Foot sarcomas: Factors affecting oncological and functional outcomes.

NewsBot · Jun 29, 2012

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Foot sarcomas: Factors affecting oncological and functional outcomes.
Kozawa E, Nishida Y, Nakashima H, Tsukushi S, Toriyama K, Kamei Y, Ishiguro N.
Oncol Lett. 2012 Jan;3(1):82-88.

Oncological and functional prognostic factors for patients with foot sarcomas have yet to be clarified. This study was undertaken to identify the prognostic factors for oncological and functional outcomes and the significance of adjuvant radiotherapy in achieving local control in patients with foot sarcomas. We reviewed 31 consecutive patients with soft tissue (24), and bone (7) sarcomas arising in the foot and analyzed the impact of patient characteristics on the functional and oncological outcomes. There were seven cases with clear cell or epithelioid sarcomas. Two of the 31 cases experienced local recurrence despite the fact that only two cases received adjuvant radiotherapy. Sixteen out of 18 cases of soft tissue sarcomas with limb salvage surgery underwent reconstructive procedures for soft tissue defects. Amputation required as a surgical treatment (p=0.002) was a poor prognostic factor. Larger size (p=0.029) and bone reconstruction (p=0.018) were poor prognostic factors for local recurrence-free survival, and amputation (p=0.001) and bone reconstruction (p=0.008) for metastasis-free survival in patients with soft tissue sarcomas. No significant factors were derived in patients with bone sarcomas. Larger size (p=0.021), amputation (p=0.016) and bone reconstruction (p=0.03) were poor prognostic factors affecting function in patients with soft tissue sarcomas, and hindfoot site (p=0.028) and amputation (p=0.028) were poor prognostic factors affecting function in patients with bone sarcomas. Surgery with a negative operative margin and reconstructive procedures achieved good local control and function. Patients that had tumors with larger size, necessitating amputation or bone reconstruction, required novel multimodal treatment in order to improve their outcomes.
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Admin2 · Jun 29, 2012

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Admin2 · Dec 7, 2012

Osteosarcoma of the hands and feet: a distinct clinico-pathological subgroup.
Anninga JK, Picci P, Fiocco M, Kroon HM, Vanel D, Alberghini M, Gelderblom H, Hogendoorn PC.
Virchows Arch. 2012 Dec 5.

Osteosarcomas of hands or feet are rare, and seemingly these cases differ in presentation and behavior compared to those in usual locations. The clinico-pathological presentation of patients with osteosarcomas of the hand or foot was studied and compared with published cases. Forty osteosarcomas were identified among 4,221 cases, representing 0.95 % of all osteosarcomas. Thirty of these were well documented. Mean age at diagnosis was 43 years (hands) and 36 years (feet) and male-female ratio was 1.2:1 and 2.0:1, respectively. In the hand, 62 % of the osteosarcomas presented in the metacarpals and 23 % in the phalanges, and only two cases occurred in the carpal bones. Distribution in the foot was tarsal bones 56 %, metatarsal bones 33 %, and phalanges 11 %.Of the cases in the hand 54 % were of high grade and of those in the foot 71 %. Survival of osteosarcomas of the hand or foot was 81 %. Only patients with high-grade osteosarcoma died of the disease. Histological grade was the only significant variable related to survival. High-grade osteosarcoma of the hand or feet should be treated similar to those in conventional sites. Osteosarcomas of hands or feet are rare and in a relative high proportion are of low grade. Survival in high-grade cases is comparable to that in conventional sites.
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NewsBot · Feb 7, 2013

Calcaneal osteosarcoma: a rare cause of heel pain in the paediatric population.
Taslakian B, Issa G, Saab R, Jabbour MN, Khoury NJ.
BMJ Case Rep. 2013 Feb 4;2013.

Osteosarcoma is the most common primary non-haemopoietic malignant bone tumour in children and adolescents. However, it rarely occurs in the calcaneus with only a few case reports in the literature. We report a case of a 14-year-old boy with calcaneal osteosarcoma, who presented with heel pain followed by swelling. The pain was initially thought to be related to a benign process and treated with analgesics, delaying the diagnosis. We discuss the clinical presentation, the differential diagnosis, multi-imaging and pathological findings of a calcaneal osteosarcoma, its clinical outcome and the importance of early diagnosis to improve outcome.
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NewsBot · Jun 6, 2013

Do malignant bone tumors of the foot have a different biological behavior than sarcomas at other skeletal sites?
Brotzmann M, Hefti F, Baumhoer D, Krieg AH.
Sarcoma. 2013;2013:7679

We analyze the delay in diagnosis and tumor size of malignant bone tumors of the foot in a retrospective study. We compared the oncological and surgical long-term results with identical tumor at other anatomical sites in order to analyze the biological behavior of sarcomas that are found in the foot. Thirty-two patients with a histologically proven malignant bone tumor (fifteen chondrosarcomas, nine osteosarcomas, and eight Ewing sarcomas) between the years 1969 and 2008 were included. The median follow-up was 11.9 years. The overall median time gap between the beginning of symptoms and diagnosis in the study group was 10 months. Ewing sarcoma presented with the longest delay in diagnosis (median of 18 months), followed by osteosarcoma (median of 15 months) and chondrosarcoma (median of 7.5 months). The delay in diagnosis of these tumors was significantly longer than that of equivalent tumors at other skeletal sites, but the 5- and 10-year survival rates and the occurrence of distant metastases were comparable. In contrast, the average size of foot tumors was 5- to 30-fold less than that of tumors analyzed at other skeletal sites. This study indicates that sarcomas of the foot demonstrate a distinct biological behavior compared to the same tumor types at other skeletal sites.
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NewsBot · Apr 10, 2014

'Beware the lump in the foot!': predictors of recurrence and survival in bone and soft-tissue sarcomas of the foot and ankle.
Salipas A, Dowsey MM, May D, Choong PF.
ANZ J Surg. 2014 Apr 9.

BACKGROUND:
Although benign lumps around the foot and ankle are common, sarcomas in this area are frequently missed, and the consequences can be disastrous. Patients are often referred to tumour centres after suboptimal prior surgical excision. The predictors of local recurrence, metastasis and survival in this cohort have yet to be elucidated.
METHODS:
We performed a retrospective review of 61 consecutive patients that were surgically treated for a bone (BS) or soft-tissue sarcoma (STS) of the foot and ankle between 1996 and 2012 at a specialist tumour centre. Factors such as tumour versus non-tumour centre surgery and BS versus STS were examined. Univariate and multivariate analyses were performed to determine which factors predicted local recurrence, metastasis and survival.
RESULTS:
The overall 5-year survival rates were 74% in the STS group and 90% in the BS group. Furthermore, 33 (54%) patients had STS. Non-tumour centre surgery was performed in 23 (38%) patients. Overall local recurrence rate was 6.6%. Intra-lesional margins predicted a local recurrence, whereas non-tumour centre surgery was a predictor for developing a metastasis post-treatment. Tumour size, STS, radical margins (i.e. entire anatomical compartment removed with tumour) and metastasis, either at the time of referral or post-treatment, were associated with higher mortality.
CONCLUSION:
STSs of the foot and ankle appear to have a worse prognosis than BSs. Early referral to a specialist tumour centre before surgical intervention is recommended.
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NewsBot · Jun 8, 2016

Benefits Associated With Early Diagnosis and Treatment of Soft Tissue Sarcomas of the Foot and Ankle
Drew Murray, BS, Jacob Topfer, BS, Alexander P. Decilveo, BA, James C. Wittig, MD
JFAS; Article in Press

Soft tissue sarcomas arising in the foot and ankle are often misdiagnosed, resulting in excision without adequate preoperative staging or surgical margins. The goal of the present study was to review a case series of soft tissue sarcomas of the foot and ankle with attention directed at unplanned excisions of sarcomas. An unplanned excision means that a patient either underwent an inadequate preoperative workup or the preoperative workup indicated a benign entity, resulting in surgical resection. We retrospectively analyzed the medical records of 10 patients with sarcomas of the foot and ankle treated at our institution. All soft tissue sarcomas were excised with the widest margin possible without any major bone or neurovascular resection to allow for preservation of the foot. All patients were followed up for a minimum of 8 months to assess pain, function, and complications. The patients were followed up for an average of 22.4 (range 8 to 44) months. Of the 10 patients, 6 had undergone preoperative magnetic resonance imaging without contrast and the sarcomas were read as benign or cystic masses. Two patients had undergone preoperative magnetic resonance imaging with contrast, and these scans were also misread. Despite having undergone previous unplanned surgery, none of these sarcomas had recurred after repeat resection with a wider margin at a mean follow-up of 22.4 (range 8 to 44) months. At the last follow-up point, 8 patients were alive without evidence of disease. Minor complications included lymph edema in 1, stress fracture in 1, and wound infection in 1 that resolved. Preoperative MRI with contrast is recommended before resecting any soft tissue masses of the foot and ankle. In the event of an unplanned excision of a soft tissue sarcoma, the patient should be referred to an orthopedic oncologist for definitive surgery to optimize the oncologic and functional results. In the present retrospective analysis, previous intervention did not seem to affect the prognosis, including local recurrence, distant metastasis, disease-free interval, and functional outcomes.
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NewsBot · Jun 10, 2016

Soft tissue sarcomas of the distal lower extremities: A single-institutional analysis of the prognostic significance of surgical margins in 120 patients.
Harati K et al
Oncol Rep. 2016 Jun 8. doi: 10.3892/or.2016.4862

Soft tissue sarcomas (STS) arising in the distal lower extremities pose a therapeutic challenge due to concerns of functional morbidity. The impact of surgical margins on local recurrence‑free survival (LRFS) and overall survival (OS) still remains controversial. The aim of this study was to identify prognostic indicators of survival and functional outcome in patients with STS of the distal lower extremities through a long‑term follow‑up. Between 1999 and 2014, 120 patients with STS of the foot, ankle and lower leg were treated surgically at our institution. The median follow‑up was 6.3 years. The results reveal that the 5‑year estimate of the OS rate was 80.0% [95% confidence interval (CI): 69.6‑87.1] for the entire series. Surgical margins attained at the resection of the primary tumor did not influence OS significantly [5‑year OS: R0 80.5% (69.7‑87.9) vs. R1 74.1% (28.9‑93.0); P=0.318]. Within the R0 subgroup, negative surgical margin widths ≤1 and >1 mm led to similar outcomes, as well as ≤5 and >5 mm, respectively. In the multivariate analysis, significant adverse prognostic features included male gender and age >60 years at the time point of primary diagnosis. In conclusion, the data from this study could not underscore the long‑term benefit of negative margins achieved at the resection of the primary tumor. Surgical efforts should aim at function‑sparing resections when feasible with negative margins. Here, close negative margins seem to be adequate.
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NewsBot · Sep 2, 2016

What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?
Matthew T. Houdek et al
Foot Ankle Spec September 1, 2016

Soft tissue sarcomas of the foot and ankle are common. Currently, there exist limited data on prognostic variables. The aim of this study was to review our institution’s experience with soft tissue sarcomas of the foot and ankle to identify factors affecting outcomes and survivorship. We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size ≥3 cm in maximal dimension was the greatest risk factor in mortality. Posttreatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were ≥3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications.
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NewsBot · Mar 28, 2017

From Podiatry Today:
Keys To Recognizing Chondrosarcomas In The Foot

NewsBot · Nov 14, 2018

Management and outcome of acral soft-tissue sarcomas.
Dean BJF et al
Bone Joint J. 2018 Nov;100-B(11):1518-1523. doi: 10.1302/0301-620X.100B11.BJJ-2018-0301.R1.

AIMS:
The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot.

PATIENTS AND METHODS:
We identified 63 patients with an acral soft-tissue sarcoma who presented to our tertiary referral sarcoma service between 2000 and 2016. There were 35 men and 28 women with a mean age of 49 years (sd 21). Of the 63 sarcomas, 27 were in the hands and 36 in the feet. The commonest subtypes were epithelioid sarcoma in the hand (n = 8) and synovial sarcoma in the foot (n = 11).

RESULTS:
In 41 patients (65%), the tumour measured less than 5 cm in its largest dimension (median size 3 cm (2 to 6)); 27 patients (43%) were diagnosed after inadvertent excision prior to their referral to the specialist sarcoma unit. After biopsy and staging, primary surgical intervention at the sarcoma unit was excision and limb salvage in 43 (68%), partial (digit or ray) amputation in 14 (22%), and more proximal amputation in six (10%). At final follow up, local recurrence had been treated by one partial amputation and six amputations, resulting in a partial amputation rate of 24% and a proximal amputation rate of 19%. The five-year survival rate was 82%. Patients who underwent inadvertent excision showed no statistically significant difference in survival or local recurrence, but were more likely to undergo amputation (p = 0.008). Large tumour size (> 5 cm) was associated with lower survival (p = 0.04) and a higher risk of local recurrence (p = 0.009;).

CONCLUSION:
Most acral soft-tissue sarcomas measure less than 5 cm at presentation, indicating that while size can be a useful prognostic factor, it should not be used as a diagnostic threshold for referral. Increased tumour size is associated with a higher rate of local recurrence and reduced survival. Sarcoma excision with limb preservation does not result in an increased risk of local recurrence
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NewsBot · Jan 6, 2019

Distal extremities soft tissue sarcomas: Are they so different from other limb localizations?
Mattei JC et al
J Surg Oncol. 2019 Jan 4

BACKGROUND AND OBJECTIVES:
Soft tissue sarcoma localization in distal extremities (DESTS) of the limbs (hand/fingers, and foot/toes) is unusual. The literature is scarce about their behavior and this study was designed to assess their epidemiological characteristics, outcomes, and prognosis compared to other limb localizations (OLSTS).

METHODS:
From 1980 to 2010, adult DESTS and OLSTS in 22 centers were included. Demographics, tumor type, treatment modalities, and latest follow-up status were collected. Primary endpoints were overall survival and local/metastatic recurrence incidences.

RESULTS:
Two hundred five DESTS and 3001 OLSTS were included. The patients were younger, with more female and smaller tumors in DESTS. There were more clear cell/epithelioid sarcomas, synovial sarcomas, and myxoid liposarcomas vs more dedifferentiated liposarcomas in OLSTS. DESTS tumors were less irradiated and more often amputated (24.3% vs 3.4%). The five-year survival rate was 78.2% compared to 68.6% in OLSTS and after multivariate analysis, STS localization did not impact survival or local/metastatic recurrence.

CONCLUSION:
Though rare and smaller than other limb localizations, DESTS are to be considered as aggressive. Despite a higher amputation rate, the prognosis remains the same as in OLSTS. Limb sparing vs amputation should be carefully assessed in DESTS, especially if grade 3 or of a poor prognosis histological subtype.
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NewsBot · Aug 5, 2021

Surgical outcomes of bone sarcoma of the foot
Yusuke Tsuda et al
Jpn J Clin Oncol. 2021 Aug 3

Objective: Limb-salvage following resection of bone sarcomas of the foot are challenging due to the complicated anatomy, adjacent neurovascular structures and few durable reconstruction options.

Methods: We retrospectively analysed 50 patients with primary malignant bone sarcoma of the foot who underwent surgery including chondrosarcoma (n = 23), Ewing's sarcoma (n = 14) and osteosarcoma (n = 13).

Results: Median follow-up was 68 months. The primary sites were metatarsal (n = 18), phalanges (n = 15), calcaneus (n = 13) and others (n = 4). The 5-year disease-specific survivals were 100, 83 and 83% in chondrosarcoma, Ewing's sarcoma and osteosarcoma, respectively. Below knee amputation, ray/toe amputation, excision and curettage were performed in 21, 24, 2 and 3 patients, respectively. Below knee amputation was performed in 94% of mid/hindfoot tumours. Surgical margins were wide/radical, marginal and intralesional margin in 42, 5 and 3 patients. Three patients (6%) developed local recurrence, whereas, local recurrence was not observed in patients with wide/radical margins. Postoperative complications occurred in 3 patients (6%; surgical site infection n = 2 and delayed wound healing n = 1). Mean MSTS functional score was 26 points (range, 19-30).

Conclusions: Good local control was achieved with acceptable functional outcomes and post-operative complications; almost all mid/hindfoot tumours required below knee amputation achieving wide/radical margins without local recurrence.
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NewsBot · Feb 28, 2022

The importance of the early appropriate management of foot and ankle soft tissue sarcomas - experiences of a regional sarcoma service
Amin Kheiran et al
Foot (Edinb). 2021 Sep 23

Introduction: Soft tissue sarcomas (STS) are a group of rare malignant tumours that can occur at almost any anatomical location in patients of any age, which often present to health care professional working outside a recognised sarcoma service. A review of foot and ankle STSs was conducted, reporting on patient and tumour characteristics, and patient outcome following surgery performed within and outside our sarcoma service.

Patients and methods: A retrospective review of all foot and ankle STSs managed by our sarcoma service over a 14 year period was performed. Patient demographics, tumour characteristics, management and patient outcomes including recurrence rates and survival were analysed.

Results: Twenty-six patients were analysed (16F:10M) with a mean age of 57.7 years (range 17-87). The mean follow-up was 6.3 years (range 1-16). Sixteen tumours involved the foot, nine the ankle, and one spanned the foot and ankle. Mean tumour size was 4.3 cm (range 0.8-15), although 61% of cases were smaller than 4 cm, and almost one third of cases smaller than 1 cm. Seven of 26 (27%) cases were diagnosed after an unplanned excision performed by non sarcoma surgeons. These patients were more likely to undergo an incomplete tumour excision (p < 0.001), suffer local recurrence (p = 0.001), and eventually undergo a secondary amputation (p = 0.034) than those patients managed exclusively by a sarcoma service. Overall, 12 (46%) patients died of their disease during follow up, equating to a five-year survival rate of 69%.

Conclusion: Our data shows that unplanned excisions continue to be performed on foot and ankle STSs, and that these have detrimental effects on patients. Despite this, our results also show that these complex patients can be managed successfully when referred appropriately to a sarcoma service, prior to any surgical treatment. This highlights the importance of vigilance amongst all health care professionals managing any foot or ankle lumps, regardless of their size.
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NewsBot · Mar 16, 2023

Pitfalls in correct diagnosis and treatment of Soft Tissue Sarcoma of the foot and ankle – A report of two challenging cases
Laurin Feuerstein et al
Fuß & Sprunggelenk; 9 March 2023

Soft Tissue Sarcoma (STS) is a heterogeneous and rare complex of over 50 histopathological subtypes of malignant tumors of the musculoskeletal system with varying prognosis. STS occurs most commonly in the extremities but any localization is possible. Surgery is the mainstay for treatment of localized STS and the quality of adequate resection margins an important factor in overall survival. In this report we present two challenging cases of STS where interdisciplinary misinterpretations lead to delayed or insufficient initial treatment.
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NewsBot · Sep 29, 2023

Foot and Ankle Soft Tissue Sarcomas-Treatment and Oncologic Outcomes: A Systematic Review of the Literature
Dino Fanfan et al
Foot Ankle Int. 2023 Sep 26

Background: Foot and ankle soft tissue sarcomas (STSs) are rare neoplasms associated with a high risk of local recurrence and metastasis. Although amputation is often performed, its impact on prognosis remains unknown. The aims of our systematic review were identifying risk factors for (1) disease-specific death, (2) local recurrence, (3) metastasis, and assessing (4) whether the type of surgery (amputation or limb-salvage) affected disease-specific survival.

Methods: This systematic review was conducted following PRISMA guidelines. The PubMed, Embase, and Scopus databases were searched. Our study was registered in PROSPERO (ID: 415624). Quality appraisal was done using STROBE guidelines.

Results: A total of 7 studies and 123 patients were included. Metastasis was the only risk factor for disease-specific death (OR = 107.85, P< .001). Previous unplanned excision (OR = 22.29, P = .009) and positive margins (OR = 64.48, P = .011) were associated with higher risk of local recurrence. Patients with high-grade tumors (OR = 13.22, P = .023) and tumors ≥6 cm (OR = 7.40, P = .022) were more likely to develop metastases. After adjusting for confounders (age, sex, and presence of metastasis), amputation was not associated with poorer disease-specific survival.

Conclusion: Metastasis was the single most important risk factor for death with foot and ankle soft tissue sarcoma. Positive margins and history of previous unplanned excision are risk factors for local recurrence. The most important risk factors for metastasis are tumor grade and size ≥6 cm. Amputation was not associated with poorer disease-specific survival.
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NewsBot · Oct 26, 2023

Biphasic synovial sarcoma with myoepithelial features: a distinctive variant with a predilection for the foot
Shahd S Almohsen et al
Virchows Arch. 2023 Oct 21

Synovial sarcoma (SS) is a tumor known for its classic monophasic spindle cell or biphasic morphology. However, it exhibits a wide range of histologic variations, leading to diagnostic challenges. Here, we present four cases of molecularly confirmed, biphasic SS originating in the feet and displaying myoepithelial differentiation. The patients were two men and two women with an age range from 19 to 71 years (mean, 45 years). Each tumor showed foci with conventional spindle cell morphology. The epithelial components included areas with nests and cords of epithelioid cells set within a hyalinized and sclerotic stroma. The cytoplasm was clear to pale and eosinophilic. The nuclei were ovoid-round with fine chromatin and small to inconspicuous nucleoli. Mitotic figures were present (2-13 per 10 high-power fields; mean, 6.5). Immunohistochemical studies showed variable staining of the myoepithelial-like regions for low molecular weight keratins, EMA, p63, and S100 protein. Molecular studies confirmed the presence of SS18::SSX1/2 fusion in all four tumors. These cases highlight an unusual variant of synovial sarcoma with an apparent predilection for the distal lower extremity and suggest that differentiation of biphasic synovial sarcoma may be impacted by the anatomic site. Awareness of this variant is important to avoid misclassification and potential treatment and prognostic implications.
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