Soft Tissue Masses: When To Treat, When To Refer

Volume 19 - Issue 6 - May 2006
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Continuing Education Course #141 — May 2006

I am pleased to introduce the latest article, “Soft Tissue Masses: When To Treat, When To Refer,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Given the potentially serious nature of soft tissue masses in the lower extremity, it is vital to ensure either an informed course of treatment or an appropriate, timely referral. Accordingly, Bradley W. Bakotic, DPM, DO, discusses common soft tissue tumors and neoplasms in the lower extremity, offers pertinent diagnostic insights and reviews indications for different biopsy techniques.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 77 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Bakotic has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: May 2006.
EXPIRATION DATE: May 31, 2007.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• differentiate between soft tissue tumors and soft tissue neoplasms in the lower extremity;
• list common soft tissue tumors that arise in the feet;
• list malignant soft tissue neoplasms that are common in the feet;
• discuss clinical findings that would prompt a biopsy of soft tissue tumors in the lower extremity;
• compare and contrast biopsy techniques for soft tissue tumors; and
• discuss which biopsy techniques would necessitate a referral to other clinicians.

Sponsored by the North American Center for Continuing Medical Education.

Here one can see an epithelioid sarcoma. Note the ill-defined area of cutaneous/subcutaneous induration with focal ulceration.

In this view of Kaposi’s sarcoma, note the red-purple patch or plaque, which may be multifocal.

Here is an angiosarcoma. Note the irregular ulcer beneath the second metatarsal head, which is secondary to high grade angiosarcoma.

Note the angioleiomyoma above. One can see the subcutaneous nodule on the posterior heel without perceivable changes in color. (Photo courtesy of Dr. Steven M. Block)

With this dermatofibroma, one can see the dermal-based papule or nodule with hyperpigmentation of the overlying epidermis. (Photo courtesy of Dr. Patrick Campbell)

This is a high-grade fibrosarcoma. A soft gelatinous neoplasm has replaced much of the soft tissue and musculature of the forefoot. Previous clinicians followed this lesion for two years with the working diagnosis of “ganglion cyst.”

Soft Tissue Masses: When To Treat, When To Refer

Author(s):

By Bradley W. Bakotic, DPM, DO

The recognition and characterization of soft tissue tumors is central to the practice of podiatric medicine. In many instances, clinicians of the lower extremity serve as the frontline physicians when it comes to the identification of such tumors. Given the inverse relationship between the amount of time prior to diagnosis and patient survival rates, the role of podiatrists may be of paramount importance.
Depending upon one’s depth of experience and comfort level, some clinicians might limit their role to clinical recognition and ordering preliminary imaging studies. Others may go a step further and definitively characterize the lesion in question through needle aspiration, Tru-Cut core needle biopsy or incisional biopsy. In some instances, it is the podiatric surgeon who will provide definitive surgical management.
The medical community at large is increasingly relying on the podiatric profession to recognize and raise awareness of skin, bone and soft tissue tumors of the lower extremity. Unfortunately, when podiatrists fail to diagnose these conditions, the resultant void may have grave consequences.

Understanding And Defining Soft Tissue Tumors And Neoplasms
The “soft tissue” is composed of all living tissue with the exception of that which is skeletal, epithelial, hematopoietic (bone marrow derived) and parenchymal (the functioning tissue of visceral organs). The nervous system is divided in such a way that the nerves and glia of the central nervous system are not considered part of the soft tissue but the nerves and nerves sheath of the peripheral nervous system are considered part of the soft tissue.

In general terms, the soft tissues consist of adipose tissue, fibrous tissue, muscle, vascular structures and peripheral nerves. Accordingly, a pyogenic granuloma (composed of vessels) is a soft tissue tumor while squamous cell carcinomas and verrucae are not. Precisely what falls under the designation “soft tissue” does become a bit more complicated as some neoplasms of disputed differentiation are also under the classification of “soft tissue.” Some examples of this are synovial sarcoma and epithelioid sarcoma.
Tumors of the soft tissue include all mass-forming lesions that are either composed of soft tissue or exhibit differentiation toward any type of soft tissue. It is important to note that although the central nervous system, visceral organs and skeletal system are not considered to be part of the soft tissue, they all have soft tissue within them in the form of vascular structures, adipose tissue, fibrous tissue and/or peripheral nerves. It is probably for this reason that we occasionally see tumors of the fibrous tissue (fibromatosis/pleomorphic fibroma, fibrosarcoma), adipose tissue (lipoma, liposarcoma) and smooth muscle (leiomyoma, leiomyosarcoma) arising in these unusual locations.
Each type of soft tissue tumor has its own distinct pattern of distribution. Overall, however, the most common locations for soft tissue neoplasms are the retroperitoneum/pelvis and thigh. For clinicians who specialize in the care of the lower extremity, notable exceptions exist. Examples of soft tissue tumors that have a predilection for the distal extremities are synovial sarcoma, epithelioid sarcoma and clear cell sarcoma (melanoma of soft parts).