Curettage and cryosurgery for enchondroma and atypical cartilaginous tumors of the long bones: Oncological results of a large series

Application of microwave ablation assisted degradation therapy in surgical treatment of intramedullary chondrosarcoma of extremities

AIM

Clinical diagnosis and surgical treatment of chondrosarcoma (CS) are continuously improving. The purpose of our study is to evaluate the effectiveness of microwave ablation (MWA) assisted degradation therapy in the surgical treatment of intramedullary chondrosarcoma of the extremities, to provide a new reference and research basis for the surgical treatment of CS.

METHODS

We recruited 36 patients with intramedullary CS who underwent MWA assisted extended curettage. Preoperative patient demographics and clinical data were recorded. Surgery was independently assisted by a medical team. Patients were followed up strictly and evaluated for oncological prognosis, radiological results, limb joint function, pain, and complications.

RESULTS

We included 15 men and 21 women (mean age: 43.5 ± 10.1). The average length of the lesion was 8.1 ± 2.5 cm. Based on preoperative radiographic, clinical manifestations, and pathological results of puncture biopsy, 28 patients were preliminarily diagnosed with CS-grade I and eight patients with CS-grade II. No recurrence or metastasis occurred in the postoperative follow-up. The average Musculoskeletal Tumor Society score was 28.8 ± 1.0, significantly better than presurgery. Secondary shoulder periarthritis and abduction dysfunction occurred in early postoperative stage CS of the proximal humerus in some, but returned to normal after rehabilitation exercise. Secondary bursitis occurred at the knee joint in some due to the internal fixation device used in treatment; however, secondary osteoarthritis and avascular necrosis of the femoral head were not observed. Overall, oncological and functional prognoses were satisfactory.

CONCLUSIONS

The application of MWA assisted degradation therapy in intramedullary CS can achieve satisfactory oncology and functional prognosis, providing a new option for the limited treatment of CS.

Diagnosis of chondrosarcoma in a noninvasive way using volatile organic compounds in exhaled breath: a pilot study

Aim: Aim of this explorative pilot study was to evaluate the capability of an electronic nose (aeoNose, the eNose Company) to classify healthy individuals and patients with chondrosarcoma, based on their volatile organic compound profiles in exhaled breath.Materials & methods: Fifty-seven patients (25 healthy controls, 24 chondrosarcoma and 8 different benign lesions) were included in the study from 2018 to 2023. An artificial neural network was used as classifier.Results: The developed model had a sensitivity of 75%, and a specificity of 65% with an AUC of 0.66.Conclusion: Results show that there is not enough evidence to include the aeoNose as diagnostic biomarker for chondrosarcoma in daily practice. However, the aeoNose might play an additional role alongside MRI, in questionable chondrosarcoma cases.

Wait-and-scan: an alternative for curettage in atypical cartilaginous tumours of the long bones

Aims

Due to its indolent clinical behaviour, the treatment paradigm of atypical cartilaginous tumours (ACTs) in the long bones is slowly shifting from intralesional resection (curettage) and local adjuvants, towards active surveillance through wait-and-scan follow-up. In this retrospective cohort study performed in a tertiary referral centre, we studied the natural behaviour of ACT lesions by active surveillance with MRI. Clinical symptoms were not considered in the surveillance programme.

Methods

The aim of this study was to see whether active surveillance is safe regarding malignant degeneration and local progression. In total, 117 patients were evaluated with MRI assessing growth, cortical destruction, endosteal scalloping, periosteal reaction, relation to the cortex, and perilesional bone marrow oedema. Patients received up to six follow-up scans.

Results

At the time of the first follow-up MRI, 8% of the lesions showed growth (n = 9), 86% remained stable (101), and 6% decreased in size (n = 7). During the third follow-up, with a mean follow-up time of 60 months (SD 23), 24 patients were scanned, of whom 13% had lesions that had grown and 13% lesions that had decreased in size. After 96 months (SD 37), at the sixth follow-up MRI, 100% of the lesions remained stable. None of the lesions showed malignant progression and although some lesions grew in size (mean 1 mm (SD 0.8)), no malignant progression occurred.

Conclusion

We conclude that active surveillance with MRI is safe for ACTs in the long bones in the short- and mid-term follow-up.

Fracture risk after intralesional curettage of atypical cartilaginous tumors

INTRODUCTION

The need for curettage of atypical cartilaginous tumors (ACT) is under debate. Curretage results in defects that weaken the bone potentially leading to fractures. The purpose of this study was to retrospectively determine postoperative fracture risk after curettage of chondroid tumors, including patient-specific characteristics that could influence fracture risk.

METHODS

A total of 297 adult patients who underwent curettage of an ACT followed by phenolisation and augmentation were retrospectively evaluated. Explanatory variables were, sex, age, tumor size, location, augmentation type, and plate fixation. The presence of a postoperative fracture was radiologically diagnosed. Included patients had at least 90 days of follow-up.

RESULTS

A total of 183 females (62%) were included and 114 males (38%), with an overall median follow-up of 3.2 years (IQR 1.6-5.2). Mean diameter of the lesions was 4.5 (SD 2.8) cm. Patients received augmentation with allograft bone (n = 259, 87%), PMMA (n = 11, 3.7%), or did not receive augmentation (n = 27, 9.1%). Overall fracture risk was 6%. Male sex (p = 0.021) and lesion size larger than 3.8 cm (p < 0.010) were risk factors for postoperative fracture.

INTERPRETATION

Curettage of ACT results in an overall fracture risk of 6%, which is increased for males with larger lesions.

Active surveillance of atypical cartilaginous tumours of bone: short term quality of life measurements

BACKGROUND

In the recent years active surveillance has been introduced for atypical cartilaginous tumours (ACT). This is the first study on the impact of this new treatment approach on patients' quality-of-life. We evaluated general health-related quality of life (HRQL) in patients diagnosed with enchondroma or ACT.

METHODS

In this prospective study, patients recently diagnosed with enchondroma and ACT of the long bones were asked to participate. Health-related quality of life (HRQL) was assessed at diagnosis and at six month follow-up, using the 36-item Short Form Health Survey (SF-36) and Numeric Pain Rating Scale (NRS). HRQL of the active surveillance group was compared to the Dutch population and a Dutch sample with locoregional cancer.

RESULTS

In total, 45 patients were included in the study, of which four patients underwent curettage and cryosurgery, 41 patients were under active surveillance. The HRQL of the active surveillance group seemed lower compared to the Dutch population, but similar to patients suffering locoregional cancers. No comparison between the surgery and the active surveillance group could be made. In the active surveillance group no statistical difference was found between baseline and six months follow-up regarding HRQL and pain during rest and activities.

CONCLUSION

Patients diagnosed with non-malignant chondroid tumours have lower HRQL compared to the healthy population. Active surveillance had no adverse effect on patients well-being, after six months active surveillance the HRQL remained unchanged. Interestingly, in our study no impact on mental health was seen, implicating that diagnosed but untreated chondroid tumours do not seem to influence patients anxiety.

Can low-grade chondrosarcoma in flat bones be treated with intralesional curettage and cryotherapy?

BACKGROUND AND OBJECTIVES

Chondrosarcomas in flat bones are thought to be more aggressive in their behavior, and little is known about intralesional treatment outcomes of low-grade chondrosarcoma in these locations. We tried to find the differences between patients who had low-grade chondrosarcoma in their flat bones versus those with long bone involvement with regard to (1) disease outcome, (2) functional outcome, and (3) treatment complications.

METHODS

We retrospectively reviewed 44 patients with primary low-grade chondrosarcoma who were treated with intralesional curettage and cryotherapy. The patients were divided by location of tumor, group I (flat bones, seven patients) and group II (long bones, 37 patients).

RESULTS

The local recurrence rate was higher in group I with 5 years disease-free survival of 80.0% in group I and 97.0% in group II (p = 0.001). All recurrent cases were noted to have initially presented with soft tissue extension (Enneking stage IB). The mean Musculoskeletal Tumor Society score at the last follow-up was 21.7 in group I and 27.9 in group II (p = 0.045).

CONCLUSIONS

Intralesional curettage and cryotherapy for low-grade chondrosarcoma appear to be a safe and reasonable surgical option for patients with lesions confined to bone (Enneking stage IA).

LEVEL OF EVIDENCE

Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Bone and soft tissue tumors at the borderlands of malignancy

This review examines findings of musculoskeletal neoplasms whose equivocal imaging and/or histopathologic features make it difficult to determine if they will show aggressive behavior. We include both intermediate tumors as defined by the World Health Organization (WHO), and a single low-grade malignancy, low-grade central osteosarcoma, which mimics a benign lesion on imaging and histology. Intermediate tumors are a broad category and are subdivided into tumors that have risk of local recurrence only, and ones that have a risk of distant limb and pulmonary metastases. Difficult intermediate musculoskeletal lesions include atypical cartilaginous tumor/grade 1 chondrosarcoma, atypical lipomatous tumor/grade 1 liposarcoma, and solitary fibrous tumor. We review diagnostic criteria, differential diagnosis, and recommendations for surveillance.

The national incidence of chondrosarcoma of bone; a review

BACKGROUND

Chondrosarcoma (CS) epidemiology has been studied by a number of authors using national cancer registry cohorts. Many reports share the common findings of a slight increase in incidence, but not all. The patterns and causes for these changes are divergent while reflection concerning methodological challenges are often missing.

METHOD

We have performed a structured literature review to find national analyses of CS incidence published from 2010 to 2020. We included eight studies of national incidence of CS, summarise their findings and patterns of change. We further discuss explanations given for these changes to better understand the real patterns and raise awareness in their interpretation.

RESULTS

Reported crude incidence ranges from 0.27 per million per year overall in Saudi Arabia to 5.4 in the Netherlands. Four studies from the USA, England, Switzerland and France report age standardised rates of 2.0-4.1 per million per year overall. While some countries report stable patterns, most report a slight increase. The Netherlands is the only country reporting a large increase, driven by a 10-fold increase in the incidence of ACT/grade 1 CS during the study period. We challenge the explanations given for this and suggest that this most likely is a result of variable interpretation and definition of CS at the lower levels of disease aggressiveness. This should raise awareness to possible over-treatment of CS in the Netherlands.

CONCLUSION

The most likely national incidence of CS of bone is between 2-4 per million per year. Three modern reports present an incidence of 3.4-4.1 per million per year.

Development and validation of a MRI-based combined radiomics nomogram for differentiation in chondrosarcoma

Objective

This study aims to develop and validate the performance of an unenhanced magnetic resonance imaging (MRI)-based combined radiomics nomogram for discrimination between low-grade and high-grade in chondrosarcoma.

Methods

A total of 102 patients with 44 in low-grade and 58 in high-grade chondrosarcoma were enrolled and divided into training set (n=72) and validation set (n=30) with a 7:3 ratio in this retrospective study. The demographics and unenhanced MRI imaging characteristics of the patients were evaluated to develop a clinic-radiological factors model. Radiomics features were extracted from T1-weighted (T1WI) images to construct radiomics signature and calculate radiomics score (Rad-score). According to multivariate logistic regression analysis, a combined radiomics nomogram based on MRI was constructed by integrating radiomics signature and independent clinic-radiological features. The performance of the combined radiomics nomogram was evaluated in terms of calibration, discrimination, and clinical usefulness.

Results

Using multivariate logistic regression analysis, only one clinic-radiological feature (marrow edema OR=0.29, 95% CI=0.11-0.76, P=0.012) was found to be independent predictors of differentiation in chondrosarcoma. Combined with the above clinic-radiological predictor and the radiomics signature constructed by LASSO [least absolute shrinkage and selection operator], a combined radiomics nomogram based on MRI was constructed, and its predictive performance was better than that of clinic-radiological factors model and radiomics signature, with the AUC [area under the curve] of the training set and the validation set were 0.78 (95%CI =0.67-0.89) and 0.77 (95%CI =0.59-0.94), respectively. DCA [decision curve analysis] showed that combined radiomics nomogram has potential clinical application value.

Conclusion

The MRI-based combined radiomics nomogram is a noninvasive preoperative prediction tool that combines clinic-radiological feature and radiomics signature and shows good predictive effect in distinguishing low-grade and high-grade bone chondrosarcoma, which may help clinicians to make accurate treatment plans.

Differentiating Enchondromas and Atypical Cartilaginous Tumors in Long Bones with Computed Tomography and Magnetic Resonance Imaging

The differentiation between the atypical cartilaginous tumor (ACT) and the enchondromas is crucial as ACTs require a curettage and clinical as well as imaging follow-ups, whereas in the majority of cases enchondromas require neither a treatment nor follow-ups. Differentiating enchondromas from ACTs radiologically remains challenging. Therefore, this study evaluated imaging criteria in a combination of computed tomography (CT) and magnetic resonance (MR) imaging for the differentiation between enchondromas and ACTs in long bones. A total of 82 patients who presented consecutively at our institution with either an ACT (23, age 52.7 ±18.8 years; 14 women) or an enchondroma (59, age 46.0 ± 11.1 years; 37 women) over a period of 10 years, who had undergone preoperative MR and CT imaging and subsequent biopsy or/and surgical removal, were included in this study. A histopathological diagnosis was available in all cases. Two experienced radiologists evaluated several imaging criteria on CT and MR images. Likelihood of an ACT was significantly increased if either edema within the bone (p = 0.049), within the adjacent soft tissue (p = 0.006) or continuous growth pattern (p = 0.077) were present or if the fat entrapment (p = 0.027) was absent on MR images. Analyzing imaging features on CT, the likelihood of the diagnosis of an ACT was significantly increased if endosteal scalloping >2/3 (p < 0.001), cortical penetration (p < 0.001) and expansion of bone (p = 0.002) were present and if matrix calcifications were observed in less than 1/3 of the tumor (p = 0.013). All other imaging criteria evaluated showed no significant influence on likelihood of ACT or enchondroma (p > 0.05). In conclusion, both CT and MR imaging show suggestive signs which can help to adequately differentiate enchondromas from ACTs in long bones and therefore can improve diagnostics and consequently patient management. Nevertheless, these features are rare and a combination of CT and MR imaging features did not improve the diagnostic performance substantially.

Der atypische chondrogene Tumor

Hintergrund

Atypische chondrogene Tumoren (ACT) der kurzen und langen Röhrenknochen, früher als Chondrosarkome G1 bezeichnet, verhalten sich lokal aggressiv, haben aber ein sehr geringes Metastasierungspotenzial. Die Abgrenzung zu benignen Enchondromen ist aus klinischer, radiologischer und histopathologischer Sicht komplex.

Ziel der Arbeit

Epidemiologie, Diagnostik und Therapie von ACT unter besonderer Berücksichtigung der Abgrenzung zu Enchondromen werden dargestellt.

Material und Methoden

Es erfolgt die Zusammenfassung der internationalen Fachliteratur zu ACT und Enchondromen.

Ergebnisse

Die Inzidenz von Enchondromen, und mehr noch von ACT, ist über die Jahre angestiegen, was auf häufiger werdende Diagnostik hinweist. Im Gegensatz zu Enchondromen können ACT mit Schmerzen verbunden sein und radiologische Zeichen aggressiven Wachstums, wie tiefes endosteales Scalloping, aufweisen. Die alleinige Biopsie zur Differenzierung zwischen Enchondromen und ACT ist oft nicht hilfreich, da aufgrund der punktuellen Probegewebsentnahme ein „sampling error“ resultieren kann. Die definitive operative Therapie von ACT der langen und kurzen Röhrenknochen hat sich über die letzten Jahre gewandelt, weg von einer radikalen Tumorentfernung hin zu intraläsionaler Kürettage. Ein Zuwarten ist bei radiologischem Verdacht auf das Vorliegen eines Enchondroms regelmäßigen Verlaufskontrollen mittels Magnetresonanztomographie (MRT) möglich.

Schlussfolgerungen

ACT weisen im Gegensatz zu Enchondromen radiologische Zeichen eines aggressiven Wachstums auf. Die heutzutage bevorzugte Therapie besteht aus einer intraläsionalen Kürettage. Sowohl Diagnostik als auch Therapie und Nachsorge von kartilaginären Tumoren sollten an einem spezialisierten Tumorzentrum erfolgen.

Curettage and cryosurgery for enchondroma and atypical cartilaginous tumors of the long bones: Oncological results of a large series

BACKGROUND AND OBJECTIVES

Intralesional surgical treatment is the preferred therapy for atypical cartilaginous tumors (ACTs) of the long bones in many institutions. However, the literature is still controversial regarding intralesional treatment versus wide resection. Due to the relative rarity of these tumors, studies reporting on the results of intralesional treatment are often small sample studies.

METHODS

We retrospectively analyzed the oncological results of 55 enchondromas, 119 ACTs, and 5 chondrosarcomas grade 2 (CS2) treated with curettage and cryosurgery between the years 2004 and 2017 at our institution. The median follow-up period was 53 months (range, 24-169 months).

RESULTS

In total, seven cases (three ACT, four CS2) recurred. Residual tumor was detected in 20 cases. Three cases underwent secondary curettage and cryosurgery due to local recurrence. Four cases underwent wide resection and reconstruction due to local recurrence with aggressive imaging characteristics. In total, 20 postoperative complications were seen.

CONCLUSION

Curettage and cryosurgery for enchondroma and ACT show very good oncological results with a low recurrence rate and acceptable complication rate. Curettage and cryosurgery is reliable as a surgical treatment for enchondroma and ACT. Further research should define the criteria for determining which specific cartilaginous tumors necessitate surgical treatment.