The Journal of Foot & Ankle Surgery 53 (2014) 282–285

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Review of Foot Tumors Seen in a University Tumor Institute

Pietro Ruggieri, MD, PhD, Andrea Angelini, MD, Fernando D. Jorge, MD, Marco Maraldi, MD,
Sandro Giannini, MD, PhD
Department of Orthopedics, Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 3 Most tumors of the foot and ankle will be benign, and it has been easy for clinicians to underestimate the
malignant potential of a given tumor. The purpose of our study was to gain insight into the incidence of
Keywords:
biopsy different tumor types diagnosed in patients with tumors of the foot and/or ankle treated at the Rizzoli Institute
carcinoma from September 1990 to December 2007. Our series included 1170 patients and 1170 lesions, with an overall
diagnosis mean age at diagnosis of 43 (range 5 to 81) years. Overall, 870 lesions (74.36%) were nonmalignant and 300
foot lesion (25.65%) were malignant. Soft tissue lesions were diagnosed in 189 patients (16.15%), of which 91 (48.15%)
primary bone tumor were nonmalignant (pseudotumors or benign). Bone lesions were diagnosed in 981 patients (83.85%), of
sarcoma which 779 (79.41%) were nonmalignant. Epidemiologic knowledge of foot abnormalities and clinical suspicion,
an organized diagnostic method, and evidence-based treatment of musculoskeletal tumors are essential el-
ements to obtaining optimal results in the treatment of malignant foot tumors.
Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

The malignant potential of a tumor on the foot has often been
underestimated. Consequently, the diagnosis of many malignant tu-
mors will be delayed despite symptom presentation early in the
disease process. This might be because although tumors of the foot
are common, relatively few will be malignant (1). Benign musculo-
skeletal tumors, for example, occur 200 times more frequently than
malignant ones, and bone tumors affecting the foot and the ankle
constitute approximately 3% of all cases. With regard to soft tissue
tumors, approximately 8% of the benign tumors and 5% of malignant
tumors will be located in the foot (2–6), confirming an unexpectedly
high prevalence with respect to the tissue volume.
Inadequate treatment has a substantial effect on the oncologic and
functional treatment outcomes (7,8). The purpose of our investigation
was to report the results of a retrospective, epidemiologic study of
bone and soft tissue tumors of the foot in patients treated at the
Rizzoli Orthopaedic Institute (Istituto Ortopedico Rizzoli, University of
Bologna, Bologna, Italy). Our primary aim was to describe the preva-
lence of the tumors regarding the type and anatomic location in the
foot. Through a comprehensive literature review and reporting of our
tertiary orthopedic oncologic referral center, we present an overview
of the prevalence of bone and soft tissue tumors of the foot.
Financial Disclosure: None reported.
Conflicts of Interest: None reported.
Address correspondence to: Pietro Ruggieri, MD, PhD, Department of Orthopedics,
Istituto Ortopedico Rizzoli, University of Bologna, Via Pupilli, 1, Bologna 40136, Italy.
E-mail address: pietro.ruggieri@ior.it (P. Ruggieri).
Patients and Methods
Our institutional archive contains the original records, including clinical docu-
mentation and imaging studies, for patients who received treatment or consultation at
the Rizzoli Orthopaedic Institute (Istituto Ortopedico Rizzoli, University of Bologna,
Bologna, Italy) since September 12, 1990. Our database includes mostly histologically
verified diagnoses, and the available slides and tissue specimens have been indexed
within our pathology department. More than 33,000 cases were recorded between the
inception of the database and December 2007. For the present investigation, we
reviewed the database to identify all patients with tumors of the foot or ankle who had
been treated from September 1990 to December 2007. We used a keyword search
(tumor name and descriptive keywords), because the “International Classification of
Diseases” and Common Procedural Terminology codes were not used in the database.
The inclusion criteria were primary or secondary lesions that involved the foot and/or
ankle; a histologically verified diagnosis; and biopsy and treatment (when performed)
at our institution. The exclusion criteria were insufficient data, including the lack of
medical record data, imaging studies, or histologic slides, all of which contributed to a
vague or inadequate identification of a tumor. All patients gave their informed consent
at admission to be included in scientific studies, and the institutional review board/
ethics committee of the Rizzoli Institute approved the protocol for our investigation.
The medical record review was conducted by 2 of us (A.A., M.M.), who abstracted
the following information: patient age at treatment, diagnosis, tumor grade, and
anatomic location. A review of all imaging studies, including plain radiographs (which
were available for all patients), computed tomography, and magnetic resonance im-
aging studies (when available), was undertaken by 2 of us (A.A., F.D.J.). Histologically
verified diagnoses, determined by biopsy or surgical specimen, were available for all
the cases, and a certified musculoskeletal pathologist had reviewed all the slides. The
study variables included the tissue of origin (bone or soft tissue); categorization of
the lesion as pseudotumoral, benign, or malignant; anatomic location, defined as the
hindfoot, midfoot, or forefoot; and the histologic subtype. The results were considered
in regard to the histologic diagnosis and treatment and published biomedical reports.
To find relevant English and non-English reports, we searched MEDLINE using PubMed
(US National Institutes of Health, National Library of Medicine, available at: http://
www.nlm.nih.gov/bsd/pmresources.html) using the following keyword phrases: “soft

1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.01.015
 P. Ruggieri et al. / The Journal of Foot & Ankle Surgery 53 (2014) 282–285 283

Table dropped due to lack of chart data or imaging studies. The mean age at
Classification of tumor lesions of the foot and ankle relative to the origin, histologic diagnosis was 43 (range 5 to 81) years. Of these tumors, 870 (74.36%)
grade, and location (n ¼ 1170 lesions in 1170 patients)
were nonmalignant and 300 (25.65%) were malignant. Of the 189 soft
Tumor Type Hindfoot Midfoot or Toes Total tissue tumors (16.15% of the total), 91 (48.15%) were nonmalignant
(talus or Metatarsus (phalanges) (n) tumors (pseudotumors or benign tumors) and 98 (51.85%) were ma-
calcaneus) (n) (lesser tarsals, (n)
metatarsals) (n)
lignant. Bone tumors accounted for 981 of the tumors (83.85%), of
which 779 (79.41%) were nonmalignant and 202 (20.60%) were ma-
Soft tissue 52 112 25 189
Pseudotumoral 20 13 13 46 lignant. The most prevalent benign lesions were multiple chon-
Pigmented villonodular 7 7 5 19 dromas, which accounted for 168 (19.31%) of the 870 nonmalignant
synovitis lesions, followed, in descending order by osteoid osteomas (164
Giant cell tumor of tendon 6 2 5 13 [18.85%]), solitary osteochondromas (47 [5.4%]), Nora’s disease lesions
sheath (reparative giant
cell granuloma)
(78 [8.9%]), calcaneal cysts (51 [5.8%]), and aneurysmal bone cysts (45
Synovial chondromatosis 5 2 0 7 [5.17%]). Of the 300 malignancies, the most prevalent types were
Ossificans myositis 0 2 3 5 Ewing’s sarcoma (44 [14.67%]), chondrosarcomas (29 [9.6%]), and
Aggressive fibromatosis 2 0 0 2 metastatic carcinoma (24 [8%]). Regarding the anatomic locations of
Benign 16 28 1 45
tumor involvement, 257 (21.97%) of the 1170 lesions were localized to
Lipoma 7 12 1 20
Schwannoma 6 8 0 14 the phalanges, 353 (30.17%) to the metatarsus, and 560 (47.86%) to the
Neurofibroma 3 8 0 11 hindfoot.
Malignant 16 71 11 98
Synovial sarcoma 10 43 3 56
Fibrosarcoma 3 11 3 17
Discussion
Malignant fibrous 0 5 3 8
histiocytoma Soft Tissue Tumors
Rhabdomyosarcoma 0 7 0 7
Liposarcoma 2 3 0 5
Plantar fibromatosis, an unencapsulated thickening and prolifer-
Epithelioid sarcoma 1 1 2 4
Leiomyosarcoma 0 1 0 1 ation of the central and medial bands of the plantar fascia, has been
Bone 508 241 232 981 the most common soft tissue pseudotumoral lesion of the foot and has
Pseudotumoral 93 28 80 201 been more common in patients with epilepsy or diabetes and alco-
Nora’s disease 0 1 77 78
holics with liver disease (9). Other common entities are ganglion
Calcaneal cyst 51 0 0 51
Aneurysmatic bone cyst 28 17 0 45
cysts, giant cell tumors of tendon sheath, pigmentous villonodular
Intraosseous mucoid cyst 13 2 0 15 synovitis, lipomas, and hemangiomas, with different percentages of
Unicameral bone cyst 0 5 1 6 prevalence reported in literature (3–5). In our population, of the 189
Brown tumor 0 2 2 4 benign or pseudotumors, the most common subtype was pigmented
Solitary eosinophilic 1 1 0 2
villonodular synovitis (19 patients [10.05%]), followed by giant cell
granuloma
Benign 286 152 140 578 tumors of the tendon sheath (giant cell granulomas; n ¼ 19 [6.80%]).
Multiple chondromas 13 80 75 168 Other pseudotumoral lesions seen in our population included syno-
Osteoid osteoma 141 13 10 164 vial chondromatosis in 7 (3.70%), an uncommon disorder character-
Solitary exostosis 17 20 10 47 ized by the formation of multiple cartilaginous nodules within the
(osteochondroma)
Enchondroma 4 10 32 46
synovium that are sometimes difficult to differentiate from malignant
Giant cell tumor 33 7 0 40 bone lesions (Fig.). The benign soft tissue tumors seen in our popu-
Chondroblastoma 32 3 0 35 lation included lipomas in 20 (10.58%), neurilemmomas (benign
Osteoblastoma 19 6 1 26 schwannomas) in 14 (7.4%), and neurofibromas in 11 (5.8%).
Other 27 13 12 52
Sarcomas are the most common malignant soft tissue tumors in
Malignant 129 61 12 202
Ewing’s sarcoma 26 17 1 44 patients aged 10 to 40 years and those older than 60 years; they are
Central chondrosarcoma 14 13 2 29 generally located on the foot’s dorsal aspect and heel (8,10–12). Sy-
Hemangioendothelioma 14 8 4 26 novial sarcoma is the most common primary soft tissue malignant
Bone metastases 11 10 3 24 tumor of the foot and ankle, accounting for 18% to 22% of all such
Carcinoma on osteomyelitis 13 2 0 15
High-grade osteosarcoma 11 2 0 13
tumors (13,14). In our series, synovial sarcoma was the most common
Classic osteosarcoma 9 2 0 11 malignant soft tissue tumor (56 of 98 [57.14%]). Malignant melanoma
Bone lymphoma 8 0 1 9 is another common soft tissue tumor of the foot and ankle; however,
Fibrosarcoma 7 2 0 9 and interestingly, no cases of malignant melanoma were found in our
Other 16 5 1 22
series.

tissue neoplasm,” “neoplasm,” “bone tissue,” and “foot.” Three of us (P.R., A.A., S.G.)
participated in the clinical management of the involved patients, and all of us (P.R., A.A.,
F.D.J., S.G.) participated in the surgical care of many of the patients. The data were
recorded using a spreadsheet (Microsoft Excel 2003, Microsoft, Richmond, WA) and
analyzed using MedCalc software, version 11.1 (MedCalc Software, Mariakerke,
Belgium) by 1 of us (A.A.). Categorical variables are expressed as the frequency count
and percentage of the total number of lesions in a specified category.
Results
Our inquiry identified 1170 tumors and patients meeting the
criteria for inclusion in our analyses (Table). No patients had to be
Bone Tumors
In a study of 255 bone tumors of the foot and ankle, 83 (32.55%)
were benign (15). In our patient population, 779 of 981 (79.41%) of
bone tumors were benign. The pseudotumors diagnosed in our pa-
tient population included aneurysmal bone cysts (46 of 981 [4.69%]),
calcaneal bone cysts (51 of 981 [5.20%]), giant cell reparative granu-
loma (AKA solid aneurysmal bone cyst; 40 of 981 [4.08%]), which,
although classified as benign tumors, can be locally aggressive and
can metastasize to the lungs.
Benign bone tumors include enchondromas, which are slow-
growing tumors composed of mature hyaline cartilage. These
284 P. Ruggieri et al. / The Journal of Foot & Ankle Surgery 53 (2014) 282–285

Fig. Synovial chondromatosis. (A) Anteroposterior foot radiograph shows extensive areas of extraarticular calcification about the second and third ray, with typical ring-and-arc
appearance of chondroid tissue in the majority of foci. Coronal magnetic resonance image reveals features of lobular growth of the neoplasm: (B) deep extrinsic erosion of bone without
marrow invasion and (C) the presence of low-signal-intensity osteochondral fragments. Intraoperative appearance of the surgical field (D) before and (E) after marginal excision of the
tumor. (F) Photograph of a coronally sectioned gross specimen reveals the mass containing synovium and embedded cartilaginous fragments.
 P. Ruggieri et al. / The Journal of Foot & Ankle Surgery 53 (2014) 282–285
account for 14.7% of all benign bone tumors of the foot and ankle. In
our series enchondroma was the most frequent benign bony lesion
in the foot (214 of 578 [37.02%]). Osteoid osteoma accounts for
19.4% of all benign bone tumors in the foot and ankle, with a
particular predilection for the talus and calcaneus (16,17). Chon-
droblastoma is a benign tumor that can affect the bones of the
tarsus in up to 16% of cases (18). Our series yielded 35 of 981 cases
(3.56%).
Just as with soft tissue sarcomas, malignant tumors of the bone are
rare in the foot and ankle. Most will affect patients older than
55 years; however, many young patients who are otherwise healthy
can present with malignant foot and ankle lesions (10,11,15,18–21). In
our study population, 202 of 981 lesions (20.59%) had malignant le-
sions. Ewing’s sarcoma affects the foot and ankle in 5% of cases and
has been the most frequent malignant bone tumor. In our series,
Ewing’s sarcoma was the most frequent malignant lesion in the foot
(44 of 202 [21.78%]). Chondrosarcomas have accounted for approxi-
mately 2% of the tumors that arise in the bones of the foot, repre-
senting only 1% to 3% of all chondrosarcomas (20,21). In our series,
chondrosarcoma was the second most frequent bony malignant lesion
observed in the foot (29 of 202 [14.36%]). All patients underwent
surgical treatment, which was amputation in one half of cases
because the primary tumor had been located in the hindfoot. Osteo-
sarcomas will affect the foot in fewer than 1% of cases (7,22). We had
11 of 202 (5.45%) in our population.
A number of methodologic shortcomings could have influenced
our conclusions, including biases related to documenting the pres-
ence and specific characteristics of a tumor and interpretation of the
abstracted data (some of the patients had been treated by the in-
vestigators). Moreover, ours is a specialty orthopedic center, and the
cases referred to it are, in some ways, specific and might be more
advanced or symptomatic, and for these reasons were referred to our
center. Despite these potential shortcomings, we believe that our
review, which included a large number of tumors, has documented
the prevalence of soft tissue and bone, malignant and benign, tumors
localized to the various anatomic areas of the foot, and thus, has
provided information that could be useful to the surgeons who treat
such lesions and others responsible for the distribution of healthcare
services.
Foot and ankle tumors are relatively rare compared with many
other lesions, and physicians approaching a patient with foot lesions
should always include malignant neoplastic disease in the differential
diagnosis, because it has been shown that pain, lesion size, and
symptom duration cannot be used to discriminate between benign
and malignant lesions (23). Early diagnosis and proper management
are key factors in increasing the life expectancy and functional
outcome of these patients.
285
Acknowledgment
The authors would like to thank their colleague and friend Dr Eric
R. Henderson for his assistance in editing the content and style of the
text.
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