Cartilage Tumors

Benign and Malignant Benign and Malignant Tumors Tumors

ofofCartilaginous OriginCartilaginous Origin

C.Pierre-Jerome,M.D.PhDC.Pierre-Jerome,M.D.PhD

General ApproachGeneral Approach Patient:Patient: Age / Gender Age / Gender Clinical History:Clinical History: Painful Solitaire Multiple Painful Solitaire Multiple Slow or Fast Growing Slow or Fast Growing History of trauma? History of trauma?

General ApproachGeneral Approach

Radiologically: L.E.D.SRadiologically: L.E.D.S LocationLocation: Epi Meta Diaphysis : Epi Meta Diaphysis Medullary or CorticalMedullary or Cortical ExtensionExtension: To Soft Tissues: To Soft Tissues DensityDensity: Lytic /Blastic/ Mixte : Lytic /Blastic/ Mixte /Ca+ /Ca+ Solitaire or MultipleSolitaire or Multiple MRI MRI Contrast Enhancement (?)Contrast Enhancement (?)

ClassificationClassification BENIGNBENIGN 1.1. EnchondromaEnchondroma 2. Osteochondroma2. Osteochondroma 3. Chondroblastoma3. Chondroblastoma 4. ChondroMyxoid Fibroma 4. ChondroMyxoid Fibroma

(CMF)(CMF) 5. PeriOsteal Chondroma5. PeriOsteal Chondroma

ClassificationClassificationMalignant Malignant ChondrosarcomasChondrosarcomas

1. Primary (de novo)1. Primary (de novo) 2. Secondary2. Secondary

1. Enchondroma1. Enchondroma General Features:General Features: Benign Intramedullary TuBenign Intramedullary Tu. of . of

hyaline cartilagehyaline cartilage 10% of all Benign Bone Tumors10% of all Benign Bone Tumors Solitaire LesionSolitaire Lesion Multiple (enchondromatosis) Multiple (enchondromatosis)

is is rarerare

1. Enchondroma1. EnchondromaClinical FeaturesClinical Features In Children and young AdultsIn Children and young Adults 60% between ages of 15 – 40 y.60% between ages of 15 – 40 y. Males = FemalesMales = Females Usually Asymptomatic Usually Asymptomatic

(incidental finding) (incidental finding)

1. Enchondroma1. Enchondroma Clinical FeaturesClinical FeaturesIt becomesIt becomes Painful: Painful: - Pathological fracture- Pathological fracture - - Malignant DegenerationMalignant Degeneration Radiol. Radiol. GrowthGrowth / Cortical / Cortical DisruptionDisruption Loss of marginal definitionLoss of marginal definition Local periosteal reactionLocal periosteal reaction

EnchondromasEnchondromasEnchondromas Enchondromas

a. a. In short bonesIn short bones (lytic) (lytic) metacarpals, phalanges metacarpals, phalanges

b. b. In long bonesIn long bones (+calcifications) (+calcifications) metaphysis….humerus,femur,tibia metaphysis….humerus,femur,tibia

1. Enchondroma1. Enchondroma Sites: Short bonesSites: Short bonesAbout About 50% in Hands50% in Hands and and FeetFeet phalangesphalanges metacarpalsmetacarpals metatarsalsmetatarsals

1. Enchondroma1. Enchondroma Radiographic FINDINGS:Radiographic FINDINGS: Radiolucent, intramedullaryRadiolucent, intramedullaryShort bone ……DiaphysisShort bone ……DiaphysisMayMay expand the bone (phalanges) expand the bone (phalanges) Thinning of Cortex….Fracture? Thinning of Cortex….Fracture?

T2W image + Fat sat

T1W + Contrast

EnchondromasEnchondromas

In long bones (+ calcifications):In long bones (+ calcifications): MetaphysisMetaphysis Humerus Humerus (proximal)(proximal) FemurFemur (proximal or distal) (proximal or distal) Tibia, fibula Tibia, fibula Also in: Also in: Pelvis, Vertebrae, Ribs (rare)Pelvis, Vertebrae, Ribs (rare)

1. Enchondroma1. Enchondroma Radiographic FINDINGS:Radiographic FINDINGS:In long tubular bones….In long tubular bones….MetaphysisMetaphysis Do not expand the boneDo not expand the bone Little (or no) cortical erosion Little (or no) cortical erosion

Presence of Ca+ Presence of Ca+ in the matrixin the matrix

1. Enchondroma1. Enchondroma MRIMRI Lobulated Lobulated intramedullaryintramedullary lesion lesionLow signal ----T1W Low signal ----T1W High signal----T2W /with Fat SatHigh signal----T2W /with Fat SatScattered areas of low signal---Ca+Scattered areas of low signal---Ca+ Contrast---Enhances(heterogeneously)Contrast---Enhances(heterogeneously)

DYNAMIC STUDY

1. Enchondroma1. Enchondroma Treatment / PrognosisTreatment / Prognosis Most are treated by Most are treated by CurettageCurettage with of without Bone Graftingwith of without Bone Grafting

Recurrence rate is Recurrence rate is less than 5%less than 5%

1. Enchondroma1. Enchondroma EnchondromatosisEnchondromatosis (Multiple) (Multiple) 1. 1. Ollier’s DiseaseOllier’s Disease Rare, Nonhereditary disorderRare, Nonhereditary disorder Usually in ExtremitiesUsually in Extremities Unilateral – shortening- deformityUnilateral – shortening- deformity 30-50% develop Sarcoma30-50% develop Sarcoma

1. Enchondroma1. Enchondroma EnchondromatosisEnchondromatosis (Multiple) (Multiple)2. Mafucci Syndrome2. Mafucci Syndrome Rare, Nonhereditary, congenitalRare, Nonhereditary, congenital Presence of Presence of HemangiomasHemangiomas Cavernous, Uni/bilateralCavernous, Uni/bilateral Presence of Phleboliths (X-Rays)Presence of Phleboliths (X-Rays) May developMay develop Malignancy Malignancy

ClassificationClassificationBENIGNBENIGN 1.1. EnchondromaEnchondroma

2. 2. OsteochondromaOsteochondroma3. 3. ChondroblastomaChondroblastoma 4. 4. ChondroMyxoid Fibroma (CMF)ChondroMyxoid Fibroma (CMF) 5. PeriOsteal Chondroma5. PeriOsteal Chondroma

2. Osteochondroma2. Osteochondroma General Features:General Features: Also called Also called ExostosisExostosisBony protuberance Bony protuberance with cortical and with cortical and

medullary continuity / cartilage cap.medullary continuity / cartilage cap.

It It arises in childhoodarises in childhood and continues to grow and continues to grow until fusion of the closest epiphyseal lineuntil fusion of the closest epiphyseal line

2. Osteochondroma2. Osteochondroma Clinical Features:Clinical Features: Males twice as FemalesMales twice as Females Presence of Mass of long durationPresence of Mass of long duration AsymptomaticAsymptomaticBecomes SymptomaticBecomes Symptomatic::

By compression of nervesBy compression of nerves Interfers with Joint FunctionInterfers with Joint Function Malignant DegenerationMalignant Degeneration

2. Osteochondroma2. Osteochondroma Clinical Features:Clinical Features: Rapid Growth Rapid Growth Development of Localized PainDevelopment of Localized Pain suggest suggest Malignant DegenerationMalignant Degeneration “ “MRI recommended” MRI recommended” to see the cartilage capto see the cartilage cap

2. Osteochondroma2. Osteochondroma RadiographicRadiographic Findings: Findings:MRIMRICartilage Cap:Cartilage Cap: 1 cm or less ----Benign Lesion1 cm or less ----Benign Lesion 2 cm or more---Suspicion of 2 cm or more---Suspicion of

Malignant Malignant DegenerationDegeneration

2. Osteochondroma2. Osteochondroma RadiographicRadiographic Findings: Findings: MRI --MRI -- Low to Intermediate-----T1WLow to Intermediate-----T1W Intermediate to High-----T2W Intermediate to High-----T2W

and Fat Sat imagesand Fat Sat imagesThe periphery of the lesion is The periphery of the lesion is

covered bycovered by Hyaline Cartilage cap Hyaline Cartilage cap

2. Osteochondroma2. Osteochondroma RadiographicRadiographic Findings: Findings: In the metaphysis of long bones.In the metaphysis of long bones. Points away from the nearby Points away from the nearby

articulationarticulation Most in---lower Femur Most in---lower Femur ---upper Humerus, Tibia ---upper Humerus, Tibia

2. Osteochondroma2. Osteochondroma OsteochondromatosisOsteochondromatosis (Multiple) (Multiple) A familial disorder, Autosomal A familial disorder, Autosomal

dominant.dominant. Males/Females ratio= 7 to 3Males/Females ratio= 7 to 3Deformity of forearm,wrist,knee… Deformity of forearm,wrist,knee… 5-25% develop Malignancies5-25% develop Malignancies

ClassificationClassificationBENIGNBENIGN 1. 1. EnchondromaEnchondroma

22. . OsteochondromaOsteochondroma

3. Chondroblastoma3. Chondroblastoma 4. ChondroMyxoid Fibroma 4. ChondroMyxoid Fibroma

(CMF)(CMF) 5. PeriOsteal Chondroma5. PeriOsteal Chondroma

3. Chondroblastoma3. Chondroblastoma General / Clinical Features:General / Clinical Features: Benign Cartilaginous TumorBenign Cartilaginous Tumor Age between Age between 5 and 25 years5 and 25 years most cases most cases in teenagersin teenagers Slight Slight Male PredominanceMale Predominance

3. Chondroblastoma3. Chondroblastoma General / Clinical Features:General / Clinical Features: Pain – most common symptomPain – most common symptom (several months or years)(several months or years) 1/3 Patients have have:1/3 Patients have have: Joint effusion, swelling, Joint effusion, swelling, limitation of motionlimitation of motion

3. Chondroblastoma3. Chondroblastoma RadiographicRadiographic FINDINGS: FINDINGS: 98% located in Epiphysis or 98% located in Epiphysis or Apophysis Apophysis

of a long boneof a long bone OsteolyticOsteolytic, well-defined, well-defined Ca+ in less than 50% of casesCa+ in less than 50% of cases

Sites: Sites: distal femur, proximal tibia, proximal distal femur, proximal tibia, proximal humerus humerus

3. Chondroblastoma3. Chondroblastoma RadiographicRadiographic FINDINGS: FINDINGS:MRI:MRI:Low signal------T1WLow signal------T1WIntermediate signal---T2W/fat satIntermediate signal---T2W/fat sat Hyaline cartilage + Hemorrage-Hyaline cartilage + Hemorrage- High signal-------T2WHigh signal-------T2W

3. Chondroblastoma3. Chondroblastoma RadiographicRadiographic FINDINGS: FINDINGS:MRIMRI** Periosteal Thickening** Periosteal Thickening Bone Marrow EdemaBone Marrow Edema Adjacent Soft Tissue EdemaAdjacent Soft Tissue Edema Scattered Ca+ Scattered Ca+

Chondroblastoma

in

Humeral Head

3. Chondroblastoma3. Chondroblastoma Treatment and Prognosis:Treatment and Prognosis: 90% 90% of Chondroblastomas are of Chondroblastomas are

treated by treated by curettage curettage and and bone chip bone chip grafting.grafting.

Recurrences may develop within 3 Recurrences may develop within 3 years---years---

99% of99% of them are cured by a second them are cured by a second CurettageCurettage

ClassificationClassificationBENIGNBENIGN

11.. EnchondromaEnchondroma 2. Osteochondroma2. Osteochondroma 3. Chondroblastoma3. Chondroblastoma

4. ChondroMyxoid Fibroma 4. ChondroMyxoid Fibroma (CMF)(CMF)

5. PeriOsteal Chondroma5. PeriOsteal Chondroma

4. 4. ChondroMyxoidFibromaChondroMyxoidFibroma General / Clinical Features:General / Clinical Features: Least commonLeast common Diagnosed in 2d. and 3Diagnosed in 2d. and 3rdrd decade decade Male predominace 2:1Male predominace 2:1Predilection for Metaphysis of long Predilection for Metaphysis of long

Tubular BonesTubular Bones

ChondroMyxoidFibromaChondroMyxoidFibroma General / Clinical Features:General / Clinical Features: 25%25% in flat bones, in flat bones, mainly Iliummainly Ilium PainPain is the presenting symptom is the presenting symptom15% of cases are incidental 15% of cases are incidental

radiographic findingsradiographic findings

ChondroMyxoidFibromaChondroMyxoidFibroma RadiographicRadiographic FINDINGS: FINDINGS: Eccentric Metaphyseal Eccentric Metaphyseal Lesion Lesion

with with Cortical ExpansionCortical ExpansionCoarse TrabeculationCoarse TrabeculationEndosteal ScallopingEndosteal Scalloping/ Sclerosis/ Sclerosis

ChondroMyxoidFibromaChondroMyxoidFibroma RadiographicRadiographic FINDINGS: FINDINGS: MRIMRILow to Intermediate signal---Low to Intermediate signal---T1WT1WIntermediate to High signal---Intermediate to High signal--- T2W /Fat satT2W /Fat sat ContrastContrast:Inhomogeneous :Inhomogeneous

enhancement enhancement

ClassificationClassification

BENIGNBENIGN 1. 1. EnchondromaEnchondroma 2. Osteochondroma2. Osteochondroma 3. Chondroblastoma3. Chondroblastoma 4. ChondroMyxoid Fibroma (CMF)4. ChondroMyxoid Fibroma (CMF)

5. PeriOsteal Chondroma5. PeriOsteal Chondroma

5. PeriOsteal Chondroma5. PeriOsteal Chondroma

General / Clinical Features:General / Clinical Features: UncommonUncommon All ages are affectedAll ages are affected Usually diagnosed Usually diagnosed under age 30under age 30 Slight Male predominanceSlight Male predominance Mild PainMild Pain (1-5 years) (1-5 years)

5. PeriOsteal Chondroma5. PeriOsteal Chondroma

RadiographicRadiographic FINDINGS: FINDINGS: At Metaphysis At Metaphysis of long Bones and of long Bones and

HandsHands Soft tissue Mass Soft tissue Mass Erosion of Adjacent CortexErosion of Adjacent Cortex Periosteal reaction Periosteal reaction

5. PeriOsteal Chondroma5. PeriOsteal Chondroma RadiographicRadiographic FINDINGS: FINDINGS: MRIMRI Low signal -----T1WLow signal -----T1W High signal -----T2WHigh signal -----T2W Ca+ ----intratumoralCa+ ----intratumoral

Contrast:Contrast: Peripheral Enhancement Peripheral Enhancement TypicalTypical

ClassificationClassification BenignBenign

Malignant Malignant ChondrosarcomasChondrosarcomas 1. Primary (de novo)1. Primary (de novo) 2. Secondary2. Secondary

ChondrosarcomasChondrosarcomas Second most commonSecond most common primary primary

sarcoma of bone sarcoma of bone Males + often than Females Males + often than Females

(2:1)(2:1)Peak age: 5Peak age: 5thth – 7 – 7thth decades (I) decades (I) 44thth – 5 – 5thth ‘’ (II) ‘’ (II)

ChondrosarcomasChondrosarcomas

Occur in the Occur in the diaphysisdiaphysis or or metaphysis metaphysis

Calcifications Calcifications with ring-like with ring-like patternpattern

Ill-defined borders Ill-defined borders

ChondrosarcomasChondrosarcomas Location within the bone: Location within the bone: Central, Peripheral, Central, Peripheral,

Juxtacortical (periosteal)Juxtacortical (periosteal) Sites:Sites: Pelvic bonesPelvic bones prox. femurprox. femur prox. humerus Scapula, Ribs prox. humerus Scapula, Ribs

ConclusionsConclusions 11. Benign. Benign:: Enchondromas….complicationsEnchondromas….complications Osteochondromas….Osteochondromas…. cartilage cap > 3cm(?)cartilage cap > 3cm(?) 2. 2. MalignantMalignant Primary or Secondary Primary or Secondary 3. 3. MRI indicationsMRI indications (contrast,cap,fracture) (contrast,cap,fracture) 4. Skip lesion (s) on MR images4. Skip lesion (s) on MR images

ConclusionsConclusions

Good LookGood Look at the imagesat the images

andand

Good Luck !!!Good Luck !!!

HAPPY NEW YEAR HAPPY NEW YEAR

2007 2007

Enchondroma