Overview , classification and important diagnostic points of different varieties of chondrosarcoma and its management.

1. CHONDROSARCOMA
DR.M.IMRAN ASHRAF
PGR ORTHOPEDIC SURGERY

2. DEFINITION
• Nonhematologic primary malignancy of bone
which occur in cartilage cells

4. SIGN AND SYPMTOMS
• PAIN WITH OR WITHOUT MASS
• PATHOLOGICAL FRACTURE IS RARE

5. PREVELENCE
• 2:1 WITH MORE IN MALES
• Most common bone sarcoma in adults
• 2nd most common primary sarcoma of bones
(1st is multiple myeloma)
• It constitutes 20% of all primary malignant
bone sarcomas

6. MOST COMMON SITES
• Proximal femur
• Distal femur
• Proximal humerus
• Pelvis
• Scapula
• Ribs
• Spine and craniofacial bones are
rare sites

7. RADIOGRAPHIC PRESENTATION
CALCIFICATIONS Have distinctive Ring and arc
pattern
Low grade chondrosarcoma
>uniformly calcified
Well defined margins
High grade chondrosarcomas
>Large non calcified areas
Irregular ill defined margins
Often extend into soft tissues

8. RADIOLOGICAL FEATURES OF
MALIGNANCY
1. Bone contour in the affected area may be
expanded
2. Cortical thickening
3. Endosteal scalloping
4. New area of lysis adjacent to calcified
areas
5. Cortical destruction and soft tissue
extension in higher grade lesions
;Extension into soft tissues is definitive

9. RADIOGRAPHIC FEATURES

10. RADIOGRAPHIC FEATURES

11. RADIOGRAPHIC FINDINGS

12. MRI OF DISTAL FEMUR

13. MRI AXIAL VIEW

14. CT SCAN
Ring and arc calcification
pattern
Cortical thickening
Periosteal reaction

15. BONE SCAN

17. RADIOGRAPH OF GRADE 2
CHONDROSARCOMA

18. SECONDARY CHONDROSARCOMAS
• Secondary chondrosarcoma arise from a pre existing lesion i.e
osteochondroma or enchondroma
• Most arise from osteochondromas
• > Scapula,Ribs,Pelvis and proximal femur
• Most are Low grade lesions

19. MALIGNANT
TRANSFORMATION OF
OSTEOCHONDROMA
• Cartilaginous cap thickness greater by
2cm
• Cortical destruction
• Back growth of cartilaginous cap into
stalk
• Lysis of calcification in cap
1.Sessile
chondroma
2.Cartilagin
ous cap
only 2-
3mm
3. cortex of
the lesion
continuous
with cortex of
the native
bone

20. GRADES OF CHONDROSARCOMA
• Grade 1 Grade 2 Grade 3
• Happens due to increase in :
• >cellularity
• >myxoid changes
• >nuclear pleomorphism
• >multinucleated lacunae
• >increase in mitosis

21. MICROSCOPIC PATHOLOGY
• Chondrosarcoma
demonstrate entrapment of
trabeculae.

22. DEDIFFERENTIATED CHONDROSARCOMA
• Dedifferentiated chondrosarcoma consists
of a low grade malignant hyaline cartilage
tumor associated with a high-grade
nonchondroid spindle sarcoma.
• The two Components are juxtaposed with
abrupt clear demarcation line
• Most commonly age presentation old than
50 yrs.
• Common sites included Pelvis, Proximal
femur, Proximal humerus ,distal femur, ribs
• Characteristically abrupt transition
between chondroid tumor and
dedifferentiated, lytic component.

23. CLEAR CELL CHONDROSARCOMA
• Low-grade malignant chondrogenic neoplasm
characterized by lobules of clear cells
• Strong predilection for the epiphysis of long
bones
• 2/3 of cases present in the humeral or femoral head
• Commonly metastasis to lungs (15%)

24. DIFFERENT RADIOGRAPHIC PRESENTATION
OF CLEAR CELL CHONDROSARCOMA

25. MESENCHYMAL CHONDROSARCOMA
• High grade cartilage forming tumor
• high-grade biphasic chondrosarcoma
characterized by poorly differentiated small
round blue cells and islands of hyaline cartilage
• widespread anatomical distribution
• 30% of cases are isolated to the soft tissue
• most common in the flat bones (ilium, ribs, skull)
• Hemangiopericytoma pattern

26. PERIOSTEAL (JUXTACORTICAL)
CHONDROSARCOMA
• A malignant, subperiosteal cartilaginous tumor that lacks osteoid production
and erodes the underlying cortical bone
• Presents as painless mass or swelling ,1/3 of pts complain of pain
• There is chondroid matrix calcification
• Similar to periosteal osteosarcoma however no hair on end periosteal
reaction
• It has larger soft tissue mass >3-4cm
• There is intramedullary canal spread
• Common sites are
• >femur ,humerus, pelvis, ribs and foot

27. RADIOGRAPHIC PRESENTATION
• Metaphyseal presentation
• There is cortical erosion with sclerotic
underlying cortex(saucer shaped
defect)
• Triangular sclerotic spur at margin of
tumor
• >5cm in diameter (usually periosteal
chondroma is <5cm)
• No hair on end periosteal reaction
(however in contrast chondroblastic
osteosarcoma has hair on end

29. NATIONAL COMPREHENSIVE CANCER NETWORK
(NCCN) CLINICAL PRACTICE GUIDELINES FOR
TREATMENT OF CHONDROSARCOMA
• Enrollment in a clinical trial should be considered when available; in
addition, whenever possible patients should be referred to a tertiary care
center with expertise in sarcoma, for treatment by a multidisciplinary
team
• Wide excision or intralesional excision with or without adjuvant therapy
for resectable low-grade and intracompartmental lesions
• Wide excision is preferred for pelvic low-grade tumors
• High-grade (grade II, III), clear cell, or extra compartmental lesions, if
resectable, should be treated with wide excision
• Wide excision should provide negative surgical margins and may be
achieved by either limb-sparing surgery or amputation
• Postoperative treatment with proton and/or photon beam radiation for
tumors in unfavorable location
• Consider radiation therapy for unresectable tumors