentiatedsmall cell malignant infiltrate
diagnostic of Ewing’s sarcoma. Note the dual cell pop-
ulation, relative uniformity of the nuclei, sparsity of
mitoses, and ill-defined cytoplasmic detail (Fig. 17).
DISCUSSION
Primary bone tumors of the foot, although considered
rare, occur with greater frequency than previously re-
ported. The overall distribution of these neoplasms, in
our series, with regard to age, sex incidence, and site
of involvement is similar to that described in previous
studies with the exception of the age and sex incidence
of our cases of osteosarcoma. In osteosarcoma, males
usually outnumber females with a peak age incidence
between 10 and 20 years.I3 In our seven cases of
osteosarcoma, females outnumbered males 5:2 and
the mean age of involvement was 30.5 years. The
bones most frequently involved were the 0s calcis and
metatarsals.
Osteochondroma, an anomaly, is reported as the
most common benign “tumor” of bone representing
42% to 50% of all benign and 10% to 20% of all primary
bone tumors.’ However, the relative infrequency of foot

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Foot & AnkleIVol. 10, No. 2/0ctober 1989 OSSEOUS NEOPLASMS 71

Fig. 1. AP radiographrevealing a lytic defect in the first metatar.sal.

Fig. 2. Photomicrograph consist-

ent with a giant cell tumor (160x/
H&E).

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72 MURARI ET AL. Foot & Ankle/Vol, 10, No. 2/0ctober 1989

Fig. 3. AP radiograph revealing a lytic defect in the first metatarsal.

Fig. 4. Photomicrographconsist-
ent with a chondromyxoid fibroma
(GOx/HBE).

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Foot & Ankle/Vol. 10, No. 210ctober 1989 OSSEOUS NEOPLASMS 73

Fig. 5. Lateral radiograph revealing an expansile lytic lesion on the

anterior superior talus.

Fig. 6. Photomicrographc(msist-
ent with an osteoblastoma (60x1
HBE).

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74 MURARI ET AL. Foot & Ankle/Vol. 10, No. 2lOctober 1989

Fig. 7. Lateral radiograph reveal-

ing a lytic defect in the 0s calcis.

Fig. 8. Photomicrographconsist-
ent with bone cyst (GOx/H&E).

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Foot & Ankle/Vol. 10, No. 2/0ctober 1989 OSSEOUS NEOPLASMS 75

Fig. 9. Lateral radiographrevealing a lytic defect in the 0 s calcis.

Fig. 10. Photomicrograph w n -

sistent with a chondroblas#toma
(16Ox/H&E).

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76 MURARI ET AL. Foot & Ankle/Vol. 10, No. 2/0ctober 1989

Fig. 11. Lateral radiograph revealing a lytic defect in the 0 s calcis.

Fig. 12. Photomicrograph con-

sistent with a chondrosarc:oma
(1GOx/H&E).

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Foot & Ankle/Vol. 10, No. 2/0ctober 1989 OSSEOUS NEOPLASMS 77

Fig. 13. teralI radic ,aph I?evealinga lytic defect in the 0s calcis.

Fig. 14. Gross photograph re-

veals a destructive lesion in the 0s
calcis.

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78 MURARI ET AL. Foot & Ankle/Vol. 10, No. 2/0ctober 1989

Fig. 15. Photomicrograph con-

sistent with an osteosarcoma
(GOx/H&E).

involvement’ was also borne out by our series where

Fig. 16. AP radiograph revealing a lytic defect in the second meta-
osteochondromas accounted for only 6.1O/O of benign
and 5.1% of all primary bone neoplasms in the foot.
Forty-one chondromyxoid fibromas in our series ac-
counted for 19.2% of the primary benign bone tumors
in the foot. Unlike other benign bone neoplasms, only
the proximal tibia appears more commonly involved by
chondromyxoid fibroma than the collective bones of the
f00t.l~
An unusual, typically benign but morphologically con-
fusing cartilage neoplasm encountered in the foot and
elsewhere, worthy of comment, is enchondromatous
giant cell tumor. Enchondromatous giant cell tumor
seems to reflect a morphologic hybrid between enchon-
droma, giant cell tumor, chondroblastoma, and chon-
dromyxoid fibroma. Occasionally, distinguishing en-
chondromatous giant cell tumor from the above, espe-
cially chondroblastoma, when the latter occurs in
nonepiphyseal locations, can be difficult. Fortunately,
chondroblastomas are characterized by a “chicken
wire” matrix pattern separating chondroblastic cells, a
feature not seen in enchondromatous giant cell tumor.
Enchondromatous giant cell tumor has potential for
local recurrence, similar to that of giant cell tumor and
rare instances of malignant “transformation”have been
encountered. In our series, two patients had enchon-
dromatous giant cell tumor and both involved the meta-
tarsals.
There have been several recent reports (including a
series of 40 cases) of osteoid osteoma and osteoblas-
toma involving the talus.5* We identified twelve
“9

tarsal. osteoid osteomas, eight involved the phalanges and

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Foot & Ankle/Vol. 10, No. 2lOctober 1989
only one involved the talus. Thirty-four osteoblastomas
in our series accounted for 16% of all benign neo-
plasms. Ten involved the talus, nine involved the pha-
langes and eight involved the metatarsals. According
to the available literature, the talus appears to be a
common site for osteoblastoma in the foot.5 However,
talar involvement was closely followed by involvement
of the phalanges and metatarsals in our series.
Chondrosarcoma,’~l 5 although reported to be rare in
the bones of the foot, was the most common malignant
neoplasm in our series of bone tumors. Twenty-two
cases accounted for 52.3% of the malignant neo-
plasms. Six were “secondary,” arising from previous
benign cartilage lesions. Two arose from antecedent
chondromyxoid fibromas and four from enchondromas.
Another primary benign neoplasm occasionally
undergoing malignant transformation is giant cell tumor.
Malignant giant cell tumors accounted for 9.3% of the
malignant neoplasms in our series of foot lesions and
while a similar percentage is also true for the skeleton
as a whole, slightly less than 1O/O of all giant cell tumors,
including those labeled malignant, have actually metas-
tasized.’, 14. l9
CONCLUSIONS
Primary osseous neoplasms of the foot may be more
common than previously reported. In our series of 255
cases, 83.5% were benign and 16.5% were malignant.
The most common benign neoplasm was giant cell
tumor and the most common malignant neoplasm,
chondrosarcoma. The metatarsals were the bones
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OSSEOUS NEOPLASMS 79
Fig. 17. Photomicrograph con-
sistent with an Ewing’s sari:oma
(160x/H&E).
most commonly involved, followed by the 0s calcis. The
cases in this study were selected from the highly spe-
cialized Orthopedic Pathology Registry which contains
many cases considered to be diagnostically difficult or
“unusual.” The authors, therefore, acknowledge the
study may be skewed in terms of a greater number of
unusual cases.
Pain and localized swelling are the most common
presenting symptoms in reports of foot neoplasm^,^,
lo* ’**
l6 and this was true for our series. Heel and
metatarsal pain, specifically, were the most common
presenting symptoms in our patients. These two com-
plaints are also frequent in patients with minor, common
foot disorders, i.e., plantar fasciitis and metatarsalgia.
One must not overlook osseous neoplasms when eval-
uating patients with these complaints. Pathologic frac-
ture as a presenting symptom was uncommon and only
one patient with an enchondroma presented in this
fashion.
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