I received a
large number of email responses to my request for differential diagnoses. The
guesses covered a broad range of pathology and included rhabdomyosarcoma,
inclusion cyst, hemangioma, leiomyoma, infection / abscess, hematoma, synovial
sarcoma, plantar fibrosarcoma, and plantar fibromatosis with malignant
tendency. Thanks for your interest and for sending those emails.
CASE CONCLUSION
3 days after
the surgical exploration and excisional biopsy were completed, I received a
phone call from the pathologist who was reviewing the slides of the surgical
specimen. (it’s never good news when you get a call from the pathologist) He
stated the initial review and staining were highly suspicious for sarcoma and
they were going to perform additional testing. The following week, the
pathologist related that the immunohistochemical stains confirmed the diagnosis
of SYNOVIAL SARCOMA.
Here are the Pathology Reports:
CLICK TO ENLARGE
TREATMENT
PLAN
The 44
year old patient was counseled extensively and consultations were made which
included oncology, orthopaedic oncology, and psychiatry. A repeat biopsy
was performed which confirmed the diagnosis and total body CT and Bone Scans
were performed to rule out metastasis. The decision was made to proceed
with a primary below knee amputation and withhold radiation / chemotherapy
unless metastasis appear. When the BKA was preformed, the patient was
fitted in the OR with a temporary prosthesis and began weight-bearing
rehabilitation within 1 week of the amputation.
This case is
just another reminder that things are not always what they appear…
