How safe is curettage of low-grade cartilaginous neoplasms diagnosed by imaging with or without pre-operative needle biopsy?

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.

Effect of Local Adjuvants Following Curettage of Benign and Intermediate Tumours of Bone: A Systematic Review of the Literature

Local adjuvants are used upon intralesional resection of benign/intermediate bone tumours, aiming at reducing the local recurrence (LR) rate. However, it is under debate whether, when and which local adjuvants should be used. This PRISMA-guideline based systematic review aimed to analyse studies reporting on the role of adjuvants in benign/intermediate bone tumours. All original articles published between January 1995 and April 2020 were potentially eligible. Of 344 studies identified, 58 met the final inclusion criteria and were further analysed. Articles were screened for adjuvant and tumour type, follow-up period, surgical treatment, and development of LR. Differences in LR rates were analysed using chi-squared tests. Altogether, 3316 cases (10 different tumour entities) were analysed. Overall, 32 different therapeutic approaches were identified. The most common were curettage combined with high-speed burr (n = 774; 23.3%) and high-speed burr only (n = 620; 18.7%). The LR rate for studies with a minimum follow-up of 24 months (n = 30; 51.7%) was 12.5% (185/1483), with the highest rate found in GCT (16.7%; 144/861). In comparison to a combination of curettage, any adjuvant and PMMA, the sole application of curettage and high-speed burr (p = 0.015) reduced the LR rate in GCT. The overall complication rate was 9.6% (263/2732), which was most commonly attributable to postoperative fracture (n = 68) and osteoarthritis of an adjacent joint during follow-up (n = 62). A variety of adjuvants treatment options are reported in the literature. However, the most important step remains to be thorough curettage, ideally combined with high-speed burring.

Natural history of intraosseous low-grade chondroid lesions of the proximal humerus

Introduction

Enchondromas and grade 1 chondrosarcomas are commonly encountered low-grade chondroid tumors in the proximal humerus. While there is a concern for malignant transformation, few studies have evaluated the natural history of these lesions. The purpose of this study is to evaluate the natural history of proximal humerus low-grade chondroid lesions managed both conservatively and surgically, and to define management criteria using clinical and radiographic findings for these low-grade chondroid lesions.

Methods

The patient population included 90 patients intended for conservative treatment and 22 patients proceeding directly to surgery. Data collection was based on a combination of chart review and patient imaging and descriptive statistics were calculated for each group.

Results

No malignant transformations were noted amongst any group. In the conservative treatment group, 7 of 64 (11%) progressed to surgery after an average of 20.3 months of conservative treatment due to persistent pain unexplained by other shoulder pathology. Importantly, 71% experienced continued pain at a mean of 53.1 months post-operatively. The group that went directly to surgery also demonstrated pain in 41% at an average follow-up of 57.3 months.

Discussion

Low-grade cartilaginous lesions of the proximal humerus without concerning imaging findings can be managed with conservative treatment and the risk of malignant transformation is very low. Patients with a clear source of their shoulder pain unrelated to their tumor and without concerning characteristics on imaging can be managed with serial annual radiographic imaging. Patients undergoing surgery for these indolent tumors are likely to experience persistent pain even after surgery.

Curettage or Resection? A Review on the Surgical Treatment of Low-Grade Chondrosarcomas

Introduction Low-grade chondrosarcomas (LG-CS), including atypical cartilaginous tumors (ACT), are locally aggressive lesions. The focus of the discussion sits on the differential diagnosis between benign lesions or aggressive cartilaginous tumors and on their treatment: intralesional curettage or wide resection. This study presents the results obtained in the surgical treatment of 21 cases of LG-CS. Methods This retrospective study includes 21 consecutive patients from a single center with LG-CS who underwent surgery from 2013 to 2021. Fourteen were located in the appendicular skeleton, and seven in the axial (shoulder blade, spine, or pelvis). Mortality rate, recurrence, metastatic disease, overall survival, recurrence-free survival, and metastatic disease-free survival were analyzed for each type of procedure and each disease location. Operative complications and residual tumors were also recorded in cases where resection was performed. Survival was calculated using the Kaplan-Meier method. Results Thirteen patients underwent intralesional curettage (11 appendicular and 2 axial lesions), and eight underwent wide resection (5 axial and 3 appendicular). There were six recurrences during the follow-up, 43% of the axial lesions recurred, rising to 100% in axial curetted ones. Appendicular LG-CS recurred in 21% of cases, and only 18% of curetted appendicular lesions were not eradicated. The overall survival for the entire follow-up is 90.5%, and the 5-year survival rate is 83% (12 patients have adequate follow-up). Recurrence-free and metastasis-free survival were higher in resection cases, with 75% and 87.5%, vs. curettage 69.2% and 76.9%, respectively. In 9% of cases, the preoperative biopsy was inconsistent with the pathology of the surgical specimen. Discussion LG-CS and ACT are described as having high survival and low potential for metastatic disease. For this reason, these lesions are subject to a change in treatment philosophy to reflect these characteristics. Intra-lesional curettage is advocated as a less invasive technique for eradicating atypical cartilage tumors and has fewer and less severe complications, which was in accordance with our findings. Diagnosis, however, is challenging; misgrading is frequent and should be considered. Because of this risk of under-treating higher-grade lesions, some authors still defend wide-resection as the treatment of choice. We observed a trend towards longer survival, less recurrence, and metastatic disease with wide resection. Metastatic disease was higher than expected, present in 19% of cases, and always associated with local recurrence. Conclusion LG-CS is still a diagnostic and treatment challenge; patient selection is fundamental. Overall survival is high, independent of treatment choice or lesion location. We found a higher rate of metastatic disease than described in the literature; this, coupled with a misgrading rate of 9%, reflects the difficulty of preoperative diagnosis and the risk of treating high-grade chondrosarcomas as a low-grade lesion. More studies should be carried out with larger samples to obtain statistically robust results.

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.

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.

Atypical Cartilaginous Tumors: Trends in Management

INTRODUCTION

Chondrosarcomas are the most common primary bone malignancy in adults within the United States. Low-grade chondrosarcomas of the long bones, now referred to as atypical cartilaginous tumors (ACTs), have undergone considerable changes in recommended management over the past 20 years, although controversy remains. Diagnostic needle biopsy is recommended only in ambiguous lesions that cannot be clinically diagnosed with a multidisciplinary team. Local excision is preferred due to better functional and equivalent oncologic outcomes. We sought to determine whether these changes are reflected in reported management of ACTs.

METHODS

The National Cancer Database (NCDB) 2004 to 2016 was queried for ACTs of the long bones. Reported patient demographics and tumor clinicopathologic findings were extracted and compared between patients who underwent local excision versus wide resection.

RESULTS

We identified 1174 ACT patients in the NCDB. Of these, 586 underwent local excision and 588 underwent wide resection. No significant differences were found in patient demographics. No significant change was found in the reported percentage of diagnostic biopsies or wide resections performed over time. After multivariate regression, the single greatest predictor of performing wide resection on an ACTs was presenting tumor size.

DISCUSSION

Evaluation of the NCDB demonstrated that despite changes in the recommended management of ACTs, there has not been a significant change in surgical treatment over time. Surgeons have been performing diagnostic biopsies and wide resections at similar to historical rates. Persistency of these practices may be due to presenting tumor size, complex anatomic location, uncertainty of underlying tumor grade, or patient choice as part of clinical shared decision making. The authors anticipate that the rate of biopsies and wide resections performed will decrease over time as a result of improvements in advanced imaging and the implementation of recently updated clinical practice guidelines.

A Radiological Scoring System for Differentiation between Enchondroma and Chondrosarcoma

Simple Summary

Background: It is challenging to differentiate between enchondromas and atypical cartilaginous tumors (ACTs)/chondrosarcomas. Methods: To evaluate the diagnostic usefulness of radiological findings for differentiation between enchondromas and chondrosarcomas, correlations between various radiological findings and final diagnoses were investigated. Based on the correlations, a scoring system combining these findings was developed. Results: In a cohort of 81 patients, periosteal reaction on X-ray, endosteal scalloping and cortical defect on CT, extraskeletal mass, multilobular lesion, abnormal signal in adjacent tissue on MRI, and increased uptake in bone scan and thallium scan was significantly correlated with final diagnoses. Based on the correlations, a radiological scoring system combining radiological findings was developed. In another cohort of 17 patients, the sensitivity, specificity, and accuracy of the radiological score rates for differentiation between enchondromas and chondrosarcomas were 88%, 89%, and 88%, respectively. Conclusion: Comprehensive assessment combining radiological findings is recommended to differentiate between enchondromas and ACTs/chondrosarcomas.

Abstract

Background: It is challenging to differentiate between enchondromas and atypical cartilaginous tumors (ACTs)/chondrosarcomas. In this study, correlations between radiological findings and final diagnosis were investigated in patients with central cartilaginous tumors. Methods: To evaluate the diagnostic usefulness of radiological findings, correlations between various radiological findings and final diagnoses were investigated in a cohort of 81 patients. Furthermore, a new radiological scoring system was developed by combining radiological findings. Results: Periosteal reaction on X-ray (p = 0.025), endosteal scalloping (p = 0.010) and cortical defect (p = 0.002) on CT, extraskeletal mass (p < 0.001), multilobular lesion (p < 0.001), abnormal signal in adjacent tissue (p = 0.004) on MRI, and increased uptake in bone scan (p = 0.002) and thallium scan (p = 0.027) was significantly correlated with final diagnoses. Based on the correlations between each radiological finding and postoperative histological diagnosis, a radiological scoring system combining these findings was developed. In another cohort of 17 patients, the sensitivity, specificity, and accuracy of the radiological score rates for differentiation between enchondromas and ACTs/chondrosarcomas were 88%, 89%, and 88%, respectively (p = 0.003). Conclusion: Radiological assessment with combined radiological findings is recommended to differentiate between enchondromas and ACT/chondrosarcomas.

Conventional Cartilaginous Tumors: Evaluation and Treatment

»

Enchondromas are benign cartilaginous lesions that rarely require surgical intervention.

»

Atypical cartilaginous tumors (ACTs), also referred to as grade-1 chondrosarcomas, may be managed without any intervention or with extended intralesional curettage and bone-void filling.

»

High-grade chondrosarcomas, or grade-2 and 3 chondrosarcomas, should be managed aggressively with wide resection.

»

Chemotherapy and radiation do not currently play a role in the treatment of chondrosarcomas.

»

Differentiating an enchondroma from an ACT and an ACT from a high-grade chondrosarcoma can be difficult and requires clinical experience, radiographic and advanced imaging, and possibly a biopsy. Ultimately, a multidisciplinary team that includes a musculoskeletal oncologist, a radiologist, and a pathologist is needed to make the most appropriate diagnosis and treatment plan for each patient.

The 2020 WHO Classification of Tumors of Bone: An Updated Review

Bone tumors are a rare and heterogeneous group of neoplasms that occur in the bone. The diversity and considerable morphologic overlap of bone tumors with other mesenchymal and nonmesenchymal bone lesions can complicate diagnosis. Accurate histologic diagnosis is crucial for appropriate management and prognostication. Since the publication of the fourth edition of the World Health Organization (WHO) classification of tumors of soft tissue and bone in 2013, significant advances have been made in our understanding of bone tumor molecular biology, classification, prognostication, and treatment. Detection of tumor-specific molecular alterations can facilitate the accurate diagnosis of histologically challenging cases. The fifth edition of the 2020 WHO classification of tumors of soft tissue and bone tumors provides an updated classification scheme and essential diagnostic criteria for bone tumors. Herein, we summarize these updates, focusing on major changes in each category of bone tumor, the newly described tumor entities and subtypes of existing tumor types, and newly described molecular and genetic data.

Pelvic Chondrosarcoma Treated by En Bloc Resection with Patient-Specific Osteotomy Guides and Reimplantation of the Extracorporeally Irradiated Bone as an Osseocartilaginous Structural Orthotopic Autograft: A Report of Two Cases with Description of the Surgical Technique

Primary tumors of the pelvis are considered difficult to treat due to the complex anatomy and the proximity of important neurovascular structures. The surgical armamentarium for the treatment of these tumors has evolved with the help of cutting-edge technology from debilitating hemipelvectomies to solutions such as precise resections guided by patient-specific instruments or computer navigation and reconstruction by modular prostheses, 3D-printed custom-made implants, or orthotopic autograft reimplantation after extracorporeal irradiation. Different combinations of these techniques have been described in the literature with various rates of success. We present two cases of pelvic chondrosarcomas successfully treated by a combination of periacetabular resection with patient-specific osteotomy guides and orthotopic reimplantation of the extracorporeally irradiated autograft resulting in retention of the native hip.

Relative Sensitivity of Core-Needle Biopsy and Incisional Biopsy in the Diagnosis of Musculoskeletal Sarcomas

BACKGROUND

There is no evidence as to the diagnostic value of the two most frequently used methods of biopsies in sarcomas: Incisional or core needle biopsy. The aim of our study was to evaluate the diagnostic sensitivity of the incisional and the core needle biopsy techniques in the diagnosis of bone and soft tissue sarcomas.

METHODS

We included 417 patients with a definitive diagnosis of bone or soft tissue sarcoma in whom a total of 472 biopsies had been performed. We correlated the results of the biopsies with the result of the definitive histopathological examination of the resected tumor. Dignity, entity, and grading (whenever possible) of the tissue samples were evaluated.

RESULTS

A total of 258 biopsies (55%) were performed in order to diagnose a soft tissue tumor and 351 biopsies (74.4%) were core needle biopsies. The number of repeat core needle biopsies, necessitated because of inconclusive histopathological results, was significantly higher (50 vs. 5; p = 0.003). We observed no significant difference regarding dignity, entity, and grading between the 2 different types of biopsies. Only with regards to the determination of dignity and entity of chondroid tumors, incisional biopsy was superior with statistical significance (p = 0.024).

CONCLUSIONS

This study represents the largest study on biopsies for bone and soft tissue sarcomas. Based only on our results, we are unable to favor one method of biopsy and found high accuracy with both methods. Considering the potential complications, the added oncological risks of incisional biopsies and the ready availability of core needle biopsies, the latter, in our assessment, represents a valid and favourable method for bone and soft tissue sarcomas.

Team Approach: Evaluation and Management of Low-Grade Cartilaginous Lesions

» Assessment of chondral lesions begins with a clinical evaluation and radiographs. » Longitudinal follow-up with serial radiographs is appropriate in cases without evidence of aggressive radiographic features. » Concerning radiographic features include periosteal reaction, soft-tissue extension, cortical destruction, endosteal scalloping of greater than two-thirds of the native cortex, larger lesion size (≥5 cm), and location in the axial skeleton. » Biomarkers such as IMP3, SOX4, microRNA, and periostin may be used as an adjunct in histologic assessment to help differentiate benign enchondroma from a low-grade chondrosarcoma. » Advanced-imaging studies, such as computed tomography (CT), bone scans, magnetic resonance imaging (MRI), dynamic contrast-enhanced MRI, and fluorodeoxyglucose positron emission tomography (FDG-PET), may be considered for borderline cases. » Aggressive or concerning radiographic features should prompt evaluation with advanced imaging or referral to an orthopaedic oncologist.

Paediatric bone lesions: diagnostic accuracy of imaging correlation and CT-guided needle biopsy for differentiating benign from malignant lesions

OBJECTIVE

To determine the sensitivity, specificity and accuracy of CT-guided needle biopsy (CT-NB) for distinguishing benign and malignant lesions in children with suspected primary bone tumours, and to assess the correlation between imaging diagnosis and final diagnosis.

METHODS

Retrospective review of children who underwent CT-NB of a suspected primary bone tumour between October 2016 and October 2019. Data collected included anatomical location, imaging diagnosis, type of needle, type of biopsy sample, CT-NB diagnosis, final diagnosis and post-procedural complications. The final diagnosis was established based on surgical histology or clinical/imaging follow-up.

RESULTS

125 patients met the inclusion criteria (68M, 57F: mean age 11 years; range 10 months-18 years). Biopsy was performed using a 10 cm Jamshidi needle (10G n = 96; 13 G n = 8); 14G Tru-Cut needle (n = 18); 14G Temno needle (n = 3). The commonest anatomical locations were the femur (n = 40), tibia (n = 25) and humerus (n = 16), while the commonest diagnoses were osteosarcoma (n = 35), CRMO (n = 15) and LCH (n = 14). A benign tumour was correctly identified on imaging in 100% of cases, and a malignant tumour in 95.8%. Sensitivity, specificity and diagnostic accuracy of CT-NB for distinguishing malignant from benign lesions were 98%, 100 and 99%. Of 24 indeterminate biopsy results, all that had a non-aggressive radiological appearance were benign. No immediate complications were recorded.

CONCLUSION

CT-NB represents a safe and very effective tool for differentiating benign and malignant lesions in children presenting with a suspected primary bone tumour. Suspected radiological diagnosis plays a pivotal role in the management of indeterminate biopsy results.

ADVANCES IN KNOWLEDGE

Paediatric bone tumours pose a significant diagnostic and therapeutic challenge. The interpretation of the imaging findings is essential for the successful management of indeterminate histological results.

The role of imaging in differentiating low-grade and high-grade central chondral tumours

Chondrosarcoma is a malignant cartilage matrix-producing tumour. Those arising de novo are called primary chondrosarcomas and are the second commonest primary malignant bone tumours. Numerous types of primary chondrosarcoma exist, namely conventional central (intramedullary), periosteal (juxta-cortical), clear cell, mesenchymal, and dedifferentiated. The biologic aggressiveness, prognosis and thus management of chondrosarcoma are dependent on the histological sub-type and grade. Accurate pre-operative diagnosis is therefore essential in determining management and outcome which requires a multidisciplinary approach taking into account clinical features, imaging findings and histopathology. In this review, we present the pertinent multimodality imaging features which aid in the differentiation of low-grade and high-grade conventional central chondrosarcoma.

The importance of MRI review following the diagnosis of atypical cartilaginous tumour using image-guided needle biopsy

OBJECTIVE

To evaluate the role of pre-biopsy MRI for management planning in patients with atypical cartilaginous tumours (ACT) diagnosed on image-guided core needle biopsy (IGCNB).

MATERIALS AND METHODS

Retrospective review of patients diagnosed with ACT of the appendicular skeleton based on IGCNB who subsequently underwent surgical curettage or resection. Data collected included age, sex, skeletal location and surgical histology classified as ACT, high-grade chondrosarcoma (HG-CS) and dedifferentiated chondrosarcoma (DD-CS). Pre-biopsy MRI studies were reviewed independently by 2 radiologists blinded to surgical histology results and graded as ACT, HG-CS and DD-CS based on MRI features.

RESULTS

The study included 24 males and 28 females (mean age 42.1 years; range 9-76 years). One patient had 2 lesions treated, making a total of 53 lesions. Tumours were located in the femur in 21 cases, humerus in 17, tibia in 9, radius in 4 and ulna and fibula in 1 each. Surgical histology was ACT in 41 cases, HG-CS in 10 and DD-CS in 2, indicating mismatch between IGCNB and surgical histology in 12/53 cases (22.6%). Predicted MRI grade for the 2 readers was ACT in 39 cases each, HG-CS in 13 and 14 cases and DD-CS in 1 and 0 cases. Sensitivity, specificity and accuracy of MRI for predicting HG-CS/DD-CS were 91%, 93% and 92%, respectively. Inter-observer correlation was very good (kappa = 0.94).

DISCUSSION

Review of MRI findings in patients with ACT diagnosed on IGCNB is vital for identifying patients with a HG-CS/DD-CS and is recommended when planning surgical management or considering repeat IGCNB.

Total Knee Arthroplasty and Atypical Cartilaginous Tumor/Enchondroma of the Distal Femur

Enchondroma is a common benign chondrogenic tumor, which typically occurs in the short bones of hands and feet. However, when affecting the long bones, it is difficult to rule out the low-grade chondrosarcoma, called atypical cartilaginous tumor (ACT), because of the highly similar clinical and radiologic features. This study reports 2 patients with advanced knee osteoarthritis, scheduled for total knee arthroplasty, who had a distal femoral lesion on imaging suggestive of ACT/enchondroma. We believe that the treatment of these patients could be a challenge for arthroplasty surgeons. This is because it might be difficult to decide whether a periarticular chondral tumor of an osteoarthritic knee is malignant and changes the plan. In this report, we described our approach to address both knee osteoarthritis and ACT/enchondroma of the distal femur. To the best of our knowledge, this issue has not yet been discussed in the literature.

Chondral tumours: discrepancy rate between needle biopsy and surgical histology

OBJECTIVE

To determine the reliability of image-guided core needle biopsy (IGCNB) for the diagnosis and grading of chondral tumours of bone compared with surgical histology.

MATERIALS AND METHODS

Retrospective review of patients with a chondral tumour of bone who underwent IGCNB and surgical resection between January 2007 and December 2017. Data collected included age, sex, skeletal location, technique used for IGCNB, IGCNB result including histological grade and comparison with surgical histology.

RESULTS

A total of 237 patients were included (135 males and 102 females with mean age 53.7 years, range 9-89 years). A total of 174 IGCNBs were CT-guided, 57 ultrasound-guided and 6 fluoroscopic-guided. Two hundred thirty-six of 237 (99.6%) IGCNBs were diagnostic for a chondral tumour, although grade could not be determined in 13 (5.5%) due to necrosis. A positive correlation for tumour grade between IGCNB and surgical histology was achieved in 181 cases (76.4%). In 36 patients (15.2%), IGCNB under-graded the tumour, while in 6 (2.5%), IGCNB over-graded the tumour. Discrepancy between IGCNB and surgical histology was significantly greater for surface/peripheral lesions (p = 0.02) and lesions arising from the flat bones or spine (p = 0.002).

DISCUSSION

IGCNB can achieve a diagnosis of a chondral tumour in a high proportion of cases when compared with final diagnosis from surgical resection specimens. However, correlation of tumour grade between IGCNB and resection histology is less reliable with discordance seen in almost one-quarter of cases, most commonly at non-appendicular sites. Therefore, IGCNB results should not be considered in isolation of imaging and clinical features when planning surgical management.

Risk stratification for central conventional chondrosarcoma of bone: A novel system predicting risk of metastasis and death in the Cancer Registry of Norway cohort

BACKGROUND AND OBJECTIVES

Interobserver variability in histological grading of central conventional chondrosarcoma (CCCS) limits the quality of patient information and research progression. We aim to quantify known and new prognostic variables and propose a risk stratification model.

METHOD

We selected 149 cases from the Cancer Registry of Norway. Cox proportional hazard models were estimated. Based on these results a dichotomous risk classification was proposed and presented by Kaplan-Meier estimates for rates of local recurrence, metastasis, and disease-specific survival.

RESULTS

The influence of axial skeletal location (Hazard ratio [HR] = 19.06), a soft tissue component ≥1 cm (HR = 13.45), and histological grade 3 (HR = 16.46) are all significant in predicting the rate of metastasis. The creation of a variable combining axial skeletal location and a soft tissue component ≥1 cm strongly predicts the risk of metastasis (HR = 14.02; P < .001) and death (HR = 2.74; P = .030) at multivariate analysis, making the histological grade insignificant. Together with metastasis at diagnosis (HR = 285.65; P < .001), this forms the basis of our proposed risk stratification, producing a small high-risk group (39 cases with 33% risk of metastasis) and a large low-risk group (103 cases with 2% risk of metastasis) without a histological grade.

CONCLUSION

Axial skeletal location and a soft tissue component ≥1 cm combined divides a CCCS cohort into low- and high-risk groups without a histological grade.

Surgical therapy of benign and low-grade malignant intramedullary chondroid lesions of the distal femur: intralesional resection and bone cement filling with or without osteosynthesis

Surgical treatment of benign and low-grade malignant intramedullary chondroid lesions at the distal femur is not well analyzed compared to higher-grade chondrosarcomas. Localization at the distal femur offers high biomechanical risks requiring sophisticated treatment strategy, but scientific guidelines are missing. We therefore wanted to analyze a series of equally treated patients with intralesional resection and bone cement filling with and without additional osteosynthesis. Twenty-two consecutive patients could be included with intralesional excision and filling with polymethylmethacrylate bone cement alone (n = 10) or with compound bone cement osteosynthesis using a locking compression plate (n = 12). Clinical and radiological outcome was retrospectively evaluated including tumor recurrences, complications, satisfaction, pain, and function. Mean follow-up was 55 months (range 7–159 months). Complication rate was generally high with lesion-associated fractures both in the osteosynthesis group (n = 2) and in the non-osteosynthesis group (n = 2). All fractures occurred in lesions that reached the diaphysis. No fractures were found in meta-epiphyseal lesions. No tumor recurrence was found until final follow-up. Clinical outcome was good to excellent for both groups, but patients with additional osteosynthesis had significantly longer surgery time, more blood loss, longer postoperative stay in the hospital, more complications, more pain, less satisfaction, and worse functional outcome. Intralesional resection strategy was oncologically safe without local recurrences but revealed high risk of biomechanical complications if the lesion reached the diaphysis with an equal fracture rate no matter whether osteosynthesis was used or not. Additional osteosynthesis significantly worsened final clinical outcome and had more overall complications. This study may help guide surgeons to avoid overtreatment with additional osteosynthesis after curettage and bone cement filling of intramedullary lesions of the distal femur. Meta-epiphyseal lesions will need additional osteosynthesis rarely, contrary to diaphyseal lesions with considerable cortical thinning.

Updates in Primary Bone Tumors: Current Challenges and New Opportunities in Cytopathology

The review summarizes the current diagnostic challenges in fine-needle aspiration of primary bone tumors, with focus on the application of new molecular and immunohistochemical techniques in the diagnosis of giant cell-rich neoplasms, chondrosarcomas, and notochordal tumors.

Enchondromas and atypical cartilaginous tumors at the proximal humerus treated with intralesional resection and bone cement filling with or without osteosynthesis: retrospective analysis of 42 cases with 6 years mean follow-up

Background

Enchondromas and atypical cartilaginous tumors (ACT) are often located at the proximal humerus. Most lesions can be followed conservatively, but surgical resection may alleviate pain, avoid pathological fractures, and prevent transformation into higher grade chondrosarcomas. Rigorous intralesional resection and filling with polymethylmethacrylate bone cement has been proposed for enchondromas but also for ACT, as an alternative for extralesional resection. We intended to analyze radiological, clinical, and functional outcome of this strategy and compare bone cement without osteosynthesis to bone cement compound osteosynthesis, which has not been analyzed so far.

Methods

We retrospectively analyzed 42 consecutive patients (mean follow-up 73 months; range 8–224) after curettage and bone cement filling with or without osteosynthesis. Exclusion criteria were Ollier’s disease and cancellous bone filling. Twenty-five patients only received bone cement. Seventeen patients received additional proximal humerus plate for compound osteosynthesis to increase stability after curettage. Demographics and radiological and clinical outcome were analyzed including surgery time, blood loss, hospitalization, recurrences, and complications. An additional telephone interview at the final follow-up assessed postoperative satisfaction, pain, and function in the quick disabilities of the arm, shoulder, and hand (DASH) score and the Musculoskeletal Tumor Society (MSTS) score. Statistics included the Student T tests, Mann-Whitney U tests, and chi-square tests.

Results

No osteosynthesis compared to compound osteosynthesis showed smaller tumors (4.2 (± 1.5) cm versus 6.6 (± 3.0) cm; p = 0.005) and smaller bone cement fillings after curettage (5.7 (± 2.1) cm versus 9.6 (± 3.2) cm; p = 0.0001). A score evaluating preoperative scalloping and soft-tissue extension did not significantly differ (1.9 (± 0.9) versus 2.0 (± 1.0); rating scale 0–4; p = 0.7). Both groups showed high satisfaction (9.2 (± 1.5) versus 9.2 (± 0.9); p = 0.5) and low pain (1.0(±1.7) versus 1.9(±1.8); p = 0.1) in a rating scale from 0 to 10. Clinical and functional outcome was excellent for both groups in the DASH score (6.0 (± 11.8) versus 11.0 (± 13.2); rating scale 0–100; p = 0.2) and the MSTS score (29.0 (± 1.7) versus 28.7 (± 1.1); rating scale 0–30; p = 0.3). One enchondroma recurrence was found in the group without osteosynthesis. Complications (one fracture and one intra-articular screw) were only detected after osteosynthesis. Osteosynthesis had longer surgery time (70 (± 21) min versus 127 (± 22) min; p < 0.0001), more blood loss (220 (± 130) ml versus 460 (± 210) ml; p < 0.0001), and longer stay in the hospital (6 (± 2) days versus 8 (± 2) days; p = 0.004).

Conclusions

Intralesional tumor resection was oncologically safe and clinically successful with or without osteosynthesis. Osteosynthesis did not reduce the risk for fracture but was more invasive.

Intralesional vs. extralesional procedures for low-grade central chondrosarcoma: a systematic review of the literature

INTRODUCTION

Chondroid lesions are very common bone tumors. In most cases, they are benign enchondromas (EC) and, in a minor percentage, chondrosarcomas (CSs), the malignant counterpart. In the latter cases, surgery is the mainstay treatment, because they are chemo- and radio-resistant unless dedifferentiation occurs. If resection is recognized as the gold standard for intermediate-, high-grade tumors, and for low-grade chondrosarcoma (LG-CS) located in the spine and pelvis to reduce the risk of local recurrence, there is still no consensus in literature on the treatment of central low-grade chondrosarcoma (cLG-CS) located in the limbs. Our aim is to perform a review of literature on evidence supporting this approach or not.

MATERIALS AND METHODS

An electronic research of the medical archives was carried out in March 2017 seeking papers evaluating the results of curettage and resection in cLG-CS.

RESULTS

We selected 13 studies corresponding to our criteria. Unfortunately, they were descriptive, retrospective, non-randomized studies. We identified a population of 471 patients for a total of 473 low-grade chondrosarcomas. Two hundred and ninety-nine lesions were treated with curettage and 174 with wide surgery. The two groups were not homogeneous for diagnosis, size and staging, so no comparison between resection and curettage was possible. The global weighted average percentage of local recurrence was 6.7% (20 cases) and 10.9% (19 cases) after curettage and resection, respectively. No cases of metastasis were reported in the group treated with intralesional surgery, compared to five cases reported in the group treated with resection. Indications for surgery were given in most cases based on symptoms and imaging.

CONCLUSIONS

The absence of a preoperative histological diagnosis and the lack of a scientific method to conduct the studies do not sufficiently support curettage for low-grade chondrosarcomas. In the absence of this, resection must be considered a general rule for every malignancy. In our opinion, based on the low biological growth rate of low-grade chondrosarcoma, every chondromatous lesion can be followed-up. Biopsies must be performed based on clinical and radiological suspicions such as pain, scalloping or increase in size, rather than on performing a PET scan to evidence more informative high metabolic areas.

Treatment strategies for central low-grade chondrosarcoma of long bones: a systematic review of the literature and meta-analysis

The need for wide local excision (WLE) versus intralesional (IL) treatment of low-grade chondrosarcomas (CS) of the appendicular skeleton remains controversial. We sought to perform a systematic review and meta-analysis to compare different conventional types of surgical treatments for grade I CS in terms of: (1) rate of local recurrence (LR) and metastases, (2) functional outcome as measured by the Musculoskeletal Tumor Society (MSTS) score, (3) complication rate. Eighteen studies enrolling 695 patients met our criteria. Studies reported on WLE versus IL treatment (n = 7), and IL treatment with or without different adjuvants (N = 11). The LR rate was not significantly different between WLE and IL treatment (OR 2.31; 95% CI, 0.85-6.2; P = 0.1). On the contrary, complication rates were significantly lower in favor of IL treatment (OR 2.27; 95% CI, 0.07-0.72; P = 0.012). The mean reported MSTS score ranged from 21.8 to 28.2 for WLE and from 26.5 to 29.7 for IL treatment, with a significant difference in favor of IL treatment. IL treatment as an alternative to WLE does not greatly increase the risk of LR or metastasis and has lower complication rates with better functional scores. In light of the retrospective nature of the studies available, our findings should be interpreted with caution.

Is Needle Biopsy Clinically Useful in Preoperative Grading of Central Chondrosarcoma of the Pelvis and Long Bones?

BACKGROUND

Central chondrosarcoma of bone is graded on a scale of 1 to 3 according to histological criteria. Clinically, these tumors can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. Although en bloc resection has been the most widely used treatment, it has become generally accepted that in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment, but prior reports have indicated that both imaging and biopsy do not always give an accurate prediction of grade.

QUESTIONS/PURPOSES

(1) What is the concordance of image-guided needle preoperative biopsy and postoperative grading in central (intramedullary) chondrosarcomas of long bones, and how does this compare with the concordance of image-guided needle preoperative biopsy and postoperative grading in central pelvic chondrosarcomas? (2) What is the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones, and how does this compare with the concordance in central pelvic chondrosarcomas?

METHODS

Between 1997 and 2014, in our institution, we treated 126 patients for central chondrosarcomas located in long bones and the pelvis. Of these 126 cases, 41 were located in the pelvis and the remaining 85 cases were located in long bones. This study considers 39 (95%) and 40 (47%) of them, respectively. We included all cases in which histological information was complete regarding preoperative and postoperative tumor grading. We excluded all cases with incomplete data sets or nondiagnostic preoperative biopsies. To evaluate the needle biopsy accuracy, we compared the histological tumor grade, obtained from the preoperative biopsy, with the final histological grade obtained from the postoperative surgical specimen. The weighted and nonweighted kappa statistics were used to evaluate the agreement.

RESULTS

Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]; odds ratio, 8, 48). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma for the determination of histological grade (0.63; 95% confidence interval [CI], 0.34-0.91 versus 0.12; -0.32 to 0.57; p < 0.001). When categorizing the lesions as low grade or high grade, concordance between the preoperative biopsy and the final pathological analysis was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (90% [36 of 40] versus 67% [26 of 39]; odds ratio, 4, 5). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (0.73; 95% CI, 0.51-0.94 versus 0.26; 0.04-0.48; p < 0.001).

CONCLUSIONS

Image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The histological grade should be correlated with imaging and the clinical presentation, but under these circumstances, experienced tumor surgeons may use this information in planning surgical treatment. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution.

LEVEL OF EVIDENCE

Level III, diagnostic study.

MRI appearances of atypical cartilaginous tumour/grade I chondrosarcoma after treatment by curettage, phenolisation and allografting: recommendations for follow-up

AIMS

The purpose of this retrospective study was to differentiate between the MRI features of normal post-operative change and those of residual or recurrent disease after intralesional treatment of an atypical cartilage tumour (ACT)/grade I chondrosarcoma.

PATIENTS AND METHODS

We reviewed the case notes, radiology and histology of 75 patients, who had been treated for an ACT/grade I chondrosarcoma by curettage, phenolisation and bone allografting between 1994 and 2005. The first post-operative Gd-enhanced MRI scan was carried out within one year of surgery. Patients had a minimum of two scans and a mean follow-up of 72 months (13 to 169). Further surgery was undertaken in cases of suspected recurrence.

RESULTS

In 14 patients (18.6%) a second procedure was undertaken after a mean period of 59 months (8 to 114). Radio frequency ablation (RFA) was used in lesions of < 10 mm and curettage, phenolisation and bone grafting for those ≥ 10 mm. Only six of these (8% of total) had a histologically-proven recurrence. No increase in tumour grade was seen at time of recurrence.

CONCLUSION

Based on this study, we have been able to classify the post-operative MRI appearances into four groups. These groups differ in follow-up, and have a different risk of recurrence of the lesion. Follow-up and treatment vary for the patients in each group. We present a flow diagram for the appropriate and safe follow-up for this specific group of patients. Cite this article: Bone Joint J 2016;98-B:1674-81.

Radiologic follow-up of untreated enchondroma and atypical cartilaginous tumors in the long bones

Background and Objectives

Both enchondroma and atypical cartilaginous tumors (ACT) are not considered malignant, so inactive and asymptomatic tumors might not need surgery. To the best of our knowledge, this is the first study that has been done to evaluate the natural course of conservative‐treated enchondroma and ACT in the long bones.

Methods

For this retrospective study, we analyzed the results of patients in whom we refrained from surgery and only regularly performed radiological follow‐up of the tumor. Minimal follow‐up after initial diagnosis was 24 months.

Results

Forty‐nine patients were included in this study. Eight out of forty‐nine cases received surgical treatment during follow‐up of the tumor. The reasons for this surgery were radiologic growth of the tumor in two cases, pain in one case, patient request in three cases, another indication for surgery in the same limb in two cases.

Conclusion

In this small series of conservatively treated enchondroma and ACT, only 6% of the patients had a medical indication for surgery. This study shows that indication for surgery should be discussed more thoroughly. Based on our results, we would recommend annual radiologic follow‐up for asymptomatic enchondroma or ACT in the long bones, irrespective of tumor size. J. Surg. Oncol. 2016;114:987–991. © 2016 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.

Local Treatment with Adjuvant Therapy for Central Atypical Cartilaginous Tumors in the Long Bones: Analysis of Outcome and Complications in One Hundred and Eight Patients with a Minimum Follow-up of Two Years

BACKGROUND

A central atypical cartilaginous tumor (ACT)--formerly known as chondrosarcoma grade 1 (CS1)--is a tumor of intermediate-type malignancy, often treated with surgery. The extent of surgery remains controversial, as some advocate resection and others favor local treatment by curettage. Because of the low prevalence of ACT/CS1, the available data are limited and generally not uniform. The purpose of this study was to present the outcome for a large cohort of patients with ACT/CS1 in the long bones who were treated with curettage and adjuvant phenolization and followed for a minimum of two years according to national guidelines.

METHODS

A retrospective study was designed to analyze data from 108 patients treated for central ACT/CS1 in the long bones between 2006 and 2012. All patients were treated with curettage and adjuvant phenolization, and defects were filled with polymethylmethacrylate, bone graft, or bone substitutes. The primary end point was local recurrence or residual tumor. Secondary end points included the type and rate of complications and reoperations.

RESULTS

All patients were free from local recurrence at a mean follow-up of 48.7 months (range, 24.3 to 97.5 months). Residual tumor was suspected in five patients, leading to a 95.4% disease-free survival rate. A fracture occurred in eleven patients (10.2%). Other complications were osseous penetration during the surgery (two patients), wound infection (one patient), arthrofibrosis (one patient), and skin necrosis (one patient). Tumor volume was related neither to the risk of fracture nor to the occurrence of residual tumor.

CONCLUSIONS

In our experience, curettage of ACT/CS1 in the long bones with adjuvant phenolization is safe, even with large tumors of up to 100 cm(3). Most worrisome is the risk of fracture, which occurred in 10.2% of our patients. Considering the relatively mild behavior of ACT/CS1, less aggressive treatment, by observation or by minimally invasive surgery, could be the next step that should be evaluated prospectively.

Radiofrequency ablation in the treatment of cartilaginous lesions in the long bones

Atypical cartilaginous tumours are usually treated by curettage. The purpose of this study was to show that radiofrequency ablation was an effective alternative treatment.

We enrolled 20 patients (two male, 18 female, mean age 56 years (36 to 72) in a proof-of-principle study. After inclusion, biopsy and radiofrequency ablation were performed, followed three months later by curettage and adjuvant phenolisation. The primary endpoint was the proportional necrosis in the retrieved material. Secondary endpoints were correlation with the findings on gadolinium enhanced MRI, functional outcome and complications.

Our results show that 95% to 100% necrosis was obtained in 14 of the 20 patients. MRI had a 91% sensitivity and 67% specificity for detecting residual tumour after curettage. The mean functional outcome (MSTS) score six weeks after radiofrequency ablation was 27.1 (23 to 30) compared with 18.1 (12 to 25) after curettage (p < 0.001). No complications occurred after ablation, while two patients developed a pathological fracture after curettage.

We have shown that radiofrequency ablation is capable of completely eradicating cartilaginous tumour cells in selective cases. MRI has a 91% sensitivity for detecting any residual tumour. Radiofrequency ablation can be performed on an outpatient basis allowing a rapid return to normal activities. If it can be made more effective, it has the potential to provide better local control, while improving functional outcome.

Cite this article: Bone Joint J 2014;96-B:1540–5.