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A 66-year-old Caucasian man presented with a 9-month history of a painful left heel with associated soft tissue swelling. Pitting oedema was present to the upper shin. Plain radiograph showed a sclerotic calcaneum with lucent patches and the CT scan revealed bony destruction at the posterosuperior aspect of the calcaneus with a moth-eaten appearance. To obtain a more definitive diagnosis, the patient underwent a CT-guided biopsy, which showed caseating granulomatous inflammation strongly suggestive of Mycobacterium infection. A Ziehl-Neilson stain did not show any microorganisms. Microbiology confirmed the presence of Staphylococcus aureas. A diagnosis of tuberculosis with concomitant Staphylococcus superinfection was made based on the histology and clinical context. The patient was treated with curettage and cementing of the lesion in order to debride the infected tissue and provide structural support to the bone. A 9-month course of quadruple antituberculous therapy was also initiated.

Recruitment into trauma and orthopaedics is competitive and has been subject to many changes in recent years, including the first national recruitment selection in 2013 for the third year of specialty training. Yasmeen Khan and colleagues describe this new national recruitment process and attempt to identify common characteristics of successful candidates

Aims Review the experience of a single institution9s multi-disciplinary sarcoma group with regards management of fibromatosis. Methods Retrospective analysis of case notes of all young people ( Results Thirty-two records were analysed; 4 children seen as second opinion only were excluded. There were 22 girls and 6 boys (3.7:1 ratio). Median age at diagnosis was 13.9 years. Twenty-three out of 28 children underwent surgical resection; 4 had complete microscopic resection, despite which 3 relapsed at a median of 13 months. Of the remaining 19 children with intra-lesional/unknown disease clearance, 4 remain in continued radiological remission at a median of 50 months, 4 had residual disease on MRI, and 11 had progressive disease at median 10.5 months after surgery. Hormonal therapies and/or non-steroidal anti-inflammatory drugs were used for 12 children; 8 had stable disease at median 43 months, whilst 3 progressed at a median of 20 months and response assessment is awaited in 1. Three with stable disease had concomitant radiotherapy. Eleven children were treated with cytotoxic chemotherapy (11 episodes), with progression after 4 episodes at a median of 29 months from diagnosis, while post 6 episodes stable/responsive disease was achieved at a median 35 months. Response assessment in 1 child is awaited. Eleven children received radiotherapy, with 1 child receiving 2 separate courses (different anatomical sites). Three children had progressive disease following radiotherapy (including the child with multi-focal disease) at a median of 67 months, whilst the remaining 8 (72%) children achieved stable/responsive disease at a median of 51.5 months. Conclusions With a caveat of small numbers, complete resection is technically more demanding and does not necessarily have a clear outcome advantage compared with incomplete histological resection. We propose excision should only be attempted if associated morbidity is low. Chemotherapeutic and non-cytotoxic agents are an alternative to avoid surgery and radiotherapy in the growing child. Radiotherapy was associated with induction of responsive/stable disease in 72% and is a useful therapy, although concerns about the impact on the growing child will limit its wider use in this patient group.

Soft tissue tumours are rare, and the exact proportion of benign to malignant lesions (sarcomas) is difficult to determine. A study of a hospital population found that benign lesions outnumbered malignant ones by 100:1; their incidence was about 300 per 100 000 population.1 In an average general practice of 3000 patients, at least three cases of benign soft tissue tumour per year may be expected. However, only one case of soft tissue sarcoma would be expected in this population every 24 years. More than 50 different types of soft tissue tumour are recognised, and management depends on the tumour stage, grade, and histological type. The consequences of a missed case of sarcoma are serious—even a low grade sarcoma may metastasise. In the experience of our unit, cases of soft tissue sarcoma are being referred with some delay. This may result in adverse consequences for patients and potential medicolegal implications. The National Institute for Health and Clinical Excellence (NICE) is currently producing outcome guidelines for bone and soft tissue sarcomas. In this editorial, we aim to raise the general index of suspicion concerning soft tissue sarcomas and thereby achieve earlier referral to specialist centres. Symptoms of soft tissue sarcomas are often insidious. A discrete lump or diffuse swelling may be the only consistent presenting feature. Size is one of the most important clinical features of a soft tissue lesion. Any soft tissue lesion over 5 cm in maximum diameter has a 20% likelihood of being malignant.2 Soft tissue malignancies are usually painless until the latter stages, when the tumour has encroached on adjacent structures either by direct invasion or by mass effect. This has previously been identified as a reason for delayed presentation of soft tissue sarcomas.3 Patients are much more likely to seek medical attention early if a swelling is associated with persistent pain. The duration of symptoms combined with changes in symptoms is a useful diagnostic factor. A lesion that has been present for 20 years and has not changed in appearance is unlikely to be malignant. A recent increase in size, however, may represent sarcomatous transformation. A history of trauma can be elicited in many cases and is sometimes proffered as an explanation by the patient. This can be misleading because a trivial traumatic episode may be the reason why a patient notices his or her lump. Recent trauma should present with concurrent clinical evidence, such as bruising or abrasions. If the injury was some time in the past then why has the patient not recovered? An abscess or cellulitis has easily recognisable signs of inflammation, but a previously present mass or swelling may cloud the picture. A ganglion should transilluminate, and should raise suspicion if it does not. Small superficial lumps are more likely to be benign. The commonest sites for soft tissue sarcomas of the extremities are the thigh and buttock, and lesions in these areas are more likely to be malignant than those in other locations.2 A deep mass greater than 5 cm in diameter, located proximally in the limb in a patient older than 50, has a 50% chance of being malignant.2 Other than a small peak in incidence in children, sarcomas are more common in elderly people. However, any tissue lesion under observation should give rise to suspicion, especially if it is enlarging. Patients with lumps should be reviewed again, preferably within six weeks of initial presentation. If a lump under observation has not resolved the diagnosis should be reconsidered and the patient referred. Magnetic resonance imaging is the gold standard for investigation of soft tissue lesions and is mandatory in the investigation of large or poorly defined lesions. Obtaining such scans should not delay the referral of patients. We cannot stress too highly how important it is to voice concerns about possible malignancy at the time of requesting investigations. We advise direct discussion with a radiologist to arrange investigations, and if a delay occurs then the patient should be referred directly to a specialist centre. It is unacceptable that a patient with a possibility of a malignant lesion should have to wait months for “non-urgent” magnetic resonance imaging. Ultrasonography has been shown to be less reliable than magnetic resonance imaging for further investigation.3 Plain radiographs may be of value in showing the relation of the lesion to bone and its tissue density, as well as in identifying some lesions, such as of synovial sarcomas, of which up to 50% show calcification. Any lesion causing concern, whether superficial or deep, should be referred to a specialist centre on an urgent “sarcoma two week wait” form, which will ensure the patient is seen within two weeks of the referral or be investigated with magnetic resonance imaging and possibly a tissue biopsy with a true cut needle. The message therefore is to be suspicious and have a low threshold for further investigation and referral. This will allow earlier detection and hopefully improve the prognosis of patients with soft tissue sarcomas.