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02/09/2018    Bryan C. Markinson, DPM

Treatment for Metastatic Cancer Spread to Feet (Roody Samimi, DPM)

It is a little bit unsettling to ponder the
original query by Name Withheld and the response
by Dr. Samimi. It is true that metastatic cancer
to the foot (generally considered rare) usually
indicates a poorer prognosis, but so does all
metastatic disease. MORE IMPORTANTLY, in
metastatic disease to the foot, and specifically
the nail unit, it is the first knowledge that any
cancer exists in the patient anywhere in a way
more than casual percentage of cases. In nail
units, it approaches 50%. This puts us in a
position to get the patient diagnosed and a chance
at treatment for the original tumor, even though
prognosis is naturally poorer.

When a patient with known history of cancer (as
stated in original post) presents with a foot
complaint or lesion, a heightened index of
suspicion is prudent, especially when initial
presenting diagnosis is obscure. For example; a
renal cancer patient with a granulating lesion in
the nail bed, or a breast cancer patient with
intractable heel pain not responding to standard
care for plantar fasciitis, etc.

In the case presented, the clinician ruled out the
obvious diagnoses of a swollen toe but does not
detail what investigations have been done. Imaging
is certainly required, and if plain x-rays are
normal, then soft tissue evaluation with
ultrasound or MRI should be done. The discussion
of local surgery is way too premature. If extended
imaging shows a soft tissue abnormality, then that
needs to be biopsied via open incisional biopsy or
core needle biopsy if lesion is large enough.

Dr. Samimi's assertion that "any suspicion for
metastatic cancer should be sent to an orthopedic
oncologist" is a bit overstated in my opinion.
While I certainly agree that management of
extremity cancer should be done by orthopedic,
surgical, and medical oncologists, podiatrists
based in academic centers and who may work closely
with orthopedic oncologists can certainly
participate.

Where podiatrists can shine is in the appropriate
initial approach to these patients, which can
adversely alter outcomes if not done properly.

But imaging, and open incisional biopsy or core
needle biopsy should be in most everyone's skill
set. Of course if any practitioner feels it is
not, then referral is always appropriate.

The editor of PM News should more carefully screen
queries that are best left out of the public view,
and perhaps referred privately to PM News
editorial staff for response.

Bryan C. Markinson, DPM, NY, NY

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