Key Principles In Diagnosing And Addressing Bone Tumors

As foot and ankle surgeons, we may incidentally come across the occasional enchondroma or intraosseous lipoma. However, do we really know how to properly manage these uncommon presentations? The main differentiating factors in treating osseous neoplasms is determining whether they are benign or malignant, and then determining whether surgery is warranted.

Obtaining a thorough medical history is paramount for these patients. Any prior history of neoplasm or family history of neoplasm can be helpful in determining the type and urgency of the tumor. How old is the patient? Was this an incidental finding or is the patient experiencing pain? How long has the patient been symptomatic? Has the patient been treated by another physician for another diagnosis? 

These patients typically describe a dull, achy type of pain that may worsen at night or with activity. Often, benign lesions present asymptomatically but a recent injury could initiate pain at this site or create a pathologic fracture. 

Often, clinical examination is difficult for a purely osseous lesion with no pronounced mass or swelling. Thorough weightbearing and non-weightbearing examination of all lower extremity joints and affected regions are key. Pertinent physical examination findings to consider in these patients include pain, tenderness and skin changes to overlying areas. If one suspects a large neoplasm, make certain to pinpoint neurovascular deficits because the tumor may invade soft tissue structures.  

First-line imaging for these patients should involve weightbearing radiographs of the foot and ankle. Radiographs give us a good idea of what kind of tumor we are dealing with and help us differentiate between benign or malignant lesions. The type of bone the mass is present in and location within the bone can narrow down the list of differentials. If the neoplasm is not well understood or visualized on X-ray, then magnetic resonance imaging (MRI) or computed tomography (CT) are indicated. One should also consider using contrast. In cases in which the tumor is ill-defined and there is concern for malignancy, one should order both tests. 

Prior to any definitive surgical intervention, a bone biopsy is initially indicated when there is any concern for potential malignancy. One can perform a bone biopsy via needle biopsy or an open procedure. An open biopsy may facilitate more exposure to surrounding soft tissues that are involved as well as greater access to the neoplasm. If the biopsy results are significant for malignancy, it is important to get oncology involved and/or refer to a specialist who is familiar with musculoskeletal neoplasms. If the tumor is benign, surgical intervention may include excision of lesion with bone grafting. If it involves a joint or a pathologic fracture has occurred, then one may consider open reduction and internal fixation (ORIF), or arthrodesis of the involved joint.

Given the infrequency of presentation, bone tumors can be frustrating to diagnose and clinically manage in the foot and ankle clinic. Hopefully, this brief primer offers a stepwise guide for diagnostic pathways, treatment and appropriate referrals when necessary. 

Dr. Pirozzi is a Fellow of the American College of Foot and Ankle Surgeons (ACFAS) and serves as Vice President for ACFAS Region 2. She is currently in private practice in Phoenix, AZ.