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This is a consult for my colleagues Simi Mutasa and Keith Tobin.
XR and forefoot MRI from today. Ankle MRI from January.
Painful masses for more than 2 years.
A dermatologist did some biopsy at some point, reported as “fibrosis”…I
don’t what was biopsied, I presume one of the subcutaneous masses.
She is Black, likely Haitian (by name and community…though I don’t know
if she lived or traveled there), diabetic and hypertensive, on Metformin
and Amlodipine.
Previous hindfoot MRI shows no real difference since Jan 2021 (not shown)
What do you think?
1 thought on “46F chronic painful foot masses XR and MRI, please help”
hilary.umans
I have gotten some helpful thoughts on this case:
From Don Resnick:
Clearly not certain.
I do not see a classic dot in circle sign of Madura foot** and lack of
infection elsewhere. Other possibilities, gout, xanthomatosis, amyloid, and
(less likely) lymphoma.
(**I specifically asked Don about Madura foot because my colleagues favored
it….I have had a few cases over the years in clinical practice and I told
them it didn’t have the classic imaging features….but it is more
convincing when Don says that!)
Nadir Omar offered this differential:
Dermatofibroma – if multiple, associated with autoimmune disease and a few
other things.
Nodular fasciitis – rare in foot
(Diabetic callus)
(Amyloidosis)
Harun Gupta’s ddx:
Differential diagnosis of multi focal soft tissue masses
Benign –
fibromatosis – subcutaneous location is unusual
Intermediate / Malignant –
kaposi’s
angiosarcoma (not changed since 2021 would be against it)
DFSP (unusual to be multiple)
Roy Gottlieb:
Given the history of multiple stable masses and h/o fibrosis on biopsy, the
findings are most likely due to multiple fibromas
(fibromatosis).
James Linklater commented:
My thoughts go to gout and DECT
Avneesh Chhabra specified:
Fibromatosis in setting of Gardner syndrome
(**we have no imaging other than her foot and gyn US….so no proof of
osteomas, and certainly don’t have dental history in our limited outpatient
e-records)
We hope to get follow up.
These masses have been stable…or relatively stable for at least 2
years…..so I doubt lymphoma or sarcoma.
My 2 cents (what is that with inflation?)
I’ve not personally seen fibromatosis infiltration tendons….I’ve asked
those who comment and I’m told it happens….though I’ve seen reports of
fibroma of tendon sheath, I’ve not seen intratendinous fibroma—–and
being a fan of Occam and his razor, I do suspect that Tib Anterior and the
subcutaneous lumps are related in this case.
Gout can certainly give soft tissue tophi and infiltrate tendons…but the
subcutaneous masses without any relationship to nearby joints seems
odd…in a pre-menopausal woman.
So I am favoring xanthomatosis….but I’m sure I don’t know!
Absolutely will need a biopsy for the answer….I hope it happens and we
get real follow up.
46F-Black-Haitian-F-Chr-pain-sts.pptx
From Don Resnick:
Clearly not certain.
I do not see a classic dot in circle sign of Madura foot** and lack of
infection elsewhere. Other possibilities, gout, xanthomatosis, amyloid, and
(less likely) lymphoma.
(**I specifically asked Don about Madura foot because my colleagues favored
it….I have had a few cases over the years in clinical practice and I told
them it didn’t have the classic imaging features….but it is more
convincing when Don says that!)
Nadir Omar offered this differential:
Dermatofibroma – if multiple, associated with autoimmune disease and a few
other things.
Nodular fasciitis – rare in foot
(Diabetic callus)
(Amyloidosis)
Harun Gupta’s ddx:
Differential diagnosis of multi focal soft tissue masses
Benign –
fibromatosis – subcutaneous location is unusual
Intermediate / Malignant –
kaposi’s
angiosarcoma (not changed since 2021 would be against it)
DFSP (unusual to be multiple)
Roy Gottlieb:
Given the history of multiple stable masses and h/o fibrosis on biopsy, the
findings are most likely due to multiple fibromas
(fibromatosis).
James Linklater commented:
My thoughts go to gout and DECT
Avneesh Chhabra specified:
Fibromatosis in setting of Gardner syndrome
(**we have no imaging other than her foot and gyn US….so no proof of
osteomas, and certainly don’t have dental history in our limited outpatient
e-records)
We hope to get follow up.
These masses have been stable…or relatively stable for at least 2
years…..so I doubt lymphoma or sarcoma.
My 2 cents (what is that with inflation?)
I’ve not personally seen fibromatosis infiltration tendons….I’ve asked
those who comment and I’m told it happens….though I’ve seen reports of
fibroma of tendon sheath, I’ve not seen intratendinous fibroma—–and
being a fan of Occam and his razor, I do suspect that Tib Anterior and the
subcutaneous lumps are related in this case.
Gout can certainly give soft tissue tophi and infiltrate tendons…but the
subcutaneous masses without any relationship to nearby joints seems
odd…in a pre-menopausal woman.
So I am favoring xanthomatosis….but I’m sure I don’t know!
Absolutely will need a biopsy for the answer….I hope it happens and we
get real follow up.
Hilary
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