SLR - January 2021 - Ruchi R. Ram

Foot Metastasis: Current Knowledge

Reference: Tomasso G., Luigi C., Domenico DM., Giacomo D., Maria Beatrice B., Gianpiero C., Giulia R., Francesco L., Giulio M., Carlo P. Foot Metastasis: Current knowledge. Orthop Rev (Pavia). 2020 Jun 25; 12(1).

Level of Evidence: 4

Scientific Literature Review

Reviewed By: Ruchi R. Ram, DPM
Residency Program: University Hospital – Newark, NJ

Podiatric Relevance: Foot metastases are rare and often overlooked due to non-specific symptoms, which often leads to their misdiagnosis and inappropriate treatment. This is often cited as the main reason why foot metastasis is a sign of poor prognosis, along with the fact that foot metastasis usually occurs only after widespread dissemination of the primary tumor. Metastatic diagnosis is often not considered because of the lack of it being at the top of a differential usually including gout, rheumatoid arthritis, or sprains. Estimates of foot metastasis may also be low due to the common practice of excluding the distal extremities from metastatic skeletal surveys or whole-body CT. The purpose of this study was to analyze articles presenting cases of foot metastasis to provide a more accurate incidence of symptomatic metastases to the foot.

Methods: A literature review using the PubMed/Medline database was performed for all articles published up till February 2020. All studies presented a case of foot metastasis with or without a known primary tumor. Forty-three studies with 45 patients were included.

Results: Thirty-seven percent of patient presented with foot metastasis as the first manifestation of the disease. The most common locations of primary tumors in patients with a positive history of neoplastic disease were the lung in 28.3 percent of cases, endometrium in 17.4 percent of cases, and breast in 10.9 percent. The large number with origin from lung cancer reflects the prevalence of lung carcinoma and its predilection for the skeleton in metastatic spread. Commonly, the localization is at the hindfoot. The chances of survival after diagnosis of foot metastasis are very low. Eight cases describe gynecological cancers with foot metastasis. Foot metastasis in gynecological cancers often occur in the calcaneus and are characterized by mostly lytic lesions. Kidney and prostate cancers are the genitourinary cancers most related to foot metastasis. Single cases of foot metastasis were reported in patients with Waldenstrom Macroglobulinemia, Ewing’s sarcoma, melanoma, pharyngeal cancer and buccal cancer.

Conclusions: Foot metastasis have likely become more frequent throughout the years, both because neoplastic patients tend to live longer and clinicians probably are more aware of the malignant potential of foot lesions. The finding of foot metastasis is indicative of an already advanced disease and poor prognosis. This underlines the importance of a thorough history taking and physical examination in patients with these symptoms and especially in those with a known history of cancer. Since foot metastases are very rarely observed, there is no standard protocol for treatment. Therapeutic management should be assigned to a multidisciplinary team of oncologists, podiatric surgeons, radiotherapists, vascular surgeons, and plastic surgeons. Because of the poor prognosis, treatment should be aimed at palliative care and preservation of function.

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