Malignancy Case Drives Home Importance of Keeping Neoplasm in Differential Diagnosis

The authors of a recent poster at the American Society of Podiatric Surgeons Annual Conference shared an interesting case study of a malignant peripheral nerve sheath tumor in an athlete. In their case, a 27-year-old male presented with symptoms of Achilles tendonitis. X-rays were unremarkable and magnetic resonance imaging (MRI) (Figure 1) revealed hemorrhagic fluid in Kager’s triangle, along with enhancement concerning for neoplasm. Excisional biopsy ruled out synovial sarcoma and rhabdomyosarcoma, with positive findings for a high-grade spindle cell sarcoma with cellular and myxoid areas. The final diagnosis was malignant peripheral nerve sheath tumor. The patient underwent wide excision, radiation, and chemotherapy, without recurrence or metastasis.

Q: What inspired you and your group to share this case?

Mark Boissonneault, DPM, one of the authors on the poster shares that the inspiration to share this case stems from the understanding that any patient could present with a malignant soft tissue tumor. He points out that this patient did not have any past medical history that could have been a predictor for this tumor. He was a basketball player that thought he injured his Achilles tendon, but later found out that he had a malignant mass along his sural nerve.
 
“After seeing how this patient’s treatment course turned out to be successful after years of follow-up, we wanted to share this with the rest of the podiatry community in hopes that they would take something away from the case,” he adds.

Q: What one thing do you hope the audience will take away from this case?

Dr. Boissonneault hopes this case encourages physicians to have soft tissue tumors on their list of differentials, even when assessing athletes.
 
“This patient presented with Achilles tendinopathy after playing basketball and landing on his foot awkwardly,” he says. “At the time he was worked up for an Achilles tendinitis and other musculoskeletal injuries.”
 
After excisional biopsy and subsequent diagnosis, he shares that the patient was immediately referred to oncology and underwent radiation therapy and chemotherapy with wide debridement.
 
“He has been in remission for 4 years now,” he adds. “We wanted other physicians to understand the importance of proper work-up and follow-up with patients and to keep soft tissue tumors as a differential when working up patients with musculoskeletal pain.”
 
Dr. Boissonneault notes that DPMs can play a key role in these types of cases.
 
“It is unfortunate that malignancies do present in our community, especially the younger population,” he says. “However, it is our mission as podiatric physicians to diagnose, treat and lead our patients in the right direction so that they have the best outcome possible.”