This document discusses several cases of malignant chondroid tumors, including primary central chondrosarcoma, secondary peripheral chondrosarcoma, dedifferentiated chondrosarcoma, clear cell chondrosarcoma, and mesenchymal chondrosarcoma. For each tumor type, the document provides details on location, symptoms, imaging findings, histology, treatment involving wide resection and reconstruction, and patient outcomes. Several case examples are presented with images and descriptions of each patient's presentation, diagnostic workup, surgery, and follow-up.

1. 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

2. Chondrosacoma

3. Primary Central
Chondrosarcoma

4. 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

5. 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.

6. CLASSIC Case #125
50 year female with chondrosarcoma prox humerus

7. Axial T-1 MRI

8. Axial T-2 MRI

9. humeral head
Proximal humeral
resection tumor bulge

10. Macro section

11. Close up macro section

12. Photomic

13. glenoid
Surgical defect
following wide
resection

14. rotator cuff
Proximal humeral
allograft ready for
implantation

15. pectoralis
Allograft placed Neer
over long stem
Neer prosthesis

16. rotator
Alloprosthetic
cuff
reconstruction
completed
pectoralis

17. Post op X-ray

18. Case #652
74 female
chondrosacoma
proximal humerus

19. Bone scan

20. Coronal T-1 MRI

21. Coronal T-2 MRI
tumor

22. glenoid
Wide resection
proximal humerus

23. cortical erosion
Resected specimen cut in path lab

24. Photomic

25. Suturing down the
allograft rotator cuff
as part of the alloprosthetic
reconstruction

26. Post op x-ray with
cemented Neer
alloprosthesis

27. Case #653
19 year male
chondrosarcoma
proximal humerus

28. tumor
Coronal proton density MRI

29. Resected specimen
cut in path lab
tumor

30. Macro section

31. Photomic

32. Case #654
28 year female with chondrosarcoma prox humerus

33. Coronal T-1 MRI

34. Axial proton density MRI

35. tumor
Axial T-2 MRI

36. Case #656
72 year male
chondrosarcoma
femur

37. Bone scan

38. Widely resected
distal femur specimen
cut in path lab

39. Close up showing
cortical break thru

40. Photomic

41. Case #657
83 year male
chondrosarcoma femur

42. Case #658
82 year female
chondrosarcoma
proximal femur

43. X-ray resected
proximal femoral
tumor with path
fractures

44. Macro section

45. Close up macro

46. Photomic

47. Case #659
52 year male
chondrosarcoma
mid femur

48. Another view

49. Bone scan

50. Coronal T-1 MRI

51. Macro section from
intercalary resection
tumor

52. bone
tumor
Photomic showing bony permeation

53. Photomic

54. Higher power

55. Post op X-ray

56. Case #660
54 year female with chondrosarcoma distal femur

57. patella
Resected distal femur including entire knee joint

58. tumor
Distal femur cut in path lab

59. tumor
Macro section

60. articular cartilage
tumor
tumor
Photomic

61. tumor bone
Close up photomic showing bone permeation by tumor

62. Post op x-ray with
excisional arthrodesis
I.M.
nail

63. Case #660.1
33 year male with painless mass in popliteal space for 1 yr
and restricted flexion of knee for 3 yrs

64. Sag T-1 T-2

65. Cor T-2 Axial T-2

66. Surgical specimen Compress rotating hinge

67. PO x-rays

68. Case #661
58 year male
chondrosarcoma
proximal tibia tumor

69. Lateral view

70. Resected specimen cut in path lab

71. Photomic

72. spherocentric knee
Proximal tibial allograft
placed over long stem
total knee replacement
with wires for patellar
tendon attachment

73. Patellar tendon
sutured to proximal
tibial allograft

74. patella
Completion of
retinacular closure

75. Post op x-ray
allograft

76. 9 years later

77. Case #662
43 year male with chondrosarcoma proximal tibia

78. Coronal T-2 MRI
tumor

79. Sagittal Gad C MRI
tumor

80. Axial T-1 MRI
tumor

81. Proximal tibial resection with tumor breakout posterior

82. anchor plug drill
spindle
Proximal tibial resection prosthesis with Compress System

83. Resected proximal tibia next to prosthesis

84. Drilling holes for
anchor plug pins
in tibia
guide

85. Placement of anchor plug and traction bar

86. mill
Milling the proximal tibial stump

87. Milling process
completed ready
for spindle placement
over traction bar

88. spindle
Spindle secured with 600 lbs of spring pressure

89. Femoral component of rotating hinge cemented in place

90. Components assembled ready for patellar ligament attachment

91. Spiked washers secure patellar ligament

92. Soft tissue reconstruction completed ready for closure

93. Post op x-ray

94. Case #663
63 year female
chondrosarcoma
pelvis

95. sciatic
notch
acetabulum
Internal hemipelvectomy resection specimen

96. sciatic notch
acetabulum
Resected specimen after autoclaving

97. Autoclaved specimen
replaced with routine
cemented total hip

98. upper resection line
Immediate post op
X-ray showing rebar
and cement fixation

99. 15 years later

100. Case #664
54 year male with chondrosarcoma mid pelvis

101. CT scan

102. Bone scan

103. Type II internal hemipelvectomy resection

104. Type II resection
tumor
specimen
femoral head

105. Photomic

106. Autoclaved specimen

107. Autoclaved specimen
reimplanted with
cemented total hip &
recon plates

108. Nine years later

109. Case #665
47 year female with chondrosarcoma mid pelvis

110. tumor
CT scan

111. tumor
Coronal T-1 MRI

112. tumor
Coronal T-2 MRI

113. Photomic

114. X-ray 1 year post op internal hemipelvectomy & THA

115. 4 years post op

116. 8 yrs PO with slight lateral shift of cup

117. Case #666
45 year female with chondrosarcoma mid pelvis

118. Coronal T-2 MRI

119. Cutting ilium with Gigli saw

120. ischium
ilium
ant ramus
Placement of 6.5 screws in ilium, ischium & ant ramus

121. iliac screws
Reconstruction of pelvic ring with recon plates

122. Placement of constrained cup prior to cementing

123. Cup cemented

124. Resected ilium & socket lying next to reconstruction

125. Hip relocated ready for greater troch attachment

126. Skin closure including biopsy site

127. Post op x-ray

128. Post op x-ray

129. Case #667
50 year male
chondrosarcoma
anterior acetabulum

130. Bone scan

131. Axial T-1 MRI

132. Type II & III resection and rebar and cement total hip

133. Case #667.1
78 yr male with primary chondrosarcoma pelvis

134. Axial T-1 MRI

135. Axial T-2 MRI

136. Axial Gad MRI showing rim enhancement

137. Coronal T-1 MRI

138. Coronal T-2 MRI

139. Coronal Gad MRI

140. Case #667.2 Recurrent chondrosarcoma
56 yr old female with prior excision of pelvic tumor 4 yrs ago

141. Current MRI
Cor T-1 T-2 Gad

142. Axial T-1 T-2
Gad

143. Sag gad Surgical specimen

144. Case #668
43 year male with chondrosarcoma body of scapula

145. 7 years later

146. CT scan

147. tumor
Another CT cut

148. tumor
Coronal T-2 MRI

149. tumor
Axial T-2 MRI

150. Total scapular prosthesis

151. Cementing humeral component

152. Scapular component positioned in muscle cuff

153. Closure of muscle cuff over scapular component

154. tumor
bulge
Resected scapula and humeral head

155. Post op x-ray

156. Case #669
tumor
47 year male with chondrosarcoma scapular body

157. tumor
Another CT cut

158. tumor
Axial proton density MRI

159. tumor
Axial proton density MRI

160. tumor
Axial T-2 MRI

161. tumor
Coronal proton density MRI

162. Case #670
52 year male with chondrosarcoma elbow

163. Cut specimen in path lab

164. Photomic

165. Case #670.1
76 year female with slow growing chondrosarcoma elbow

166. Axial
T-1
T-2 T-2

167. Sag T-1 Sag STIR

168. Cor T-1 Cor STIR

169. Surgical debulking

170. Case #671
26 year male
chondrosarcoma
radius

171. Coronal T-1 MRI

172. Photomic

173. Case #672
36 year male with chondrosarcoma distal radius

174. CT scan

175. Case #673
56 year male
enchondroma
2nd metacarpal

176. 3.5 years later with
chondrosarcoma

177. Photomic

178. Case #674
77 year female with chondrosarcoma os calcis

179. Os calcis view

180. T-1 MRI

181. tumor
T-2 MRI

182. tumor
Sagittal T-2 MRI

183. Photomic

184. Case #674.1
55 year male with slight pain and swelling about ankle for 2 years

185. Bone scan

186. CT Scan

187. Sag PD T-2
Gad

188. Axial PD T-2
Gad

189. Case #675
tumor
72 year male with chondrosarcoma chest wall

190. tumor
Lateral view

191. CT scan

192. Another CT cut

193. Photomic

194. Case #676
52 year male with chondrosarcoma rib

195. rib
tumor
Macro section of resected specimen

196. Photomic

197. Case #676.1
38 year male
chondrosarcoma
L-1 with block on
myelogram

198. CT scan

199. Photomic

200. Case #676.2
74 yr male with low grade chondrosarcoma LD spine 2 yrs

201. CT scan

202. Sag T-1 Sag T-2 Sag Gad

203. Axial T-1 Axial T-2 Axial Gad

204. Case #676.3 Chondrosarcoma L-3
48 year old male with low back pain for 1 year

205. Bone scan

206. Axial T-1 T-2

207. Sag T-2

208. Case #677
46 year male with chondrosarcoma mandible

209. Photomic

210. Case #678
39 year male
chondrosarcoma
mandible

211. Secondary
Peripheral
Chondrosarcoma

212. 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.

213. CLASSIC Case #126
exostosis
tumor
56 year male with 2ndary peripheral chondrosarcoma ilium

214. Coronal T-2 MRI
tumor

215. ilium
Resected specimen cut in path lab

216. ilium
Macro section

217. Low power photomic

218. Higher power with ditto forms

219. Case #679
60 year female with chondrosarcoma pubic area

220. tumor
Gross resection specimen

221. tumor
pubic bone
Gross specimen cut in path lab

222. tumor
pubic bone
Macro section

223. pubic bone
Close up macro section

224. Photomic

225. Post op x-ray

226. Case #680
exostosis
31 year male
chondrosarcoma tumor
ilium in multiple
exostosis patient

227. exostosis
tumor
Axial proton density MRI

228. Axial T-2 MRI
tumor

229. tumor
Axial T-2 MRI

230. Photomic

231. X-ray of knees with multi exostoses

232. Case #681
18 year female
chondrosarcoma
pelvis and multi
hereditary exostoses

233. Oblique view

234. CT scan

235. tumor
Bone scan

236. tumor
Resected specimen

237. Macro section

238. Photomic

239. Multi exostoses knee

240. Lateral view

241. Several years after type I resection

242. Case #682
38 year female with osteochondroma C-spine

243. CT scan

244. Surgical photo at at same time

245. cap
Surgical specimen cut in path lab

246. Recurrence 3 years
later

247. Recurrence CT scan

248. Coronal T-1 MRI
of recurrence and
chondrosarcoma
tumor

249. Chondrosarcoma photomic

250. Case #683
42 year female with 2ndary chondrosarcoma ilium

251. CT scan

252. tumor
Coronal T-1 MRI

253. tumor
Axial T-1 MRI

254. tumor
Axial T-2 MRI

255. Case #684
33 year male
2ndary chondrosarcoma
os calcis

256. Lateral view

257. CT scan

258. chondrosarc
Soft tissue CT scan
exostosis

259. tumor
Coronal proton density MRI

260. tumor
Coronal T-2 MRI

261. Surgical specimen cut in path lab

262. Photomic

263. Case #685
30 year male with multi exostoses & chondrosarcoma
chest wall

264. Case #686
42 year male with 2ndary chondrosarcoma

265. chondrosarc
bone stock
Macro section

266. Case #686A
42 year male with peripheral chondrosarcoma ulna

267. Dedifferentiated
Chondrosarcoma

268. 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.

269. 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.

270. CLASSIC
Case #127
44 year male
dedifferentiated
chondrosarcoma
proximal femur

271. 2 years later with
increased size

272. Coronal T-1 MRI
tumor

273. tumor
Axial T-2 MRI

274. Photomic at juncture of high and low grade tumor

275. Low grade chondrosarcoma portion

276. osteoid
High grade OGS portion

277. Case #127.1 Dedifferentiated chondrosarc
63 yr male with recent
hip fracture

278. Bone scan

279. Cor T-1

280. Sag T-1 STIR

281. Axial PD
Axial PD

282. Surgical resection

283. Rconstruction completed

284. Post op X-ray

285. Case #687
high
grade
73 year female
dedifferentiated
chondrosarcoma
distal femur
low
grade

286. high grade
Lateral view
low grade

287. Bone scan

288. high
Coronal T-1 MRI
low

289. high grade
low grade
Resected distal femur cut in path lab

290. Photomic showing low grade left & high grade right

291. Low grade chondrosarcoma

292. osteoid
High grade OGS

293. Post op x-ray with
prosthetic recon

294. Case #688
33 year female
dedifferentiated
chondrosarcoma
distal femur

295. 400 lbs pressure
Reconstruction with Compress system after wide resection

296. Completion of rotating hinge arthroplasty

297. Immediate post op x-ray

298. X-ray at 2 months showing
early callous formation

299. anchor
plug
Early osseointegration
at 5 months
spindle

300. X-ray at one year

301. Stable osseointegration
at 5 years with no signs
of stress shielding
AP view

302. anterior
cortex
Lateral view

303. 10 years post op

304. 14 years post op

305. Case #688.1 Dedifferentiated chondrosarcoma
89 year male with mild knee pain 3 months

306. Coronal T-1 T-2 Sagittal T-2

307. Axial
T-1 T-2
Gad

308. Immediate Post Op x-rays

309. Case #689
42 year female
dedifferentiated
chondrosarcoma
pelvis

310. Bone scan

311. Sagittal T-1 MRI
tumor
post column
acetabulum

312. Axial T-1 MRI

313. tumor
Coronal T-2 MRI

314. Low power photomic

315. Low grade chondrosarcoma

316. High grade portion

317. recon plate
Internal hemipelvectomy reconstruction

318. Post op x-ray

319. Case #689.1
42 year male with right hip pain for 3 months

320. Bone scan

321. CT scan

322. Cor T-1 STIR
Gad Gad

323. Axial T-1 T-2
T-2 Gad

324. Clear Cell
Chondrosacoma

325. 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-

326. 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.

327. CLASSIC Case #128
25 year male with clear cell chondrosarcoma femoral head

328. Low power photomic

329. Higher power showing clear cells

330. Case #690
51 year male with clear cell chondrosarcoma femoral head

331. Frog leg lateral

332. Post op x-ray following
head & neck resection
and total hip replacement

333. Case #690.1 Clear cell chondrosarcoma
Post reduction
Acute pathologic fracture left shoulder in 43 yr female

334. CT scan

335. Cementation PO

336. Case #690.1
20 year female with clear cell chondrosarc prox tibia

337. Lateral view

338. tumor
Coronal T-1 MRI

339. Sagittal T-1 MRI
tumor

340. Mesenchymal
Chondrosarcoma

341. 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.

342. CLASSIC
Case #129
34 year female
mesenchymal
chondrosarcoma tumor
LD spine & paraplegia
Sagittal MRI

343. Photomic showing low grade chondroid portion

344. High grade round cell portion of tumor

345. Case #691
tumor
36 year male with mesenchymal chondrosarc humeral head

346. CT scan

347. Post op x-ray
following humeral
head resection and
prosthetic recon

348. Cartilagenous
Pseudotumors

349. Case #692 Pseudotumor
8 year female with multi focal TBc looking like Ollier’s

350. Geographic lesions in both elbows

351. Langhans giant cell
Photomic showing tuberculous granuloma

352. Case #693
10 year child
TBc granuloma
proximal tibia looking
like chondroblastoma

353. Case #694
hip
54 year female with tumoral calcinosis looking like chondrsarc

354. Sagittal T-1 MRI

355. Axial T-1 MRI

356. Amorphous calcium
phosphate flowing
from biopsy site

357. Resected specimen cut in path lab

358. Photomic showing heavy calcifcation

359. Case #695
64 yr male with giant bone island looking like chondrosarc

360. CT scan

361. Case #696 AP x-ray hip
55 yr female with geode(DOA) looking like chondrosarc

362. Axial CT scan

363. Sagittal CT scan

364. Bone scan

365. Coronal T-1 MRI

366. Axial proton density MRI

367. Axial T-2 MRI

368. Case #697
52 yr female with bone infarct looking like enchondroma

369. Sagittal T-1 MRI
knee joint

370. Case #697.1 Sag & Cor T-1 Bone infarcts
74 yr female with tender lump mid pretibial area for 1 year

371. Cor T-2
Gad
Gad

372. Axial T-1
T-2

373. Axial T-2

374. Case #698
45 yr female with epiphyseal infarct looking like
chondroblastoma

375. Case #699
77 year female
rheumatoid arthritis
shoulder looking like
chondrosarcoma
proximal humerus

376. AP x-ray shoulder

377. Bone scan

378. CT scan

379. Another CT cut

380. Axial T-1 MRI

381. Axial T-1 MRI

382. Sagittal T-2 MRI

383. Coronal T-2 MRI

384. Resected proximal
humerus specimen