Solitary Osteochondroma Workup

  • Author: Ian D Dickey, MD, FRCSC; Chief Editor: Harris Gellman, MD   more...
 
Updated: Apr 29, 2011
 

Imaging Studies

Plain radiography is the mainstay of imaging for osteochondroma. Good quality radiographs should be obtained in 2 perpendicular planes to characterize the lesion fully. Classic radiographic features include orientation of the lesion away from the physis and medullary continuity.[24] See images below.

Solitary osteochondroma. Anteroposterior radiograpSolitary osteochondroma. Anteroposterior radiograph of a pedunculated osteochondroma of the distal femur. Solitary osteochondroma. Lateral radiograph of a pSolitary osteochondroma. Lateral radiograph of a pedunculated osteochondroma of the distal femur. Orientation is away from the growth plate, and medullary continuity is clear. Solitary osteochondroma. Anteroposterior radiograpSolitary osteochondroma. Anteroposterior radiograph of sessile osteochondroma of the humerus.

In certain bones, such as the pelvis and the scapula, CT scanning is a useful adjunct to localize the lesion. CT localization can be useful when planning resection.[25] See images below.

Solitary osteochondroma. CT scan of the pelvis depSolitary osteochondroma. CT scan of the pelvis depicting a massive solitary osteochondroma. Solitary osteochondroma. CT scan of the same sessiSolitary osteochondroma. CT scan of the same sessile osteochondroma of the humerus as in Image 6.

MRI is needed only in cases in which malignancy is a concern or in which relevant soft-tissue anatomy needs to be delineated. MRI is the modality of choice to assess cartilage cap thickness, as in the image below. While not an absolute indication, cartilage cap thickness is related to malignancy. Thick cartilage caps (>4 cm) are suggestive of malignant degeneration, especially when they are associated with pain.

Solitary osteochondroma. MRI of sessile osteochondSolitary osteochondroma. MRI of sessile osteochondroma of the femur demonstrating the thickness of the cartilage cap.

Bone scans, as a rule, are not useful in the workup of osteochondromas or for preoperative planning for resection.[26]

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Histologic Findings

Grossly, the stalk is contiguous with the intramedullary marrow. By definition, the medullary canal of the affected bone and the canal of the tumor are connected. The stalk is made up of mature bone. The cartilage cap, which tops the lesion and can be quite thick in children, is replaced by enchondral bone formation in maturing patients, as in the images below.

Solitary osteochondroma. Gross osteochondroma specSolitary osteochondroma. Gross osteochondroma specimen at the time of resection. Bone stalk and overlying membrane on cartilage cap. Solitary osteochondroma. Cut surface of surgical oSolitary osteochondroma. Cut surface of surgical osteochondroma specimen. Cartilage cap and underlying bone with medullary continuity.

On microscopic examination, the cartilage cap can exhibit varying amounts of cellularity. The cap has an overlying fibrous layer that contains mesenchymal cells, which are thought to be responsible for the lesion's growth.[27] The cells in the cartilage are orientated vertically, as is found in a growth plate. In skeletally immature patients, the cells undergo enchondral bone formation, as in the images below. While no specific cartilage cap thickness is an absolute indicator of risk for malignancy, less than 4 cm generally is thought to be in the range of normal. Further, the cap should not thicken in persons older than 30 years.

Solitary osteochondroma. Histology of cut osteochoSolitary osteochondroma. Histology of cut osteochondroma specimen. Cartilage cap and orientation of enchondral bone formation. Solitary osteochondroma. High-power view of benignSolitary osteochondroma. High-power view of benign cartilage cells arranged in vertical growth plate pattern.
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Staging

Osteochondromas are benign lesions and can be staged under the Musculoskeletal Tumor Society (MSTS) staging for benign lesions, as follows:

  • Stage I - Inactive or static lesions
  • Stage II - Actively growing lesions
  • Stage III - Actively growing lesions that are locally destructive/aggressive

Most osteochondromas are stage I or II. However, significant deformity secondary to mass effect can occur in areas such as the radioulnar joint and tibiofibular joint. While classification is not perfect, such lesions could be considered stage III lesions, as in the image below. These cases likely represent a pressure erosive process, rather than a truly invasive process (as the staging for benign lesions is defined), a subtle but distinct biologic process.

Solitary osteochondroma. Radiograph demonstrating Solitary osteochondroma. Radiograph demonstrating the deformation of the distal tibiofibular joint in a patient with a solitary osteochondroma.

In the rare case of malignant degeneration of the cartilage cap, the lesion is usually a low-grade chondrosarcoma that would be graded a low-grade extracompartmental lesion, MSTS stage IB.

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Contributor Information and Disclosures
Author

Ian D Dickey, MD, FRCSC  Adjunct Professor, Department of Chemical and Biological Engineering, University of Maine; Consulting Staff, Adult Reconstruction, Orthopedic Oncology, Department of Orthopedics, Eastern Maine Medical Center

Ian D Dickey, MD, FRCSC is a member of the following medical societies: American Academy of Orthopaedic Surgeons, British Columbia Medical Association, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Stryker Orthopaedics Consulting fee Consulting; Cadence Honoraria Speaking and teaching

Specialty Editor Board

Lynn A Crosby, MD, FACS  Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine

Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Sean P Scully, MD, PhD  Professor, Department of Orthopedics, University of Miami

Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

  1. Garrison RC, Unni KK, McLeod RA, Pritchard DJ, Dahlin DC. Chondrosarcoma arising in osteochondroma. Cancer. May 1 1982;49(9):1890-7. [Medline].

  2. Staals EL, Bacchini P, Mercuri M, Bertoni F. Dedifferentiated chondrosarcomas arising in preexisting osteochondromas. J Bone Joint Surg Am. May 2007;89(5):987-93. [Medline].

  3. Akahane T, Shimizu T, Isobe K, Yoshimura Y, Kato H. Dedifferentiated chondrosarcoma arising in a solitary osteochondroma with leiomyosarcomatous component: a case report. Arch Orthop Trauma Surg. Jan 12 2008;[Medline].

  4. Purandare NC, Rangarajan V, Agarwal M, Sharma AR, Shah S, Arora A, et al. Integrated PET/CT in evaluating sarcomatous transformation in osteochondromas. Clin Nucl Med. Jun 2009;34(6):350-4. [Medline].

  5. Florez B, Mönckeberg J, Castillo G, Beguiristain J. Solitary osteochondroma long-term follow-up. J Pediatr Orthop B. Mar 2008;17(2):91-4. [Medline].

  6. Heinritz W, Hüffmeier U, Strenge S, Miterski B, Zweier C, Leinung S, et al. New mutations of EXT1 and EXT2 genes in German patients with Multiple Osteochondromas. Ann Hum Genet. May 2009;73:283-91. [Medline].

  7. Mavrogenis AF, Papagelopoulos PJ, Soucacos PN. Skeletal osteochondromas revisited. Orthopedics. Oct 2008;31(10):[Medline].

  8. Nogier A, De Pinieux G, Hottya G, Anract P. Case reports: enlargement of a calcaneal osteochondroma after skeletal maturity. Clin Orthop Relat Res. Jun 2006;447:260-6. [Medline].

  9. D'Ambrosia R, Ferguson AB Jr. The formation of osteochondroma by epiphyseal cartilage transplantation. Clin Orthop. Nov-Dec 1968;61:103-15. [Medline].

  10. Hameetman L, Szuhai K, Yavas A, Knijnenburg J, van Duin M, van Dekken H, et al. The role of EXT1 in nonhereditary osteochondroma: identification of homozygous deletions. J Natl Cancer Inst. Mar 7 2007;99(5):396-406. [Medline].

  11. Hecht JT, Hogue D, Strong LC, et al. Hereditary multiple exostosis and chondrosarcoma: linkage to chromosome II and loss of heterozygosity for EXT-linked markers on chromosomes II and 8. Am J Hum Genet. May 1995;56(5):1125-31. [Medline].

  12. Coughlan B, Feliz A, Ishida T, Czerniak B, Dorfman HD. p53 expression and DNA ploidy of cartilage lesions. Hum Pathol. Jun 1995;26(6):620-4. [Medline].

  13. Legeai-Mallet L, Margaritte-Jeannin P, Lemdani M, et al. An extension of the admixture test for the study of genetic heterogeneity in hereditary multiple exostoses. Hum Genet. Mar 1997;99(3):298-302. [Medline].

  14. Legeai-Mallet L, Munnich A, Maroteaux P, et al. Incomplete penetrance and expressivity skewing in hereditary multiple exostoses. Clin Genet. Jul 1997;52(1):12-6. [Medline].

  15. Park KJ, Shin KH, Ku JL. Germline mutations in the EXT1 and EXT2 genes in Korean patients with hereditary multiple exostoses. J Hum Genet. 1999;44(4):230-4. [Medline].

  16. Kitsoulis P, Galani V, Stefanaki K, Paraskevas G, Karatzias G, Agnantis NJ, et al. Osteochondromas: review of the clinical, radiological and pathological features. In Vivo. Sep-Oct 2008;22(5):633-46. [Medline].

  17. Galasso O, Mariconda M, Milano C. An enlarging distal tibia osteochondroma in the adult patient. J Am Podiatr Med Assoc. Mar-Apr 2009;99(2):157-61. [Medline].

  18. Coenen L, Biltjes I. High radial nerve palsy caused by a humeral exostosis: a case report. J Hand Surg [Am]. Jul 1992;17(4):668-9. [Medline].

  19. Mnif H, Koubaa M, Zrig M, Zammel N, Abid A. Peroneal nerve palsy resulting from fibular head osteochondroma. Orthopedics. Jul 2009;32(7):528. [Medline].

  20. Karasick D, Schweitzer ME, Eschelman DJ. Symptomatic osteochondromas: imaging features. AJR Am J Roentgenol. Jun 1997;168(6):1507-12. [Medline].

  21. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. Radiographics. Sep-Oct 2000;20(5):1407-34. [Medline].

  22. El-Khoury GY, Bassett GS. Symptomatic bursa formation with osteochondromas. AJR Am J Roentgenol. Nov 1979;133(5):895-8. [Medline].

  23. Day FN, Ruggieri C, Britton C. Recurrent osteochondroma. J Foot Ankle Surg. Mar-Apr 1998;37(2):162-4; discussion 173. [Medline].

  24. Robbin MR, Murphey MD. Benign chondroid neoplasms of bone. Semin Musculoskelet Radiol. 2000;4(1):45-58. [Medline].

  25. Hudson TM, Springfield DS, Spanier SS, et al. Benign exostoses and exostotic chondrosarcomas: evaluation of cartilage thickness by CT. Radiology. Sep 1984;152(3):595-9. [Medline].

  26. Lange RH, Lange TA, Rao BK. Correlative radiographic, scintigraphic, and histological evaluation of exostoses. J Bone Joint Surg Am. Dec 1984;66(9):1454-9. [Medline].

  27. Robinson D, Hasharoni A, Oganesian A, et al. Role of FGF9 and FGF receptor 3 in osteochondroma formation. Orthopedics. Aug 2001;24(8):783-7. [Medline].

  28. Ohnishi T, Horii E, Shukuki K, Hattori T. Surgical treatment for osteochondromas in pediatric digits. J Hand Surg Am. Mar 2011;36(3):432-8. [Medline].

  29. Fageir MM, Edwards MR, Addison AK. The surgical management of osteochondroma on the ventral surface of the scapula. J Pediatr Orthop B. Sep 1 2009;[Medline].

  30. Humbert ET, Mehlman C, Crawford AH. Two cases of osteochondroma recurrence after surgical resection. Am J Orthop. Jan 2001;30(1):62-4. [Medline].

  31. Chin KR, Kharrazi FD, Miller BS, Mankin HJ, Gebhardt MC. Osteochondromas of the distal aspect of the tibia or fibula. Natural history and treatment. J Bone Joint Surg Am. Sep 2000;82(9):1269-78. [Medline].

  32. Fogel GR, McElfresh EC, Peterson HA, Wicklund PT. Management of deformities of the forearm in multiple hereditary osteochondromas. J Bone Joint Surg Am. Jun 1984;66(5):670-80. [Medline].

  33. Govender S, Parbhoo AH. Osteochondroma with compression of the spinal cord. A report of two cases. J Bone Joint Surg Br. Jul 1999;81(4):667-9. [Medline].

  34. Peterson HA. Multiple hereditary osteochondromata. Clin Orthop. Feb 1989;(239):222-30. [Medline].

  35. Porter DE, Benson MK, Hosney GA. The hip in hereditary multiple exostoses. J Bone Joint Surg Br. Sep 2001;83(7):988-95. [Medline].

  36. Snearly WN, Peterson HA. Management of ankle deformities in multiple hereditary osteochondromata. J Pediatr Orthop. Jul-Aug 1989;9(4):427-32. [Medline].

  37. Wuyts W, Ramlakhan S, Van Hul W. Refinement of the multiple exostoses locus (EXT2) to a 3-cM interval on chromosome 11. Am J Hum Genet. Aug 1995;57(2):382-7. [Medline].

  38. Wicklund CL, Pauli RM, Johnston D. Natural history study of hereditary multiple exostoses. Am J Med Genet. Jan 2 1995;55(1):43-6. [Medline].

 
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Solitary osteochondroma. Anteroposterior radiograph of a pedunculated osteochondroma of the distal femur.
Solitary osteochondroma. Lateral radiograph of a pedunculated osteochondroma of the distal femur. Orientation is away from the growth plate, and medullary continuity is clear.
Solitary osteochondroma. Lateral radiograph of a sessile osteochondroma of the distal femur.
Solitary osteochondroma. Anatomic and age distribution of solitary osteochondromas.
Solitary osteochondroma. CT scan of the pelvis depicting a massive solitary osteochondroma.
Solitary osteochondroma. Anteroposterior radiograph of sessile osteochondroma of the humerus.
Solitary osteochondroma. CT scan of the same sessile osteochondroma of the humerus as in Image 6.
Solitary osteochondroma. MRI of sessile osteochondroma of the femur demonstrating the thickness of the cartilage cap.
Solitary osteochondroma. Gross osteochondroma specimen at the time of resection. Bone stalk and overlying membrane on cartilage cap.
Solitary osteochondroma. Cut surface of surgical osteochondroma specimen. Cartilage cap and underlying bone with medullary continuity.
Solitary osteochondroma. Histology of cut osteochondroma specimen. Cartilage cap and orientation of enchondral bone formation.
Solitary osteochondroma. High-power view of benign cartilage cells arranged in vertical growth plate pattern.
Solitary osteochondroma. Radiograph demonstrating the deformation of the distal tibiofibular joint in a patient with a solitary osteochondroma.
 
 
 
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