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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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