Cancer, Chondroblastoma


Article Author:
Faten Limaiem


Article Editor:
Prashanth Rawla


Editors In Chief:
William Gossman
Manu Rathee


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/2/2019 2:41:15 PM

Introduction

Chondroblastoma is a benign, chondroid-producing neoplasm composed of chondroblasts. It accounts for less than 1% of all bone tumors and usually arises in the epiphyses or apophysis of skeletally immature patients.[1] The treatment of choice of chondroblastoma is surgical. In general, chondroblastoma has a good prognosis, and patients often experience full resolution after surgical treatment.

Etiology

The exact etiology of chondroblastoma is still unknown, and so are the predisposing factors.

Epidemiology

Chondroblastoma is a rare benign neoplasm, accounting for less than 1% of all primary bone tumors. Most chondroblastomas are diagnosed in the second to third decade of life (mean age, 19 to 23 years) with a male predominance (2 to 1).[1] More than 75% of cases involve the long bones; the most common anatomical sites are the epiphyseal regions of the proximal and distal femur, proximal tibia and proximal humerus.[2][3] Rarely they can be encountered in flat bones as well as in the bones of the hands and feet.[4] Chondroblastomas almost invariably involve a single bone.

Pathophysiology

Histogenesis:

The histogenesis of chondroblastomas remains controversial. However, cartilage germ cells or epiphyseal cartilage cells are presumed to be the cell of origin.[4] 

Genetics:

Flow cytometric studies reveal that most chondroblastomas are diploid with low proliferation fractions.[5][6] There are reports of clonal abnormalities in 14 chondroblastomas.[7]  Heterogeneous rearrangements of chromosomes 5 and 8 both balanced and unbalanced, appear to be the most common. IDH1 and IDH2 mutations are absent.[8] Recently, research has shown that chondroblastomas have distinctive driver mutations in the genes that encode histone H3.3. Chondroblastomas harbor mutations in the H3F3B gene far more commonly than the H3F3A gene.[9] An antibody directed against the H3F3 K36M mutation has been found to be specific for chondroblastoma.[10]

Histopathology

Macroscopic findings:

Grossly, chondroblastomas appear as multiple pinkish-tan soft tissue fragments which may exhibit areas of calcification, hemorrhage or cystic changes.

Histopathological findings:

Histologically, a chondroblastoma characteristically presents with a sheet-like proliferation of small to intermediate-sized round polygonal cells.[1] These cells have well-defined cytoplasmic borders, clear to slightly basophilic cytoplasm and a round to ovoid nucleus (chondroblasts). They often exhibit longitudinal grooves and one or more small or inconspicuous nucleoli. Randomly distributed osteoclast-type giant cells are almost always present. Variably-sized nodules of amorphous to eosinophilic material (chondroid) accompany the chondroblasts. Mature hyaline cartilage is relatively uncommon. A fine network of pericellular ''chicken wire'' calcifications is characteristic. Recurrent chondroblastomas may show cytological atypia which should not be interpreted as a sign of malignant transformation.

Immunohistochemical findings:

Immunohistochemically, the chondroblasts are positive for vimentin, neuron-specific enolase, and S100 protein.[1] Sox9 is a transcriptional factor that shows positivity in chondroblastomas.[11] DOG1 is a useful marker which helps to distinguish chondroblastoma from other giant cell-containing bone tumors.[12] Observable positivity for keratins, namely 8, 18 and 19 and p63, is frequently in evidence.[13]

History and Physical

Clinical complaints are often nonspecific.[14] Symptoms are typically present for many months before the patient seeks medical attention. They include[3]:

  • Insidious onset of bone pain: the most common
  • Other nonspecific complaints: local swelling, joint stiffness and/or effusion, and the development of a limp
  • In tumors arising from the skull bones: seizures and progressive hearing loss can also occur

Physical examination of patients with chondroblastoma can disclose the following findings[1]:

  • Local tenderness
  • Joint effusion
  • Decreased range of motion in the affected joint
  • Muscular atrophy
  • Rarely: a palpable mass

Evaluation

Several imaging modalities are available for establishing the diagnosis of chondroblastoma. They include:

  • Plain radiographs
  • Computed tomography (CT)
  • and Magnetic resonance imaging (MRI)

A well-demarcated eccentric and lytic lesion with a thin rim of sclerotic bone is the typical radiologic presentation of chondroblastomas. Chondroblastomas are relatively small (3 to 6 cm) and occupy less than half of the epiphysis. There is generally no expansion of the bone.

Plain radiographs:

Plain radiographs show a fuzzy, round-to-oval, well-delineated lesion, with a sclerotic rim.[15]

Computed tomography :

Computed tomography can demonstrate calcifications that are not detectable on plain radiographs. It can depict cortical erosion, matrix mineralization, and soft tissue extension.[16]

Magnetic resonance imaging:

In chondroblastomas, MRI  demonstrates extensive edema surrounding the lesion. The signal intensity on T1- and T2-weighted MRI images depends on the amounts of various components within the lesion. Most cases show variable intensity on T2-weighted images.[17]

Treatment / Management

The treatment of choice of chondroblastoma is surgical. It consists in complete surgical curettage with or without bone grafting, en bloc resection, or rarely, amputation. Surgical resection alleviates pain, avoids the propagation into the joint and adjacent soft tissues, diminishes the likelihood of recurrence and accurately establishes the diagnosis of chondroblastomas.  Surgical management depends on[18][19]:

  • Extent of bone and/or joint involvement
  • Anatomic location of the lesion
  • Staging

In stage1 (latent) or stage 2 (active), intralesional excision may be indicated, associated with local adjuvants.

In stage 3 (aggressive) is an indication for marginal or wide resection.[19]

Adjunctive therapy that can be used includes chemical cauterization with phenol or cryosurgery. Bone grafting and cryotherapy after surgical curettage decrease the risk of recurrence.[1] Some authors suggest that radiofrequency should be an option as an alternative treatment method in the management of chondroblastomas.[4] There is no definite role for adjuvant chemotherapy or radiotherapy. For recurrent tumors, resection remains the treatment of choice.[1]

Differential Diagnosis

  • Giant cell tumor of bone
  • Chondromyxoid fibroma
  • Aneurysmal bone cyst
  • Clear cell chondrosarcoma
  • Chondroblastoma-like variant of osteosarcoma

Toxicity and Side Effect Management

The complications of surgical treatment include[4]:

  • Damage of the articular cartilage or even an open growth plate 
  • Recurrence in surgically treated patients 
  • Hematoma
  • Infection
  • Fracture
  • Limb-length discrepancy

Prognosis

If left untreated, chondroblastoma does not undergo spontaneous regression.  Recurrence rates of chondroblastomas range from 8.3% to 21.4% and may be explained by the retention of tumor material during surgery.[20][21] The risk of recurrence increases in case of inadequate surgery, location in the hip and pelvis, young age and aneurysmal bone cyst components.[22] Rarely, pulmonary metastases occur from histologically benign chondroblastomas. However, these metastases are clinically nonprogressive and treatable by surgical resection or simple observation.[23] Malignant transformation of a chondroblastoma is extremely rare. There are no reliable histological parameters capable of predicting more aggressive behavior.

Complications

The most common complication associated with chondroblastoma is local recurrence after surgery. Patients require long term monitoring post surgery for any recurrence of the tumor.[24][21] Pathological fractures can also occur. Rarely, malignant transformation may take place as documented in few case reports.[25][26]

Consultations

Orthopedics

Oncology

Deterrence and Patient Education

Chondroblastoma is mostly a benign bone tumor, and patients and their families need education on how to recognize the early signs and symptom of bone tumors. Patients with signs of bone pain, swelling of bones or joints, any palpable mass found on the bones, fractures not associated with trauma should seek early intervention. Treatment for chondroblastoma is predominantly surgical. Prognosis is usually good once treated. Local recurrence can occur after surgery, and rarely malignant transformation has been reported in few cases. Long term follow-up is recommended to monitor these patients closely.

Enhancing Healthcare Team Outcomes

Chondroblastoma is ideally managed by a multidisciplinary team that consists of orthopedists, radiologists, and pathologists. Correlation between gross, radiographic and microscopic features of the lesion is crucial to establish the definitive diagnosis of chondroblastoma. Postoperatively, patients require long term follow-up due to the possibility of tumor recurrence.


  • Image 8468 Not availableImage 8468 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Cancer, Chondroblastoma - Questions

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A 17-year-old male patient presented with a 5-month history of left thigh pain. He reported that he was occasionally awakened at night by the pain and that it worsened with activity. Physical examination was remarkable for pain upon palpation of the proximal left medial thigh with soft tissue swelling. X-rays demonstrated an eccentric osteolytic lesion with a sclerotic margin in the distal diaphysis of the left femur. The patient underwent excision and curettage with allograft placement. Histological examination showed a hypercellular lesion composed of sheets of round-to-oval cells with oval nuclei and occasional nuclear grooves. Giant cells were few and scattered. There were multiple areas of chicken-wire microcalcification. What is the most likely diagnosis?



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Which of the following statements regarding chondroblastoma is true?



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Which of the following statements regarding chondroblastoma is true?



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Which of the following statements regarding chondroblastoma is false?



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A 16-year-old male patient presented with a 3-month history of right thigh pain. He reported that he was occasionally awakened at night with the pain and that the pain was worsened with activity. Physical examination was remarkable for pain upon palpation of the proximal right medial thigh with soft tissue swelling. X-rays demonstrated an eccentric osteolytic lesion with smooth margins and a thin sclerotic rim. The patient underwent an excision/curettage. Histological examination showed calcium deposition surrounding the chondroblasts, which were polyhedral in shape, resulting in typical "chicken-wire calcification." What is the best sentence which is true about this condition?



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A 16-year-old male presents with complaints of pain in his right arm. He has swelling noted to the distal part of his right arm and also has a possible mass like lesion noted in that area. Extensive workup reveals chondroblastoma. The patient undergoes curettage and grafting. The patient does not have any complications during surgery. The patient asks whether he is completely cured of this condition. What is the most common complication associated with chondroblastoma?



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A 19-year-old male presents to the clinic with complaints of pain in his right thigh. He has swelling noted to the distal part of his right thigh and also joint pain, muscle wasting, tenderness noted to the right distal thigh area. X-rays show a well-demarcated eccentric and lytic lesion with a thin rim of sclerotic bone. The patient is diagnosed with chondroblastoma on further workup. Which statement is true about this condition?



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Cancer, Chondroblastoma - References

References

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Riddell RJ,Louis CJ,Bromberger NA, Pulmonary metastases from chondroblastoma of the tibia. Report of a case. The Journal of bone and joint surgery. British volume. 1973 Nov;     [PubMed]
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Behjati S,Tarpey PS,Presneau N,Scheipl S,Pillay N,Van Loo P,Wedge DC,Cooke SL,Gundem G,Davies H,Nik-Zainal S,Martin S,McLaren S,Goodie V,Robinson B,Butler A,Teague JW,Halai D,Khatri B,Myklebost O,Baumhoer D,Jundt G,Hamoudi R,Tirabosco R,Amary MF,Futreal PA,Stratton MR,Campbell PJ,Flanagan AM, Distinct H3F3A and H3F3B driver mutations define chondroblastoma and giant cell tumor of bone. Nature genetics. 2013 Dec;     [PubMed]
Amary MF,Berisha F,Mozela R,Gibbons R,Guttridge A,O'Donnell P,Baumhoer D,Tirabosco R,Flanagan AM, The H3F3 K36M mutant antibody is a sensitive and specific marker for the diagnosis of chondroblastoma. Histopathology. 2016 Jul;     [PubMed]
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