Mesenchymal chondrosarcoma of bone and soft tissue. A review of 111 cases

P-glycoprotein expression in cartilaginous tumors

BACKGROUND AND OBJECTIVES

Malignant cartilage tumors demonstrate chemotherapeutic resistance through undetermined mechanisms. P-glycoprotein is the protein product of the multiple drug resistance gene 1 (MDR-1) and confers multidrug chemotherapeutic resistance in a variety of malignancies.

METHODS

MDR-1 expression was examined in 55 benign and malignant cartilage tumor specimens by immunohistochemistry using C219, C494, and JSB-1 antibodies, and by in situ hybridization with an MDR-1 specific oligonucleotide cDNA probe.

RESULTS

Constitutive expression of P-glycoprotein was observed in all benign and malignant cartilage tumor specimens with a similar pattern of immunohistochemical staining present with all three antibodies. In benign tumors and low grade chondrosarcomas, the staining pattern was weak to intermediate and localized to clusters of cells. However, higher grade-tumors (Grade II and III) expressed P-glycoprotein in a higher percentage of cells and with more intense staining. P-glycoprotein expression was absent in normal human articular cartilage, but was focally present in costal and growth plate cartilage. The immunohistochemistry results were confirmed by in situ hybridization in 10 cases.

CONCLUSIONS

P-glycoprotein is expressed constitutively in cartilaginous tumors, with greatest expression in high grade malignancies. The findings may account for the resistance of cartilage tumors to chemotherapeutic agents.

Mesenchymal chondrosarcoma of the maxilla. A case report

A case of mesenchymal chondrosarcoma of the maxilla is reported. This rare tumour is characterized by slow growth, late metastasis (up to 20 years after first presentation) and poor prognosis. The diagnosis is often difficult to make because of the low incidence among malignant bone tumours.

Malignant cartilaginous tumors of the mediastinum: clinicopathological study of six cases presenting as extraskeletal soft tissue masses

Cartilage and bone-forming tumors of the mediastinum are extremely rare neoplasms with very few cases having been reported in the literature. We studied six cases of primary malignant cartilaginous tumors presenting as extraskeletal soft tissue masses in the posterior mediastinum. The patients were five women and one man aged 11 to 63 years (median, 31 years). Histologically, the lesions showed a spectrum of features that ranged from mesenchymal chondrosarcoma, to extraskeletal myxoid chondrosarcoma, to moderately well to poorly differentiated chondrosarcoma. In all cases, the lesions presented as well-circumscribed tumor masses centered in the soft tissues in the posterior mediastinum without radiographic evidence of origin from bone. Because of their relatively small size, good circumscription, focal areas of calcification, and posterior mediastinal location, the preoperative clinical diagnoses included benign neurogenic tumor and neuroblastoma. All of the lesions were treated by complete surgical excision, followed in two cases by postoperative radiation therapy. Clinical follow-up was available in five cases: two patients with mesenchymal chondrosarcoma presented with local recurrence after 3 and 7 years, one developed metastases to the sacrum 8 years after initial diagnosis and died, and one was alive and well without evidence of disease after 6 years. The patient with myxoid chondrosarcoma of the posterior mediastinum developed bilateral pulmonary metastases 10 months after surgery and has been lost to follow-up since. Our findings reinforce previous observations on the occurrence of extraskeletal cartilaginous tumors in the mediastinum and indicate that these tumors can show a propensity for local aggressive behavior with high recurrence rate and a definite potential for distant metastases. Such tumors should be considered in the differential diagnosis of malignant neoplasms presenting as a soft tissue mass in the posterior mediastinum.

MR imaging of dedifferentiated chondrosarcoma

MR imaging of a dedifferentiated chondrosarcoma of the humerus is presented and correlated with gross and microscopic histology from the surgical specimen. The classification of chondrosarcoma and specific MR signal characteristics that suggest dedifferentiation are discussed.

CD99 reactivity in mesenchymal chondrosarcoma

CD99 reactivity has been reported to be a sensitive and specific marker for Ewing's sarcoma (ES) and primitive neuroectodermal tumor (PNET). However, within the group of "small round blue cell tumors," the specificity has not been extensively examined. We investigated the immunoreactivity of mesenchymal chondrosarcoma to CD99 using the O13 antibody and found reactivity in 11 of 11 (100%) of cases, specifically in the "small round blue cell" component. All cases showed strong reactivity involving more than 50% of the small round blue cells with a distinct membrane pattern of staining. Staining was either absent or focal and weak in cartilaginous areas. We conclude that mesenchymal chondrosarcoma cannot be distinguished from ES/PNET on the basis of CD99 immunoreactivity.

Multicentric chondrosarcomas

Multicentric chondrosarcomas, other than those from mesenchymal chondroma, are rare and difficult to differentiate from metastatic disease. Eight new patients with multicentric chondrosarcomas are reported. Five patients had chondrosarcomas that were monomelic, 3 had disseminated chondrosarcomas, 3 had synchronous involvement, and 5 had metachronous involvement; 1 patient had Ollier's disease. A bimodal age distribution was apparent: 4 patients were between 62 and 76 years old, and the remaining 4 were between 16 and 33 years old. Average duration of followup was 6 years, 4 months. Each of the patients with synchronous chondrosarcomas had single bone lower extremity involvement and presented with symptoms occurring at only 1 of the 2 sites of tumor. Each of the 5 patients with metachronous chondrosarcomas experienced involvement of a different bone when the second tumor presented. Only 1 of these metachronous chondrosarcomas was limited to the lower extremity. The second tumor occurred in all patients after excellent control of the primary tumor by wide excision. The average duration between diagnosis of the 2 tumors was 4 years, 4 months (range, 8 months-12 years, 9 months). Patients who had nonmonomelic malignancies must be viewed with a considerably more guarded prognosis than those who had monomelic chondrosarcoma because each of the 2 deaths resulting from progressive disease occurred among the 3 patients with nonmonomelic chondrosarcoma. The nonmonomelic malignancies may represent metastatic chondrosarcoma with a rare predilection to bony involvement. Monomelic chondrosarcoma simply may represent lesions analogous to the skip lesions observed in osteosarcoma.

Mesenchymal chondrosarcoma: a clinicopathologic and flow cytometric study of 13 cases presenting in the central nervous system

BACKGROUND

Mesenchymal chondrosarcomas arising in the central nervous system are extremely rare. Morphologic features have not been found to correlate reliably with prognosis.

METHODS

Eight intracranial and five intraspinal mesenchymal chondrosarcomas were reviewed with regard to location, treatment, and long term follow-up data. The histopathologic and immunohistochemical results, including Ki-67 nuclear staining frequency, were critically reviewed, and deoxyribonucleic acid content was analyzed by flow cytometry.

RESULTS

Microscopically, all 13 cases were remarkably similar. Immunoreactivity in the small cell component included vimentin in 100% and cytokeratin and glial fibrillary acidic protein in 25% of cases. S-100 immunoreactivity was noted in the cartilaginous component of 100% of cases, and in rare cells in the small cell component along the interface. Flow cytometry of the eight tumors studied revealed a diploid pattern in six, aneuploidy in two, and a wide range of S-phase fractions (0-36.5%).

CONCLUSIONS

Review of the literature and the findings of the current series indicates that mesenchymal chondrosarcomas presenting in the brain and spinal cord pursue a progressive course that correlates most reliably with extent of surgical resection. This limited retrospective study also suggests that survival may be shorter for those patients with a high S-phase fraction and a high Ki-67 staining frequency.

Cytogenetic study of extraskeletal mesenchymal chondrosarcoma. A case report

Extraskeletal mesenchymal chondrosarcoma (EMC) is a rare and highly malignant type of chondrosarcoma of soft tissue origin. We performed a cytogenetic study on a patient with EMC. Cytogenetic analysis revealed the tumor karyotype: 48-49,XX, t(4;9)(q23;q22), add(10)(q?26), +16, ?del(19)(p13), +1-2mar[cp12] / 48-50,idem, t(1;20)(q21;q13), +mar[cp6] / 46,XX [7].

Mesenchymal chondrosarcoma of the foot, an unusual location: case report and review of the literature

We present a case of primary mesenchymal chondrosarcoma of the proximal phalanx of the first toe. The bones of the foot represent an infrequent primary site for this neoplasm. The tumour consisted of layers of undifferentiated round cells with scanty cytoplasm and hyperchromatic nuclei. The presence of brain, lung, and left auricle metastasis was demonstrated, and the patient died due to brain edema 18 days after admission. Mesenchymal chondrosarcoma is a rare tumor that more frequently involves the pelvic bones, the femur, and the humerus. To our knowledge, only nine cases of primary mesenchymal chondrosarcoma arising from the bones of the foot have been previously reported, with none involving the phalanx of the toe.

Mesenchymal chondrosarcoma of the rib: report of a case

Mesenchymal chondrosarcoma is a rare malignant cartilaginous tumor arising within the bone or soft tissue. An 18-year-old woman presented with a tumor on her left fourth rib. We performed a wide resection of the tumor and administered three cycles of postoperative adjuvant chemotherapy. Three years after the operation, the patient is alive without any evidence of either local recurrence or distant metastases. The findings of this case may thus support the usefulness of a radical resection and adjuvant chemotherapy for mesenchymal chondrosarcoma.

Mesenchymal chondrosarcoma. A cytogenetic, immunohistochemical and ultrastructural study

A case of mesenchymal chondrosarcoma was studied. The tumor was near-tetraploid and the clonal structural chromosomal abnormalities included add(7)(p13), add(22)(q13), markers, and double minutes. The ultrastructural and immunohistochemical findings were consistent with the diagnosis. Strong immunoreactivity for desmin was an unusual, not previously reported, feature of the neoplasm.

Mesenchymal chondrosarcoma of the maxilla

We report, to our knowledge, the 10th recorded case of mesenchymal chondrosarcoma (MC) occurring in the maxilla. Our case is the youngest person reported with a tumour in this location. The prognosis for cure is poor with a high incidence of local recurrence as well as metastases. Treatment is based on radical surgery. Radiotherapy and chemotherapy have a adjuvant role but additional experience with this tumour is required to define the most efficacious treatment.

Mesenchymal chondrosarcoma of the orbit. Report of three new cases and review of the literature

BACKGROUND

Extraskeletal mesenchymal chondrosarcoma is a rare tumor characterized by undifferentiated mesenchymal cells with islands of mature hyaline cartilage. Considering all sites, long-term survival is approximately 30%. Only seven cases of orbital mesenchymal chondrosarcoma have been reported.

METHODS

The records of three cases of orbital mesenchymal chondrosarcoma treated at the Columbia-Presbyterian Medical Center, and the seven previously reported cases of this tumor were reviewed to determine clinical characteristics and appropriate therapy.

RESULTS

Nine of the 10 patients were female; age of onset ranged from 10 to 35 years. Of eight patients with at least 2 years of observation, five survived 5 or more years after resection, or after resection plus adjuvant therapy. Two patients died of metastatic disease 2 and 5 years, respectively, after the initial treatment, and one died of pneumonia 6 months after surgery. Review of the histology of the three cases treated at Columbia-Presbyterian Medical Center did not identify distinct histologic types that might guide therapy. Presenting symptoms were typical of symptoms of an orbital mass: proptosis, pain, diplopia, change in visual acuity, ptosis, and tearing.

CONCLUSION

The small number of reported cases of mesenchymal chondrosarcoma of the orbit prevents definitive conclusions, but it appears that resection is adequate therapy in some cases. Extraskeletal mesenchymal chondrosarcoma of the orbit may have a better prognosis than tumors in other sites.

p53 expression and its relationship to DNA alterations in bone and soft tissue sarcomas

The p53 gene is one of the best studied tumour suppressor genes. Recently we performed mutation analysis on the p53 gene in a large number of bone and soft tissue sarcomas, and found that approximately one-third of the sarcomas have some type of DNA alteration at the p53 locus (Toguchida et al., 1992). However, the expression of the p53 protein resulting from these alterations still remains to be clarified. In this study, p53 expression in the sarcoma tissues was analysed immunohistochemically using antibody PAb421 (Oncogene Science) and its relationship to DNA alterations was examined. Of 113 tumours, 29 (25.7%) showed positive staining for the p53 protein. These included 19 of 67 osteosarcomas, five of 20 chondrosarcomas, four of 11 malignant fibrous histiocytomas (MFHs) and one Ewing's sarcoma. In chondrosarcomas, most of the p53-positive tumours belonged to highly malignant and atypical tumour types (dedifferentiated or mesenchymal type), suggesting a role for p53 mutation in the progression of cartilaginous tumours. All the cases with a missense mutation showed strongly positive staining, while no immunoreactivity was observed in the remaining three-quarters with DNA alterations including gross rearrangement, frame-shift mutation, nonsense mutation or mutation at splicing site except in one case. These results demonstrated the dominance of the p53 mutations with null protein expression in bone and soft tissue sarcomas, showing a unique characteristic of these types of tumours compared with other malignancies such as colon carcinomas.

A mesenchymal chondrosarcoma of a child with the reciprocal translocation (11;22)(q24;q12)

The reciprocal translocation (11;22)(q24;q12) was observed in a seven day culture from a mesenchymal chondrosarcoma of the bone, a tumor not characterized cytogenetically so far. We suggest that because of the presence of a similar cytogenetic abnormality, mesenchymal chondrosarcoma may belong to the wide group of "t(11;22)-small round cell tumors".

Small cell osteosarcoma of bone: an immunohistochemical study with differential diagnostic considerations

Seventy-nine cases of small round cell tumors involving bone were studied in an attempt to learn whether the immunohistochemical features of the lesions might allow distinction of small cell osteosarcoma from other potential differential diagnostic considerations, including Ewing's sarcoma, atypical Ewing's sarcoma, primitive neuroectodermal tumor, mesenchymal chondrosarcoma, lymphoma, and the Askin tumor. The tissues studied were all formalin-fixed, decalcified, paraffin sections from patients between the ages of 16 and 48 years. With one exception (a small cell osteosarcoma), none of the lesions was cytokeratin positive. Moreover, none of the lesions was epithelial membrane antigen, desmin, factor VIII-related antigen, synaptophysin, or Leu-M1 positive. Accordingly, strong positivity for these antibodies in a majority of tumor cells should prompt inclusion of tumor types other than those listed above in the differential diagnosis. Vimentin positivity was seen in a majority of the tumors studied irrespective of histologic type. Scattered tumor cells (< 25%) showed positivity with antibodies to muscle-specific actin and smooth muscle actin in several of the different tumor types studied. No lesions other than lymphoma were leukocyte-common antigen (LCA) positive; all but two lymphomas were LCA positive, while all but one lymphoma were L26 positive. One (lymphoblastic) lymphoma was LCA and L26 negative. S-100, neuron-specific enolase, and Leu-7 did not prove to be specific for "neural-associated" tumors, but rather appeared in some small cell osteosarcomas, Ewing's sarcomas, atypical Ewing's sarcomas, primitive neuroectodermal tumors, mesenchymal chondrosarcomas, lymphomas, and Askin tumors. Antibody to cell surface antigen HBA71 was positive in three Ewing's sarcomas (two typical and one atypical) and negative in small cell osteosarcoma (three cases), mesenchymal chondrosarcoma (two cases), and lymphoma (one case). While some guidance may be derived from analysis of immunohistochemical staining patterns in a given lesion, the results reported in the present study do not suggest that routine immunohistochemistry alone will permit distinction of these small cell tumors of bone from one another. The value of immunohistochemical studies appears to lie particularly in the use of antibodies to LCA and S-100 protein to distinguish lymphoma and mesenchymal chondrosarcoma, and perhaps antibody to HBA71 to distinguish neural family lesions (such as Ewing's sarcoma), from other small cell tumors, such as small cell osteosarcoma.

Intracranial mesenchymal chondrosarcoma: a case report and literature review

Intracranial mesenchymal chondrosarcoma is a rare entity. The case of a 13-year-old girl with mesenchymal chondrosarcoma which seemed to arise from the dura mater is presented here together with a review of the literature. In the present case, the tumor involved the superior sagittal sinus. It recurred 21 months after gross total removal of the mass and coagulation of the involved wall of the superior sagittal sinus. Reoperation was performed followed by radiation therapy.

Case report 790. Mesenchymal chondrosarcoma of the sacrum

We have presented a case of mesenchymal chondrosarcoma of the sacrum in a 20-year-old woman. We have emphasized that CT and MR are the best imaging modalities for the assessment of the neoplasm and the surgical decision-making process. Histologic study is mandatory for diagnosis of the tumor, with its characteristic dual pattern of chondroid tissue and undifferentiated mesenchymal cells. The rarity of the neoplasm, its deep pelvic location and nonspecific symptomatology led to a late diagnosis and an unfortunate but necessary sacral amputation resulting in bladder and bowel functional sequelae.

Extraskeletal myxoid chondrosarcoma of the falx

Intracranial cartilaginous tumors are unusual lesions, of which myxoid chondrosarcoma is the rarest. We describe this tumor arising from the falx in a 28-year-old woman treated at recurrence with a second operation and a radiation implant. The behavior of classic chondrosarcoma and mesenchymal chondrosarcoma is also reviewed.

Morphometric analysis of cartilaginous tumors

144 chondromas and chondrosarcomas have been investigated. Morphometry has been performed: the relative volume density of tumor cell nuclei (Vv%n) and the nuclear area have been measured. The results show that the relative volume density of nuclei is a useful parameter, regarding the localisation of the tumors, to discriminate chondromas and chondrosarcomas, while the nuclear area is no safe criterion to separate these entities.

Morphological typing of chondrosarcoma: a study of 94 cases

Ninety-four chondrosarcomas of the Hamburg Bone Tumour Registry were reviewed in a retrospective study. The purpose of this study was to examine the morphological characteristics of different types of chondrosarcomas and to describe distinctive features of location, the age distribution and the male to female ratio. Central chondrosarcomas can be divided into classical chondrosarcomas, dedifferentiated chondrosarcomas, mesenchymal chondrosarcomas and clear-cell chondrosarcomas. Five periosteal chondrosarcomas were represented. Classical chondrosarcomas and clear-cell chondrosarcomas show a significant predominance of males; no sex predilection was seen in dedifferentiated and mesenchymal chondrosarcomas. Nearly 60% of classical and mesenchymal chondrosarcomas occur in the trunk. Eighty-five percent of dedifferentiated chondrosarcomas are located in the long bones of the limbs. Clear-cell chondrosarcomas arise in the proximal part of the femur. There is a marked predilection for mesenchymal chondrosarcomas in the second and third decades of life. The average age of patients with classical chondrosarcomas was 54 years, but clear-cell chondrosarcomas occur 10 years earlier and dedifferentiated chondrosarcomas 10 years later. Characteristically, classical chondrosarcomas produce a pure chondroid matrix with variable differentiation of tumour chondrocytes. The most important histological feature of the defifferentiated chondrosarcoma is the close association of two different cellular components. One of these consists of cartilage, which is generally well differentiated. In most of our cases the second component showed features of osteosarcoma (50%). Mesenchymal chondrosarcoma is characterized by concentric infiltration of cartilage islands by small tumour cells. Clear-cell chondrosarcomas show regions of cartilaginous tumour and areas of closely packed, glycogen-rich, large tumour cells with distinct boundaries. Osteoid formation and multinucleated giant cells are present in clear-cell areas. Knowledge of this group of tumours is indispensable for correct histological diagnosis and typing and is important in the design of surgical therapy and the prediction of biological behaviour.

Primary extraskeletal mesenchymal chondrosarcoma of the lid

A 15-year-old girl presented with a painless nodule in the nasal lower-lid portion of the left eye at the beginning of 1989. The tumor was excised in March 1989, and the histopathologic diagnosis was - erroneously - a chondromatous choristoma of the lid. The tumor recurred within several weeks. Another excision was performed, which led to the diagnosis of a malignant mesenchymal chondrosarcoma of the lid. Histopathology revealed the typical bimorphic pattern, with well-differentiated chondrocytes being surrounded by small anaplastic cells. The tumor cells stained positive for S100-protein and vimentin, were negative for cytokeratin and were studied ultrastructurally. Radical excision and adjuvant chemotherapy were performed in our patient; at 18 months after the onset of tumor growth, she is free of local or general tumor recurrence. To our knowledge, primary mesenchymal chondrosarcoma has not previously been described in the lid area.

Meningeal mesenchymal chondrosarcoma of the spine: a case report

Primary soft-tissue chondrosarcomas are most often of the mesenchymal variety. When affecting the central nervous system, these tumors usually arise from the intracranial meninges. Intraspinal meningeal lesions are much less common but may be considered, especially in the pediatric age group, when clinical or radiologic presentation is atypical. The author presents a case report including MR imaging studies of a 7-year-old girl with intraspinal dural chondrosarcoma.

Case report: mesenchymal chondrosarcoma occurring in the parapharyngeal space

Mesenchymal chondrosarcomas are rare tumours, the minority arising in an extraskeletal site. We describe a case of extraskeletal mesenchymal chondrosarcoma occurring in the parapharyngeal space. This was demonstrated by computed tomography (CT), magnetic resonance imaging (MRI) and angiography.

Small cell osteosarcoma. A clinicopathologic study of 27 cases

We report a study of 27 patients with small cell osteosarcoma (SCO), 17 from the M. D. Anderson Cancer Center (MDAH) and ten from the Pediatric Oncology Group (POG). There were 12 male patients and 15 female patients; 19 were white, five were black, and three were Hispanic. They ranged from 6 to 28 years of age with a median of 14 years. Histologically there were three patterns: Ewing's-like, lymphoma-like, and spindle cell. All cases showed osteoid formation and a few had chondroid areas. There was cytoplasmic glycogen in ten cases. Initial treatment for MDAH patients included intraarterial infusion of cisplatin in ten, amputation in four, partial mandibulectomies in two, and biopsy with local radiotherapy and systemic chemotherapy in one. All POG patients had resection or amputation followed by adjuvant chemotherapy. Twelve patients are alive, of whom nine have had significant follow-ups for 25 to 90 months. Fourteen patients are dead of lung, spine, and brain metastases from 1 to 23 months after initial diagnosis. One patient is alive with lung relapse at 4 months. In summary, SCO is a high-grade variant of osteosarcoma, with an incidence of up to 4% of all osteosarcomas, that affects patients of the same age group and has the same anatomic location as conventional osteosarcoma. Currently, SCO appears to have a prognosis that is the same as or slightly worse than that of conventional osteosarcoma. Furthermore, although intraarterial infusion is effective for the primary tumors in the bone, distant metastases are difficult to control.

Dedifferentiated chondrosarcoma with muscle and cytokeratin differentiation in the anaplastic component

Dedifferentiated chondrosarcoma is a biphasic tumour, comprising well-differentiated chondrosarcoma and an anaplastic non-cartilaginous sarcoma juxtaposed but distinct from each other. Two cases of dedifferentiated chondrosarcoma, one primary and one recurrent, demonstrated muscle differentiation when studied with monoclonal antibodies to muscle specific actin, desmin and myoglobin. One of the tumours was also positive for cytokeratin, identified by AE1/AE3 and CAM 5.2 antibodies. Our findings are consistent with the concept that these tumours are capable of diverse patterns of morphological and immunophenotypic differentiation.

Chondrosarcoma. I. A selected literature review

More than 200 articles and texts relating to chondrosarcoma in the general skeleton, in the head and neck area, and in extraskeletal soft tissues, were reviewed and summarized. In the interest of space conservation and avoidance, to the extent possible, of distracting referential interjections in the text, the entire list of materials reviewed has not been referenced. For example, articles that contribute essentially nothing more than single case reports are not included in the list of references. Effort has been made, however, to include articles of historical significance, articles reporting series of cases, and articles exploring ideas and concepts. The authors believe this review to be a comprehensive summary of the chondrosarcoma literature. An analysis of 37 cases of chondrosarcoma of the jaws will be published as Part II.