Dedifferentiated chondrosarcoma: our clinico-pathological experience and dilemmas in 25 cases

A Systematic Review of Adjuvant Chemotherapy in Localized Dedifferentiated Chondrosarcoma

Dedifferentiated chondrosarcoma (DDCS) is a high-grade subtype of chondrosarcoma with the bimorphic histological appearance of a conventional chondrosarcoma component with abrupt transition to a high-grade, non-cartilaginous sarcoma. DDCS can be radiographically divided into central and peripheral types. Wide resection is currently the main therapeutic option for localized DDCS. Moreover, the effectiveness of adjuvant chemotherapy remains controversial. Therefore, we performed a systematic review of available evidence to evaluate the effect of adjuvant chemotherapy on localized DDCS. The purpose was to compare the 5-year survival rate among patients treated with surgery plus adjuvant chemotherapy or surgery alone for localized DDCS. The search was conducted in PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Of the 217 studies shortlisted, 11 retrospective non-randomized studies (comprising 556 patients with localized DDCS) were selected. The 5-year survival rates were similar between the two treatment groups (28.2% (51/181) vs. 24.0% (90/375), respectively). The overall pooled odds ratio was 1.25 (95% confidence interval: 0.80-1.94; p = 0.324), and heterogeneity I2 was 2%. However, when limited to peripheral DDCS, adjuvant chemotherapy was associated with prolonged survival (p = 0.03). Due to the paucity of included studies and the absence of prospective comparative studies, no conclusions can be drawn regarding the effectiveness or ineffectiveness of adjuvant chemotherapy for localized DDCS.

Dedifferentiated Chondrosarcoma: Diagnostic Controversies and Emerging Therapeutic Targets

PURPOSE OF REVIEW

The pathogenesis of dedifferentiated chondrosarcoma is controversial, and no genetic abnormality has consistently been identified in the disease. Focusing on the diagnostic challenges encountered in dedifferentiated chondrosarcoma, the following review aims at summarizing the tumor's active neoplastic pathways while highlighting therapeutic modalities that could potentially be explored to enhance patient survivorship.

RECENT FINDINGS

Owing to the challenging examination of small needle biopsy sampling as well as the disease's overlapping morphological and immunohistochemical features with other bone and soft-tissue sarcomas, the diagnosis of dedifferentiated chondrosarcoma can be problematic. While combined doxorubicin- and cisplatin-based regimens remain the first-line systemic chemotherapy in the disease, ~50% of tumors carry EXT1/2 or IDH1/2 mutations, advancing EXT or IDH inhibitors as potential alternative therapies, respectively. Despite systemic chemotherapy, dedifferentiated chondrosarcoma remains an aggressive tumor with dismal prognosis and limited survival. A multidisciplinary collaboration across multiple cancer centers is warranted to yield an accurate diagnosis, understand the disease's underlying pathogenesis, develop adequate treatment, and improve patient survivorship.

Dedifferentiated chondrosarcoma: current standards of care

Dedifferentiated chondrosarcomas are aggressive variants of chondrosarcoma, associated with poor outcomes. Tumor biphasism is the norm. The majority of these tumors are symptomatic at presentation. Radiologically, large soft tissue masses with bony destruction predominate. Treatment protocols of these tumors are not well defined. Surgical resection forms the standard of care for localized disease. (Neo)adjuvant therapies remain controversial as the results from multiple (mainly retrospective) studies remain conflicting. Age at presentation, stage and ability to obtain negative resection margins are important prognostic factors. The overall prognosis is dismal. Newer and novel therapies targeting the complex genetic makeup of these tumors have renewed interest in the adjuvant setting that could hold promise in the near future.

Pathology of pleomorphic/undifferentiated and dedifferentiated bone neoplasms

Primary malignant bone tumors are uncommon and their accurate classification requires careful correlation of clinical, radiological, and pathologic findings. It is a heterogeneous group of tumors with a wide spectrum of morphology and their biological potential can be of low- or high-grade, depending on their risk for developing metastases. Over the past several decades, the classification of bone sarcomas has remained largely constant. However, some of the tumors have been reclassified and several new entities have emerged. In this review, we will focus on pleomorphic fibrosarcoma/UPS and dedifferentiated bone tumors, discuss their key diagnostic features, differential diagnosis, and their relation to prognosis.

Dedifferentiated chondrsarcoma: a clinicopathologic analysis of 25 cases

Background

To investigate the clinical, imaging and pathological features of dedifferentiated chondrosarcoma for better diagnosis.

Methods

Patients who had been confirmed to have dedifferentiated chondrosarcoma were enrolled in this study and analyzed in the clinical, imaging and pathological data.

Results

Twenty-five patients had pathologically confirmed dedifferentiated chondrosarcoma including 15 males and 10 females with an age range of 24–74 (median 58, interquartile range 49–65). Ten patients had the tumor at the femur, four at the ilium, two at the humerus, two at the tibia, two at cotyle, and one at each of the following locations: scapula, sacrum, rib, pubic branch, and calcaneus. Twenty-one patients had local pain and a soft tissue mass while the other four patients had only local pain without a soft tissue mass. Four patients had pathological fractures. Imaging showed extensive bone destruction with calcification inside the lesion and possible pathological fractures. On gross observation of the specimen, the chondrosarcoma components were usually located inside the bone, and the dedifferentiated sarcoma components were mainly located outside the bone. Microscopy showed the dedifferentiated tumor had two components: well-differentiated chondrosarcoma and poorly differentiated non-chondral sarcoma including malignant fibrous histiocytoma in eleven cases, osteosarcoma in ten cases, fibrosarcoma in two, liomyosarcoma in one, and lipoblastoma in the remaining one.. Followed up from 3 moths to 60 months (mean 15.6), eight patients died with a survival time of 10–23 months (mean 16), and the other 17 patients survived with the survival duration from three to 60 months (15).

Conclusion

Dedifferentiated chondrosarcoma is a fatal disease with multiple components, and most of the cases have dual morphological and imaging features of chondrosarcoma and non-chondrosarcoma. The imaging presentations are primarily of common central chondrosarcoma, combined with cortical destruction, soft tissue mass, and pathological fractures.

H3K27me3 deficiency defines a subset of dedifferentiated chondrosarcomas with characteristic clinicopathological features

Dedifferentiated chondrosarcoma is a rare bone sarcoma, whose genetic background remains incompletely understood. Mutations in SUZ12 or EED, which encode polycomb repressive complex 2 (PRC2) components, and resulting deficiency in H3K27me3 are characteristic features of the majority of malignant peripheral nerve sheath tumors. Here, we investigated H3K27me3 and PRC2 status in dedifferentiated chondrosarcoma. Among 19 evaluable dedifferentiated chondrosarcoma cases, six (32%) showed immunohistochemical loss of H3K27me3 only in the dedifferentiated component, whereas the well-differentiated component retained H3K27me3. H3K27me3-deficient dedifferentiated chondrosarcoma occurred in two men and four women with a median age of 66. All of these tumors affected bones of the upper half of the body, with the ribs being preferentially involved, which represented a significantly different distribution compared to that in the 13 H3K27me3-intact dedifferentiated chondrosarcomas. H3K27me3-deficient dedifferentiated chondrosarcomas were histologically different from H3K27me3-intact dedifferentiated chondrosarcomas, as the former invariably demonstrated dedifferentiated histology with a striking similarity to classic malignant peripheral nerve sheath tumor, comprising sweeping to swirling fascicles of relatively uniform spindle cells. Heterologous rhabdomyoblastic differentiation, the focal presence of grade 3 chondrosarcoma histology, and a cartilaginous component in the metastatic sites were exclusively seen in some cases of H3K27me3-deficient dedifferentiated chondrosarcoma. In all three H3K27me3-deficient dedifferentiated chondrosarcomas that contained focal grade 3 histology, dedifferentiated components did not juxtapose to the grade 3 areas but transitioned abruptly from the grade 1-2 components. Targeted next generation sequencing, which was successfully performed on four H3K27me3-deficient dedifferentiated chondrosarcomas, identified an IDH2 mutation in one case and COL2A1 truncations in three cases. The dedifferentiated areas of three cases harbored SUZ12 or EED alterations, which were absent in the well-differentiated component, suggesting a role for PRC2 aberrations in dedifferentiation. H3K27me3 deficiency defines a novel subset of dedifferentiated chondrosarcoma that requires recognition because of its diagnostic and potential clinical implications.

Dedifferentiated chondrosarcoma: A survival analysis of 159 cases from the SEER database (2001-2011)

BACKGROUND AND OBJECTIVES

Dedifferentiated chondrosarcoma is a rare malignancy with reported 5-year overall survival rates ranging from 7% to 24%. The purpose of this investigation is to determine the overall survival of dedifferentiated chondrosarcoma in a modern patient series and how it is impacted by patient demographics, tumor characteristics, and surgical treatment factors.

METHODS

This is a retrospective review of the Surveillance, Epidemiology, and End Results (SEER) database from 2001 to 2011. Kaplan Meier analyses were used for overall and disease-specific survival. Univariable and multivariable cox regression models were used to identify prognostic factors.

RESULTS

Five year overall- and disease-specific survival was 18% (95% CI: 12-26%) and 28% (95% CI: 18-37%), respectively. Individuals with extremity tumors had a worse prognosis than individuals with a primary tumor in the chest wall or axial skeleton (HR 0.20, 95% CI: 0.07-0.56; P = 0.002 and HR 0.60, 95% CI: 0.36-0.99; P = 0.04, respectively). Patients with AJCC stage III or IV disease (HR 2.51, 95% CI: 1.50-4.20; P = 0.001), tumors larger than 8 cm (HR 2.17, 95% CI: 1.11-4.27; P = 0.046), metastatic disease at diagnosis (HR 3.25, 95% CI: 1.98-5.33; P < 0.001), and those treated without surgical resection (amputation: HR 0.43, 95% CI 0.23-0.80; P = 0.01; limb salvage/non-amputation resection: HR 0.41, 95% CI: 0.24-0.69; P = 0.001) had a significant increase in risk of mortality.

CONCLUSIONS

The overall prognosis of dedifferentiated chondrosarcoma is poor with a 5-year overall survival of 18%. Patients with a primary tumor located in the chest wall had a better prognosis. Tumors larger than 8 cm, presence of metastases at diagnosis, and treatment without surgical resection were significant predictors of mortality.

Dedifferentiated chondrosarcoma: Radiological features, prognostic factors and survival statistics in 23 patients

Background

Dedifferentiated chondrosarcoma is a rare, highly malignant tumor with a poor survival. There are many confusing issues concerning the imaging feature that can facilitate early diagnosis and the factors that might be related to outcomes.

Methods

Twenty-three patients with dedifferentiated chondrosarcoma confirmed by pathology were retrospectively reviewed from 2008 to 2015. The patients’ clinical information, images from radiographs (n = 17), CT (n = 19), and MRI (n = 17), histological features, treatment and prognosis were analyzed.

Results

There were 12 males and 11 females, and the mean age was 50.39 years old. Fourteen cases affected the axial bone (pelvis, spine), and 9 cases involved the appendicular bone. Seven (41.17%), 9 (47.36), and 12 (66.66%) lesions showed a biphasic nature on radiograph, CT and MRI, respectively. Of the lesions, 17.39% (4/23) were accompanied by pathological fractures. Histologically, the cartilage component was considered histological Grade1 in 12 patients and Grade 2 in 11 patients. The dedifferentiated component showed features of osteosarcoma in 8 cases, malignant fibrous histiocytoma in3 cases, myofibroblastic sarcoma in 1 case and spindle cell sarcoma in 11cases. Twenty-two cases were treated with surgical resection, and 17 cases achieved adequate (wide or radical) surgical margin. In 8 cases, surgery was combined with adjuvant chemotherapy. The overall median survival time was nine months; 17.4% of patients survived to five years.

Conclusion

Axial bone location, lung metastasis at diagnosis, inadequate surgical margin, incorrect diagnosis before surgery and pathological fractures was related to poorer outcome. Pre- or postoperative chemotherapy had no definitively effect on improved survival.

Tumors of the coracoid process: clinical evaluation of twenty-one patients

OBJECTIVE

We present the incidence and management of bone tumors of the coracoid process and discuss the related clinical and imaging findings and treatment.

MATERIALS AND METHODS

We present 21 patients (7 males and 14 females; mean age, 39 years) treated for bone tumors of the coracoid process from 1900 to 2010. Mean follow-up was 44 months (range, 12-132 months). Clinical presentation, imaging, surgical treatment, complications, range of shoulder motion, and Musculoskeletal Tumor Society (MSTS) function were evaluated.

RESULTS

Bone tumors were benign in 7 (33%) and malignant in 14 (67%). The most common were chondrosarcomas, osteoblastomas, and chondroblastomas. The most common presentation was pain and palpable mass for a mean duration of 11 months. Limb salvage, with or without megaprosthetic reconstruction, was achieved in 20 patients. One patient required forequarter amputation. One patient with chondroblastoma and 2 with chondrosarcoma had local recurrence. The range of shoulder motion varied according to the type of resection: patients with curettage and limited resections without involvement of the abductor mechanism had better shoulder motion, and patients with scapulectomy and proximal humeral resections had significant limitations of motion. The mean MSTS score was 80% (range, 50%-100%).

CONCLUSIONS

Chondrosarcomas, osteoblastomas, and chondroblastomas are the most common bone tumors of the coracoid process. Limited resections are associated with nearly normal range of motion and excellent function; however, limited resections are acceptable in only in a small number of patients. In patients with malignant and recurrent lesions, wide resection is required, which is associated with significant limitations of shoulder function.

Chondrosarcomas revisited

Chondrosarcomas are malignant bone tumors with pure hyaline cartilage differentiation; myxoid changes, calcification, or ossification may be present. Several subtypes of chondrosarcomas exist. Behavior patterns vary, ranging from slow-growing nonmetastasizing lesions to aggressive metastasizing sarcomas. Symptoms are usually mild, with duration ranging from several months to years, and usually consist of persistent, dull, aching pain or palpable masses. Radiographic findings include bone expansion with cortical thickening, radiolucent areas with variably distributed punctate or ring-like matrix calcifications, cortical erosion or destruction, endosteal scalloping, and scant or absent periosteal reaction; extension into the soft tissue may be present. Histological differential diagnosis from benign cartilaginous lesions can be achieved by increased cellularity, enlarged plump nuclei, binucleated cells, hyperchromatic nuclear pleomorphism, and permeation of cortical or medullary bone. Atypia is usually mild to moderate; necrosis and mitoses can be seen, particularly in high-grade lesions. Adequate surgery is the mainstay of treatment. High-grade and pelvic chondrosarcomas are best managed with wide resection. Because of the low metastatic potential and low local recurrence rate noted with intralesional surgery, low-grade chondrosarcomas can be treated with curettage (with or without treatment of the defect cavity) with a local adjuvant, such as phenol or cryotherapy. Adjuvant chemotherapy may be considered for mesenchymal and dedifferentiated chondrosarcomas. Radiation therapy can be considered after incomplete resection or if resection is not feasible or would cause unacceptable morbidity.

The clinical management of chondrosarcoma

OPINION STATEMENT

Chondrosarcomas (CHS) represent a heterogeneous group of disorders ranging from indolent, low-grade tumors to aggressive, high-grade forms. Surgical resection represents the primary and preferred treatment modality for individuals with localized disease. Radiation therapy is appropriate for the treatment of positive surgical margins or palliation of disease-related symptoms. The treatment of advanced, metastatic disease is particularly challenging given the recognition that conventional chemotherapy has proven to be largely ineffective. Systemic chemotherapy may be considered in variant forms such as mesenchymal or dedifferentiated chondrosarcomas but high-quality data supporting its use is limited. There is universal agreement, however, that novel treatment strategies are desperately needed. This review will highlight the need for a coordinated multidisciplinary approach to optimize the management and care of patients.

Dedifferentiated chondrosarcoma of the thumb: a case report

Dedifferentiated chondrosarcoma (DDCS) comprises approximately 10% of all chondrosarcomas and has the worst outcome with 5-year survival of 10%. The preferred localizations are femur, humerus and pelvis. We report a case of DDCS that arose in proximal phalanx of left-hand thumb of a 66-year-old man. He was admitted with a 2-month history of pain and swelling in his thumb. He had experienced a fracture 15 years ago in the same localization with a history of suspected preexisting enchondroma. Plain radiographs showed an expansive osteolytic lesion with milimetric calcifications while magnetic resonance imaging revealed intraosseous focal globular hyperintense spots consistent with chondroid areas as well as a surrounding soft tissue mass with intermediate signal intensity. In biopsy specimen we observed a low-grade chondrosarcoma next to a spindle cell sarcoma with an abrupt transition. He was treated with amputation and died of the disease within 9 months following the surgery. The presence of dedifferented chondrosarcoma in bones of hands was not previously reported. The presented case was provided with the macroscopic and microscopic features observed in amputation specimen in comparison with radiological findings.

Tissue microarrays analysis in chondrosarcomas: light microscopy, immunohistochemistry and xenograft study

Background

Chondrosarcoma (Chs) is the third most frequent primary malignant tumour of bone and can be primary or secondary, the latter results mainly from the malignant transformation of a benign pre-existing tumour.

Methods

All the cases diagnosed as Chs (primary tumours, recurrences and/or metastasis and xenotransplanted Chs) from the files of our Department were collected. Only cases with paraffin blocks available were selected (Total 32 cases). Six Tissue Microarrays (TMAs) were performed and all the cases and biopsies were distributed into the following groups: a) only paraffin block available from primary and/or metastatic tumours (3 TMAs), b) paraffin block available from primary and/or metastatic tumours as well as from the corresponding Nude mice xenotransplant (2 TMAs), c) only paraffin block available from xenotransplanted Chs (1 TMA). A reclassification of all the cases was performed; in addition, conventional hematoxylin-eosin as well as immunohistochemistry staining (S100, SOX-9, Ki-67, BCL-2, p53, p16, CK, CD99, Survivin and Caveolin) was analyzed in all the TMA.

Results

The distribution of the cases according to the histopathological pattern and the location of tumours were as follows: fourteen Grade I Chs (all primaries), two primary Grade II Chs, ten Grade III Chs (all primaries), five dedifferentiated Chs (four primaries and one primary with metastasis), and two Chs from cell cultures (Ch grade III). One recurrent extraskeletal myxoid Chs was included as a control in the TMA. Although there was heterogeneity in immunohistochemistry results of the different material analyzed, S100, SOX-9, Caveolin and Survivin were more expressed. The number of passages in xenotransplants fluctuated between 1 and 13. Curiously, in Grade I Chs, these implanted tumours hardly grew, and the number of passages did not exceed one.

Conclusion

The study of Chs by means of TMA techniques is very important because it will improve the assessment of different antibodies applied in the immunohistochemical assays. Xenotransplanted tumours in TMA improve knowledge concerning the variability in the morphological pattern shown by these tumours during the evolution in nudes.