A 55 years-old female presented with insidious right foot pain and swelling over 6 months in absence of trauma. Symptoms worsened with walking and standing.
In April 2007 the patient underwent unplanned excision of the lump in the right Achilles’ tendon. Histology showed a myxofibrous inflammatory sarcoma grade 2 according to FNLCC classification.
Magnetic resonance imaging (MRI) was negative for local recurrence at 6 and 12 months after surgery. No further follow-up was performed during the next 4 years.
In August 2012 the patient was referred to our Institute for pain lasting 2 years. At the physical examination, the foot presented a lump, slightly painful, attached to the Achille’s tendon, with no signs of infection.
In October 2014 MRI showed a lump of 5 × 2,5 × 2 cm into Achille’s tendon with invasion of the anterior fat tissue but no invasion of the surrounding bones (Fig. 1). A few days later, the patient was referred to our emergency ward for a distal tibia and bimalleolar fractures, which was treated through internal osteosynthesis. Before surgery, a needle biopsy was performed and histology showed a grade 2 epitheliomorphus sarcoma. After 1 months with no weight-bearing, x-rays showed initial fracture healing. Then the patient underwent tumor excision and reconstruction of the tendinous defect with peroneus brevis transfer. Histology showed epithelioid sarcoma, with immunohistochemical stains positive for epithelial membrane antigen (EMA), but INI 1 CD 31, S100, Mucine 4 and cytokeratin AE1/3 negative (Figs. 2, 3). Surgical margins were wide. Patient was discharged with a not walking plaster boot.
Forty days later the patient was re-admitted for plaster cast removal and to start adequate physiotherapic protocol. She was allowed to walk with progressive weight bearing, wearing ankle brace.
Follow up visits, Thoracic computerized tomography (CT) and foot and ankle MRI were then scheduled at every 4 months for 3 years, then every 6 months until the fifth year after surgery and then annually until the tenth year.
In January 2015 the patient presented a small area of skin defect and in February she was treated with negative pressure wound therapy for 3 months. In June the skin was completely healed, the MRI showed no sign of local recurrence (Fig. 4) and the CT scan was negative for metastasis.
One year later ankle range of movement was 45° in flexion, with a good ankle stability.
At the final follow-up at 5 years in 2019 there was no evidence of oncological disease and the patient was able to walk without pain nor limping, she could walk on tiptoe and remained a slight defect of 10° of flexion comparing to the contralateral side.