http://upload.orthobullets.com/topic/8019/images/Case F - prox tibia - xray - Parsons_moved.png
http://upload.orthobullets.com/topic/8019/images/Case F - prox tibia - CT - Parsons_moved.png
http://upload.orthobullets.com/topic/8019/images/Histology A_moved.png
http://upload.orthobullets.com/topic/8019/images/Histology C_moved.jpg
http://upload.orthobullets.com/topic/8019/images/Case A - prox humerus - xray - Parsons_moved.png
http://upload.orthobullets.com/topic/8019/images/Case B - prox humerus - xray - Parsons_moved.png
Introduction
  • A rare type of chondroma (benign chondrogenic lesion) which occur on surface of long bones  
  • Epidemiology
    • demographics
      • occur in 10-20 year-olds
    • locationsurface of long bones (under periosteum) in distal femur, proximal humerus, and proximal femur
      • 59% of lesions in proximal humerus
      • other locations in the hand (metacarpal or phalanges)
Presentation
  • Symptoms
    • many are painful secondary to irritation of tendons
Imaging
  • Radiographs
    • well-demarcated, shallow cortical defect
    • punctate mineralization (calcification) in 1/3.
    • saucerization of underlying bone 
    • radiographs important to differentiate from chondrosarcoma (histology may be similar)
Studies
  • Histology
    • similar to enchondroma except for increased cellularity and more malignant looking cells (can look like chondrosarcoma)
      • bland hyaline cartilage 
      • small chondroid cells in lacunar spaces 
Treatment
  • Operative
    • marginal excision including underlying cortex
      • indications
        • severe symptoms interferring with function
      • technique
      • lesion will recur if cartilage is left behind
      • bone graft any large defects
Differentials & Groups
 
Surface Lesion
 
May have similar chondrogenic histology
 
Treated with marginl excison (2)
   
Periosteal chondroma
 
 
   
Osteochondroma / MHE
           
Parosteal osteosarcoma
           
Periosteal osteosarcoma
           
Enchondroma / Olliers / Marfuccis    
       
Osteochondroma (MHE)    
       
Chondrosarcoma    
       
Neurilemoma (soft tissue)        
   
Nodular fasciitis (soft tissue)        
   
Epidermal inclusion cyst        
   
Glomus tumor        
   
 ASSUMPTIONS: (2) assuming no impending fracture
 
IBank
  Location
Xray
Xray
CT
Bone scan
MRI
MRI
Case A prox. humerus          
Case B prox. humerus      
Case C prox. humerus          
Case D wrist        
Case E prox. tibia        
 

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Questions (1)

(OBQ08.173) A 19-year-old male presents with 2 months of night pain in the right shoulder. A radiograph is shown in Figure A and axial CT scan images are found in Figure B and C. A needle biopsy is performed and the representative histology slide is shown in Figure D. What is the most appropriate treatment for this tumor? Review Topic

QID:559
FIGURES:
1

Observation with serial radiographs

10%

(66/678)

2

Irradiation treatment course with maximum dosage of 60 grays

2%

(12/678)

3

Marginal excision including the underlying cortex

31%

(210/678)

4

Wide surgical excision

30%

(204/678)

5

Neoadjuvant chemotherapy, surgical excision, followed by adjuvant chemotherapy

27%

(182/678)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

This case is an example of periosteal chondroma which is a rare benign surface lesion composed of cartilage. It can be similar in appearance and location to malignancies such as periosteal osteosarcoma or periosteal chondrosarcoma, so refining a differential diagnosis is important.

Figure A shows an eccentric, longitudinally oriented periosteal mass with an outer, sclerotic shell of reactive periosteum. Pressure from growth of the lesion may create a saucer shaped or complex shaped defect in the underlying bone. Periosteal chondromas can look similar to osteochondromas but they do not have a stalk or peduncle and myositis ossificans rarely involves the cortex like periosteal chondromas do.

Figures B and C show axial CT images illustrating the tumor extension from the underlying cortex.

Figure D shows a medium power histology of a periosteal chondroma displaying chondroid matrix with multiple chondrocytes in lacunae. Treatment of periosteal chondromas includes marginal excision including the underlying cortex.

The level 4 review by Lewis et al. presents a literature review and 10 cases of periosteal chondroma. They reported that all were treated by marginal or intralesional excision and there were no recurrences found.

Incorrect answers:
#1:Observation with serial radiographs is reserved for tumors such as osteochondroma or enchondroma.
#2: Irradiation treatment is not indicated for periosteal chondroma. Irradiation treatment is used more often as an option for Ewing sarcoma, primary lymphoma, or as an adjuvant to surgical excision of soft tissue sarcomas. Additionally it should be noted that the stated maximum dosage of 60 grays is relevant as irradiation beyond this would likely lead to soft tissue not healing.
#4:Wide surgical excision is reserved for malignancy such as chondrosarcoma, parosteal osteosarcoma, chordoma, and adamantinoma.
#5:Neoadjuvant chemotherapy, surgical excision, followed by adjuvant chemotherapy is appropriate treatment for intramedullary osteosarcoma, periosteal osteosarcoma, Ewing sarcoma, fibrosarcoma, rhabdomyosarcoma, and dedifferentiated chondrosarcoma.


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