Clinical Radiology (1992) 45, 131 133
Case Report: Metadiaphyseal Chondroblastoma M. D W A I K a n d P. B. D E V L I N Altnagelvin A r e a Hospital, Londonderry
We report the case of a 13-year-old girl who presented with a pathological fracture of the lower tibia, which proved to be chondroblastoma on histology. D w a i k , M. & Devlin, P.B. (1992). Clinical R a d i o l o g y 45, 131 133. Case Report: M e t a d i a p h y s e a l C h o n d r o b l a s t o m a
We report the case of a 13-year-old girl who presented with a pathological fracture of the lower tibia. In spite of the atypical site, this proved to be c h o n d r o b l a s t o m a on histology. Review of the literature reveals 13 previously reported cases of extra-epiphyseal c h o n d r o b l a s t o m a (Table I). O u r case represents the fifth reported case of a metadiaphyseal c h o n d r o b l a s t o m a . CASE R E P O R T A 13-year-old girl presented to the Accident and Emergency Department having fractured the lower third of the left tibia. Radiographs showed that the fracture line traversed a radiolucent lesion involvingthe metadiaphysis of the lower end of tibia. The distal tibial epiphysis was not involved (Fig. 1). A simple bone cyst and nonossifying fibroma were considered in the differential diagnosis. The leg was immobilized in plaster and follow up showed the fracture to heal satisfactorily. Two years later she started to complain of pain at the fracture site. Radiographs showed that the lesion had enlarged over the intervening period with expansion of the tibial shaft and endosteal sclerosis at the proximal end of the lesion (Fig. 2). Initially she was observed but excision curettage with bone grafting was performed after 6 months. Histological examination of the 16 g of bone chippings revealed an exceedingly cellular tumour. The lesion contained numerous multinucleated giant cells admixed with foci of calcification,chrondroblasts devoid of cartilaginous matrix and lobules of neoplastic cartilage. The chondroblasts revealed a moderate degree of nuclear pleomorphism but mitotic figures were rare. The appearances are those of chondroblastoma (Fig. 3). DISCUSSION C h o n d r o b l a s t o m a is an u n c o m m o n lesion, comprising less than 1% of all p r i m a r y t u m o u r s (Dahlin, 1986). Correspondence to: Dr M. Dwaik, Department of Clinical Radiology, Royal Victoria Hospital, Grosenover Road, Belfast BTI2.
The majority present in patients in the second decade of life. The t u r n o u t is b e n i g n a n d has neither a m a l i g n a n t c o u n t e r p a r t n o r a p r o p e n s i t y for m a l i g n a n t t r a n s f o r m a tion (McLeod and Beabout, 1973). Typical sites of i n v o l v e m e n t are the femur, tibia a n d humerus. A characteristic feature of c h o n d r o b l a s t o m a is its location. In K r i s h n a n ' s series Of 275 cases 37"/0 were entirely epiphyseal, while 60% involved the epiphysis but also extended into the metaphysis. Thus 97% of the lesions were solely epiphyseal or h a d an epiphyseal c o m p o n e n t ( K r i s h n a n a n d M c L e o d , 1989). W h e n they extend into the metaphysis, that part of the lesion in the epiphysis is virtually always larger than the segment in the m e t a p h y sis. A purely metaphyseal location is exceedingly rare ( S h e r m a n a n d Uzel, 1956; Bloem a n d Mulder, 1985). Radiographically c h o n d r o b l a s t o m a s typically a p p e a r as well defined lyric epiphyseal lesions usually less t h a n 5 cm in size. A thin sclerotic rim may separate the lesion from the adjacent bone. T h e presenting s y m p t o m is usually pain which m a y be o f some years duration. I n K r i s h n a n ' s series (1989) pathological fracture was noted in 12% of c h r o n d r o b l a s t o m a s . O f the 13 previously reported extra-epiphyseal c h o n d r o b l a s t o m a s nine were in the metaphysis and four in a metadiaphyseal location. Bloem a n d M u l d e r (1985) reviewed 104 cases, of which four were in the metaphysis. The diaphyseal location in our case, as in the other reported cases, p r o b a b l y represents extension of the lesion from the metaphysis (Bloem a n d Mulder, 1985; M c L e o d and Beabout, 1973; Schwinn, 1976). The recorded details of the previously reported cases do n o t permit any distinction regarding the frequency of pathological fracture between epiphyseal a n d extraepiphyseal c h o n d r o b l a s t o m a s .
Table 1 - Extra-epiphysealchondroblastomas Author
Age (years)
Sex
Anatomical location
Hatcher and Campbell ( 195l) Sherman and Uzel (1956) Kunkel et al. (1956) Salzer et al. (1968) Schajowicz and Gallardo (1970)
8 9 8 18 13 15
M F M M F M
Proximal metaphysis of right tibia Proximal metaphysis of right tibia Distal metaphysis of femur, SNS Distal metaphysis of left tibia Distal metaphysis of left femur Distal metaphysis of right femur Distal metaphysis of tibia, SNS Distal metaphysis and shaft of femur, SNS Right femoral neck; epiphysis and trochanters not involved Right femoral neck;epiphysisand greater trochanter not involved Metadiaphysis of radius, SNS Metadiaphysis of humerus, SNS Proximal metaphysis and diaphysis of left femur
Dahlins and lvins (1972) Fechner and Wilde (1974) Aronsohn et al. (1976) Schwinn (1976) Bloem and Mulder (1985)* Sotelo-Avilaet al. (1986)
No details t3 13 18 14 25 11.5
F F M M F F
SNS, Side not stated. * Three other metaphyseal cases are mentioned by these authors but no further details are recorded.
132
CLINICAL RADIOLOGY
Fig. 1
Fig. 2 REFERENCES
Fig. 3 Acknowledgements. We thank Mr A. R. Wray for permitting us to report on his patient, Dr D. F. Hughes and Dr Mary Catto for their histological opinions and Mrs S. Gilfillan for typing the manuscript.
Aronsohn, RS, Hart, WR & Martel, W (1976). Metaphyseal chondroblastoma of bone. American Journal of Roentgenology, 127, 686 688. Bloem, JL & Mulder, JD (1985). Chondroblastoma: a clinical and radiological study of 104 cases. Skeletal Radiology, 14, I 9. Dahlin, DC (1986). Benign Chondroblastoma in Bone Turnouts: General Aspects and Data on 8,542 Cases. 4th ed. pp. 52 67. Charles C Thomas, Springfield. Dahlin, DC & Ivins, JC (1972). Benign chondroblastoma, a study of 125 cases. Cancer, 30, 401-413. Fechner, RE & Wilde, HD (1974). Chondroblastoma in the metaphysis of the femoral neck. A case report and review of the literature. Journal of Bone and Joint Surgery, 56A, 413--415.
METADIAPHYSEAL CHONDROBLASTOMA Hatcher, CH & Campbel, JC (1951). Benign chondroblastoma of bone. lts radiologic variations and report of a late sarcoma in the site of bone. Bulletin of Hospital Joint Disease, 12, 411-430. Krishnan, K & McLeod, RA (1989). Chondroblastoma of bone. Human pathology, 20, 965-976. Kunkel, MG, Dahlin, DC & Young, HH (1956). Benign chondroblastoma. Journal qf Bone and Joint Surgery, 38A, 817-827. McLeod, RA & Beabout, JW (1973). The roentgenographic features of chondroblastoma. American Journal of Roentgenology, 118, 464 471. Salzer, M, Salzer-Kuntschik, M & Kretschmer, G (1965), Benign condroblastoma. Archives of" Orthopaedic and Traumatic Surgery, 64, 229-244.
133
Schajwicz~ F & Gallardo, H (1970). Epiphyseal chondroblastoma of bone. A clinicopathological study of sixty-nine cases. Journal of Bone Surgery, 52-B, 205 226. Schwinn, CP (1976). Difj'erential Diagnosis of Giant Cell Lesions of Bone, in Bones and Joints. Eds. Ackerman, CV, Spjut, HJ & Abell, MR. pp. 254-258. Williams and Wilkins, Baltimore. Sherman, RS & Uzel, AR (1956). Benign chondroblastoma of bone. Its roentgen diagnosis. American Journal o[' Roentgenology and Radiotherapy, diagnosis. 76, 1132 1140. Sotelo-Avila, C & Sundaram, MD (1986). Case Report 373. Skeletal Radiology, 15, 387 390.
Case Report: Metadiaphyseal Chondroblastoma M. D W A I K a n d P. B. D E V L I N Altnagelvin A r e a Hospital, Londonderry
We report the case of a 13-year-old girl who presented with a pathological fracture of the lower tibia, which proved to be chondroblastoma on histology. D w a i k , M. & Devlin, P.B. (1992). Clinical R a d i o l o g y 45, 131 133. Case Report: M e t a d i a p h y s e a l C h o n d r o b l a s t o m a
We report the case of a 13-year-old girl who presented with a pathological fracture of the lower tibia. In spite of the atypical site, this proved to be c h o n d r o b l a s t o m a on histology. Review of the literature reveals 13 previously reported cases of extra-epiphyseal c h o n d r o b l a s t o m a (Table I). O u r case represents the fifth reported case of a metadiaphyseal c h o n d r o b l a s t o m a . CASE R E P O R T A 13-year-old girl presented to the Accident and Emergency Department having fractured the lower third of the left tibia. Radiographs showed that the fracture line traversed a radiolucent lesion involvingthe metadiaphysis of the lower end of tibia. The distal tibial epiphysis was not involved (Fig. 1). A simple bone cyst and nonossifying fibroma were considered in the differential diagnosis. The leg was immobilized in plaster and follow up showed the fracture to heal satisfactorily. Two years later she started to complain of pain at the fracture site. Radiographs showed that the lesion had enlarged over the intervening period with expansion of the tibial shaft and endosteal sclerosis at the proximal end of the lesion (Fig. 2). Initially she was observed but excision curettage with bone grafting was performed after 6 months. Histological examination of the 16 g of bone chippings revealed an exceedingly cellular tumour. The lesion contained numerous multinucleated giant cells admixed with foci of calcification,chrondroblasts devoid of cartilaginous matrix and lobules of neoplastic cartilage. The chondroblasts revealed a moderate degree of nuclear pleomorphism but mitotic figures were rare. The appearances are those of chondroblastoma (Fig. 3). DISCUSSION C h o n d r o b l a s t o m a is an u n c o m m o n lesion, comprising less than 1% of all p r i m a r y t u m o u r s (Dahlin, 1986). Correspondence to: Dr M. Dwaik, Department of Clinical Radiology, Royal Victoria Hospital, Grosenover Road, Belfast BTI2.
The majority present in patients in the second decade of life. The t u r n o u t is b e n i g n a n d has neither a m a l i g n a n t c o u n t e r p a r t n o r a p r o p e n s i t y for m a l i g n a n t t r a n s f o r m a tion (McLeod and Beabout, 1973). Typical sites of i n v o l v e m e n t are the femur, tibia a n d humerus. A characteristic feature of c h o n d r o b l a s t o m a is its location. In K r i s h n a n ' s series Of 275 cases 37"/0 were entirely epiphyseal, while 60% involved the epiphysis but also extended into the metaphysis. Thus 97% of the lesions were solely epiphyseal or h a d an epiphyseal c o m p o n e n t ( K r i s h n a n a n d M c L e o d , 1989). W h e n they extend into the metaphysis, that part of the lesion in the epiphysis is virtually always larger than the segment in the m e t a p h y sis. A purely metaphyseal location is exceedingly rare ( S h e r m a n a n d Uzel, 1956; Bloem a n d Mulder, 1985). Radiographically c h o n d r o b l a s t o m a s typically a p p e a r as well defined lyric epiphyseal lesions usually less t h a n 5 cm in size. A thin sclerotic rim may separate the lesion from the adjacent bone. T h e presenting s y m p t o m is usually pain which m a y be o f some years duration. I n K r i s h n a n ' s series (1989) pathological fracture was noted in 12% of c h r o n d r o b l a s t o m a s . O f the 13 previously reported extra-epiphyseal c h o n d r o b l a s t o m a s nine were in the metaphysis and four in a metadiaphyseal location. Bloem a n d M u l d e r (1985) reviewed 104 cases, of which four were in the metaphysis. The diaphyseal location in our case, as in the other reported cases, p r o b a b l y represents extension of the lesion from the metaphysis (Bloem a n d Mulder, 1985; M c L e o d and Beabout, 1973; Schwinn, 1976). The recorded details of the previously reported cases do n o t permit any distinction regarding the frequency of pathological fracture between epiphyseal a n d extraepiphyseal c h o n d r o b l a s t o m a s .
Table 1 - Extra-epiphysealchondroblastomas Author
Age (years)
Sex
Anatomical location
Hatcher and Campbell ( 195l) Sherman and Uzel (1956) Kunkel et al. (1956) Salzer et al. (1968) Schajowicz and Gallardo (1970)
8 9 8 18 13 15
M F M M F M
Proximal metaphysis of right tibia Proximal metaphysis of right tibia Distal metaphysis of femur, SNS Distal metaphysis of left tibia Distal metaphysis of left femur Distal metaphysis of right femur Distal metaphysis of tibia, SNS Distal metaphysis and shaft of femur, SNS Right femoral neck; epiphysis and trochanters not involved Right femoral neck;epiphysisand greater trochanter not involved Metadiaphysis of radius, SNS Metadiaphysis of humerus, SNS Proximal metaphysis and diaphysis of left femur
Dahlins and lvins (1972) Fechner and Wilde (1974) Aronsohn et al. (1976) Schwinn (1976) Bloem and Mulder (1985)* Sotelo-Avilaet al. (1986)
No details t3 13 18 14 25 11.5
F F M M F F
SNS, Side not stated. * Three other metaphyseal cases are mentioned by these authors but no further details are recorded.
132
CLINICAL RADIOLOGY
Fig. 1
Fig. 2 REFERENCES
Fig. 3 Acknowledgements. We thank Mr A. R. Wray for permitting us to report on his patient, Dr D. F. Hughes and Dr Mary Catto for their histological opinions and Mrs S. Gilfillan for typing the manuscript.
Aronsohn, RS, Hart, WR & Martel, W (1976). Metaphyseal chondroblastoma of bone. American Journal of Roentgenology, 127, 686 688. Bloem, JL & Mulder, JD (1985). Chondroblastoma: a clinical and radiological study of 104 cases. Skeletal Radiology, 14, I 9. Dahlin, DC (1986). Benign Chondroblastoma in Bone Turnouts: General Aspects and Data on 8,542 Cases. 4th ed. pp. 52 67. Charles C Thomas, Springfield. Dahlin, DC & Ivins, JC (1972). Benign chondroblastoma, a study of 125 cases. Cancer, 30, 401-413. Fechner, RE & Wilde, HD (1974). Chondroblastoma in the metaphysis of the femoral neck. A case report and review of the literature. Journal of Bone and Joint Surgery, 56A, 413--415.
METADIAPHYSEAL CHONDROBLASTOMA Hatcher, CH & Campbel, JC (1951). Benign chondroblastoma of bone. lts radiologic variations and report of a late sarcoma in the site of bone. Bulletin of Hospital Joint Disease, 12, 411-430. Krishnan, K & McLeod, RA (1989). Chondroblastoma of bone. Human pathology, 20, 965-976. Kunkel, MG, Dahlin, DC & Young, HH (1956). Benign chondroblastoma. Journal qf Bone and Joint Surgery, 38A, 817-827. McLeod, RA & Beabout, JW (1973). The roentgenographic features of chondroblastoma. American Journal of Roentgenology, 118, 464 471. Salzer, M, Salzer-Kuntschik, M & Kretschmer, G (1965), Benign condroblastoma. Archives of" Orthopaedic and Traumatic Surgery, 64, 229-244.
133
Schajwicz~ F & Gallardo, H (1970). Epiphyseal chondroblastoma of bone. A clinicopathological study of sixty-nine cases. Journal of Bone Surgery, 52-B, 205 226. Schwinn, CP (1976). Difj'erential Diagnosis of Giant Cell Lesions of Bone, in Bones and Joints. Eds. Ackerman, CV, Spjut, HJ & Abell, MR. pp. 254-258. Williams and Wilkins, Baltimore. Sherman, RS & Uzel, AR (1956). Benign chondroblastoma of bone. Its roentgen diagnosis. American Journal o[' Roentgenology and Radiotherapy, diagnosis. 76, 1132 1140. Sotelo-Avila, C & Sundaram, MD (1986). Case Report 373. Skeletal Radiology, 15, 387 390.
