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Chondrosarcoma Imaging

  • Author: Geoff Hide, MBBS, MRCP, FRCR; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
 
Updated: Nov 29, 2015
 

Overview

Chondrosarcoma is the second most frequent primary malignant tumor of bone, representing approximately 25% of all primary osseous neoplasms. Chondrosarcomas are a group of tumors with highly diverse features and behavior patterns, ranging from slow-growing non-metastasizing lesions to highly aggressive metastasizing sarcomas.[1, 2, 3, 4]

Frontal radiograph of the left fibula head demonst Frontal radiograph of the left fibula head demonstrates a lucent lesion that contains the typical chondroid matrix calcification. Low-grade tumor.

Giuffrida et al used the Surveillance, Epidemiology and End Results (SEER) database to identify demographic and prognostic characteristics of chondrosarcoma and to describe its natural history following treatment. Multivariate analysis of the 2,890 cases of chondrosarcoma in the United States over the last 30 years showed that survival rates did not change over that period and that only grade and stage are independent prognostic factors for survival. Giuffrida et al recommended that routine post-treatment surveillance be extended to 10 years of follow-up; beyond that point, patients were more likely to die of causes unrelated to chondrosarcoma.[4]

Preferred examination

Radiographs are essential for the initial diagnosis of chondrosarcoma; radiography is sometimes supplemented with computed tomography (CT) scanning, which is more sensitive for detecting matrix calcification and for confirming deep endosteal cortical scalloping in intramedullary tumors. Magnetic resonance imaging (MRI) is the preferred modality for evaluating the extent of intramedullary tumors and for demonstrating extraosseous extension. MRI is useful in evaluating the thickened cartilage cap in an osteochondroma in which a secondary chondrosarcoma develops. MRI is less sensitive than CT in identifying small amounts of matrix calcification within a tumor.[5, 6, 7, 8, 9]

The imaging appearances of chondrosarcoma may overlap with those of other lesions, especially other cartilaginous tumors such as enchondroma. The presence of pain with any lesion (without a pathologic fracture in lesions of the hands and feet) is highly suggestive of malignancy.

Other findings suggestive of malignancy in a cartilaginous tumor include endosteal cortical scalloping of more than two thirds of the thickness of the cortex, ill-defined border and/or zone of transition, and a large soft-tissue mass. Both benign and malignant cartilaginous tumors may show central lucency; however, lucency of an area that previously showed matrix calcification is highly suggestive of chondrosarcoma.

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Radiography

Radiographs typically show a lucent lesion, which frequently contains matrix calcification, particularly in well-differentiated tumors. The degree of organization of the matrix calcification may be correlated with the grade of the tumor. Aggressive tumors contain irregular calcifications, and they often have large areas showing no calcification at all. Well-differentiated lesions tend to have more developed matrix; the typical appearance is of rings and arcs. (See the images below.)[7]

Frontal radiograph of the left fibula head demonst Frontal radiograph of the left fibula head demonstrates a lucent lesion that contains the typical chondroid matrix calcification. Low-grade tumor.
Frontal radiograph of the left acetabulum demonstr Frontal radiograph of the left acetabulum demonstrates an expansile lucent lesion with no internal matrix calcification. Low-grade central tumor.
Frontal radiograph of right side of upper abdomen Frontal radiograph of right side of upper abdomen demonstrates a destructive, expansile lesion of the 12th rib. The lesion contains irregular calcification. High-grade central tumor.
Frontal radiograph of the pelvis demonstrates exte Frontal radiograph of the pelvis demonstrates extensive calcification overlying the left ilium and in the lateral soft tissues. No bone destruction is shown. High-grade secondary peripheral tumor.
Lateral radiograph of the distal femur in a patien Lateral radiograph of the distal femur in a patient with hereditary multiple exostoses. Several osteochondromas of varying appearances arise from the metaphyseal region; these typically grow away from the joint. Soft-tissue calcification is shown overlying the most posterior osteochondroma. High-grade secondary peripheral tumor.

The margin of intramedullary lesions is determined by the degree of aggression of the tumor. It is frequently ill defined. Endosteal scalloping may be present; when its depth is more than two thirds the normal thickness of the cortex, this scalloping is useful in distinguishing chondrosarcoma from enchondroma, except in lesions of the hands and feet. Benign enchondromas in these areas may cause considerable cortical thinning; such enchondromas may occur as a pathologic fracture.

The presence of cortical destruction or a soft-tissue mass is indicative of malignancy. Destruction of matrix calcification that was previously visible in an enchondroma is indicative of malignant transformation.

Degree of confidence

Radiographs alone are often inadequate for assessing the size of the tumor; MRI is useful for demonstrating both the intramedullary extension and the soft-tissue extension of the lesion. CT scanning may be helpful in identifying matrix calcification in some lesions that appear entirely lucent on radiographs.

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Computed Tomography

In as many as 90% of cases, tumors appear as lucent areas containing chondroid matrix calcification. Endosteal scalloping and cortical destruction are frequently easier to appreciate on CT scans than on radiographs. (See the images below.)[5, 9]

Bone-window CT scan of left acetabulum demonstrate Bone-window CT scan of left acetabulum demonstrates matrix calcification in the expansile lucent lesion in the anterior column. Low-grade central tumor.
CT of the right side of the upper abdomen demonstr CT of the right side of the upper abdomen demonstrates the expansile tumor with a large, associated soft-tissue mass containing foci of calcification. High-grade central tumor.
CT scan of the pelvis demonstrates a large soft-ti CT scan of the pelvis demonstrates a large soft-tissue mass that contains calcification arising from a broad-based sessile osteochondroma on the posterior aspect of the ilium. High-grade secondary peripheral tumor.
CT scan of the distal femur demonstrates a broad-b CT scan of the distal femur demonstrates a broad-based osteochondroma with a thick overlying soft-tissue cap that contains focal calcification. The metaphyseal contour is irregular because of the presence of several other osteochondromas in this patient with hereditary multiple exostoses. High-grade secondary peripheral tumor.

CT scanning may be used to guide percutaneous biopsy, and it is the modality of choice for investigating possible pulmonary metastatic disease.

Degree of confidence

CT scanning may often be used to successfully categorize the lesion as being of cartilaginous origin. The medullary extension of the lesion may be assessed more accurately with CT than with radiography. However, MRI is superior, and it is also the most useful modality for determining soft-tissue extension.

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Magnetic Resonance Imaging

MRI typically demonstrates lobulated lesions of high signal intensity on T2-weighted images. Lobules are commonly separated by septa of low signal intensity. On T1-weighted images, the lesion generally displays low signal intensity. (See the images below.)[6, 7, 8, 9]

T2-weighted axial MRI of the pelvis demonstrates t T2-weighted axial MRI of the pelvis demonstrates the high signal intensity of the acetabular lesion. Low-grade central tumor.
T1-weighted axial MRI of the pelvis demonstrates t T1-weighted axial MRI of the pelvis demonstrates the low signal intensity of the acetabular lesion. Low-grade central tumor.
T2-weighted axial MRI of the pelvis demonstrates a T2-weighted axial MRI of the pelvis demonstrates a lobulated high-signal-intensity soft tissue with local-signal-intensity septa arising from the osteochondroma on the posterior aspect of the ilium. Several areas of low signal intensity are shown; these correspond to focal areas of dense calcification. This appearance is typical of cartilaginous material. High-grade secondary peripheral tumor.
Fast spin-echo T2-weighted axial MRI of the distal Fast spin-echo T2-weighted axial MRI of the distal femur in a patient with hereditary multiple exostoses. Image demonstrates the thick cartilage cap overlying a broad-based osteochondroma. Areas of focal reduced signal intensity in the cartilage cap correspond to foci of dense calcification. High-grade secondary peripheral tumor.

Areas of matrix calcification are shown as signal voids on images obtained with all sequences, but small amounts of calcification may not be identifiable. MRI may demonstrate large aggregates of calcium, but tiny scattered calcifications may be completely missed because of partial-volume averaging. MRI may be used to assess soft-tissue extension and the intramedullary extent of the tumor. MRIs may demonstrate endosteal cortical scalloping, but this feature is more easily assessed with CT.

MRI is useful in assessing the thickness of the cartilage cap of osteochondromas to identify chondrosarcoma transformation. Chondrosarcomas show variable patterns of enhancement after the administration of contrast material.

Degree of confidence

MRI is the method of choice for clarifying the intramedullary and extraosseous extension of a chondrosarcoma; features related to cortical bone and matrix calcification are more accurately assessed with CT.

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Ultrasonography

Ultrasonography has no role in the evaluation of intramedullary lesions confined to the bone. It may demonstrate soft-tissue extension; therefore, it may be useful in guiding percutaneous biopsy.

Ultrasonography is useful as a means of assessing the thickness of the cartilage cap overlying an osteochondroma, although access to the lesion may be difficult in certain areas. If the cap measures more than 1.5 cm in a skeletally mature patient, transformation to chondrosarcoma may have occurred.

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Nuclear Imaging

Central chondrosarcomas typically show significantly increased uptake of the radioisotope on isotopic bone scans, but differentiation between chondrosarcoma and enchondroma is unreliable. Uptake on isotopic bone scanning may indicate either metabolic activity in an osteochondroma or malignant transformation; these two conditions cannot be distinguished on the basis of such a finding. In the absence of an increase in uptake, malignancy is highly unlikely.[9]

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Contributor Information and Disclosures
Author

Geoff Hide, MBBS, MRCP, FRCR Consultant Musculoskeletal Radiologist, Department of Radiology, Freeman Hospital; Honorary Clinical Lecturer, Newcastle University Upon Tyne, Faculty of Medicine, UK

Geoff Hide, MBBS, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, Royal College of Radiologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Murali Sundaram, MBBS FRCR, FACR, Professor of Radiology and Consulting Staff, Cleveland Clinic Lerner College of Medicine of CWRU

Murali Sundaram, MBBS is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Michael A Bruno, MD, MS, FACR Professor of Radiology and Medicine, Pennsylvania State University College of Medicine; Director, Radiology Quality Management Services, The Penn State Milton S Hershey Medical Center

Michael A Bruno, MD, MS, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging, Society of Skeletal Radiology

Disclosure: Received royalty from Oxford Press for book author/editor & reviewer; Received royalty from Elsevier Press for book author / editor.

References
  1. Flemming DJ, Murphey MD. Enchondroma and chondrosarcoma. Semin Musculoskelet Radiol. 2000. 4(1):59-71. [Medline].

  2. Marco RA, Gitelis S, Brebach GT, Healey JH. Cartilage tumors: evaluation and treatment. J Am Acad Orthop Surg. 2000 Sep-Oct. 8(5):292-304. [Medline].

  3. Gelderblom H, Hogendoorn PC, Dijkstra SD, van Rijswijk CS, Krol AD, Taminiau AH, et al. The clinical approach towards chondrosarcoma. Oncologist. 2008 Mar. 13(3):320-9. [Medline].

  4. Giuffrida AY, Burgueno JE, Koniaris LG, Gutierrez JC, Duncan R, Scully SP. Chondrosarcoma in the United States (1973 to 2003): an analysis of 2890 cases from the SEER database. J Bone Joint Surg Am. 2009 May. 91(5):1063-72. [Medline].

  5. Langheinrich AC, Stolle C, Kampschulte M, Lommel D, Rau WS, Bassaly B. Diagnostic Value of Ex-Vivo Three-Dimensional Micro-Computed Tomography Imaging of Primary Nonhematopoietic Human Bone Tumors: Osteosarcoma versus Chondrosarcoma. Acta Radiol. 2008 Jul 11. 1-8. [Medline].

  6. Murata H, Horie N, Matsui T, Akai T, Ueda H, Oshima Y, et al. Clinical usefulness of thallium-201 scintigraphy and magnetic resonance imaging in the diagnosis of chondromyxoid fibroma. Ann Nucl Med. 2008 Apr. 22(3):221-4. [Medline].

  7. Crim J, Schmidt R, Layfield L, Hanrahan C, Manaster BJ. Can imaging criteria distinguish enchondroma from grade 1 chondrosarcoma?. Eur J Radiol. 2015 Nov. 84 (11):2222-30. [Medline].

  8. Müller U, Kubik-Huch RA, Ares C, Hug EB, Löw R, Valavanis A, et al. Is there a role for conventional MRI and MR diffusion-weighted imaging for distinction of skull base chordoma and chondrosarcoma?. Acta Radiol. 2015 Feb 25. [Medline].

  9. Kapoor N, Shinagare AB, Jagannathan JP, Shah SH, Krajewski KM, Hornick JL, et al. Clinical and radiologic features of extraskeletal myxoid chondrosarcoma including initial presentation, local recurrence, and metastases. Radiol Oncol. 2014 Sep. 48 (3):235-42. [Medline].

 
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Frontal radiograph of the left fibula head demonstrates a lucent lesion that contains the typical chondroid matrix calcification. Low-grade tumor.
Frontal radiograph of the left acetabulum demonstrates an expansile lucent lesion with no internal matrix calcification. Low-grade central tumor.
Bone-window CT scan of left acetabulum demonstrates matrix calcification in the expansile lucent lesion in the anterior column. Low-grade central tumor.
T2-weighted axial MRI of the pelvis demonstrates the high signal intensity of the acetabular lesion. Low-grade central tumor.
T1-weighted axial MRI of the pelvis demonstrates the low signal intensity of the acetabular lesion. Low-grade central tumor.
Frontal radiograph of right side of upper abdomen demonstrates a destructive, expansile lesion of the 12th rib. The lesion contains irregular calcification. High-grade central tumor.
CT of the right side of the upper abdomen demonstrates the expansile tumor with a large, associated soft-tissue mass containing foci of calcification. High-grade central tumor.
Frontal radiograph of the pelvis demonstrates extensive calcification overlying the left ilium and in the lateral soft tissues. No bone destruction is shown. High-grade secondary peripheral tumor.
CT scan of the pelvis demonstrates a large soft-tissue mass that contains calcification arising from a broad-based sessile osteochondroma on the posterior aspect of the ilium. High-grade secondary peripheral tumor.
T2-weighted axial MRI of the pelvis demonstrates a lobulated high-signal-intensity soft tissue with local-signal-intensity septa arising from the osteochondroma on the posterior aspect of the ilium. Several areas of low signal intensity are shown; these correspond to focal areas of dense calcification. This appearance is typical of cartilaginous material. High-grade secondary peripheral tumor.
Lateral radiograph of the distal femur in a patient with hereditary multiple exostoses. Several osteochondromas of varying appearances arise from the metaphyseal region; these typically grow away from the joint. Soft-tissue calcification is shown overlying the most posterior osteochondroma. High-grade secondary peripheral tumor.
CT scan of the distal femur demonstrates a broad-based osteochondroma with a thick overlying soft-tissue cap that contains focal calcification. The metaphyseal contour is irregular because of the presence of several other osteochondromas in this patient with hereditary multiple exostoses. High-grade secondary peripheral tumor.
Fast spin-echo T2-weighted axial MRI of the distal femur in a patient with hereditary multiple exostoses. Image demonstrates the thick cartilage cap overlying a broad-based osteochondroma. Areas of focal reduced signal intensity in the cartilage cap correspond to foci of dense calcification. High-grade secondary peripheral tumor.
 
 
 
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