volume 5
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TRANSCRIPT
Volume 5
Malignant Chondroid Tumors
Primary central chondrosarcoma----------Case 125 & 652-678
Secondary peripheral chondrosarcoma---Case 126 & 679-686
Dedifferentiated chondrosarcoma---------Case 127 & 687-689
Clear cell chondrosarcoma-----------------Case 128 & 690
Mesenchymal chondrosarcoma------------Case 129 & 691
Cartilaginous pseudotumors---------------Case 692-699
Chondrosacoma
Primary Central
Chondrosarcoma
Primary Central Chondrosarcoma The primary or central conventional chondosarcoma is a low
grade but malignant cartilagenous tumor found typically in adults
between the ages of 30 and 60 years. The tumor arises from the
medullary canal of a large bone such as the pelvis, femur, tibia or
proximal humerus. Because the tumor is slow growing, there is
little symptomatology and the tumor frequently becomes quite
sizable before a physician is consulted. Primary chondrosarcoma
is extremely rare in small bones of the hand or foot. The meta-
physeal portion of a long bone is the most common location
although diaphyseal locations are not unusual. 85% of central
chondrosarcomas are low grade lesions which on radiographic
examination demonstrate matrix calcification similar to that seen
in benign enhondromas, whereas the high grade chondrosarcomas,
which are rare, are frequently noncalcified and take on the
permeative appearance similar to other high grade sarcomas such
as fibrosarcoma and Ewing’s sarcoma. Histologically, the low
grade central chondrosarcoma has a fairly well differentiated
chondroid matrix like that of an enchondroma but shows evidence
of permeative invasion into the adjacent cortical and cancellous
structures. There is rarely any mitotic activity in the low grade
lesions. They have larger nuclear patterns with a higher degree
of atypicism compared to benign enchondromas.
These low grade tumors have a good prognosis in terms of a
low metastatic incidence to the lung but they must be treated
aggressively with a wide resection in order to prevent local
recurrence. One cannot rely on adjuvant therapy such as radiation
or systemic chemotherapy because these low grade lesions are
notoriously resistant to adjuvant therapy.
CLASSIC Case #125
50 year female with chondrosarcoma prox humerus
Axial T-1 MRI
Axial T-2 MRI
Proximal humeral
resection tumor bulge
humeral head
Macro section
Close up macro section
Photomic
Surgical defect
following wide
resection
glenoid
Proximal humeral
allograft ready for
implantation
rotator cuff
Allograft placed
over long stem
Neer prosthesis
pectoralis Neer
Alloprosthetic
reconstruction
completed
rotator
cuff
pectoralis
Post op X-ray
Case #652
74 female
chondrosacoma
proximal humerus
Bone scan
Coronal T-1 MRI
Coronal T-2 MRI tumor
Wide resection
proximal humerus
glenoid
Resected specimen cut in path lab
cortical erosion
Photomic
Suturing down the
allograft rotator cuff
as part of the alloprosthetic
reconstruction
Post op x-ray with
cemented Neer
alloprosthesis
Case #653
19 year male
chondrosarcoma
proximal humerus
Coronal proton density MRI
tumor
Resected specimen
cut in path lab
tumor
Macro section
Photomic
Case #654
28 year female with chondrosarcoma prox humerus
Coronal T-1 MRI
Axial proton density MRI
Axial T-2 MRI
tumor
Case #656
72 year male
chondrosarcoma
femur
Bone scan
Widely resected
distal femur specimen
cut in path lab
Close up showing
cortical break thru
Photomic
Case #657
83 year male
chondrosarcoma femur
Case #658
82 year female
chondrosarcoma
proximal femur
X-ray resected
proximal femoral
tumor with path
fractures
Macro section
Close up macro
Photomic
Case #659
52 year male
chondrosarcoma
mid femur
Another view
Bone scan
Coronal T-1 MRI
Macro section from
intercalary resection
tumor
Photomic showing bony permeation
tumor
bone
Photomic
Higher power
Post op X-ray
Case #660
54 year female with chondrosarcoma distal femur
Resected distal femur including entire knee joint
patella
Distal femur cut in path lab
tumor
Macro section
tumor
Photomic
tumor
tumor
articular cartilage
Close up photomic showing bone permeation by tumor
tumor bone
Post op x-ray with
excisional arthrodesis
I.M.
nail
Case #660.1
33 year male with painless mass in popliteal space for 1 yr
and restricted flexion of knee for 3 yrs
Sag T-1 T-2
Cor T-2 Axial T-2
Surgical specimen Compress rotating hinge
PO x-rays
Case #661
58 year male
chondrosarcoma
proximal tibia tumor
Lateral view
Resected specimen cut in path lab
Photomic
Proximal tibial allograft
placed over long stem
total knee replacement
with wires for patellar
tendon attachment
spherocentric knee
Patellar tendon
sutured to proximal
tibial allograft
Completion of
retinacular closure
patella
Post op x-ray
allograft
9 years later
Case #662
43 year male with chondrosarcoma proximal tibia
Coronal T-2 MRI
tumor
Sagittal Gad C MRI
tumor
Axial T-1 MRI tumor
Proximal tibial resection with tumor breakout posterior
Proximal tibial resection prosthesis with Compress System
spindle
anchor plug drill
Resected proximal tibia next to prosthesis
Drilling holes for
anchor plug pins
in tibia
guide
Placement of anchor plug and traction bar
Milling the proximal tibial stump
mill
Milling process
completed ready
for spindle placement
over traction bar
Spindle secured with 600 lbs of spring pressure
spindle
Femoral component of rotating hinge cemented in place
Components assembled ready for patellar ligament attachment
Spiked washers secure patellar ligament
Soft tissue reconstruction completed ready for closure
Post op x-ray
Case #663
63 year female
chondrosarcoma
pelvis
Internal hemipelvectomy resection specimen
acetabulum
sciatic
notch
Resected specimen after autoclaving
sciatic notch
acetabulum
Autoclaved specimen
replaced with routine
cemented total hip
Immediate post op
X-ray showing rebar
and cement fixation
upper resection line
15 years later
Case #664
54 year male with chondrosarcoma mid pelvis
CT scan
Bone scan
Type II internal hemipelvectomy resection
Type II resection
specimen tumor
femoral head
Photomic
Autoclaved specimen
Autoclaved specimen
reimplanted with
cemented total hip &
recon plates
Nine years later
Case #665
47 year female with chondrosarcoma mid pelvis
CT scan
tumor
Coronal T-1 MRI
tumor
Coronal T-2 MRI
tumor
Photomic
X-ray 1 year post op internal hemipelvectomy & THA
4 years post op
8 yrs PO with slight lateral shift of cup
Case #666
45 year female with chondrosarcoma mid pelvis
Coronal T-2 MRI
Cutting ilium with Gigli saw
ilium
Placement of 6.5 screws in ilium, ischium & ant ramus
ischium
ant ramus
Reconstruction of pelvic ring with recon plates
iliac screws
Placement of constrained cup prior to cementing
Cup cemented
Resected ilium & socket lying next to reconstruction
Hip relocated ready for greater troch attachment
Skin closure including biopsy site
Post op x-ray
Post op x-ray
Case #667
50 year male
chondrosarcoma
anterior acetabulum
Bone scan
Axial T-1 MRI
Type II & III resection and rebar and cement total hip
Case #667.1
78 yr male with primary chondrosarcoma pelvis
Axial T-1 MRI
Axial T-2 MRI
Axial Gad MRI showing rim enhancement
Coronal T-1 MRI
Coronal T-2 MRI
Coronal Gad MRI
Case #667.2
56 yr old female with prior excision of pelvic tumor 4 yrs ago
Recurrent chondrosarcoma
Cor T-1 T-2 Gad
Current MRI
Axial T-1 T-2
Gad
Sag gad Surgical specimen
Case #668
43 year male with chondrosarcoma body of scapula
7 years later
CT scan
Another CT cut
tumor
Coronal T-2 MRI
tumor
Axial T-2 MRI
tumor
Total scapular prosthesis
Cementing humeral component
Scapular component positioned in muscle cuff
Closure of muscle cuff over scapular component
Resected scapula and humeral head
tumor
bulge
Post op x-ray
Case #669
47 year male with chondrosarcoma scapular body
tumor
Another CT cut
tumor
Axial proton density MRI
tumor
Axial proton density MRI
tumor
Axial T-2 MRI
tumor
Coronal proton density MRI
tumor
Case #670
52 year male with chondrosarcoma elbow
Cut specimen in path lab
Photomic
Case #670.1
76 year female with slow growing chondrosarcoma elbow
Axial
T-1
T-2 T-2
Sag T-1 Sag STIR
Cor T-1 Cor STIR
Surgical debulking
Case #671
26 year male
chondrosarcoma
radius
Coronal T-1 MRI
Photomic
Case #672
36 year male with chondrosarcoma distal radius
CT scan
Case #673
56 year male
enchondroma
2nd metacarpal
3.5 years later with
chondrosarcoma
Photomic
Case #674
77 year female with chondrosarcoma os calcis
Os calcis view
T-1 MRI
T-2 MRI
tumor
Sagittal T-2 MRI
tumor
Photomic
Case #674.1
55 year male with slight pain and swelling about ankle for 2 years
Bone scan
CT Scan
Sag PD T-2
Gad
Axial PD T-2
Gad
Case #675
72 year male with chondrosarcoma chest wall
tumor
Lateral view
tumor
CT scan
Another CT cut
Photomic
Case #676
52 year male with chondrosarcoma rib
Macro section of resected specimen
tumor
rib
Photomic
Case #676.1
38 year male
chondrosarcoma
L-1 with block on
myelogram
CT scan
Photomic
Case #676.2
74 yr male with low grade chondrosarcoma LD spine 2 yrs
CT scan
Sag T-1 Sag T-2 Sag Gad
Axial T-1 Axial T-2 Axial Gad
Case #676.3
48 year old male with low back pain for 1 year
Chondrosarcoma L-3
Bone scan
Axial T-1 T-2
Sag T-2
Case #677
46 year male with chondrosarcoma mandible
Photomic
Case #678
39 year male
chondrosarcoma
mandible
Secondary
Peripheral
Chondrosarcoma
Secondary Peripheral Chondrosarcoma
The vast majority of secondary peripheral chondrosarcomas arise
from a prexisting osteochondroma and do not occur before puberty.
These lesions tend to be slow growing with minimal to mild
symptoms. The most common site is the pelvis, followed by the
proximal femur, proximal humerus, and ribs. Plain radiographs show
a large calcifying mass on the surface of bone that measure over
5 cm in girth. When one sees an osteochondroma with a cartilagenous
cap over 3 cm in thichness, there is a strong likelihood for a
secondary chondrosarcoma. The overall prognosis for the secondary
peripheral chondrosarcoma is much better than that for the primary
central chondrosarcoma and usually requires only a simple wide
resection with little chance for local recurrence.
CLASSIC Case #126
56 year male with 2ndary peripheral chondrosarcoma ilium
tumor exostosis
Coronal T-2 MRI
tumor
Resected specimen cut in path lab
ilium
Macro section
ilium
Low power photomic
Higher power with ditto forms
Case #679
60 year female with chondrosarcoma pubic area
Gross resection specimen
tumor
Gross specimen cut in path lab
pubic bone
tumor
Macro section
pubic bone
tumor
Close up macro section
pubic bone
Photomic
Post op x-ray
Case #680
31 year male
chondrosarcoma
ilium in multiple
exostosis patient
tumor
exostosis
Axial proton density MRI
tumor
exostosis
Axial T-2 MRI
tumor
tumor
Axial T-2 MRI
Photomic
X-ray of knees with multi exostoses
Case #681
18 year female
chondrosarcoma
pelvis and multi
hereditary exostoses
Oblique view
CT scan
Bone scan
tumor
Resected specimen
tumor
Macro section
Photomic
Multi exostoses knee
Lateral view
Several years after type I resection
Case #682
38 year female with osteochondroma C-spine
CT scan
Surgical photo at at same time
Surgical specimen cut in path lab
cap
Recurrence 3 years
later
Recurrence CT scan
Coronal T-1 MRI
of recurrence and
chondrosarcoma
tumor
Chondrosarcoma photomic
Case #683
42 year female with 2ndary chondrosarcoma ilium
CT scan
Coronal T-1 MRI
tumor
Axial T-1 MRI
tumor
Axial T-2 MRI
tumor
Case #684
33 year male
2ndary chondrosarcoma
os calcis
Lateral view
CT scan
Soft tissue CT scan
exostosis
chondrosarc
Coronal proton density MRI
tumor
Coronal T-2 MRI
tumor
Surgical specimen cut in path lab
Photomic
Case #685
30 year male with multi exostoses & chondrosarcoma chest wall
Case #686
42 year male with 2ndary chondrosarcoma
Macro section
bone stock
chondrosarc
Case #686A
42 year male with peripheral chondrosarcoma ulna
Dedifferentiated
Chondrosarcoma
Dedifferentiated Chondrosarcoma
Of all the chondrosarcoma variants, by far the most malignant and
potentially fatal is the dedifferentiated chondrosarcoma that
accounts for approximately 5-10% of all chondrosarcomas. It
most likely arises as a result of a second mutation within a pre-
existing low to intermediated grade chondrosarcoma, resulting in
the formation of a malignant fibrous histiocytoma or osteo-
sarcoma immediately adjacent to the lower grade chondrosarcoma
Histologically, the low and high grade portions of this tumor are
geographically separated by sharp margins. These tumors usually
occur in patients between the ages of 50 and 70 years in the
same areas where primary centeral chondrosarcomas are found:
the pelvis, femur and proximal humerus. The characteristic
radiographic appearance is that of a flocculated calcific lytic
lesion arising from the central area of bone with an adjacent area
with more extensive infiltration into the surrounding cortical bone.
There is no evidence of calcification in the high grade portion of the
lesion and it typically breaks out through the cortex and into the
subperiosteal space.
The prognosis for this variant of chondrosarcomqa is extremely
poor, most patients dying from metastatic disease within one or two
years after the diagnosis is established. Adjavent chemotherapy or
radiation therapy is not very effective, mainly because of the older
age group in which the tumor occurs. The primary treatment
modality is wide surgical resection.
CLASSIC
Case #127
44 year male
dedifferentiated
chondrosarcoma
proximal femur
2 years later with
increased size
Coronal T-1 MRI
tumor
Axial T-2 MRI
tumor
Photomic at juncture of high and low grade tumor
Low grade chondrosarcoma portion
High grade OGS portion
osteoid
Case #127.1
63 yr male with recent
hip fracture
Dedifferentiated chondrosarc
Bone scan
Cor T-1
Sag T-1 STIR
Axial PD
Axial PD
Surgical resection
Rconstruction completed
Post op X-ray
Case #687
73 year female
dedifferentiated
chondrosarcoma
distal femur
high
grade
low
grade
Lateral view
high grade
low grade
Bone scan
Coronal T-1 MRI high
low
Resected distal femur cut in path lab
high grade
low grade
Photomic showing low grade left & high grade right
Low grade chondrosarcoma
High grade OGS
osteoid
Post op x-ray with
prosthetic recon
Case #688
33 year female
dedifferentiated
chondrosarcoma
distal femur
Reconstruction with Compress system after wide resection
400 lbs pressure
Completion of rotating hinge arthroplasty
Immediate post op x-ray
X-ray at 2 months showing
early callous formation
Early osseointegration
at 5 months
spindle
anchor
plug
X-ray at one year
Stable osseointegration
at 5 years with no signs
of stress shielding
AP view
Lateral view
anterior
cortex
10 years post op
14 years post op
Case #688.1 Dedifferentiated chondrosarcoma
89 year male with mild knee pain 3 months
Coronal T-1 T-2 Sagittal T-2
Axial
T-1 T-2
Gad
Immediate Post Op x-rays
Case #689
42 year female
dedifferentiated
chondrosarcoma
pelvis
Bone scan
Sagittal T-1 MRI
tumor
post column
acetabulum
Axial T-1 MRI
Coronal T-2 MRI
tumor
Low power photomic
Low grade chondrosarcoma
High grade portion
Internal hemipelvectomy reconstruction
recon plate
Post op x-ray
Case #689.1
42 year male with right hip pain for 3 months
Bone scan
CT scan
Cor T-1 STIR
Gad Gad
Axial T-1 T-2
T-2 Gad
Clear Cell
Chondrosacoma
Clear Cell Chondrosarcoma
The clear cell chondrosarcoma is one of the rarest variants of the
chondrosarcoma. It is found more commonly in males than females
between the ages of 20 and 50 years. The most common location
for this tumor is in the femoral head. Radiographically the clear cell
chondrosarcoma has the appearance of a lytic lesion in the epiphysis,
similar to the chondroblastoma in a younger age group for which it
is frequently misdiagnosed. It has a geographic pattern with central
stippled calcification similar to that of a chondroblastoma. Histo-
locally it also has the appearance of a chondroblastoma with the
presence of benign macrophages and polyhedral stem cells with a
clear cell chicken wire appearance. But in some areas one will see
evidence of a low grade chondrosarcoma in which giant cells are not
seen, clearly separating it from the chondroblastoma.
The treatment for this condition consists of a wide resection which
in the femoral head would be a transcervical resection and replace-
ment with a bipolar prosthesis. If the lesion is treated by simple
curettement, the recurrence rate is quite high compared to the
chondroblastoma. The chance for pulmonary metastasis is very
unlikely and local recurrence is rare following a wide resection.
CLASSIC Case #128
25 year male with clear cell chondrosarcoma femoral head
Low power photomic
Higher power showing clear cells
Case #690
51 year male with clear cell chondrosarcoma femoral head
Frog leg lateral
Post op x-ray following
head & neck resection
and total hip replacement
Case #690.1
Post reduction
Acute pathologic fracture left shoulder in 43 yr female
Clear cell chondrosarcoma
CT scan
Cementation PO
Case #690.1
20 year female with clear cell chondrosarc prox tibia
Lateral view
Coronal T-1 MRI
tumor
Sagittal T-1 MRI
tumor
Mesenchymal
Chondrosarcoma
Mesenchymal Chondrosarcoma
The mesenchymal chondrosarcoma is another rare variant of the
chondrosarcoma. It consists of low grade chondrosarcoma com-
ponents with an infiltration of primitive mesenchymal cells giving
it the histological appearance of a Ewing’s sarcoma or a hemangio-
pericytoma. It can be seen in soft tissue as well as bone in young
adults, more often in females. The most common location is in the
jaw, followed next by the spine or ribs, with a very few cases seen
in long bones. Because of the high grade component of this lesion,
it is treated as a high grade sarcoma with adjavent chemotherapy
and radiation therapy along with a wide resection if possible.
Despite this aggressive program of treatment, the prognosis is very
poor because of a high incidence of pulmonary metastases and
local recurrence.
CLASSIC
Case #129
34 year female
mesenchymal
chondrosarcoma
LD spine & paraplegia tumor
Sagittal MRI
Photomic showing low grade chondroid portion
High grade round cell portion of tumor
Case #691
36 year male with mesenchymal chondrosarc humeral head
tumor
CT scan
Post op x-ray
following humeral
head resection and
prosthetic recon
Cartilagenous
Pseudotumors
Case #692
8 year female with multi focal TBc looking like Ollier’s
Pseudotumor
Geographic lesions in both elbows
Photomic showing tuberculous granuloma
Langhans giant cell
Case #693
10 year child
TBc granuloma
proximal tibia looking
like chondroblastoma
Case #694
54 year female with tumoral calcinosis looking like chondrsarc
hip
Sagittal T-1 MRI
Axial T-1 MRI
Amorphous calcium
phosphate flowing
from biopsy site
Resected specimen cut in path lab
Photomic showing heavy calcifcation
Case #695
64 yr male with giant bone island looking like chondrosarc
CT scan
Case #696
55 yr female with geode(DOA) looking like chondrosarc
AP x-ray hip
Axial CT scan
Sagittal CT scan
Bone scan
Coronal T-1 MRI
Axial proton density MRI
Axial T-2 MRI
Case #697
52 yr female with bone infarct looking like enchondroma
Sagittal T-1 MRI
knee joint
Case #697.1 Sag & Cor T-1
74 yr female with tender lump mid pretibial area for 1 year
Bone infarcts
Cor T-2
Gad
Gad
Axial T-1
T-2
Axial T-2
Case #698
45 yr female with epiphyseal infarct looking like
chondroblastoma
Case #699
77 year female
rheumatoid arthritis
shoulder looking like
chondrosarcoma
proximal humerus
AP x-ray shoulder
Bone scan
CT scan
Another CT cut
Axial T-1 MRI
Axial T-1 MRI
Sagittal T-2 MRI
Coronal T-2 MRI
Resected proximal
humerus specimen