Cemented K-wire external fixation in juxta-articular enchondroma-related phalangeal pathological fracture

PURPOSE

This study aimed to introduce a technique of external fixation using a combination of bone cement and K-wires, to treat pathological fractures related to solitary digital enchondroma close to the finger joints.

METHODS

From October 2015 to January 2021, 21 patients (8 males and 13 females) with acute pathological fracture due to solitary digital enchondroma close to the finger joints were treated with cemented K-wire external fixators. Mean age was 32 (19-51) years. The digits involved were the index (n = 4), long (n = 4), ring (n = 6), and little (n = 7) fingers. Time to bone healing and complications were assessed. At final follow-up, active range of motion, grip strength and key pinch strength of the tumor-involved and contralateral healthy digits were measured and compared. Functional outcomes were evaluated on Takigawa criteria. Pain was measured on a 10-cm visual analog scale. We assessed the affected upper extremity on the Musculoskeletal Tumor Society score questionnaire.

RESULTS

Mean bone healing time was 5.5 (4-8) weeks. Pin site infection was observed in 1 patient and cured with dressing changes. Mean follow-up was 34 months, with no recurrences or refractures. Mean active range of motion of the proximal interphalangeal joint, grip and key pinch strength of the involved digits reached 92%, 97%, and 99% of the contralateral digits, respectively. On Takigawa criteria, 20 functional results were excellent and 1 good. Mean pain score was 1 (0-3) cm. Mean Musculoskeletal Tumor Society score was 95 (80-100).

CONCLUSION

The combination of bone cement and K-wires is a reliable technique for pathological fracture related to solitary enchondroma close to the joints of the digits, leading to good functional outcomes.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

Impact of Patient and Tumor Characteristics on Range of Motion and Recurrence Following Treatment of Enchondromas of the Hand

PURPOSE

The approach to the treatment of enchondromas of the hand is varied, and there is no clear consensus on graft source, fixation, or need for intraoperative adjuvant therapy. We reviewed a cohort of patients who underwent curettage and bone grafting with cancellous allograft chips without internal fixation or adjuvant therapy and reported on postoperative range of motion (ROM) and recurrence rates.

METHODS

We performed a retrospective review of patients who underwent surgical treatment for hand enchondroma over a 23-year period. We collected information on demographics and presenting enchondroma characteristics, including Takigawa classification and presence of pathologic fracture or associated syndromes. Patients were treated with open biopsy with curettage and grafting with cancellous allograft chips. Postoperative ROM, complications, and recurrences were recorded.

RESULTS

Our series included 111 enchondromas in 104 patients. Seventeen of 104 patients (16%) had a diagnosis of Ollier disease. Average length of follow-up was 3.1 years. Eighty-one percent of patients achieved full ROM. Treatment of patients who presented with preoperative pathologic fracture resulted in a greater frequency of reduced postoperative ROM at 28% (9/32) compared to 15% (11/72) of those patients who did not present with preoperative pathologic fracture. Local recurrence developed in 5 of 50 (10%) patients with a minimum of 2 years of follow-up. Local recurrence occurred at higher-than-average rates in patients with giant form Takigawa classification (43%, 3/7) and Ollier disease (23%, 3/13).

CONCLUSIONS

Treatment of enchondromas with biopsy, curettage, and allograft results in full ROM in 81% of patients. Patients with preoperative pathologic fracture should be advised of a greater risk of postoperative extension deficit. Recurrence remains rare and is associated with syndromic presentation and giant form lesions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radiofrequency ablation for the treatment of a presumed enchondroma in the flat bones of the pelvis

Herein, a 30-year-old Caucasian female who presented with a persistent pain in the right pelvic region due to an enchondroma and treated with RF ablation is described. An initial MRI of the pelvis revealed a well-circumscribed lesion in the right inferior ischiopubic ramus with a maximum diameter of 9.5 mm. The final diagnosis was established by a percutaneous CT-guided bone biopsy, which excluded malignancy and revealed an enchondroma. About a month after the biopsy, a percutaneous radiofrequency ablation (RFA) of the lesion was performed. The symptoms resolved completely gradually 2 months after the treatment and a follow-up imaging with MRI showed complete resolution of the pathological enhancement indicating necrosis of the lesion. RFA has not been previously reported as a treatment option of enchondromas found in flat bones of the pelvis and could be a safe alternative minimally invasive treatment option in such cases, avoiding major operations.

Nasal chondrogenic tumors: Case reports of primary chondroma and recurrence of atypical cartilaginous tumor (chondrosarcoma grade I) with review of the literature

Nasal chondromas and nasal atypical cartilaginous tumors (or chondrosarcoma grade 1) are very rare chondrogenic tumors. Approximately 150 cases of nasal chondroma and fewer than 50 cases of nasal atypical cartilaginous tumors have been described. We reported a case with nasal chondroma in the right ethmoid area and a case with a nasal atypical cartilaginous tumor of the anterior septum. No chondroma recurrence was noted for 17 years after endoscopic resection. Recurrence was noted for the nasal atypical cartilaginous tumor 36 months after wide surgical excision via midfacial degloving. Revision surgery was performed again via midfacial degloving. Recurrences of nasal chondroma and atypical cartilaginous tumors are extremely rare. The current data indicate adequate surgical excision, in some cases even radical, as the most important parameter to avoid recurrence. For inoperable recurrent cases of atypical cartilaginous tumors, observation may be followed.

Rare Presentation of Pediatric Multiple Enchondromatosis Limited to Single Ray or Single Nerve Distribution in the Hand: A Multicenter Case Series

BACKGROUND

Multiple enchondromas in the pediatric hand is a relatively rare occurrence and the literature regarding its incidence and treatment is sparse. Within this rare subset of patients, we identified a unique cohort in which lesions are confined to multiple bones in a single ray or adjacent rays within a single nerve distribution. We review the clinical and pathologic characteristics and describe the indications for and outcomes of treatment in this unique subset of patients as well as offer conjectures about its occurrence.

METHODS

Institutional review board (IRB)-approved retrospective multicenter study between 2010 and 2018 identified subjects with isolated multiple enchondromas and minimum 2-year follow-up. Data analyzed included demographics, lesion quantification and localization, symptoms and/or fracture(s), treatment of lesion(s), complications, recurrence, and presence of malignant transformation.

RESULTS

Ten patients were evaluated with average age at presentation of 9 years (range: 4 to 16) and mean clinical follow-up of 6 years (range: 2.8 to 8.6). Five subjects had multiple ray involvement in a single nerve distribution and 5 had single ray involvement with an average of 4 lesions noted per subject (range: 2 to 8). All children in the study had histopathologic-proven enchondromas and underwent operative curettage±bone grafting. Indications for surgical intervention included persistent pain, multiple prior pathologic fractures, impending fracture and deformity. During the study period three subjects experienced pathologic fracture treated successfully with immobilization. Recurrence was noted in 40% at an average of 105 weeks postoperatively (range: 24 to 260) and appears higher than that reported in the literature. No case of malignant transformation was observed during the study period.

CONCLUSIONS

A rare subset of pediatric patients with multiple enchondromas of the hand is described with lesions limited to a single ray or single nerve distribution. Further awareness of this unique subset of patients may increase our understanding of the disease and improve patient outcomes.

LEVEL OF EVIDENCE

Level IV-therapeutic (case series).

Chondroma of the urinary bladder: A case report

RATIONALE

Chondromas are benign tumors comprising cartilaginous tissue that commonly occur in the small bones of the hands and feet. Chondromas are extremely rare in extraskeletal soft tissues, and only six cases of bladder chondromas have been reported thus far.

PATIENT CONCERNS

A 75-year-old woman presented with abdominal pain and urinary symptoms, including increased frequency and a weak stream.

DIAGNOSIS

Cystoscopy revealed a well-defined bladder mass over the anterior bladder wall. The pathology report showed neoplastic chondrocytes within the hyalinized and focal myxoid matrix, and immunopositivity for S-100, leading to the seventh known diagnosis of bladder chondroma.

INTERVENTIONS

The tumor was endoscopically resected. The postoperative stay was uneventful, and 5 days later, the patient was discharged after the removal of the urinary catheter.

OUTCOMES

One month after surgery, repeated cystoscopy showed no recurrence of the bladder tumor, and the patient reported improvement in urinary symptoms and relief of lower abdominal pain.

LESSONS

Chondromas of the urinary bladder can present as urinary symptoms and abdominal pain in older patients. Transurethral resection is the treatment of choice.

Imaging characteristics of slow-growing soft tissue chondroma of the tongue: A case report

INTRODUCTION

Extraskeletal soft tissue chondroma (STC) is a rare benign tumor. Soft-tissue chondromas rarely occur in the oral cavity. In this study, we aimed to confirm a slow-growing tongue mass using magnetic resonance imaging.

PATIENT CONCERNS

A 60-year-old woman presented with a painful, slow-growing tongue mass that had persisted for 17 years. Intraoral examination revealed a pedunculated mass covered with mucosa on the right side of her tongue.

DIAGNOSIS

CT and MRI revealed a lobulated heterogeneously enhancing mass without calcification. Compared with previous images obtained 17 years prior, the mass presented slow growth, more prominent enhancement, and lobulated contour. Histopathological examination confirmed the presence of STC.

INTERVENTIONS

Excision of the mass surrounding normal tissue was performed under general anesthesia.

OUTCOMES

During 1-year follow-up period, no recurrence was observed.

CONCLUSIONS

In this study, STC lesions were slow-growing, and changed from weakly homogeneous enhancement and clean margins to markedly heterogeneous enhancement and lobulated margins over time.

Soft Tissue Chondroma: A Possible Diagnosis of Single-Digit Nail Clubbing

Supplemental Digital Content is Available in the Text.

Carney's triad in an adult male from a tertiary care center in India: a case report

BACKGROUND

Carney's triad is a rare syndrome comprising gastrointestinal stromal tumor, extra-adrenal paraganglioma, and pulmonary chondroma along with newer additions of adrenal adenoma and esophageal leiomyoma. The triad is completely manifest in only 25-30% cases, with most patients presenting with two out of three parts of the syndrome. Wild-type succinate-dehydrogenase-deficient gastric gastrointestinal stromal tumor forms the most common component of Carney's triad and is usually multicentric and multifocal. It usually demonstrates indolent behavior and resistance to imatinib; hence, the management remains predominantly surgical. Pulmonary chondromas are commonly unilateral and multiple with slow-growing nature, which allows for conservative management. Adrenocortical adenomas are found in 20% of patients and are usually detected as incidentalomas.

CASE PRESENTATION

A 49-year-old Asian male presented with upper gastrointestinal bleed and was diagnosed with multiple gastric succinate-dehydrogenase-deficient gastrointestinal stromal tumors. On evaluation, he was found to have left pulmonary chondroma and non-secretory adrenal adenoma, thus completing the Carney's triad. He underwent surgery with sleeve gastrectomy and excision of the antral tumor nodule, while the adrenal and pulmonary tumors have been under close follow-up.

CONCLUSION

Literature regarding Carney's triad is scarce, especially from the Indian setting. Our report aims to highlight the various manifestations of this syndrome with emphasis on management of wild-type succinate-dehydrogenase-deficient gastrointestinal stromal tumor. Radical gastric surgeries do not offer a survival advantage in this condition; hence, more conservative modalities of resection can be adopted.

Early Surgical Treatment of Both Tumor and Fracture in Patients With Enchondroma of the Hand Combined With Pathologic Fracture

PURPOSE

The aims of this study were to evaluate the degree of cortical thinning and the tumor area in simple radiographs in patients with enchondroma of the hand combined with pathologic fracture and to determine the surgical outcome of simultaneous tumor curettage and internal fixation of fracture.

METHODS

We enrolled 23 bone lesions of 21 patients diagnosed with enchondroma of the hand. Of them, 9 bone lesions of 8 patients had pathologic fracture. We evaluated the degree of cortical thinning and tumor area in simple radiographs and compared them between patients with and without pathologic fracture. For patients with pathologic fracture, we performed curettage of the tumor through the fracture site and fixed the fracture using K-wires. We then evaluated the clinical outcome of these patients using the visual analog scale to measure pain intensity and Takigawa's criteria 1 year after surgery.

RESULTS

There was a significant difference in the degree of cortical thinning between the 2 groups (P < 0.001); however, there was no significant difference in the percentage of tumor area (P = 0.259). The average time from surgery to bony union was 8.5 weeks in patients with pathologic fracture. The patients reported that they could return to their previous activities of daily living within 12 weeks of surgery. The average visual analog scale score was 0.6 at 1 year after surgery, and 6 patients were graded as excellent and 2 as good according to Takigawa's criteria.

CONCLUSIONS

Cortical thinning seems to be related to pathologic fracture. Our scoring system for cortical thinning may be helpful in evaluating the risk for pathologic fracture. Early 1-stage surgical treatment for pathologic hand fracture with enchondroma is a very useful method with satisfactory outcomes that could shorten the treatment period.

Chondromyxoid fibroma of the temporal bone: A rare case report

RATIONALE

Chondromyxoid fibroma (CMF) is a rare form of benign bone tumor and easily misdiagnosed as fibrosarcoma. Hence, to explore the clinical manifestations, diagnostic tests, and therapeutic procedures for temporal bone cartilage myxoid fibroma, it is important to optimize patient treatment and avoid overtreatment. Previous research has discussed cases of CMF, but this paper presents a systematic, complete, and comprehensive introduction of this disease based on this case and related literature.

PATIENT CONCERNS

A 52-year-old male patient presented with pain in his right ear for 2 years and hearing loss in his right ear with tinnitus for 1 year. The patient had a history of hypertension for 9 years and it was well-controlled.

DIAGNOSIS

A computed tomography (CT) scan of the temporal bone showed an expansive growth on the right temporal bone plate and tympanic plate, presenting as a cloud-like ground glass opaque shadow involving the temporom and ibular joint, middle skull base, and small auditory bones. A magnetic resonance imaging (MRI) of the temporal bone showed a large and irregular soft tissue mass shadow on the right temporal bone plate. The right temporal bone plate was occupied by the lesion, consistent with a bone origin. From the results of the imaging examination of the patient, a lesion occupying the temporal bone in the right ear and mastoiditis in the right middle ear was initially diagnosed.

INTERVENTIONS

Right ear temporal bone tumor resection and abdominal fat extraction were conducted.

OUTCOMES

Postoperative pathological results demonstrated myxoid fibroma of the temporal bone cartilage. No recurrence or severe complications were observed in 8 months of follow-up.

LESSONS

A finding of myxoid fibroma of the temporal bone cartilage is rare in the clinic. The growth of such tumors is slow. The temporal bone CT and inner ear MRI were helpful in diagnosis. Surgery was the principal treatment.

Dysphagia Induced by Nasal Septal Chondroma: A Case Report

Chondromas rarely occur in the nasal area and are usually found in the metaphyseal area of thephalanges and metacarpals of the hands, as well as the pelvis, sternum and scapula. The authorspresent an unusual case of dysphagia induced by histologically confirmed chondroma arising fromthe nasal septum. Treatment is to completely remove the mass with adequate margins of normaltissues to prevent recurrence and malignancy. Intranasal endoscopic removal of tumor with anadequate margin of normal tissue. After one year of treatment, there was no evidence of recurrence.We present a case of nasal septal chondroma in 18 year male.

Radiographic Enchondroma Surveillance: Assessing Clinical Outcomes and Costs Effectiveness

BACKGROUND

Enchondromas are a common long bone benign tumor often discovered incidentally on imaging for adjacent pathology. These benign cartilaginous tumors can be difficult to differentiate from low-grade chondrosarcomas on imaging and histology. Multiple advanced imaging studies and clinic visits are required to confirm stability. Surveillance for these lesions can lead to significant patient costs without a clear oncologic or functional benefit. There is a lack of evidence-based consensus guidelines for the surveillance of enchondromas. The purposes of our study are: 1) to determine the number and proportion of low-grade cartilaginous tumors that demonstrate growth or require treatment and 2) to optimize the efficacy and cost-effectiveness of surveillance strategies for detecting biologically active lesions.

METHODS

A retrospective single-institution study was performed on 55 subjects, 18 years or older, with long bone enchondromas without concerning radiographic characteristics that were referred to our institution's orthopaedic oncology clinic from July 1, 2009 to November 30, 2016. All subjects had at least 12 months of radiographic follow-up. We performed a chart and imaging review to assess for growth of the lesion over time. The number of pre-referral imaging and the number of follow-up imaging studies were recorded. The costs of plain radiographs and advanced imaging were estimated using our institution's global charge list in 2016.

RESULTS

For stable enchondromas, 35 out of 52 lesions (67.3%) presented in the lower extremities compared to three out of three (100%) growing cartilaginous tumors. Three out of 55 (5.45%) long bone cartilaginous lesions exhibited growth at a median of 23 (range 21-25 months) follow-up. There was no apparent difference in median presenting age for stable versus growing lesions (58.5 versus 55.0 years old, p =0.5673) or median lesion size at presentation (4.1 cm versus 3.6 cm, p = 0.2923). None of these lesions presented with pain attributable to the lesion. One out of seven biopsied cartilaginous lesions (four stable and three growing) had a histology diagnosis of grade 1 chondrosarcoma. There was no significant difference in the median number of total clinical visits for stable (four) and growing (five) enchondromas (p = 0.0807). The median pre-referral costs per patient were: plain radiographs ($383.00), CT scans ($0.00), and MRI imaging ($3,969.00). The median post-referral costs for plain radiographs and MRI per patient were $1,326.00 and $4,668.00, respectively. The annual median costs for plain radiographs and MRI were $609.23 and $2,240.64, respectively.

DISCUSSION

In conclusion, enchondroma growth was a rare event and typically occurred at two years follow-up in our series. Given the low risk for malignant transformation, we propose surveillance with plain radiographic follow-up for stable enchondromas every 3-6 months for the first year and then annually for at least three years of total follow-up. The most significant costs savings can be made by limiting MRI imaging in the absence of clinical or radiographic concern. Additional studies are needed to determine the long-term risk of growth or declaration of chondrosarcoma.Level of Evidence: IV.

[Pulmonary Chondroma; Report of a Case]

A 66-year-old man was pointed out a nodular shadow in the right lower lobe by chest computed tomography (CT) 4 years ago. Since the size of the shadow has been increasing for 4 years, he hospitalized for surgery. Partial resection of the right lower lobe was performed. Histopathologically, the tumor was composed of cartilage tissue without epithelial components, and was diagnosed as a chondroma. Postoperative course was uneventful and there has been no recurrence at 1 years and 8 months after surgery.

Individualized reconstruction for severe periprosthetic fractures around the tumor prosthesis of knee under assistance of 3D printing technology: A case report

INTRODUCTION

Periprosthetic femoral fractures (PFF) around tumor prosthesis of knee are stubborn problems for surgeons, huge bone defect and inappropriate biomechanics of the revision implant design can be disaster for reconstruction. With the development of three-dimensional (3D) printing technology, surgeons participate more in precise preoperative design and simulation for treatment of such fractures. In this study we explored an accurate and feasible way to restore normal anatomy and function of the knee joint with 3D printing technology.

CASE PRESENTATION

Rationale: This report explored an accurate and feasible way to treat PFF around tumor knee prosthesis in a 32 years old women with 3D printing technology, which restored normal anatomy and function of the knee joint. Patient concerns: Pain in left thigh lasted for 10 months after resection of left femoral chondroma and knee joint replacement four years ago. Diagnoses: periprosthetic femoral fractures (PFF) around tumor knee prosthesis.

INTERVENTIONS

CT images of the patient were collected and reconstructed. Parameters of bilateral femurs were virtually sliced and measured. Novel femoral stem and nail paths were specially designed by doctors according to these parameters. The prosthetic femoral stem components and navigator were customized by engineers according to the doctor's design. The residual femoral resin model, customized components and navigator were printed with Stereo Lithography Apparatus 3D printer. The shape-preconcerted allograft bone was selected as patch for the bone defect before operation with the printed bone model. All the steps were simulated preoperatively with the models printed, and then the operation was carried out.

OUTCOMES

The operation was successfully performed. The postoperative x-ray image, MSTS93 scores were examined and the function restoration sustained well in the follow-up period from 1 month to 27 months.

LESSONS

3D printing and medical interaction are key points in complex PFF cases.

CONCLUSION

As for PFF of the complex tumor of knee, preoperative design and simulation with 3D printing technology may provide more accurate and effective operative outcome than traditional methods, which might be considered as a method suitable for popularization in complex and severe cases.

Treatment of cryotherapy and orthotopic transplantation following chondromyxoid fibroma of zygomatic bone: A case report

INTRODUCTION

Chondromyxoid fibrotherma (CMF) is a rare benign cartilage tumor that occurs more frequently in young males at the age of 20 to 30. It occurs more frequently on long bones, but rarely involves craniofacial bones.

CASE PRESENTATION

This study mainly introduced a 30-year-old male with CMF of zygomatic bone. Single tumor excochleation was conducted initially. However, CMF reoccurred, and then the following steps were adopted: firstly, the tumor was extensively excised; secondly, in vitro tumor excochleation was conducted; thirdly, the excised tumor bone was placed in liquid nitrogen for 3 cycles of cryoablation; finally, the orthotopic transplantation was performed to reconstruct the zygomatic appearance, with satisfactory follow-up efficacy obtained.

CONCLUSIONS

Orthotopic transplantation after tumorectomy and cryopreservation of tumor bone in liquid nitrogen could lead to excellent therapeutic efficacy and deserves to be widely applied in clinical practice in the treatment of a male patient with CMF of zygomatic bone, because it not only radically eliminates the tumor and kills tumor cells, but also provides bony skeleton for the growth of new bone, thus greatly promoting postoperative aesthetic degree and reducing the occurrence rates of complications.

Ectomesenchymal chondromyxoid tumor: a comprehensive updated review of the literature and case report

Prompted by a unique case of an ectomesenchymal chondromyxoid tumor (ECT) of the palate in a 54-year-old female, we reviewed the English and German literature on this entity until the end of 2016 using PubMed. The search produced 74 lingual cases with a nearly equal sex distribution and a mean age of 39.3 years, and two extra-lingual cases sharing histological and immunohistological features including nodular growth, round, fusiform or spindle-shaped cellular architecture, and chondromyxoid stroma. Immunophenotyping showed the majority of cases to be positive for glial fibrillary acidic protein (GFAP), S-100 protein, glycoprotein CD57, pancytokeratin (AE1/AE3), and smooth muscle actin (SMA); in isolated cases there was molecular-genetic rearrangement or gain of Ewing sarcoma breakpoint region 1 (EWSR1) but no rearrangement of pleomorphic adenoma gene 1 (PLAG1). At present, ectomesenchymal cells that migrate from the neural crest are considered to play a pivotal role in tumor origin. All cases had a benign course, although there were three recurrences. Because of the rarity of this tumor and the need for differential diagnostic differentiation from myoepithelioma and pleomorphic adenoma, both oral surgeons and pathologists should be aware of this entity.

The management and surgical intervention timing of enchondromas: A 10-year experience

Enchondroma, reportedly the most common primary tumor of the long bones of the hand, usually develops during the first till fourth decades of life. However, there has no consensus been reached regarding the surgical intervention timing for these patients. We aim to evaluate the optimal surgical intervention timing for the patients with fractures due to enchondromas, investigate the impact of pathological fractures on the treatment and outcomes in these patients.Medical records and X-rays of patients treated for enchondroma of the hand from 2005 to 2015 were retrospectively reviewed. We collected 148 cases in total and 92 of them had complete information including X-rays, medical records, and files of follow up.There were no significant differences in terms of consolidation time after surgery, recurrence rate, and DASH scores between the groups with and without fractures; the treatment costs were higher in the group with fractures than those without fractures; however, patients without fractures were able to resume work earlier than those with fractures.The pathological fractures associated with enchondromas have no significant impact on the treatment outcomes compared to those with simple nonfractured enchondromas. Although the cost was more expensive for patients treated primarily with pathological fractures due to enchondromas, these patients could resume their work normally much earlier than those treated by delayed surgery. Early surgical intervention is recommended for better results and no increased risks for patients with pathological fractures caused by enchondromas.

Solitary Enchondroma at the Hand. Long-Term Follow-Up Study after Operative Treatment⋆

Twenty-one patients (17 women and four men) who underwent operative treatment for a solitary enchondroma of the hand were examined at a follow-up of between 2 and 18 years (mean, 9 years). Radiographs showed normal cancellous bone at the site of surgery in 11 cases, three had recurrent enchondroma and seven had bone defects so that recurrence could not be excluded. Two of the three recurrences underwent reoperation.

Previous studies have regarded persistent bony defects as evidence of complete excision without recurrence. However, in view of the slow asymptomatic growth of this tumour this opinion is incorrect. As shown in this study, recurrences may occur in these defects many years after excision surgery and go undetected until they cause widening or cortical erosion.

We recommend periodical radiological re-examination for asymptomatic recurrences before weakness of bone leads to pathological fracture.

[Carney triad]

Carney triad is a synchronous or metachronous association of gastric gastrointestinal stromal tumors (GIST), pulmonary chondroma and extra-adrenal paraganglioma. The majority of patients have only one or two components of the triad, all three tumors being found in only about 2% of the patients at the time of the first diagnosis. The most common combination is gastric and pulmonary tumors. We report a case of Carney triad which was diagnosed at Masaryk Memorial Cancer Institute. A 57-year-old female patient with a history of gastric resection for leiomyosarcoma at the age of 14 and with an unclear pulmonary lesion evident on chest X-ray since as early as 2003. She was referred to our Clinic of Comprehensive Cancer Care after being diagnosed with unspecified tumors of the stomach, the left retroperitoneum and two liver metastases. Biopsy of the retroperitoneal mass was performed and histological examination showed pheochromocytoma. The patient underwent resection of the retroperitoneal tumor and wedge resection of the gastric tumor, left hemihepatectomy and left adrenalectomy (in two separate operations). The excised gastric tumor was a gastrointestinal stromal tumor (GIST) with a low risk of malignancy. Analysis of a liver specimen, however, showed two GIST metastases. No pathology was found in the left adrenal gland and the retroperitoneal tumor was positive for chromogranin A. Paraganglioma was thus diagnosed. Subsequently, mutational analysis of genes coding for succinate dehydrogenase subunits B, C and D (SDHB, SDHC, SDHD) and analysis of DNA methylation at the gene locus of SDHC was made. Carney triad was thus confirmed and the unclear pulmonary lesion could be described as benign chondroma. This report demonstrates the difficulty in distinguishing between Carney triad and Carney-Stratakis syndrome. Molecular information should improve the diagnosis of Carney triad.Key words: Carney triad - GIST pulmonary chondroma extraadrenal paragangliomaCarney-Stratakis syndrome.

[A Case of a Nasopharyngeal Chondroma Originating from the Eustacian Tube]

Chondroma of the head and neck are commonly found in the nasal cavity, paranasal sinus, or larynx but rarely at other sites. Here we report a rare case of nasopharyngeal chondroma arising from the Eustacian tube. The patient was a 55-year-old male with chief complaints of nasal obstruction and left ear fullness. Nasal observation showed a white mass lesion filling the area extending from the left Eustachian tube to the nasopharynx. Computed tomography and magnetic resonance imaging of the pharynx showed a mass lesion occupying the nasopharyngeal cavity. We performed surgical excision of the nasopharyngeal tumor via the endoscopic endonasal approach. Histopathological examination performed at our hospital led to the diagnosis of chondroma. As of this report, 4 months have passed since surgery and the patient has not experienced a relapse. Although chondroma is a benign tumor, local recurrence or malignant transformation is possible. Therefore, these patients should continue to be followed up regularly.

Enchondroma in the distal phalanx of the finger: An observational study of 34 cases in a single institution

The goal of our study was to report the clinical presentation, treatment, and complications of enchondroma in the distal phalanx of the finger. This was a retrospective study of 34 patients (19 women and 15 men) who underwent surgery between May 2004 and September 2012 for enchondroma in the distal phalanx of the finger. The average age of the patients was 39.38 ± 10.97 years old (range 14-59). The presenting symptoms and imaging features were recorded. The surgical procedure was performed under regional or general anesthesia. The surgical technique involved removal of tumors by opening a cortical window and curetting the cavity. The defects were filled with an injectable calcium phosphate cement. All patients received follow-up in our outpatient clinic every 6 months. Expansion of bone or thinning of the cortex present in the radiological imaging, including anteroposterior and lateral plain radiographs of the fingers, was used to assess for tumor recurrence. The observational end-point was reoperation.All tumors were confirmed as enchondromas by the pathological results. None of the patients had a tumor recurrence. Three patients (9% of cases) developed an infection. After antibiotic treatment, 2 patients were cured, and 1 patient required an amputation. Enchondroma in the distal phalanx of the finger presents with a variety of clinical symptoms. Injectable calcium phosphate cement is adequate for bone grafting. Postoperative infection is more common than tumor recurrence. If patients have an infection or bilateral bone cortex defects, bone grafting is challenging.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Juxtacortical Chondroma of the Hand: Treatment by Resection of the Tumour and the Adjacent Bone Cortex

A recurrence of a juxtacortical chondroma of the finger after marginal excision prompted us to review the treatment of this condition. Although the recommended treatment is simple curettage or marginal excision, the reported recurrence rate is significantly higher for lesions in the hand than those in other locations and recurrences only occurred in patients who had local treatments which did not include excision of the adjacent bone cortex.

We report five patients with juxtacortical chondroma of the fingers. The first patient underwent marginal excision without resection of the underlying bone cortex. The other four patients underwent intralesional, marginal or wide excisions of tumour with resection of the bone cortex underlying the lesion. Recurrence was only seen in the patient who did not undergo resection of the bone cortex. Resection of the underlying bone cortex after excision of this tumour may be advisable for the treatment of this tumour in the hand to reduce the rate of recurrence.

Recurrence of Enchondroma in a Middle Finger after Curettage and Back-filling with Calcium Phosphate Bone Cement: a Case Report

We report a case of recurrence of enchondroma in a middle finger after curettage and back-filling with calcium phosphate bone cement (CPC). The radiograph showed a lytic lesion around the CPC filling which showed no signs of absorption after 12 years. The tumor was curated easily, however, a steel bar was needed to remove the CPC mass in a carefully manner not to break the cortex. CPC has an advantage of immediate biomechanical stability, on the other hand, a disadvantage of being unabsorbed inside of bone. Although enchondroma has a low recurrence rate after surgery generally, in consideration of recurrence, we recommend the use of absorbable materials when a use of artificial bone substitute to fill the defect is planned.

The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study

Bone defects are a very common problem in hand surgery, occurring in bone tumor surgery, in complicated fractures, and in wrist surgery. Bone substitutes may be used instead of autologous bone graft to avoid donor site morbidity. In this article, we will review our experience with the use of Cerament bone void filler (Bonesupport, Lund, Sweden) in elective and trauma hand surgery. A prospective clinical study was conducted with 16 patients treated with this bone graft substitute in our department over a period of 3.5 years. Twelve patients (2 female, 10 male; with an average age of 42.42 years) with monostoic enchondroma of the phalanges were treated and 4 patients (1 female, 3 male; with an average age of 55.25 years) with complicated metacarpal fractures with bone defect. Data such as postoperative course with rating of pain, postoperative complications, functional outcome assessment at 1, 2, 3, 6 months, time to complete remodeling were registered. Postoperative redness and swelling after bone graft substitute use was noticed in 7 patients with enchondroma surgery due to the thin soft-tissue envelope of the fingers. Excellent total active motion of the involved digit was noticed in 10 of 12 enchondroma patients and in all 4 fracture patients at 2-month follow-up. In summary, satisfying results are described, making the use of injectable bone graft substitute in the surgical treatment of enchondromas, as well as in trauma hand surgery a good choice.

[Tumor of the Parotid Gland]

Salivary gland tumors are a rare, histologically heterogeneous group of tumors which constitute approximately 4–6 % of all head and neck neoplasms. In 2/3 of cases they are benign, especially in the parotid gland. We report about a rare tumor of the parotid gland presenting as an extraskeletal chondroma. Histologically there were multiple S 100 protein-positive nests of chondrocytes. The externally completed cytology suspected a pleomorphic adenoma, nevertheless, the final histopathological findings showed another tumor entity.

[Benign cartilage tumors. What should I do with incidental findings?]

BACKGROUND

The majority of benign bone tumors are cartilage tumors. Most common are enchondroma and osteochondroma. Often they represent incidental findings in radiological diagnostics. Thus, the incidence of cartilage tumors is unknown, as most of them are never diagnosed due to the absence of any symptoms.

OBJECTIVES

This article describes the diagnostic and therapeutic approach of benign cartilage tumors, focusing on incidental findings.

METHODS

The current knowledge and our own experience in the diagnostics and treatment of benign condroid tumors are presented.

RESULTS

As enchondroma represent most often the classic incidental finding without any symptoms or clinical findings, osteochondroma are often diagnosed in young patients by clinical examination showing a painless swelling that can increase in size according to skeletal growth. Most of these asymptomatic enchondroma and osteochondroma are so called "leave me alone lesions" and do not need any treatment, while other benign tumors (e.g., atypical cartilage tumors, chondroblastoma, chondromyxoidfibroma or osteochondroma with a cartilage cap of over 2 cm) need surgical treatment. These active or local aggressive tumors must be differentiated from the "leave me alone lesions". Additionally, patients with syndromes like Ollier disease (enchondromatosis), Maffucci syndrome or hereditary multiple exostosis must be examined and checked carefully as malignant degradation is possible.

CONCLUSION

As most cartilage tumors are benign and remain benign, inappropriate diagnostics or operative treatment just to provide security is obsolete. Plain X-ray is often enough for follow-up and other modalities only become necessary when symptoms occur.

Recurrent Metacarpal Enchondroma Treated With Strut Allograft: 14-year Follow-up

Enchondroma of the hand is a common lesion with a recurrence rate of up to 13.3% after curettage and bone grafting. Pathologic fractures often occur. Although allograft bone chips are widely used in the surgical treatment of enchondroma, the use of structural allograft bone has not been reported before. This case report presents a recurrent enchondroma of the fifth metacarpal with pathologic fracture in a 13-year-old girl who had 2 previous interventions and 2 more interventions for other enchondromas in the same hand. These interventions consisted of curettage and autogenous iliac crest bone grafting. The metacarpal diaphysis was resected and reconstructed with an intercalary freeze-dried strut allograft fibular bone segment to avoid further donor graft site morbidity. At 14 years of follow-up, the patient had full range of motion of the hand, with no symptoms, and the allograft bone had been incorporated completely, with no recurrence of the tumor. With strut allograft bone, healing occurs by creeping substitution at its ends that is limited to a few millimeters. Limited vascularization also occurs on the allograft surface, leaving most of the allograft segment devoid of vascularity and leading to the complications seen in massive bone allografts. However, because of their thin cortices and decreased total volume, smaller bone allografts show higher rates of osteointegration and revascularization. In selected cases, a strut allograft bone may be considered a suitable material for long-term reconstruction of the hand after enchondroma excision, especially in young patients, who have increased healing potential compared with older patients.

A case of a CD56-expressing ectomesenchymal chondromyxoid tumor of the tongue: potential diagnostic usefulness of commonly available CD56 over CD57

Ectomesenchymal chondromyxoid tumors (ECTs) are rare. Only approximately 55 cases have been reported in the English literature. Distinguishing ECTs from soft tissue myoepithelioma (STM) is often difficult owing to morphological and immunohistochemical similarities. Here, we present a case of an ECT arising from the anterior dorsum of the tongue in a 24-year-old woman. Grossly, the tumor was soft, had a myxoid appearance, and measured 8×7×7 mm. Microscopically, it was well-demarcated, lacked a fibrous capsule, and predominantly consisted of short, spindle to ovoid cells in a myxoid background. Vimentin, glial fibrillary acidic protein (GFAP), and S-100 protein were strongly positive on immunohistochemical analysis. While CD56 was moderately immunopositive, cytokeratin (AE1/AE3) and alpha-smooth muscle actin (αSMA) showed focal weak positivity. Thus, the immunohistochemical findings suggested a diverse immunophenotype, indicating mesenchymal (vimentin and αSMA positive), neurogenic (S100, GFAP, and CD56 positive), and epithelial differentiation (cytokeratin positive). This reflected the fact that ECTs probably arise from uncommitted ectomesenchymal cells that have the potential for multilineage differentiation. The immunohistochemical staining pattern observed for ECTs slightly differs from that of STMs. Strongly positive staining for GFAP and weakly positive staining for cytokeratin are observed in ECTs, whereas the opposite is typically observed for STMs. These findings indicated that the patterns of expression on immunohistochemistry differ between ECTs and STMs, although inevitably, there was some overlap. Thus, CD56 expression in the case presented here is noteworthy, and it could potentially become an adjunct diagnostic marker for ECT instead of previously used CD57.

Synchronous adrenocortical neoplasms, paragangliomas, and pheochromocytomas: syndromic considerations regarding an unusual constellation of endocrine tumors

The most common clinical syndromes presenting with paragangliomas and/or pheochromocytomas as their endocrine components are multiple endocrine neoplasia type 2, neurofibromatosis, Von Hippel-Lindau syndrome, Carney-Stratakis syndrome, Carney triad, and the recently described hereditary paraganglioma syndrome. Only Carney triad is known to also present with adrenocortical adenomas, currently representing the only described syndrome in which all 3 of the aforementioned tumors are found together. In most cases, prototypical lesions of the triad such as gastrointestinal stromal tumor and pulmonary chondromas are also seen. We present a case of a young woman with synchronous paragangliomas, adrenal/extra-adrenal cortical neoplasms, and pheochromocytoma without genetic mutations for multiple endocrine neoplasia 2, Von Hippel-Lindau syndrome, neurofibromatosis, and succinate dehydrogenase. We speculate that this represents a previously undescribed presentation of Carney triad and, at the very least, indicates the need for monitoring for the development of other tumors of the triad.

Focal periosteal chondroma of the hand: a review of 24 cases

INTRODUCTION

Periosteal chondroma is a benign cartilaginous tumour that is less common than enchondroma and rarely arises at the hand.

PATIENTS AND METHOD

We report a retrospective review of 24 patients with focal periosteal chondroma of the hand and a mean follow-up of seven years and four months. The 13 females and 11 males had a mean age of 41 years and three months.

RESULTS

Radiographs performed to investigate a hard lump on a finger established the diagnosis in 23 (95.8%) patients, and histological documentation was obtained consistently. The proximal and distal phalanges were the most common sites of involvement. The tumour recurred in a single patient, a 10-year-old child, 10 months after surgery.

CONCLUSION

No other complications were recorded. Tumour excision and curettage of the lesion are the suggested treatments for periosteal chondroma. Most recurrences occur early after initial surgery.

LEVEL OF EVIDENCE

Level IV.

[INFLUENCE FACTORS ANALYSIS OF SURGICAL EFFECTIVENESS FOR SOLITARY ENCHONDROMA OF HAND WITH PATHOLOGIC FRACTURE]

OBJECTIVE

To expore the influence factors of the surgical effectiveness for solitary enchondroma of the hand with pathologic fracture.

METHODS

A retrospective analysis was made on the clinical data of 65 patients with solitary enchondroma of the hand with pathologic fracture who were treated with operation and were accorded with selective standard between March 2010 and June 2013. There were 26 males and 39 females, aged 17 to 63 years (mean, 36 years). The left hands were involved in 32 cases and the right hands in 33 cases. The tumor located at the metacarpus in 18 cases, and at the phalanx in 47 cases (at the proximal phalanx in 30 cases, at the middle phalanx in 9 cases, and at the distal phalanx in 8 cases). The duration from fracture to operation was 2 days to 2 years (mean, 56 days). The operative methods were curettage and bone grafting. The ratios of the total active range of motion (ROM) of the metacarpophalangeal joint and interphalangeal joint between ipsilateral and contralateral fingers were used to evaluate the ipsilateral fingers' function. The time of returning to work was recorded. The multiple linear regressions were performed to analyze the risk factors of the effectiveness.

RESULTS

A total of 65 cases were followed up 5-44 months (mean, 24 months). All incisions achieved primary healing. No infection, re-fracture, or recurrence occurred. The X-ray films showed fracture healing, the healing time was 5-10 weeks (mean, 6.5 weeks). All the bone grafts healed well. At last follow-up, the ROM ratio of the fingers was 0.46-1.00 (mean, 0.90). The time of returning to work was 92-180 days (mean, 130 days). Multiple linear regressions showed that internal fixation was risk factor for the ROM ratio of the fingers (P = 0.013). The duration from fracture to operation, internal fixation, and the tumor site were risk factors for the time of returning to work (P < 0.05).

CONCLUSION

To obtain good effectiveness for patients with solitary enchondroma of the hand with pathologic fracture, it is suggested that immediate operative treatment including tumor curettage, open reduction, and internal fixation with plate and screws of the fracture.

Chondroblastoma-like chondroma of the hand: case report

Chondroblastoma-like chondroma is a rare tumor that almost exclusively manifests in the hand and presents with a set of unique diagnostic features. This tumor has been described in only a limited number of publications and is thus commonly omitted in the differential diagnosis of hand tumors. The diagnostic imaging and histological specimens may initially appear consistent with a number of relatively more common hand tumors, thereby delaying the diagnosis. We present the case of a 49-year-old woman with chondroblastoma-like chondroma of the hand treated with marginal excision. The physical examination, imaging, and needle biopsy made an initial case for giant cell tumor of tendon sheath until histological analysis of the excised specimen yielded the correct diagnosis.

Case presentation of soft tissue parapharyngeal chondroma in a pediatric patient

Soft tissue chondromas are uncommon benign tumors found mostly in the hands and feet and rarely reported in the pediatric population. In this case presentation we describe a 10 year old boy who had an MRI for facial paralysis due to Ramsey Hunt Syndrome, which incidentally revealed a parapharyngeal mass. He underwent transoral resection of the mass without complication, and histopathology confirmed the diagnosis of soft tissue chondroma. This case is unique due to the unusual location of the tumor and its presentation in a child.

Usual clinical presentation of bizarre parosteal osteochondromatous proliferation (BPOP) with unusual histology

Bizarre parosteal osteochondromatous proliferation (BPOP) or Nora's lesion is a unique, bony lesion that most often arises in the small bones of the hands and feet. The lesion was first described by Nora et al. in 1983, and documented cases have now shown the lesion to arise in the long bones, skull, maxilla and mandible. Radiographically, the bony lesion typically lacks a connection with the adjacent medullary cavity which is commonly seen with osteochondroma, the main differential diagnosis for Nora's lesion. Reported is the case of a 35-year-old male who presented to the orthopedic clinic after a non-painful mass arising on the right index finger was identified on routine physical examination. The lesion was surgically removed and sent for pathologic evaluation. Microscopic examination of the lesion revealed a disordered spindle cell proliferation and trabecular bone with no cartilaginous cap. The findings were believed to represent an osteocartilaginous neoplasm with radiographs and magnetic resonance imaging (MRI) suggestive of Nora's lesion. Thus, it was felt that the lesion fell within the overall spectrum of BPOP. The lesion is a unique entity that requires a complete history and physical exam along with radiographic and histologic analysis for proper identification. The lesion is benign but may be locally aggressive. Complete excision is the treatment of choice, and recurrence is common.

Soft tissue chondroma of the index finger: clinical, histological and radiological findings in a unique case

A chondroma is a benign, slow-growing cartilaginous tumor. When arising in the medullary cavity of a bone it is referred to as an enchondroma-a very common bone tumor. When occurring in soft tissue without any connection to bone, which is extremely rare, it is known as a soft-tissue chondroma (STC). A 38-year-old female presented with a 2- year history of right index finger pulp swelling in the absence of trauma. On physical examination a firm, immobile nodule, approximately 1 cm in diameter, was observed on the palmar side of the right index finger. The overlying skin was normal. Plain X-ray showed a dense, soft tissue shadow without calcification in the right index finger pulp, but the adjacent bones were intact. MRI showed a 1-cm diameter, well-demarcated lesion with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. MRI also showed that the tumor had no bony involvement and that the adjacent bones were normal. Histopathological examination of the biopsy specimen showed lobules of mature hyaline cartilage with chondrocytes in the lacunae in the dermal and subdermal layers. Mitotic figures and an increase in cellular atypism were not observed. Based on the histopathological and radiological findings, the mass was thought to be an STC and total excision was performed. Examination of the excised mass confirmed the diagnosis of STC. STC should be considered in patients with a slowly growing, mildly painful cutaneous mass.