Medical mystery: How a tiny bump in a Norristown woman’s foot led to an amputation

What once appeared to be a harmless, pinhead-sized bump in the arch of Maria Pagnotta’s right foot had grown to the size of a golf ball.

In the year since the 35-year-old bank manager first noticed the bump, it had become increasingly painful and disruptive. The 10-mile runs she once enjoyed near her Norristown home were out of the question — even wearing shoes was uncomfortable.

She decided it was time to see a doctor. But even then, getting a diagnosis took months. Her insurance balked at covering an MRI the podiatrist ordered and she got the scan only after visiting a different doctor, who paid for the MRI out of his own pocket in 2021.

The MRI results and a biopsy her new podiatrist, Youssef Kabbani, ordered revealed that the lump was far from the harmless cyst Pagnotta suspected: She had synovial sarcoma, a rare form of cancer with no known cause that affects the tissue around joints.

Synovial sarcoma typically appears in hips, knees, ankles or shoulders, mostly affects males under 30 and is more common among white people than among people of color, said William L. Dahut, chief scientific officer for the American Cancer Society.

There are only about 800 cases of synovial sarcoma a year in the United States, according to Dahut, and malignancies in the foot account for only about 1% of cancer cases, said Kabbani, whose practice, Kabbani Foot and Ankle Associates, has offices in Philadelphia and Lancaster.

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When Pagnotta showed up at his office, Kabbani knew from personal experience that he needed to act fast. As a 6-year-old growing up in Lebanon, Kabbani watched his mother suffer after injuring her foot and ultimately needing a leg amputation because by the time she sought medical care, an infection had spread. He worried that the growth on Pagnotta’s foot could have health implications if not addressed immediately.

If identified early, synovial sarcoma can typically be treated with radiation and limb salvage surgery. Although Pagnotta could see a lump, sarcoma often forms in places it can’t be seen or felt.

“It’s a very slow, insidious process that occurs over a period of time,” Kabbani said. “Maria is lucky in a sense because she could actually see it.”

Sarcoma can be difficult to treat. Unlike other cancerous tumors that can be surgically removed, sarcoma can spread to nearby tissue if it’s not removed extremely carefully. It’s critical to obtain appropriate imaging and a biopsy before operating, said Cara Cipriano, chief of orthopedic oncology at Penn Medicine.

“If surgery is performed without this information, you typically have additional contaminated tissues that need to be removed,as well, or the tumor will recur and continue to grow,” she said.

In more than 90% of sarcoma cases, the limb can be salvaged and reconstructed so it is functional, and there is a low chance of the cancer recurring.

Unfortunately, limb reconstruction wasn’t a good option for Pagnotta.

In order to remove the tumor, doctors had to take out all of the critical neurovascular structures in the foot, along with a lot of soft tissue, Cipriano said. Her foot would have lost sensation as well as function, and there was a higher chance of the tumor coming back.

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She would have also needed radiation, which could contribute to pain and stiffness of the remaining tissues.

For Pagnotta, getting a prosthesis and moving on with her life was a better option — though a tough decision.

She spent the next several months processing the upcoming amputation, talking to others who’d gone through similar operations, and researching what life would be like afterward.

Pagnotta had surgery in May to remove her right foot and the portion of her lower leg starting at the middle of her shin. During the procedure, she had additional microsurgery to help reduce phantom pain — pain that feels as if it’s coming from a body part that’s no longer there.

She spent four days in the hospital, had a home nurse for several weeks, and then started several months of physical therapy. She will have surveillance imaging of her chest and the lymph nodes in her legs for the next 10 years to be sure she remains cancer free.

Pagnotta has relied on her family, especially her boyfriend, Michael Poderis, who urged her to seek treatment. Her recovery has been slow, but she’s committed to returning to her active lifestyle.

“I want to walk and exercise again,” she said, “and get my life back.”