Primary chondrosarcoma of long bones and limb girdles

[Cartilage tumours of the bone. Diagnosis and therapy]

Primary malignant bone tumours are rare. The annual incidence of these tumours is 10 per 1 million. Nearly 30% of the primary malignant bone tumours are malignant cartilage tumours. The frequency of benign cartilage tumours cannot be definitely estimated because these tumours are normally clinically inapparent and therefore often diagnosed as an incidental finding. The cartilage tumours appear as benign lesions (e.g. chondroma), as borderline tumours (proliferative chondroma vs grade I chondrosarcoma) or as highly malignant chondrosarcoma (e.g. dedifferentiated chondrosarcoma). Commensurate with the different clinical and oncological manifestations of the cartilage tumours, there are wide differences in the treatment and clinical course of the individual tumour. This article discusses the problems in the diagnosis and treatment of cartilage tumours from an orthopaedic point of view.

Fine-needle aspiration of chondrosarcoma

Fine-needle aspiration (FNA) is a reliable, safe and cost-effective procedure with an established role in the diagnosis of various solid tissue neoplasms. However, the role of FNA in the diagnosis of primary bone tumors, including chondrosarcoma (CS) is controversial. To determine the accuracy of FNA as a diagnostic procedure, the author reviewed the institutional experience of a series of patients with CS who underwent FNA for diagnosis. The author's objectives were to determine the accuracy of the technique as well as possible limitations to sensitivity and specificity, and perhaps to suggest the most appropriate use for this procedure. Computer records and then subsequently archives of the department were searched for patients diagnosed and treated for CS between 1993 and 2003. Patients without adequate clinical follow-up, missing materials or records otherwise unavailable for review were eliminated from study. All patients who underwent FNA for a diagnosis had to have a subsequent histological confirmation to be included in the study. FNAs were largely performed with image-guided assistance. In those that were palpable, the aspiration was performed by the aspiration cytologist using standard methods. Histologic materials were processed according to standard methods. All cytological and histologic materials were reviewed for accuracy and appropriateness of diagnosis by the author. There were 34 aspirates from 32 patients with CS (2 patients with 2 aspirates each). Attempts at diagnoses were made from 27 primary lesions, 6 recurrent lesions, and one metastatic lesion. There were an additional two patients who were assigned a diagnosis of CS on FNA who ultimately were proven to have chondroblastic osteosarcoma. Of the primary CS, 18 were definitively diagnosed as CS or "malignant chondroid neoplasm," 8 of the aspirates were considered equivocal in that an additional diagnostic procedure was required to clarify or confirm the diagnosis. Two aspirates were diagnosed as negative. Both of the false negatives were due to inadequate sampling of the lesion on FNA. Diagnostic accuracy of FNA for primary CS in this series was 67% (18/27). Accuracy for recurrent or metastatic lesions was higher at 86% (6/7). FNA appears to be a reliable means of diagnosis of recurrent and/or metastatic CS in patients with a documented history. In primary lesions, however, the accuracy of the technique is lower. In addition, there are problems of sampling chondroid components of non-CS lesions such as this study's experience with chondroblastic osteosarcoma.

Pelvic tumor presenting as chronic back pain in a young adult

A large proportion of Emergency Department visits are for chronic pain, specifically for chronic back pain. Often this entity requires minimal diagnostics. However, certain populations and presentations require a higher vigilance and a more detailed evaluation. This report describes the clinical presentation of a young adult with chronic back pain who exhibited new symptoms and subtle examination findings that expedited the ultimate diagnosis of pelvic chondrosarcoma.

[Low-grade central chondrosarcoma: difficult diagnosis in an adolescent girl]

Central chondrosarcoma of the tibia is exceptional, particularly in young patients. Low-grade tumors raise difficult problems for histological distinction with enchondroma. We report a case of grade 1 chondrosarcoma located in the upper portion of the tibia in a 17-year-old girl. After radical surgery, outcome was favorable with no recurrence or metastasis at three years follow-up. The distinction between low-grade central chondrosarcoma and enchondroma is one of the most difficult challenges in bone pathology. Clinical, radiographic and pathological data must be considered together to reach certain diagnosis.

The MAPK-AP-1/-Runx2 signalling axes are implicated in chondrosarcoma pathobiology either independently or via up-regulation of VEGF

AIMS

To investigate whether and how the JNK/ERK-AP-1/-Runx2 signalling pathways and vascular endothelial growth factor (VEGF) are engaged in the pathogenesis of cartilaginous tumours. Chondrosarcoma is the third most common primary skeletal malignancy. Nevertheless, the molecular events underlying its pathogenesis remain elusive. JNK/ERK MAPKs and their downstream effectors, c-Jun and c-Fos (AP-1), are involved in chondroblastic differention/proliferation. These proteins interact with the Runx2 transcription factor, which is also implicated in chondroblast biology. VEGF, a key angiogenic factor, is up-regulated in human chondrosarcomas.

METHODS AND RESULTS

Normal cartilage and neoplastic cells from 45 chondrosarcomas and 21 enchondromas were investigated immunohistochemically. We evaluated the cellular levels of JNK2, p-JNK2 (phosphorylated/activated JNK2), its main substrate, c-Jun, pc-Jun (phosphorylated/activated c-Jun) and c-Fos. Moreover, the levels of p-ERK (phosphorylated/activated ERK), Runx2 and VEGF were assessed. Positive immunostaining for all proteins was observed in the majority of the examined chondrosarcomas and in a small fraction of enchondromas. The expression levels of all proteins were positively and significantly correlated with each other. These levels were substantially augmented in high-grade compared with low-grade chondrosarcomas and in low-grade tumours compared with benign enchondromas, implying a potential use as molecular markers for prediction of high-grade neoplasms.

CONCLUSIONS

The JNK/ERK-AP-1/-Runx2 signal transduction 'network' is associated with chondroblastic malignant transformation and chondrosarcoma development, either separately or through coordinated induction of VEGF.

Surgical treatment and outcome of conventional pelvic chondrosarcoma

We reviewed 124 patients with a conventional pelvic chondrosarcoma who had been treated over a period of 20 years. We recorded the type of tumour (central or peripheral), type of operation (limb salvage surgery or hemipelvectomy), the grade of tumour, local recurrence and/or metastases, in order to identify the factors which might influence survival. More satisfactory surgical margins were achieved for central tumours or in those patients treated by hemipelvectomy. However, grade 1 tumours, whatever the course, did not develop metastases or cause death, while grade 3 tumours had the worst outcome and prognosis. Central, high-grade tumours require aggressive surgical treatment in order to achieve adequate surgical margins, particularly in those lesions located close to the sacroiliac joint. By contrast, grade 1 peripheral chondrosarcomas may be treated with contaminated margins in order to reduce operative morbidity, but without reducing survival.

cDNA expression profiling of chondrosarcomas: Ollier disease resembles solitary tumours and alteration in genes coding for components of energy metabolism occurs with increasing grade

Conventional central chondrosarcomas are malignant cartilaginous tumours, occasionally arising secondary to either solitary or multiple (Ollier disease) enchondromas. Recurrences may have progressed in grade. The aims of the present study were to identify putative differences in gene expression between solitary and Ollier disease-related tumours, and to elucidate signalling pathways involved in tumour progression by genome-wide cDNA expression analysis. Arrays enriched for cartilage-specific cDNAs and genes involved in general tumourigenesis were used to analyse enchondromas (n = 3, two with Ollier disease), chondrosarcomas of different grades (n = 19, three with Ollier disease), normal resting-zone cartilage (n = 2), and chondrosarcoma cells in culture (n = 7). The arrays were analysed by unsupervised hierarchical clustering, significant analysis of microarray, and T-tests. Confirmation of data was performed by immunohistochemistry and quantitative reverse transcriptase polymerase chain reaction (RT-PCR). Ollier disease cases and solitary tumours revealed similar expression profiles, suggesting that the same signalling pathways are involved in tumourigenesis. Interestingly, JunB protein expression was significantly higher in grade I chondrosarcomas than in enchondromas (p = 0.009), which could be of diagnostic relevance. Upon chondrosarcoma progression, matrix-associated genes are down-regulated, reflecting the histology of high-grade tumours. An increase in glycolysis-associated, and a decrease in oxidative phosphorylation-related, genes was found in high-grade tumours. These findings suggest an adaptation in energy supply upon progression towards higher grade.

Emerging pathways in the development of chondrosarcoma of bone and implications for targeted treatment

Chondrosarcoma is a malignant cartilage-forming tumour of bone, of which distinct clinicopathological subtypes are known. Conventional chondrosarcoma is notorious for its locally aggressive behaviour as well as for its resistance to chemotherapy and radiotherapy; so far surgery is the only effective therapeutic option. During the past 10 years, substantial new insights have been gained about molecular cell biology, molecular cytogenetics, and immunopathology, leading to better understanding of chondrosarcoma development at the molecular level, which will ultimately lead to better clinical understanding and possibly to the development of targeted treatment.

[Therapy of enchondroma in long bones]

The treatment of enchondroma in long tubular bones has been the subject of controversial discussions for several years. Whereas secondary malignancy is very rare when the enchondroma is located in a hand, a position near to the trunk represents a high risk of transformation into a chondrosarcoma. For an enchondroma in long tubular bones, authors recommend a whole variety of approaches ranging from regular controls to radical en bloc resection. Between 1989 and 2001 we followed a concept of intralesional resection and cement filling. After an interval without recurrences, the cement was extracted and replaced by a spongiosaplasty. Of 16 patients 12.5% suffered from an intralesional fracture in the course of the treatment, and 25% complained of persistent pain and loss of function after surgery. These complications led us to change our concept. Though there were two cases of secondary transformation into chondrosarcoma G1, we now prefer to keep the patients under close clinical and radiological control without performing surgery.

Chondrosarcoma of the scapula

BACKGROUND

Chondrosarcoma is the second most common primary sarcoma of bone. It often develops within flat bones, such as the pelvis, ribs, and scapula. In the current study, the authors reviewed the surgical experience and long-term oncologic outcomes of patients with chondrosarcoma arising in the scapula.

METHODS

The medical records of 29 consecutive patients with chondrosarcoma of the scapula were reviewed. The patients were treated between 1954 and 1994. All patients had localized disease at the time of presentation. The tumors were classified histologically as Grade 1 (10 patients), Grade 2 (10 patients), Grade 3 (7 patients), dedifferentiated (1 patient), and mesenchymal (1 patient) (using the criteria of Evans et al.). The mean maximal dimension of the tumors was 11 cm. Twenty-five patients underwent limb-sparing surgical resection and 4 patients underwent forequarter amputations. The median follow-up was 13 years (range, 1-35 years).

RESULTS

At last follow-up, 22 patients (76%) were free of disease and 7 patients (24%) had died of their disease. Local recurrence occurred in 4 patients at 7 months, 16 months, 40 months, and 43 months, respectively. The local recurrence-free survival rate was 86% at 5 years, 10 years, and 20 years. Disease-specific survival was 83% at 5 years, 74% at 10 years, and 74% at 20 years. Patients who had low-grade chondrosarcomas had better survival compared with patients who had high-grade chondrosarcomas (P = 0.07).

CONCLUSIONS

Patients who had localized chondrosarcoma of the scapula had a favorable long-term outcome, most likely due to the unique anatomic features that improved the likelihood of achieving wide surgical margins with limb-sparing surgery, despite the frequent presentation of locally advanced disease.

Chondrosarcoma of the chest wall: a retrospective clinical analysis

Primary chondrosarcoma of the chest wall is uncommon, and reports of treatment from one institution are limited. Treatment of this lesion is difficult because of the anatomic location, which is in close proximity to surrounding neurovascular and visceral structures. The purpose of this study was to review the outcome of surgical resection of chondrosarcoma of the chest wall, and to delineate the prognostic factors related to local recurrence and survival. Twenty-four patients with chondrosarcoma of the chest wall were treated at our institution between 1986 and 2000. There were 14 males and 10 females, with an average age of 54 years (range, 11-76 years). Patients were observed for a minimum of 3 years or until death. The median followup was 71 months. The anatomic locations of chondrosarcoma of the chest wall were the rib in 16 patients, the ribs and sternum in two patients, the ribs and spine in three patients, and the sternum only in three patients. Histologically, 17 patients had Grade 1 disease and seven patients had Grade 2 disease. At followup, 17 patients were alive without disease, two were alive with disease, two died without disease, and three died secondary to progressive disease. The overall survival estimate at 5 years was 92%. The recurrence rate for patients with adequate surgical margins was 10%, compared with 75% for patients with inadequate margins. The 5-year survival rate for patients with adequate surgical margins was 100%, compared with 50% in patients with inadequate surgical margins. An inadequate margin of resection was associated with a significantly worse overall survival and a higher chance of having local recurrence develop.

Primary malignant tumours of bone and soft tissue in the elderly

AIMS

This study reports outcome, functional results and quality of life of 45 elderly patients with age over 70 after surgery for primary malignant bone and soft tissue tumours.

METHODS

There were 24 primary malignant bone tumours and 21 soft tissue sarcomas. The most frequent diagnoses were: chondrosarcoma, malignant fibrous histiocytoma and liposarcoma. Local tumour resection with and without osteosynthesis, endoprostheses, and amputations had been performed for surgery. The patients were prospectively followed in a tumour register.

RESULTS

Complication and revision rate, functional outcome using the Musculoskeletal Tumor Society score, 5-year survival rate, median survival time and quality of life according to the Life Satisfaction Index A and the global health and quality-of-life scale of the QLQ-C30 revealed results that are only slightly inferior to those reported in younger tumour patients.

CONCLUSIONS

The results of this study generally justify even extensive tumour surgery in the elderly patient over 70 although outcomes are not quite as good as those reported for younger adults. However, especially in the old patient indications like general condition and comorbidity should be given due consideration before any decision is made on whether surgery should be performed and if so what surgical technique should be applied.

Scapular chondrosarcomas have high rates of local recurrence and metastasis

This is the first report of a large series of patients with scapular chondrosarcomas. The grade distributions, locations of the tumors in the scapula, surgical techniques, status of margins, chondrosarcoma subtypes, Enneking stages, adjuvant therapies, local recurrence rates, metastasis rates, and survival prognoses of patients with scapular chondrosarcoma were evaluated. Forty-seven patients treated between 1921 and 1999 were analyzed retrospectively. Grade 3 disease was significantly associated with a poorer survival prognosis when compared with Grades 1 or 2 disease. Patients with tumors smaller than 5 cm were treated mainly with partial scapulectomy, and patients with tumors larger than 5 cm often were treated with total scapulectomy. The survival prognoses of patients with intralesional resections at initial surgery showed a tendency toward poorer survival when compared with patients with wide resections at initial surgery. Metastasis and local recurrence (21.3% and 40.4%) were higher in scapular chondrosarcomas than rates reported for patients with general chondrosarcomas, and local recurrence or metastasis was associated with limited survival. The 5- and 15-year survival probabilities subsequent to diagnosis were 79% and 53%, respectively. The high rates of local recurrence and metastasis likely were caused by the difficult anatomic relationships encountered during scapular resections. This study shows the importance of wide margins which must be achieved to provide local disease control.

Maternal and Neonatal Outcomes in Pregnancies Complicated by Bone and Soft-Tissue Tumors

OBJECTIVE

Primary bone and soft-tissue tumors occur rarely in pregnancy. The objective of this study was to describe the outcome of a large cohort of pregnant patients with these rare tumors.

METHODS

Pregnant women diagnosed with bone or soft-tissue tumors during pregnancy or within 3 months after delivery were identified retrospectively for the years 1983-2003 in the University Health Network database, University of Toronto. Relevant maternal and neonatal data were collected on a standardized data form.

RESULTS

In more than 60,000 deliveries during the study period, 17 patients were identified. Gestational age at diagnosis ranged from 11 weeks to 2 months postpartum. Eight cases involved the lower extremity and 6 involved the upper extremity. Osteosarcoma, chondrosarcoma, and giant-cell tumors were the most common histological types. Metastases occurred in 7 cases. Nine cases were treated surgically during the course of pregnancy. The majority of patients were delivered at term. Chemotherapy was deferred until the postpartum period. One patient elected for early termination of pregnancy. Three patients were delivered before 37 weeks of gestation to proceed with therapy. One neonate delivered at 34 weeks developed respiratory distress syndrome and required intubation. Three patients died, all as the result of metastatic disease. There were no perinatal or infant deaths.

CONCLUSION

Most cases of soft-tissue and bone tumors during pregnancy can be successfully managed with surgery during gestation. Therapies with fetal toxicity were more likely to be deferred to the postpartum period.

NOV (CCN3) regulation in the growth plate and CCN family member expression in cartilage neoplasia

Growth plate chondrocytes undergo a coordinated differentiation process resulting in terminal differentiation and new bone formation. Enchondromas are pre-malignant, benign cartilaginous lesions that arise from growth plate chondrocytes that fail to undergo terminal differentiation. NOV (nephroblastoma overexpressed) is a member of the CCN family of proteins, which share a common multi-modular organization. While the role of NOV in chondrocyte development and cartilage neoplasia is not known, other CCN family members play a role in chondrocyte differentiation, or are differentially regulated in cartilage neoplasia. In embryonic murine growth plates, NOV was expressed in pre-hypertrophic and early hypertrophic chondrocytes. PTHrP treatment (which inhibits terminal differentiation) decreased NOV expression in murine femurs maintained in organ culture, and decreased the activity of a NOV reporter construct in vitro. Expression of the CCN family members NOV, CTGF, CYR61, and WISP-1 was examined in 15 chondrosarcomas of various grades and in three enchondromas. Expression of all of the family members was lower in the higher-grade tumours. As identification of the grade of cartilage neoplasia can sometimes be difficult using histology alone, the level of expression of CCN family members could be a useful adjunct in the determination of tumour grade.

Unresolving hip tendonitis leads to discovery of malignant tumor

OBJECTIVE

To discuss a case of malignant bone tumor in the left hip of a patient who sought treatment following a tennis injury.

CLINICAL FEATURES

A 27-year-old male patient visited a chiropractic clinic 6 months after a twisting injury to his left hip which occurred while playing tennis. His pain had remained moderate in intensity and intermittent to frequent in frequency since it originated but became more intense the week prior to his visit.

INTERVENTION AND OUTCOME

The patient was diagnosed with a tendonitis/bursitis and received 3 weeks of treatment. Care consisted of various forms of passive modalities to reduce pain and inflammation, as well as hip mobilization and tissue stretching. Plain film examination was then performed, due to lack of progress, and revealed a possible chondroblastoma of the femoral head. The patient was referred to his primary care physician (PCP) for follow-up imaging. Surgical resection of the lesion occurred approximately 2 months later. Biopsy of the resected cells confirmed a new diagnosis of clear cell chondrosarcoma. A computed tomography (CT) scan of the chest was performed to rule out metastasis to the lungs. Regular follow-up care and imaging continued and revealed, 9 months following, that the femoral head lesion had returned and hip replacement surgery would be needed.

CONCLUSION

Tendonitis, bursitis, and sprains commonly occur following sports-related trauma to the appendicular skeleton. A conservative trial of care should be performed on suspected soft tissue injuries. However, when lack of improvement occurs within the first month, further examination, special studies, or referral are warranted to ensure a proper diagnosis and to rule out a pathological condition.

Diagnosis and grading of chondrosarcomas on FNA biopsy material

A consecutive series of 47 chondrosarcomas was reviewed to identify the most useful criteria for cytological diagnosis, and grading in comparison to histology grade. This series includes 39 evaluable cases, including 2 patients with Ollier's disease and 2 with extraskeletal chondrosarcomas. Eight cases were excluded because of lack of histologic confirmation (3). nondiagnostic cytology (4). and one inconclusive histologic diagnosis. The cytologic diagnosis of these tumors was based on the identification of chondrocytes and a chondromyxoid stroma. The chondrocytes often showed double nuclei (34/39) and macronucleoli (20/39). Nuclear atypia in terms of distinct variation in size was less common (16/39). Cytoplasmic granules and vacuoles were often seen (34/39 and 29/39, respectively). In smears, chondroid fragments and a chondromyxoid background were seen in a majority of cases (36/39 and 30/39, respectively). By grade, concordance with histology was present in 4/7 grade I tumors, 26/29 grades II-III, and 5/5 grade IV, respectively.

Prognostic relevance of cell biologic and biochemical features in conventional chondrosarcomas

BACKGROUND

Conventional chondrosarcoma is the second most common malignant solid tumor of bone, and its management still poses a challenge for the orthopedic surgeon. Currently, tumor grade is the only parameter of prognostic significance besides stage and, possibly, resection margins. Additional independent prognostic markers therefore would be highly valuable for patient management.

METHODS

In the current study, the authors evaluated biologic markers for various chondrocytic phenotypes by histochemical and immunohistochemical technology in a large series of clinically well defined cases of enchondromas and conventional chondrosarcomas, each with at least 5 years of clinical follow-up.

RESULTS

The authors' results confirm the strong correlation between clinical behavior and cell differentiation as expressed by marker genes. The phenotypes of the tumor cells are the biologic substrate of the histopathologic appearance of the neoplasms and, thus, the biologic basis for classic tumor grading. Collagen Types II and X, as well as the proteoglycan aggrecan, suggest a mature neoplastic phenotype and good prognosis, i.e., low recurrence rate, rare metastasis, and long survival. Conversely, collagen Type I, together with cell spindling, indicates a transition to a more proliferative, so-called "dedifferentiated" phenotype, which clearly is associated with a poorer prognosis. The changes in cellular phenotypes are accompanied by changes in proliferative activity. Thus, low-grade neoplasms showing mainly mature and terminally differentiated (hypertrophic) chondrocytes display only scant proliferation whereas less differentiated chondrosarcomas with biologically dedifferentiated chondrocytes show significantly higher proliferative activity, a feature that is also highly correlated with prognosis.

CONCLUSIONS

These data indicate that molecular markers are to a large extent the biologic basis of the conventional grading, rather than representing independent prognostic markers. The authors' results further indicate that COL1 has significant value in the distinction between enchondromas and low-grade chondrosarcomas including these that are histologically similar. Further understanding of chondrocytic phenotypes will be a promising way to provide new tumor markers for better understanding, diagnosis, and treatment of chondroid neoplasms.

Treatment and outcome of recurrent pelvic chondrosarcoma

Little has been published about the outcome of patients with recurrent chondrosarcoma of the pelvis. The current study is a review of patients with surgically treated locally recurrent pelvic chondrosarcoma at one institution. Twenty-one patients had surgical resection of recurrent pelvic chondrosarcoma between July 1974 and July 1996. There were nine women and 12 men with a mean age of 46 years (range, 24-67 years) at first recurrence. Patients were followed up for a minimum of 3.3 years and median of 12 years from first (index) recurrence or until death. The mean time to index recurrence was 27 months (range, 5-87 months). In three cases (14%), the tumor at index recurrence was a higher grade than the initial lesion. There were six additional tumors that became a higher grade during subsequent recurrences. Fifteen of the 21 patients (71%) had a second local recurrence. Five patients (24%) had distant metastasis. At death or final followup, 11 patients (52%) had no evidence of disease, two patients (10%) are alive with disease, and eight patients (38%) died of their disease. The three patients with high-grade tumors at index recurrence all died of disease. The treatment of recurrent pelvic chondrosarcoma is a challenging problem. Tumor-free margins may require radical surgery, and the best chance of cure is at the time of initial resection. With aggressive surgical intervention, approximately 50% of patients with recurrent pelvic chondrosarcoma can achieve long-term survival.

Infiltration of sarcomas into the hip joint: comparison of CT, MRI and histologic findings in 67 cases

We analyzed the incidence, route, and characteristics of hip joint infiltration in pelvic or proximal femoral sarcomas. 67 patients with a sarcoma that originated around the hip joint (50 pelvic and 17 femoral) were included in this study. Preoperative CT and MRI were matched with the histological findings in tumor specimens. Tumor infiltration into the hip joint was suspected on the basis of preoperative imaging in 29 patients due to articular cartilage disruption, diffuse signal changes in the acetabulum or femoral neck, signs of a tumor in the joint, or markedjoint effusion. Of these 29 patients, 15 showed tumor invasion on histological examination. 12 of 31 chondrosarcomas, none of 12 Ewing's sarcomas, and 3 of 24 osteosarcomas infiltrated into the hip joint (p = 0.008). 10 of 26 low-grade sarcomas and 5 of 41 high-grade sarcomas infiltrated into the hip joint (p = 0.02). The joint infiltration rate of the chondrosarcomas was related to their size. Of 10 tumors originating in the acetabulum, 9 penetrated through or around the osseous-ligamentous junction and one through the acetabular cartilage. In 5 proximal femur lesions, all infiltrated the joint through the femoral neck, 3 of them also through the ligamentum teres.

Cartilaginous lesions of bone

Cartilaginous lesions of the skeleton are very unusual. It is extremely important to correlate the roentgenographic features, the clinical features, and the histological features to arrive at a definite diagnosis. Most cartilaginous lesions are benign or of low-grade malignancy. However, there are some subtypes of chondrosarcoma that behave in a highly aggressive fashion.

Cytogenetic aberrations and their prognostic impact in chondrosarcoma

Chondrosarcoma is the second most common primary malignancy of bone. Cytogenetic data are available from close to 100 cases, including all subtypes of chondrosarcoma. Specific chromosomal rearrangements have been identified only in extraskeletal myxoid chondrosarcoma (EMC). Strong prognostic factors are largely missing, although size and, in particular, histologic tumor grade have been implicated. In the present study, we investigated the genomic aberrations in 59 chondrosarcomas (six grade 1, 24 grade 2, and 29 grade 3, including dedifferentiated tumors), excluding EMC, by chromosome banding analysis and DNA flow cytometry and correlated the findings with clinical outcome. Hyperhaploid to near-diploid karyotypes were found in half of the cases, and there was a good correlation between cytogenetics and flow cytometry data; discrepancies were seen primarily in cases with normal karyotypes and in those with -Y as the sole anomaly. Abnormal karyotypes, excluding those with -Y as the only change, were found in 36 cases. No recurrent structural aberration was found, but a nonrandom pattern of aberrations was seen. Total or partial gains and losses were the dominant karyotypic features. Genomic imbalances found in at least 10 cases included -1p36, -1p13-p22, -4, -5q13-q31, -6q22-qter, +7p13-pter, -9p22-pter, -10p, -10q24-qter, -11p13-pter, -11q25, +12q15-qter, -13q21-qter, -14q24-qter, -18p, -18q22-qter, +19, +20pter-q11, +21q, and -22q13. At the latest follow-up, 19 patients had experienced distant metastases, and the 5-year metastasis-free survival rate was 0.69. By univariate analysis, malignancy grade and loss of material from 6q, 10p, 11p or 11q, 13q, and 22q were associated with impaired metastasis-free survival. Only -13q was an independent prognostic factor for metastasis, regardless of tumor grade or size.

Prognostic factors and outcome of pelvic, sacral, and spinal chondrosarcomas: a center-based study of 69 cases

BACKGROUND

The surgical treatment of chondrosarcoma of the pelvis, sacrum, and spine is complex and technically demanding. As such, adequate surgical margins have been difficult to achieve, resulting in poor local control and survival. The objective of this study was to assess the outcome of patients with chondrosarcomas in these sites who were treated at a tumor center by using modern, aggressive surgical techniques and to identify prognostic factors.

METHODS

Sixty-nine consecutive patients with chondrosarcoma of the pelvis (46 cases), sacrum (11 cases), and mobile spine (12 cases) who were treated at Sahlgrenska University Hospital from 1967 to 1999 were included in this study. Demographic information and follow-up data were obtained and statistically analyzed.

RESULTS

There were 53 men and 16 women with a mean age of 45 years and a mean tumor size of 12 cm. There were 61 conventional chondrosarcomas, Grades 1-3 (with 13 arising in a preexisting osteochondroma) and 8 Grade 4 chondrosarcomas (7 dedifferentiated and one mesenchymal). The overall local recurrence rate was 27%, and the estimated overall 5- and 10-year survival rates were 72% and 67%, respectively. In contrast, the observed local recurrence rate was 3% (1 patient) in 31 patients whose conventional chondrosarcomas were resected with adequate surgical margins; 90% of these patients survived and most of them (26 of 31 or 84%) were continuously disease free. Significant factors associated with a worse prognosis with respect to local control and/or survival were high histologic tumor grade, increasing patient age, primary surgery outside of a tumor center, incisional biopsy versus a noninvasive diagnostic procedure, and inadequate surgical margins.

CONCLUSIONS

Center-based diagnosis and treatment using modern aggressive surgical techniques significantly improve the prognosis of patients with chondrosarcoma of the pelvis, sacrum, and spine.

Up-regulation of PTHrP and Bcl-2 expression characterizes the progression of osteochondroma towards peripheral chondrosarcoma and is a late event in central chondrosarcoma

Chondrosarcomas are malignant cartilage-forming tumors arising centrally in bone (central chondrosarcoma) or within the cartilaginous cap of osteochondroma (peripheral chondrosarcoma). For hereditary multiple osteochondromas, two responsible genes, EXT1 and EXT2, have been cloned. Their recently elucidated role in heparan sulfate biosynthesis and Hedgehog diffusion leads to the hypothesis that EXT inactivation affects fibroblast growth factor (FGF) and Indian Hedgehog (IHh)/parathyroid hormone-related peptide (PTHrP) signaling, two important pathways in chondrocyte proliferation and differentiation. The expression of PTHrP, PTHrP-receptor, Bcl-2, FGF2, FGFR1, FGFR3, and p21 is investigated by immunohistochemistry in osteochondromas (n = 24) and peripheral (n = 29) and central (n = 20) chondrosarcomas. IHh/PTHrP and FGF signaling molecules are mostly absent in osteochondromas. Although no somatic EXT mutations were found in sporadic osteochondromas, the putative EXT downstream targets are affected similarly in sporadic and hereditary tumors. In chondrosarcomas, re-expression of FGF2, FGFR1, PTHrP, Bcl-2, and p21 is found. Expression levels increase with increasing histological grade. Up-regulation of PTHrP and Bcl-2 characterizes malignant transformation of osteochondroma because PTHrP and Bcl-2 expression is significantly higher in borderline and grade I peripheral chondrosarcomas compared with osteochondromas. In contrast, up-regulation of PTHrP and Bcl-2 seems to be a late event in central cartilaginous tumorigenesis because expression is mainly restricted to high-grade central tumors.

Near-haploidy and subsequent polyploidization characterize the progression of peripheral chondrosarcoma

Chondrosarcomas are malignant cartilaginous tumors arising centrally in bone (central chondrosarcoma), or secondarily within the cartilaginous cap of osteochondroma (peripheral chondrosarcoma). We previously used DNA flow cytometry to demonstrate that near-haploidy is relatively frequent in peripheral chondrosarcomas. We performed fluorescence in situ hybridization (FISH) to interphase nuclei using centromeric probes, a genome wide loss of heterozygosity (LOH) analysis, and comparative genomic hybridization on five peripheral chondrosarcomas. We demonstrated near-haploidy in two low-grade tumors with only one copy and LOH of most chromosomes. Few chromosomes are disomic, with retention of heterozygosity and overrepresentation at comparative genomic hybridization. One tumor contains both a near-haploid clone with chromosomes in monosomic and disomic state, and an exactly duplicated clone. Two high-grade tumors clearly demonstrate polyploidization because most chromosomes show LOH and two copies at FISH, whereas few chromosomes have four copies with retention of heterozygosity. Using DNA from a relative, we demonstrate that chromosome loss is random regardless of parental origin. Using FISH on paraffin slides, we exclude near-haploidy to result from meiosis-like division in binucleated cells, characteristic for chondrosarcoma. In conclusion, our results indicate that near-haploidy characterizes the progression from osteochondroma toward low-grade chondrosarcoma. Moreover, further progression toward high-grade chondrosarcoma is characterized by polyploidization.

Cartilage tumors: evaluation and treatment

The proper treatment of cartilaginous tumors is dependent on the clinicopathologic and radiologic findings. Enchondroma is a benign tumor that is usually asymptomatic and thus should be treated nonoperatively. Symptomatic enchondromas are often treated by intralesional excision. Intramedullary low-grade chondrosarcoma is a malignant tumor that is usually painful. The treatment of low-grade chondrosarcoma may range from intralesional excision with or without adjuvant therapy to wide excision. Although intralesional excisions have a higher bone and joint preservation rate than wide excisions, they may be associated with a higher local recurrence rate. Intermediate- and high-grade chondrosarcomas are treated with wide excisions. The treatment of these cartilaginous lesions should involve a multidisciplinary team including a musculoskeletal surgeon, a radiologist, and a pathologist.

National cancer database report on chondrosarcoma of the head and neck

BACKGROUND

Management of chondrosarcoma of the head and neck is largely based on single-institution reports with small numbers accrued over several decades.

METHODS

The American College of Surgeons' National Cancer Data Base included 400 cases of chondrosarcoma of the head and neck diagnosed between 1985 and 1995. Chi square analyses of selected contingency tables and Wilcoxon regression analyses of selected survival stratifications were performed.

RESULTS

Histologic types included conventional (80.8%), myxoid (10.5%), and mesenchymal (8.8%). The mesenchymal and myxoid subtypes were rare among white patients (17.1%) and more common among African-American (31.8%) and Hispanic patients (44.9%). Treatment was most commonly surgery alone (59.5%) and surgery with irradiation (21.0%). Disease-specific survival was 87.2% at 5 years and 70.6% at 10 years. Worse 5-year survival was associated with higher grade (67.3%), regional or distant spread (71.0%), and the myxoid (45.0%) or mesenchymal (53.2%) subtypes.

CONCLUSIONS

Chondrosarcoma of the head and neck encompasses a variety of lesions that differ substantially by demographic and tumor characteristics. Individual tumors can be classified further according to site of origin, histologic subtype, and tumor grade, which can be used to predict biologic behavior and prognosis.

Abl expression, tumour grade, and apoptosis in chondrosarcoma

AIMS

To determine whether Abl immunoreactivity correlates with grade and cell kinetics (apoptosis and mitosis) in chondrosarcoma.

METHODS

Sections from 16 chondrosarcomas were stained immunohistochemically using a polyclonal antibody to the c-Abl/Bcr-Abl oncoprotein. Apoptotic indices and mitotic indices were assessed in all tumours. Sections from 24 paraffin wax blocks of human fetal rib (gestational ages, 15-42 weeks) were also stained to determine whether the Abl protein is synthesised consistently throughout endochondral ossification.

RESULTS

Abl staining in immature fetal rib chondrocytes at all stages of development was predominantly nuclear, and 70% of cells showed moderate to strong staining. Abl immunoreactivity was minimal or absent in hypertrophic chondrocytes about to undergo apoptosis at the growth plate. There was strong Abl staining in grade 1 and grade 2 chondrosarcomas but staining was greatly reduced or absent in grade 3 chondrosarcomas. There was a very significant linear correlation between apoptotic index (mean, 0.68%; range, 0-3.2%) and mitotic index (mean, 0.23%; range, 0-0.9%), and both indices were significantly lower in grade 1 than in grade 2 and grade 3 chondrosarcomas.

CONCLUSIONS

These data suggest that abl gene expression is associated with differentiation and apoptosis inhibition in fetal and neoplastic chondrocytes. However, these putative effects cannot be ascribed solely to the Abl protein, because several additional factors contribute to the regulation of both differentiation and apoptosis.

Chondrosarcoma of the phalanx: a locally aggressive lesion with minimal metastatic potential: a report of 35 cases and a review of the literature

BACKGROUND

Enchondroma is the most common primary benign bone tumor of the hand, especially the phalanges, whereas chondrosarcoma is uncommon at this site. Although phalangeal chondrosarcoma may have ominous histologic features, its biologic behavior is relatively indolent.

METHODS

Thirty-five cases of phalangeal lesions previously diagnosed as chondrosarcoma were studied. Histologic and tumor-biologic parameters (Ki-67 and p53 immunohistochemistry) were investigated and correlated with clinical behavior.

RESULTS

All cases were characterized by unequivocal malignant histologic features (Grade 2 or higher) or Grade 1 malignant histologic features combined with the presence of cortical destruction and soft tissue extension. The median age of the patients at the time of diagnosis was 67 years (range 21-87 years), with a slight female predominance. Occurrence in the hand was more common than in the foot, with the proximal phalanx affected most often. Treatment varied from local therapy (curettage or local excision) in 16 patients to amputation or exarticulation in 19 cases. Follow-up ranged from 8-432 months for 28 patients. Ten of 15 tumors treated by local therapy recurred whereas none of 13 tumors treated by radical surgery recurred. The median survival was 20.8 years; none of 28 patients developed metastases nor died of disease. Both the type of treatment and localization in the proximal phalanx were associated independently with local recurrence.

CONCLUSIONS

Phalangeal chondrosarcoma behaves as a locally aggressive lesion and, in contrast to chondrosarcomas located elsewhere, rarely metastasizes. Treatment is indicated only because of its locally destructive growth. The authors believe that given the excellent survival data, curettage with adequate follow-up should be considered as the treatment of choice if technically feasible, especially in those cases in which amputation would lead to a significant loss of hand function.