Mr JC is a 75 year old gentleman who was referred to our practice by his General Practitioner after Mr JC's very astute chiropractor was concerned about a large lump in his achilles tendon. On further questioning, the lump had progressively enlarged in size over the preceding three months. It was not painful, and not associated with any neurological or vascular symptoms.
Mr JC had a history of well controlled type II diabetes but no history of malignancy. He was otherwise a fit, active gentleman.
On examination, a palpable lump approximately 7cm in diameter was evident 10cm from the insertion of the achilles tendon. It was smooth, well circumscribed and non-tender. It was not translucent. It did not appear adherent to the achilles tendon, and squeeze test suggested the achilles tendon was intact. There were no neurological symptoms and in particular the sural nerve was intact.
An ultrasound ordered by Mr JC's General Practitioner was concerning for a soft tissue sarcoma, and an urgent MRI scan was ordered (images below):
An urgent phone call and referral to musculoskeletal orthopaedic tumour surgeon Mr Grant Pang was made after explaining the results of the MRI scan to Mr JC.
Mr JC underwent local and systemic staging of the tumour, including a chest CT scan looking for pulmonary metastases. A biopsy confirmed the malignant soft tissue tumour, leiomyosarcoma.
Mr Pang performed wide excision of the lesion, which included removing the achilles tendon due to the proximity of the tumour to the tendon. A flexor hallucis longus tendon transfer was performed at the time to replace the function of the removed achilles tendon. A free flap to cover the moderate sized skin defect was performed by a plastic and reconstructive surgeon.
Mr JC then underwent a course of radiotherapy.
Eighteen months later, Mr JC is cancer free and doing very well. His routine screening has not demonstrated any local recurrence of the tumour, nor any evidence of pulmonary metastases. He will require life-long monitoring, but his prognosis is excellent.
Many thanks again to my colleague Mr Grant Pang for ongoing management with this complex case.
Discussion
Leiomyosarcoma is a rare, malignant soft tissue tumour that is though to arise from the smooth muscle lining blood vessels. It commonly presents in the fifth and sixth decade of life. There were a number of features for this gentleman that were concerning for a malignant soft tissue tumour:
rapidly growing lesion
large lesion (>5cm in size)
deep to the superficial fascial plane
Malignant bone and soft tissue tumours should always be managed by an experienced, orthopaedic musculoskeletal tumour surgeon as part of a multidisciplinary musculoskeletal tumour centre. In Victoria, the tumour centre is St Vincent's public hospital in conjunction with the Peter McCallum Cancer Centre. If a malignant bone tumour or sarcoma is suspected, urgent medical review followed by local and systemic staging, usually with an MRI scan and PET scan is required. Histological diagnosis is required before definitive surgery, but the initial biopsy needs to be done in consultation with the orthopaedic tumour surgeon and reviewed by a multidisciplinary team consisting of radiology, pathology, plastic and reconstructive surgery and cancer nursing. This is because the tumour 'seeds' along the biopsy tract, which also needs to be excised as part of definitive surgery. Advances in surgical and medical treatments for soft tissue sarcoma continues to improve. Collaboration between all disciplines is vital in managing bone and soft tissue tumours, and early recognition and referral decreases mortality and morbidity. Mr JC's astute chiropractor effectively saved his life by detecting the lump and escalating their concerns.
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