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Volume 5
Malignant Chondroid Tumors
Primary central chondrosarcoma----------Case 125 & 652-678
Secondary peripheral chondrosarcoma---Case 126 & 679-686
Dedifferentiated chondrosarcoma---------Case 127 & 687-689
Clear cell chondrosarcoma-----------------Case 128 & 690
Mesenchymal chondrosarcoma------------Case 129 & 691
Cartilaginous pseudotumors---------------Case 692-699
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Primary Central
Chondrosarcoma
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Primary Central Chondrosarcoma The primary or central conventional chondosarcoma is a low
grade but malignant cartilagenous tumor found typically in adults
between the ages of 30 and 60 years. The tumor arises from the
medullary canal of a large bone such as the pelvis, femur, tibia or
proximal humerus. Because the tumor is slow growing, there is
little symptomatology and the tumor frequently becomes quite
sizable before a physician is consulted. Primary chondrosarcoma
is extremely rare in small bones of the hand or foot. The meta-
physeal portion of a long bone is the most common location
although diaphyseal locations are not unusual. 85% of central
chondrosarcomas are low grade lesions which on radiographic
examination demonstrate matrix calcification similar to that seen
in benign enhondromas, whereas the high grade chondrosarcomas,
which are rare, are frequently noncalcified and take on the
permeative appearance similar to other high grade sarcomas such
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as fibrosarcoma and Ewing’s sarcoma. Histologically, the low
grade central chondrosarcoma has a fairly well differentiated
chondroid matrix like that of an enchondroma but shows evidence
of permeative invasion into the adjacent cortical and cancellous
structures. There is rarely any mitotic activity in the low grade
lesions. They have larger nuclear patterns with a higher degree
of atypicism compared to benign enchondromas.
These low grade tumors have a good prognosis in terms of a
low metastatic incidence to the lung but they must be treated
aggressively with a wide resection in order to prevent local
recurrence. One cannot rely on adjuvant therapy such as radiation
or systemic chemotherapy because these low grade lesions are
notoriously resistant to adjuvant therapy.
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CLASSIC Case #125
50 year female with chondrosarcoma prox humerus
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Proximal humeral
resection tumor bulge
humeral head
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Close up macro section
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Surgical defect
following wide
resection
glenoid
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Proximal humeral
allograft ready for
implantation
rotator cuff
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Allograft placed
over long stem
Neer prosthesis
pectoralis Neer
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Alloprosthetic
reconstruction
completed
rotator
cuff
pectoralis
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Case #652
74 female
chondrosacoma
proximal humerus
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Coronal T-2 MRI tumor
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Wide resection
proximal humerus
glenoid
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Resected specimen cut in path lab
cortical erosion
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Suturing down the
allograft rotator cuff
as part of the alloprosthetic
reconstruction
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Post op x-ray with
cemented Neer
alloprosthesis
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Case #653
19 year male
chondrosarcoma
proximal humerus
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Coronal proton density MRI
tumor
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Resected specimen
cut in path lab
tumor
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Case #654
28 year female with chondrosarcoma prox humerus
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Axial proton density MRI
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Axial T-2 MRI
tumor
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Case #656
72 year male
chondrosarcoma
femur
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Widely resected
distal femur specimen
cut in path lab
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Close up showing
cortical break thru
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Case #657
83 year male
chondrosarcoma femur
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Case #658
82 year female
chondrosarcoma
proximal femur
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X-ray resected
proximal femoral
tumor with path
fractures
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Case #659
52 year male
chondrosarcoma
mid femur
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Macro section from
intercalary resection
tumor
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Photomic showing bony permeation
tumor
bone
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Case #660
54 year female with chondrosarcoma distal femur
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Resected distal femur including entire knee joint
patella
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Distal femur cut in path lab
tumor
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Macro section
tumor
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Photomic
tumor
tumor
articular cartilage
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Close up photomic showing bone permeation by tumor
tumor bone
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Post op x-ray with
excisional arthrodesis
I.M.
nail
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Case #660.1
33 year male with painless mass in popliteal space for 1 yr
and restricted flexion of knee for 3 yrs
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Cor T-2 Axial T-2
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Surgical specimen Compress rotating hinge
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Case #661
58 year male
chondrosarcoma
proximal tibia tumor
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Resected specimen cut in path lab
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Proximal tibial allograft
placed over long stem
total knee replacement
with wires for patellar
tendon attachment
spherocentric knee
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Patellar tendon
sutured to proximal
tibial allograft
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Completion of
retinacular closure
patella
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Post op x-ray
allograft
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Case #662
43 year male with chondrosarcoma proximal tibia
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Coronal T-2 MRI
tumor
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Sagittal Gad C MRI
tumor
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Axial T-1 MRI tumor
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Proximal tibial resection with tumor breakout posterior
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Proximal tibial resection prosthesis with Compress System
spindle
anchor plug drill
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Resected proximal tibia next to prosthesis
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Drilling holes for
anchor plug pins
in tibia
guide
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Placement of anchor plug and traction bar
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Milling the proximal tibial stump
mill
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Milling process
completed ready
for spindle placement
over traction bar
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Spindle secured with 600 lbs of spring pressure
spindle
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Femoral component of rotating hinge cemented in place
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Components assembled ready for patellar ligament attachment
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Spiked washers secure patellar ligament
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Soft tissue reconstruction completed ready for closure
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Case #663
63 year female
chondrosarcoma
pelvis
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Internal hemipelvectomy resection specimen
acetabulum
sciatic
notch
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Resected specimen after autoclaving
sciatic notch
acetabulum
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Autoclaved specimen
replaced with routine
cemented total hip
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Immediate post op
X-ray showing rebar
and cement fixation
upper resection line
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Case #664
54 year male with chondrosarcoma mid pelvis
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Type II internal hemipelvectomy resection
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Type II resection
specimen tumor
femoral head
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Autoclaved specimen
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Autoclaved specimen
reimplanted with
cemented total hip &
recon plates
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Nine years later
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Case #665
47 year female with chondrosarcoma mid pelvis
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Coronal T-1 MRI
tumor
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Coronal T-2 MRI
tumor
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X-ray 1 year post op internal hemipelvectomy & THA
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8 yrs PO with slight lateral shift of cup
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Case #666
45 year female with chondrosarcoma mid pelvis
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Cutting ilium with Gigli saw
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ilium
Placement of 6.5 screws in ilium, ischium & ant ramus
ischium
ant ramus
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Reconstruction of pelvic ring with recon plates
iliac screws
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Placement of constrained cup prior to cementing
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Resected ilium & socket lying next to reconstruction
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Hip relocated ready for greater troch attachment
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Skin closure including biopsy site
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Case #667
50 year male
chondrosarcoma
anterior acetabulum
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Type II & III resection and rebar and cement total hip
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Case #667.1
78 yr male with primary chondrosarcoma pelvis
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Axial Gad MRI showing rim enhancement
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Case #667.2
56 yr old female with prior excision of pelvic tumor 4 yrs ago
Recurrent chondrosarcoma
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Cor T-1 T-2 Gad
Current MRI
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Axial T-1 T-2
Gad
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Sag gad Surgical specimen
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Case #668
43 year male with chondrosarcoma body of scapula
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Another CT cut
tumor
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Coronal T-2 MRI
tumor
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Axial T-2 MRI
tumor
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Total scapular prosthesis
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Cementing humeral component
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Scapular component positioned in muscle cuff
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Closure of muscle cuff over scapular component
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Resected scapula and humeral head
tumor
bulge
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Case #669
47 year male with chondrosarcoma scapular body
tumor
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Another CT cut
tumor
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Axial proton density MRI
tumor
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Axial proton density MRI
tumor
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Axial T-2 MRI
tumor
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Coronal proton density MRI
tumor
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Case #670
52 year male with chondrosarcoma elbow
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Cut specimen in path lab
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Case #670.1
76 year female with slow growing chondrosarcoma elbow
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Axial
T-1
T-2 T-2
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Sag T-1 Sag STIR
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Cor T-1 Cor STIR
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Surgical debulking
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Case #671
26 year male
chondrosarcoma
radius
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Case #672
36 year male with chondrosarcoma distal radius
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Case #673
56 year male
enchondroma
2nd metacarpal
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3.5 years later with
chondrosarcoma
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Case #674
77 year female with chondrosarcoma os calcis
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Sagittal T-2 MRI
tumor
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Case #674.1
55 year male with slight pain and swelling about ankle for 2 years
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Axial PD T-2
Gad
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Case #675
72 year male with chondrosarcoma chest wall
tumor
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Lateral view
tumor
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Case #676
52 year male with chondrosarcoma rib
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Macro section of resected specimen
tumor
rib
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Case #676.1
38 year male
chondrosarcoma
L-1 with block on
myelogram
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Case #676.2
74 yr male with low grade chondrosarcoma LD spine 2 yrs
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Sag T-1 Sag T-2 Sag Gad
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Axial T-1 Axial T-2 Axial Gad
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Case #676.3
48 year old male with low back pain for 1 year
Chondrosarcoma L-3
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Case #677
46 year male with chondrosarcoma mandible
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Case #678
39 year male
chondrosarcoma
mandible
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Secondary
Peripheral
Chondrosarcoma
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Secondary Peripheral Chondrosarcoma
The vast majority of secondary peripheral chondrosarcomas arise
from a prexisting osteochondroma and do not occur before puberty.
These lesions tend to be slow growing with minimal to mild
symptoms. The most common site is the pelvis, followed by the
proximal femur, proximal humerus, and ribs. Plain radiographs show
a large calcifying mass on the surface of bone that measure over
5 cm in girth. When one sees an osteochondroma with a cartilagenous
cap over 3 cm in thichness, there is a strong likelihood for a
secondary chondrosarcoma. The overall prognosis for the secondary
peripheral chondrosarcoma is much better than that for the primary
central chondrosarcoma and usually requires only a simple wide
resection with little chance for local recurrence.
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CLASSIC Case #126
56 year male with 2ndary peripheral chondrosarcoma ilium
tumor exostosis
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Coronal T-2 MRI
tumor
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Resected specimen cut in path lab
ilium
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Macro section
ilium
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Low power photomic
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Higher power with ditto forms
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Case #679
60 year female with chondrosarcoma pubic area
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Gross resection specimen
tumor
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Gross specimen cut in path lab
pubic bone
tumor
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Macro section
pubic bone
tumor
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Close up macro section
pubic bone
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Case #680
31 year male
chondrosarcoma
ilium in multiple
exostosis patient
tumor
exostosis
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Axial proton density MRI
tumor
exostosis
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Axial T-2 MRI
tumor
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tumor
Axial T-2 MRI
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X-ray of knees with multi exostoses
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Case #681
18 year female
chondrosarcoma
pelvis and multi
hereditary exostoses
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Resected specimen
tumor
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Multi exostoses knee
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Several years after type I resection
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Case #682
38 year female with osteochondroma C-spine
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Surgical photo at at same time
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Surgical specimen cut in path lab
cap
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Recurrence 3 years
later
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Recurrence CT scan
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Coronal T-1 MRI
of recurrence and
chondrosarcoma
tumor
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Chondrosarcoma photomic
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Case #683
42 year female with 2ndary chondrosarcoma ilium
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Coronal T-1 MRI
tumor
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Axial T-1 MRI
tumor
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Axial T-2 MRI
tumor
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Case #684
33 year male
2ndary chondrosarcoma
os calcis
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Soft tissue CT scan
exostosis
chondrosarc
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Coronal proton density MRI
tumor
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Coronal T-2 MRI
tumor
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Surgical specimen cut in path lab
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Case #685
30 year male with multi exostoses & chondrosarcoma chest wall
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Case #686
42 year male with 2ndary chondrosarcoma
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Macro section
bone stock
chondrosarc
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Case #686A
42 year male with peripheral chondrosarcoma ulna
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Dedifferentiated
Chondrosarcoma
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Dedifferentiated Chondrosarcoma
Of all the chondrosarcoma variants, by far the most malignant and
potentially fatal is the dedifferentiated chondrosarcoma that
accounts for approximately 5-10% of all chondrosarcomas. It
most likely arises as a result of a second mutation within a pre-
existing low to intermediated grade chondrosarcoma, resulting in
the formation of a malignant fibrous histiocytoma or osteo-
sarcoma immediately adjacent to the lower grade chondrosarcoma
Histologically, the low and high grade portions of this tumor are
geographically separated by sharp margins. These tumors usually
occur in patients between the ages of 50 and 70 years in the
same areas where primary centeral chondrosarcomas are found:
the pelvis, femur and proximal humerus. The characteristic
radiographic appearance is that of a flocculated calcific lytic
lesion arising from the central area of bone with an adjacent area
with more extensive infiltration into the surrounding cortical bone.
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There is no evidence of calcification in the high grade portion of the
lesion and it typically breaks out through the cortex and into the
subperiosteal space.
The prognosis for this variant of chondrosarcomqa is extremely
poor, most patients dying from metastatic disease within one or two
years after the diagnosis is established. Adjavent chemotherapy or
radiation therapy is not very effective, mainly because of the older
age group in which the tumor occurs. The primary treatment
modality is wide surgical resection.
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CLASSIC
Case #127
44 year male
dedifferentiated
chondrosarcoma
proximal femur
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2 years later with
increased size
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Coronal T-1 MRI
tumor
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Axial T-2 MRI
tumor
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Photomic at juncture of high and low grade tumor
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Low grade chondrosarcoma portion
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High grade OGS portion
osteoid
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Case #127.1
63 yr male with recent
hip fracture
Dedifferentiated chondrosarc
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Axial PD
Axial PD
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Surgical resection
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Rconstruction completed
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Case #687
73 year female
dedifferentiated
chondrosarcoma
distal femur
high
grade
low
grade
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Lateral view
high grade
low grade
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Coronal T-1 MRI high
low
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Resected distal femur cut in path lab
high grade
low grade
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Photomic showing low grade left & high grade right
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Low grade chondrosarcoma
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High grade OGS
osteoid
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Post op x-ray with
prosthetic recon
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Case #688
33 year female
dedifferentiated
chondrosarcoma
distal femur
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Reconstruction with Compress system after wide resection
400 lbs pressure
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Completion of rotating hinge arthroplasty
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Immediate post op x-ray
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X-ray at 2 months showing
early callous formation
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Early osseointegration
at 5 months
spindle
anchor
plug
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X-ray at one year
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Stable osseointegration
at 5 years with no signs
of stress shielding
AP view
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Lateral view
anterior
cortex
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10 years post op
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14 years post op
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Case #688.1 Dedifferentiated chondrosarcoma
89 year male with mild knee pain 3 months
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Coronal T-1 T-2 Sagittal T-2
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Axial
T-1 T-2
Gad
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Immediate Post Op x-rays
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Case #689
42 year female
dedifferentiated
chondrosarcoma
pelvis
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Sagittal T-1 MRI
tumor
post column
acetabulum
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Coronal T-2 MRI
tumor
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Low power photomic
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Low grade chondrosarcoma
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High grade portion
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Internal hemipelvectomy reconstruction
recon plate
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Case #689.1
42 year male with right hip pain for 3 months
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Cor T-1 STIR
Gad Gad
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Axial T-1 T-2
T-2 Gad
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Clear Cell
Chondrosacoma
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Clear Cell Chondrosarcoma
The clear cell chondrosarcoma is one of the rarest variants of the
chondrosarcoma. It is found more commonly in males than females
between the ages of 20 and 50 years. The most common location
for this tumor is in the femoral head. Radiographically the clear cell
chondrosarcoma has the appearance of a lytic lesion in the epiphysis,
similar to the chondroblastoma in a younger age group for which it
is frequently misdiagnosed. It has a geographic pattern with central
stippled calcification similar to that of a chondroblastoma. Histo-
locally it also has the appearance of a chondroblastoma with the
presence of benign macrophages and polyhedral stem cells with a
clear cell chicken wire appearance. But in some areas one will see
evidence of a low grade chondrosarcoma in which giant cells are not
seen, clearly separating it from the chondroblastoma.
The treatment for this condition consists of a wide resection which
in the femoral head would be a transcervical resection and replace-
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ment with a bipolar prosthesis. If the lesion is treated by simple
curettement, the recurrence rate is quite high compared to the
chondroblastoma. The chance for pulmonary metastasis is very
unlikely and local recurrence is rare following a wide resection.
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CLASSIC Case #128
25 year male with clear cell chondrosarcoma femoral head
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Low power photomic
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Higher power showing clear cells
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Case #690
51 year male with clear cell chondrosarcoma femoral head
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Frog leg lateral
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Post op x-ray following
head & neck resection
and total hip replacement
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Case #690.1
Post reduction
Acute pathologic fracture left shoulder in 43 yr female
Clear cell chondrosarcoma
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Case #690.1
20 year female with clear cell chondrosarc prox tibia
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Coronal T-1 MRI
tumor
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Sagittal T-1 MRI
tumor
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Mesenchymal
Chondrosarcoma
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Mesenchymal Chondrosarcoma
The mesenchymal chondrosarcoma is another rare variant of the
chondrosarcoma. It consists of low grade chondrosarcoma com-
ponents with an infiltration of primitive mesenchymal cells giving
it the histological appearance of a Ewing’s sarcoma or a hemangio-
pericytoma. It can be seen in soft tissue as well as bone in young
adults, more often in females. The most common location is in the
jaw, followed next by the spine or ribs, with a very few cases seen
in long bones. Because of the high grade component of this lesion,
it is treated as a high grade sarcoma with adjavent chemotherapy
and radiation therapy along with a wide resection if possible.
Despite this aggressive program of treatment, the prognosis is very
poor because of a high incidence of pulmonary metastases and
local recurrence.
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CLASSIC
Case #129
34 year female
mesenchymal
chondrosarcoma
LD spine & paraplegia tumor
Sagittal MRI
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Photomic showing low grade chondroid portion
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High grade round cell portion of tumor
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Case #691
36 year male with mesenchymal chondrosarc humeral head
tumor
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Post op x-ray
following humeral
head resection and
prosthetic recon
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Cartilagenous
Pseudotumors
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Case #692
8 year female with multi focal TBc looking like Ollier’s
Pseudotumor
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Geographic lesions in both elbows
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Photomic showing tuberculous granuloma
Langhans giant cell
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Case #693
10 year child
TBc granuloma
proximal tibia looking
like chondroblastoma
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Case #694
54 year female with tumoral calcinosis looking like chondrsarc
hip
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Sagittal T-1 MRI
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Amorphous calcium
phosphate flowing
from biopsy site
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Resected specimen cut in path lab
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Photomic showing heavy calcifcation
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Case #695
64 yr male with giant bone island looking like chondrosarc
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Case #696
55 yr female with geode(DOA) looking like chondrosarc
AP x-ray hip
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Sagittal CT scan
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Axial proton density MRI
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Case #697
52 yr female with bone infarct looking like enchondroma
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Sagittal T-1 MRI
knee joint
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Case #697.1 Sag & Cor T-1
74 yr female with tender lump mid pretibial area for 1 year
Bone infarcts
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Case #698
45 yr female with epiphyseal infarct looking like
chondroblastoma
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Case #699
77 year female
rheumatoid arthritis
shoulder looking like
chondrosarcoma
proximal humerus
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AP x-ray shoulder
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Sagittal T-2 MRI
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Resected proximal
humerus specimen