10/28/2020    Bryan C. Markinson, DPM

Case Study: Large Solitary Neurofibroma of the Toe (Andrew Levy, DPM, Stanley Kalish, DPM)

Although I wish Dr. Levy did not invoke my name
in his initial correct comments on this article,
the response by Dr. Kalish has degenerated the
conversation to a level that I hope to put to
rest with this post.

There are certain accepted and widely practiced
surgical oncology principles that neither the
youth of Dr. Levy or the "judgment call of the experienced surgeon" as Dr. Kalish stated, can ignore,
dispute or change.

Neither Drs Levy, Kalish, or I are
musculoskeletal oncologists, the specialty which
is charged with the expertise and knowledge and
research regarding the initial management of a
soft tissue mass.

My particular experience and clinical interest in
this subject is born out of training in
pathology, and working in collaboration with
musculoskeletal oncology surgeons,
musculoskeletal pathologists, and medical
oncologists as a team member of a cancer
institute since 1995. I claim no special
expertise beyond a very concentrated focus in
this area in my clinical life.


Dr. Kalish’s legendary mentorship over several
decades in podiatric surgery deserves
extraordinary kudos over a broad breath of
teaching, publication, and innovation. I believe
that the main intent of the paper in question was
to present the uniqueness of the lesion (which
should be applauded) and not to discuss
appropriate management. However, the details of
the management were well described, prompting the
comments of Dr. Levy and subsequent response of
Dr. Kalish.

Having said the above, these are the accepted
principles regarding the initial management of a
soft tissue mass, such as the case presented:

1) Biopsy before excision is the most appropriate
approach

2) All soft tissue masses with concern for
malignancy making their way to the OR get a plain
x-ray and MRI evaluation pre-op.

3) Concern for multiple procedures as stated by
Dr. Kalish is easily avoided with frozen section
biopsy at the time of the planned excision.
Alternatively, an office based core needle biopsy
is the best way to accomplish this.

4) Lack of bone involvement on pre-operative x-
rays and visual characterization of the mass
being well encapsulated at time of operation are
very WEAK evidence of the lesion being benign. In
fact, encapsulation is actually a histologic
finding. On several trips I have made to the
frozen section area, lesions looking well
encapsulated were in fact NOT well encapsulated
on histology.

5) The principles of biopsy before excision have
to do with staging and management of the patient
in the event biopsy reveals malignancy. Some
malignant soft tissue lesions, depending on size,
histology, and aggressiveness of the tumor are
best treated with chemo and radiation BEFORE
excision, and there is an opportunity for staging
to determine extent of disease before local wide
excision. Also critically important is
determining the necessary margins of local wide
excision. Removal of the lesion before this
absolutely and forever removes the ability to
know where the mass began and ended,
necessitating a much larger area of wide local
excision when definitive surgery is planned.
Since the foot and ankle are small areas, what
would have conservatively been a wide local
excision involving a toe or ray amputation, (if
the lesion was intact) now would have to be
graduated to a forefoot or even below knee
amputation, as margins of the excised lesion can
never be determined. In my opinion, no podiatric
surgeon should ever be associated with having
caused this to occur

6) Removal of a lesion as done in this case
introduces luck into the equation. Luckily most
soft tissue masses in the foot and ankle are
benign, which is why the clinical outcome in most
cases like this is not at issue. However, no
degree of experience in podiatric surgery endows
anyone with the ability to know if a mass is
benign or malignant, and as such, no advice to
any practitioner at any age or level of
experience

should ignore the very well accepted principle of
knowing the biology of a mass before removing it.

Bryan C. Markinson, DPM, NY, NY

There are no more messages in this thread.