How To Handle Plantar Fibromas

Author(s): 
By Matt Sabo, DPM

Aggressive infantile fibromatosis is a rare single or multiple nodule mass that has a rapid growth and occurs within the first year of life. Histologically, it resembles fibrosarcoma. Surgical excision is recommended with local aggression but some may regress with observation.

Other Key Points To Consider During The Clinical Exam
Plantar fibromatosis is a common soft tissue tumor of the foot. As the disease progresses in the elderly population, plantar contracture develops in approximately 25 percent of the patient population. The incidences of superficial plantar fibromatosis and cerebriform mesodermic hamartomas are unknown. Its clinical representation of a plantar fibromatosis is rare.

Typically, the various forms of plantar fibromatosis are asymptomatic. They present as a mass of a solitary lesion or multiple nodules within the medial and or central bands of the plantar aponeurosis. Symptomatic patients have difficulty wearing shoes and the ability to stand or ambulate because of the irregularity of the contour of the plantar arch.

Plantar fibromatosis is typically bilateral. Local infiltrates often recur with just local resection. However, performing a complete plantar fasciotomy will reduce recurrence. Superficial plantar fibromatosis may grow gradually and recur when one excises them. Both aggressive infantile fibromatosis and fibrosarcoma have an infiltrative course but only aggressive infantile fibromatosis does not metastasize.

In regard to plantar fibromatosis, one would see this in the middle-aged to elderly population. Juvenile aponeurotic fibroma is more prominent in younger males than young females. Aggressive infantile fibromatosis and cerebriform mesodermic hamartomas are the only exceptions in that they only occur within the first year of life.

Differentiating Lesions From A Histological Perspective
In regard to plantar fibromatosis, the proliferation of tumor cells grows both superficial and deep from the aponeurosis. It will replace the adipose tissue. However, it will not affect the overlying epidermal and dermal layers.

Superficial plantar fibromatosis’ cellular limits are usually not well defined. Areas of the disease may be similar to fibrosarcoma in which the cellular structures are closely packed together with a dense fibrocytic component. Some areas can be scar-like and acellular. Superficial plantar fibromatosis is commonly located in the posteromedial and plantar portion of the heel. The nodules are usually asymptomatic with round to flattened lesions with a fibrous consistency.

In juvenile aponeurotic fibroma, the cellular structures are oat-shaped. In the aggressive forms, there is an increase in mitotic activity and they are more cellular. The nodular lesions are hard, slow growing and adhere to the deep structures of the foot.
Aggressive infantile fibromatosis appears within the first year of life. The lesion is a fast growing tumor that rapidly infiltrates the subcutaneous fat, aponeurosis and muscle. Its course is similar to fibrosarcoma but metastasis does not occur.

A Guide To Staging Of Soft Tissue Tumors
Classification schemes are based on the radiographic, histological and clinical presentations. Enneking classified benign soft tissue tumors in three stages: latent, active and local aggressive growth. With stage I, the latent stage, the tumors are usually static or inactive and asymptomatic. In Stage II, the active stage, the lesions are actively growing and cause clinical symptoms. In Stage III, the local aggressive growth stage, lesions are locally aggressive, histologically immature and show progressive growth not limited to normal boundaries.

Malignancy is rare in the various forms of plantar fibromatosis. The staging of malignant tumors acts as a baseline for determining prognosis and treatment protocols. Soft tissue sarcomas are based on a number of variables. These variables include: histological grade, tumor size, tumor depth, compartment status and the presence or absence of metastasis.

Comments

Have you had any experience using topical Verapamil? I have had very good results redcuing the size and the symptoms of plantar fibromatosis using topical Verapamil from my local compounding pharmacist. In fact, I have not excised one in several years. Ronald W. Hines, DPM Oklahoma City, Oklahoma.

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