Outcome of intralesional curettage for low-grade chondrosarcoma of long bones

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Abstract

Background

Different treatment strategies for low-grade chondrosarcomas are reported in the literature with variable outcomes. The aim of this study was to assess the oncological and functional outcomes associated with intralesional curettage and cementation of the lesion as a treatment strategy.

Patients and methods

We performed a retrospective review of 39 consecutive patients with intramedullary low-grade chondrosarcoma of long bones treated by intralesional curettage and cementation at our institution between 1999 and 2005.

Results

There were 10 males and 29 females with a mean age of 55.5 years (32–82), and a mean follow-up of 5.1 years (3–8.7). Local recurrence occurred in two patients (5%) within the first two years following index surgery. Both were treated by re-curettage and cementation of the resultant defects. A second local recurrence developed a year later in one of these two patients, for which a further curettage followed by local liquid nitrogen treatment was performed. Overall, there were no cases of post-operative complications or metastases. The patients were assessed using the Musculoskeletal Tumour Society scoring system (MSTS) to determine limb function. The average score achieved was 94% (79–100%).

Conclusion

Intralesional curettage is an effective treatment strategy for low-grade intramedullary chondrosarcoma of long bones, with excellent oncological and functional results. Careful case selection with stringent clinical and radiographic follow-up is recommended.

Introduction

Chondrosarcoma is the second most commonly occurring primary malignant bone tumour, with a peak incidence between the fourth and seventh decades of life.1, 2, 3, 4, 5 These tumours were first described as a separate entity by Phemister in 1930.6 In adults, the pelvis, ribs, shoulder girdle, femur, and humerus are mainly affected, while in children, facial bones and the knee region are the main sites.7 The majority of lesions arise centrally in normal bone, uncommonly in pre-existing benign cartilaginous tumours (secondary chondrosarcoma), and rarely in synovial chondromatosis or ‘de novo’ in the synovium.1, 8, 9 They have a variable and often unpredictable outcome, ranging from slowly growing indolent lesions, to highly aggressive invasive sarcomas.10 Authors link the prognosis to tumour size, anatomical location, and most importantly, histological grade.10, 11 Five to 10 year survival rates for patients with low-grade tumours range from 85% to 100%, and from 20% to 40% for high-grade tumours.10, 11, 12, 13, 14, 15, 16, 17 The treatment of chondrosarcoma is primarily surgical because of its resistance to chemotherapy and irradiation,1, 16, 18, 19 and while there is a universal acceptance that high-grade lesions in the appendicular skeleton are best treated by wide surgical resection, the diagnosis and management of low-grade lesions remains a controversial issue.19 Firstly, distinguishing intramedullary low-grade chondrosarcoma from enchondroma is difficult, particularly on needle core biopsy because of potential sampling issues.20 Secondly, there is currently no consensus with respect to the optimal surgical treatment for these cases. Different methods reported in the literature include wide excision, marginal excision, and intralesional curettage. Some authors advocate wide excision, necessitating substantial reconstructive surgery, often requiring massive endoprostheses or allografts.21, 22 In contrast, many others believe that less extensive surgery is indicated for less aggressive lesions.5, 13, 19, 23, 24, 25 This would minimises the need for complex limb reconstruction and results in a good functional outcome. In this paper, we examine the oncological and functional outcomes of intralesional curettage and cementation as a treatment strategy.

Section snippets

Patients and methods

Between 1999 and 2005, 39 consecutive patients with histologically verified low-grade intramedullary chondrosarcoma of long bones underwent intralesional curettage and cementation of their lesion at our institution. These patients were identified using our department's histopathology database and then were retrospectively reviewed. The inclusion criteria included a definitive histological diagnosis of grade 0.5 or 1 chondrosarcoma, intramedullary lesions arising in long bones, and a minimum

Oncological outcome

One patient died at 3.5 years post-operatively of an unrelated cause (myocardial infarction). She had had a grade 1 tumour in her left proximal humerus. At her last follow-up (3 years), she was completely pain-free and had excellent shoulder function. No signs of recurrence were noted on plain radiography at the time of review. Two of the 39 patients (5%) developed local recurrence within the first two years following index surgery. The first patient was a 60-year-old female with an original

Discussion

There is currently no universally accepted operative treatment for low-grade chondrosarcoma of long bones. Intralesional curettage, either alone or combined with local adjuvant treatments, marginal resection, and en bloc resection with biologic or endoprosthetic reconstruction are all described in the literature.5, 13, 19, 21, 22, 23, 24, 25

In contrast, high-grade chondrosarcoma is almost always treated with wide excision achieved by either amputation, or resection of the tumour with limb

Conclusion

This study supports the view that intralesional curettage is an effective treatment strategy for low-grade chondrosarcoma of long bones, with excellent oncological and functional results. We propose that this treatment option is a rational alternative to more radical procedures, as it preserves function, has low morbidity, is cost effective, and does not appear to have an adverse effect on long-term outcome. Careful patient selection with stringent clinical and radiographic follow-up is crucial

Conflict of interest

The authors declare that they have no conflict of interest.

References (35)

  • P. Casali et al.

    Malignant bone tumour other than osteosarcoma and Ewing's sarcoma. Oxford text book of oncology

    (1995)
  • D.C. Dahlin et al.

    Chondrosarcoma, a surgical and pathological problem; review of 212 cases

    J Bone Joint Surg Am

    (1956)
  • J.H. Healey et al.

    Chondrosarcoma

    Clin Orthop Relat Res

    (1986)
  • K.K. Unni

    Bone tumours: general aspects and data on 11,087 cases. Dahlin's bone tumours

    (1996)
  • T. Leerapun et al.

    Surgical management of conventional grade I chondrosarcoma of long bones

    Clin Orthop Relat Res

    (2007)
  • D.B. Phemister

    Chondrosarcoma of bone

    Surg Gynecol Obstet

    (1930)
  • A.G. Huvos et al.

    Chondrosarcoma in the young. A clinicopathologic analysis of 79 patients younger than 21 years of age

    Am J Surg Pathol

    (1987 Dec)
  • L.G. Kindblom et al.

    Myxoid chondrosarcoma of the synovial tissue. A clinicopathologic, histochemical, and ultrastructural analysis

    Cancer

    (1983 Nov 15)
  • F. Bertoni et al.

    Chondrosarcomas of the synovium

    Cancer

    (1991 Jan 1)
  • N.G. Sanerkin et al.

    A review of the behaviour of chondrosarcoma of bone

    J Bone Joint Surg Br

    (1979)
  • H.L. Evans et al.

    Prognostic factors in chondrosarcoma of bone: a clinicopathologic analysis with emphasis on histologic grading

    Cancer

    (1977)
  • F. Fiorenza et al.

    Risk factors for survival and local control in chondrosarcoma of bone

    J Bone Joint Surg Br

    (2002)
  • H.C. Bauer et al.

    Low risk of recurrence of enchondromas and low-grade chondrosarcoma in extremities: 80 patients followed for 2–25 years

    Acta Orthop Scand

    (1995)
  • P. Bergh et al.

    Prognostic factors and outcome of pelvic, sacral, and spinal chondrosarcomas: a centre based study of 69 cases

    Cancer

    (2001)
  • D. Donati et al.

    Surgical treatment and outcome of conventional pelvic chondrosarcoma

    J Bone Joint Surg Br

    (2005)
  • F.Y. Lee et al.

    Chondrosarcoma of bone: an assessment of outcome

    J Bone Joint Surg Am

    (1999)
  • C.J. Van Loon et al.

    Chondrosarcoma of bone: oncological and functional results

    J Surg Oncol

    (1994)
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