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Review Question - QID 212986

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QID 212986 (Type "212986" in App Search)
A 59-year-old patient presents with increasing right hip pain of 8 months duration. The patient reports pain at night and during activities. The patient denies any weight loss or fevers. Figures A and B are the radiograph and MRI of the pelvis. Figure C is the biopsy of the lesion. What is the most likely diagnosis and next best step in treatment?
  • A
  • B
  • C

Osteosarcoma; chemotherapy

4%

81/2194

Malignant fibrous histiocytoma; chemotherapy

2%

51/2194

Fibrosarcoma; wide resection

2%

49/2194

Chondrosarcoma; wide resection

88%

1941/2194

Chordoma; radiation and wide resection

2%

54/2194

  • A
  • B
  • C

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The patient is presenting with chondrosarcoma of the pelvis. The best treatment option would be wide surgical resection with negative margins.

Chondrosarcomas are slow-growing malignant tumors of the bone that mostly affect the pelvis and femur. These tumors are resistant to chemotherapy and radiation due to the presence of chondroid matrix, low blood supply, and a smaller percentage of cells in the growth phase. Treatment usually consists of wide surgical resection with negative margins. In grade 1 lesions, local curettage can be curative, but this isn't recommended with pelvic involvement.

Normand et al. performed a retrospective review of eight patients that underwent curettage for grade 1 periacetabular chondrosarcoma. The authors reported a higher recurrence rate with this approach as the histologic grade was high in the curetted specimen than the fine needle aspirate. The authors recommend wide en bloc resection of pelvic chondrosarcomas regardless of fine needle aspirate histologic grade.

Lee et al. followed 227 patients diagnosed with chondrosarcoma for three to 25 years after diagnosis. The authors found that patients with pelvic lesions, grade III lesions, and local recurrence were more likely to develop metastasis or die from the disease. Further, the authors found that adjuvant chemotherapy and radiation did not demonstrate any alteration of the disease course. The authors concluded that the most important aspect of treatment is obtaining a wide negative margin.

Figure A is an AP radiograph of the pelvis depicting a lytic lesion in the right supra-acetabular region. Figure B is a T2 coronal MRI of the pelvis demonstrating a large hyperintense heterogenous mass in the right supra-acetabular innominate bone. Figure C demonstrates the histology of chondrosarcoma. Illustration A demonstrates the histology of osteosarcoma. Illustration B depicts the histology of malignant fibrous histiocytoma. Illustration C depicts the histology of fibrosarcoma. Illustration D depicts the histology of chordoma.

Incorrect answers:
Answers 1, 2, 3, 5: The histology from the biopsy depicts chondrosarcoma, which is best treated with wide surgical resection.

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