Curettage and cryosurgery for low-grade cartilage tumors is associated with low recurrence and high function

BACKGROUND

Chondrosarcomas of bone traditionally have been treated by wide or radical excision, procedures that may result in considerable lifelong disability. Grade 1 chondrosarcomas have little or no metastatic potential and are often difficult to distinguish from painful benign enchondromas. Curettage with adjuvant cryosurgery has been proposed as an alternative therapy for Grade 1 chondrosarcomas given the generally better function after the procedure. However, because it is an intralesional procedure, curettage and cryosurgery may be associated with higher rates of recurrence.

QUESTIONS/PURPOSES

We asked whether Grade 1 chondrosarcomas and enchondromas of uncertain malignant potential treated by curettage and cryosurgery are associated with low recurrence rates and high functional scores.

PATIENTS AND METHODS

We retrospectively reviewed the records of 46 patients with Grade 1 chondrosarcomas and enchondromas of uncertain malignant potential treated by curettage and cryosurgery. Forty-one patients had tumors of the long bones. Patients were followed a minimum of 18 months (average, 47.2. months; range, 18-134 months) for evidence of recurrence and for assessment of Musculoskeletal Tumor Society (MSTS) functional score.

RESULTS

Two of the 46 patients had recurrences in the original tumor site (4.3% recurrence rate), which subsequently were removed by wide excision, and both patients were confirmed to be disease-free 36 and 30 months, respectively, after the second surgery. The mean MSTS score was 27.2 of 30 points (median, 29 points).

CONCLUSIONS

Our observations show curettage with cryosurgery is associated with low recurrence of Grade 1 chondrosarcoma and high functional scores. Curettage with cryosurgery is a reasonable alternative to wide or radical excision as the treatment for Grade 1 chondrosarcomas, and allows for more radical surgery in the event of local recurrence.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

PTHR1 mutations associated with Ollier disease result in receptor loss of function

PTHR1-signaling pathway is critical for the regulation of endochondral ossification. Thus, abnormalities in genes belonging to this pathway could potentially participate in the pathogenesis of Ollier disease/Maffucci syndrome, two developmental disorders defined by the presence of multiple enchondromas. In agreement, a functionally deleterious mutation in PTHR1 (p.R150C) was identified in enchondromas from two of six unrelated patients with enchondromatosis. However, neither the p.R150C mutation (26 tumors) nor any other mutation in the PTHR1 gene (11 patients) could be identified in another study. To further define the role of PTHR1-signaling pathway in Ollier disease and Maffucci syndrome, we analyzed the coding sequences of four genes (PTHR1, IHH, PTHrP and GNAS1) in leucocyte and/or tumor DNA from 61 and 23 patients affected with Ollier disease or Maffucci syndrome, respectively. We identified three previously undescribed missense mutations in PTHR1 in patients with Ollier disease at the heterozygous state. Two mutations (p.G121E, p.A122T) were present only in enchondromas, and one (p.R255H) in both enchondroma and leukocyte DNA. Assessment of receptor function demonstrated that these three mutations impair PTHR1 function by reducing either the affinity of the receptor for PTH or the receptor expression at the cell surface. These mutations were not found in DNA from 222 controls. Including our data, PTHR1 functionally deleterious mutations have now been identified in five out 31 enchondromas from Ollier patients. These findings provide further support for the idea that heterozygous mutations in PTHR1 that impair receptor function participate in the pathogenesis of Ollier disease in some patients.

Respiratory symptoms in a boy revealing Carney triad

The association of gastrointestinal stromal cell tumor (GIST), paraganglioma, and pulmonary chondroma is known as the Carney triad, occurring predominantly in young adult females. We present the case of a 14-year-old male with respiratory symptoms resulting in the diagnosis Carney triad.

Tenosynovial (extraarticular) chondromatosis: an analysis of 37 cases of an underrecognized clinicopathologic entity with a strong predilection for the hands and feet and a high local recurrence rate

Tenosynovial chondromatosis is a multinodular cartilaginous proliferation that arises from the tenosynovial membranes. This report describes the clinical, radiologic, and histopathologic findings in 37 cases of this uncommon entity. There were 17 males and 20 females, ranging in age from 20 to 86 years (mean and median age, 46 years). The process involved tenosynovium of the fingers (n = 19), feet (n = 8), wrists (n = 4), ankles (n = 2), hand, not otherwise specified, or palm (n = 2), knee (n = 1), and forearm (n = 1). Signs of disease or symptoms were present for 5 weeks to 18 years (median duration, approximately 2 years) before surgical excision. The two most common complaints were a painless mass and a mass that was mildly tender with pressure. None of the tumors had clinical, radiologic, or histopathologic evidence of articular or bone involvement. Histologically, all tumors consisted of a multinodular cartilaginous proliferation involving tenosynovium and/or subsynovial connective tissue. Mild or moderate atypia, as encountered in chondroma of soft parts and synovial chondromatosis, was a frequent finding. Follow-up information was available for 16 patients (43%). Only two patients with follow-up information remained disease free after their initial surgical procedure. Seven patients had one recurrence and seven patients had two or more recurrences. Tenosynovial chondromatosis appears to be an extraarticular counterpart of synovial (intraarticular) chondromatosis. Our review indicates this process is often confused with chondroma of soft parts, in part, because both entities have a predilection for the hands and feet. Diagnosis of this underrecognized entity is of clinical importance because of the high local recurrence rate.

[Vascularized peroneal reconstruction after bloc resection of tumors or congenital malformations of the upper limb in children]

Limb salvage surgery is the standard care for most malignant tumor affecting the extremities in the child, and a vascularized fibula transfer is probably the most popular microsurgical option to reconstruct long-bone defects. Between 1994 and 1999, nine children with intractable diseases of the upper limb were treated using free vascularized fibula grafts (one patient had resection in 1983 and initially prosthetic reconstruction, then fibula transplant in 1996). There were 6 boys and 3 girls. Mean age was 10 years (between 6 and 16). Eight patients had defects after sarcoma resection, one had an aggressive enchondroma. The reconstructed sites were the humerus (= 6), the radius (n = 3). The length of the bone defect ranged from 8 to 19 cm (mean: 14.4 cm). The fibula head with the cartilage and the growth plate was used in 3 children. One girl, 4.5 years old with congenital pseudoarthrosis of radius and cubitus had a resection and reconstruction with a U shaped fibula transplant. One patient died from lung and brain metastasis, two years after the reconstruction. There were no local recurrences. The complications were numerous but usually benign; fracture of the grafted fibula n = 7, necessity of additional bone grafts (n = 4) malunion (n = 1) needed reoperation, pseudoarthrosis (n = 2) with reoperation, ankle valgus (n = 1) required reoperation, necrosis of the fibula head (n = 1), radial inclination (n = 1). The ten patients had bone union. The mean period required to obtain radiographic bone union was 5 months. The functional results of the remaining patients were evaluated according to the scale of ENNEKING. The results ranged from 21 to 30 points. Our results were satisfactory with regard to pain, emotional acceptance, manual dexterity. The vascularized fibula graft is indicated in children with large bone defects, more than 8 cm in the humerus, radius and ulna.

Use of the Ilizarov external fixator in the treatment of patients with Ollier's disease

The authors present the results of treatment of 10 patients with Ollier's disease using the Ilizarov technique. The Ilizarov device was used to treat leg length discrepancy and to enhance the conversion of chondroma cartilage into normal mature bone, with no curettage and bone grafting. The mean duration of treatment was 9.4 months. This technique was highly efficient in treating the disease. It led to conversion of the abnormal cartilage into histologically mature bone in all patients. Some complications were seen, such as decreased knee mobility, which required prolonged use of the device. The Ilizarov technique is successful in treating patients with Ollier's disease despite some complications and the difficulty in using the technique.

Synovial chondromatosis

Two patients were evaluated for a complaint of long-standing hip pain. No etiology of their progressively disabling symptoms was found by routine diagnostic studies. Hip arthrography and arthrotomography in each case, however, demonstrated multiple intraarticular filling defects consistent with nonradiopaque loose bodies. These were subsequently confirmed at arthrotomy. Synovial chondromatosis is a rare disease in which intrasynovial cartilage metaplasia results in multiple intracapsular loose bodies. Its presence in plain radiographs is uncommon, but has been previously documented. This can account for frequent long delays in accurate diagnosis. Arthrography and/or arthrotomography, however, can be key diagnostic tools. They are recommended in the evaluation of patients whose relatively normal initial clinical examination, laboratory, and roentgenographic studies fail to adequately explain the presence of genuinely disabling symptoms.

[Synovial osteochondromatosis]

The Authors have examined the clinical history, roentgenograms, differential diagnosis and treatment of synovial osteochondromatosis.

Osteochondroma of the mandibular condyle. Report of a case and review of the literature

Osteochondroma (osteocartilaginous exostosis) is a rare tumour in the region of the mandibular condyle. Much confusion seems to exist in the literature in differentiating these tumours from condylar chondromas as well as from condylar hyperplasias. A case of condylar osteochondroma with a review of the literature is presented.

Inverse activity of masticatory muscles with and without trismus: a brainstem syndrome

Clinical and EMG findings in 10 cases of intrinsic brainstem lesions are reported with paradoxical activity of jaw closing muscles during jaw opening, with and without trismus. In five cases with trigeminal anaesthesia, the inverse activity of jaw closers is interpreted as a manifestation of disturbance in the central programming of mastication in the motor trigeminal area of the brainstem. Stretch reflex mechanisms and disinhibition of the trigeminal motor neurones play no part in the origin of inverse activity. The distinct brainstem syndrome can only be detected by EMG and the special clinical features.

Gaze-induced laughter

Pathological laughter was stimulated by pursuit eye movements with a large extramedullary brainstem tumour. Laughter was also evoked by intense direct light. The mechanism by which visual stimuli could induce pathological laughter is discussed.

[Right lumbo-crural sciatica due to a vertebral osteochondroma]

The above case-report is about unilateral lumbar-crural-sciatalgie which has led to the finding of a spinal tumour situated within the articular block on the right side of the third and fourth lumbar vertebrae. The clinical picture produced by this slowly growing tumour was that of spinal root compression which has called for its surgical removal. Histological examination of the tumour revealed an osteochondroma, the original aspects of which lie in its localization, the presenting symptoms, the age of the patients an in its course.