|Year : 2015 | Volume
| Issue : 3 | Page : 669
Chondroblastoma of the scaphoid: A case report
Sandeep Vijayan1, Anil K Bhat1, Shamsi Abdul Hameed2, Bhaskarananda Kumar1
1 Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
2 Department of Orthopaedics, Hamad Medical Corporation, Doha, Qatar
|Date of Web Publication||9-Oct-2015|
Dr. Sandeep Vijayan
Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Benign Chondroblastoma generally occur in the epiphysis of long bones and rarely arise in carpal bones. We report a young male with chondroblastoma of scaphoid treated with curettage, bone grafting and K-wire fixation. At the last follow-up, 4 years after surgery, the patient was asymptomatic without recurrence.
Keywords: Carpal bones, chondroblastoma, scaphoid
|How to cite this article:|
Vijayan S, Bhat AK, Hameed SA, Kumar B. Chondroblastoma of the scaphoid: A case report. J Can Res Ther 2015;11:669
| > Introduction|| |
Primary tumors of the carpal bone are rare (0.14-0.2%).  The name chondroblastoma was given for the variant of giant cell tumor with cartilage by Jaffe and Lichtenstein in 1942.  Chondroblastoma generally occurs in the epiphyses of long bones, ,,,,,,,, and is extremely rare in the carpal bones. Only 21 cases of chondroblastoma have been reported in the carpal bones. ,,,,,,
| > Case report|| |
A 30-year-old male, presented with pain, swelling, and stiffness in his right wrist without trauma since 2 months. Minimal swelling over the dorsoradial aspect of right wrist with tenderness over the anatomical snuffbox and restriction of dorsiflexion and radial deviation were noted. The patient had full range of motion of his thumb and fingers. Dynamometer grip strength was 70% that of his nondominant hand. (Mean left hand grip strength was 72 lb and mean right hand grip strength was 51 lb.).
Radiographs showed a lytic lesion in the scaphoid body with well-defined margins and suspicious breech in the cortex on the radial aspect. An ill-defined sclerotic margin was also noted around the lytic area without juxtaarticular osteopenia [Figure 1]. Magnetic resonance imaging (MRI) showed well-defined lesion with thin hypointense rim and loss of cortical margins with minimal effusion and perilesional soft tissue edema [Figure 2].
|Figure 1: Anteroposterior and lateral radiographs of the wrist showing a lytic lesion in the scaphoid body with suspicious cortical breech and sclerotic margins|
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|Figure 2: T2-weighted magnetic resonance image of the wrist showing the well-defined lesion with thin hypo-intense rim, loss of cortical margins at places, and peri-lesional oedema|
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Differential diagnoses of enchondroma, giant cell tumor, intraosseous ganglion, and aneurysmal bone cyst were considered. Intraoperatively, the tumor composed of gritty material that was easily curetted [Figure 3]. Curettage, iliac crest bone grafting, and fixation with a K-wire was performed and scaphoid cast was applied.
|Figure 3: Intra-operative photograph showing the cortical break and gritty material inside the scaphoid|
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Microscopy showed proliferating chondroblasts characterized by polyhedral cells with thick cell membranes, elongated oval to spindle-shaped vesicular nuclei with nuclear indentations interspersed with osteoclast-like giant cells, immature chondroid cells, areas of necrosis, calcification, and thin-walled blood vessels [Figure 4]. The periphery showed dense trabecular bone with variable calcification. Reticulin staining showed reticulin fibers surrounding each individual cell and a diagnosis of chondroblastoma was made by the pathologist. After 12 weeks, the K-wire was removed and mobilization was initiated. Four years after surgery, the patient remains asymptomatic with normal range of motion of the wrist and no signs of recurrence [Figure 5].
|Figure 4: Histopathological slide showing oval to polygonal cells with distinct cell membranes, oval to spindle-shaped nuclei with abundant eosinophilic cytoplasm, hyalinization, and pericellular calcification admixed in a chondroid matrix (hematoxylin and eosin (H and E) staining, ×40 magnification)|
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|Figure 5: Anteroposterior radiograph of right wrist at 4 years after surgery showing complete incorporation of the graft and no evidence of recurrence or radiocarpal arthritis|
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| > Discussion|| |
Chondroblastoma is a rare (<1%) primary benign bone tumor, commonly affecting the epiphysis of long bones. It occurs in the 2 nd decade of life with a male to female ratio of 2:1. , Patients beyond the 2 nd decade tends to develop this lesion at unusual sites like small bones of the hand and feet, flat bones, and skull and facial bones. ,,, Pain is the most characteristic complaint. Local tenderness and joint stiffness and rarely swelling and joint effusion are clinical characteristics of this tumor. , Chondroblastoma is uncommon in the hand and feet and few cases of chondroblastoma of carpal bones have been reported [Table 1]. ,,,,,,
On radiography, it appears as lytic, round, or ovoid lesion often with well-defined sclerotic borders involving the epiphysis of a long bone with open physis. When epi-metaphyseal in location, it is more eccentric and causes cortical expansion. Varying amount of central and/or peripheral radiopaque stippled or fluffy calcification is seen. At uncommon sites (flat bones, small bones of hand and feet, and skull and facial bones), it shows atypical features like ill-defined margins, articular extension, cortical destruction, periosteal new bone formation, pathological fracture, soft tissue mass and synovitis of adjacent joints, and can mimic locally aggressive lesions. ,,,,,,
High resolution T2-weighted MRI images show the characteristic lobular pattern with foci of low, intermediate, and high signal intensity corresponding to calcifications, chondroid matrix, and fluid/hemorrhage, respectively. Our patient also was in his early 30s and presented predominantly with pain and mild swelling similar to the cases reported by Murray et al. Even though our patient's radiograph and MRI did not show cortical expansion and soft tissue extension, there was loss of cortical margins, minimal joint effusion, and perilesional soft tissue edema; and it was mimicking a locally aggressive lesion. However, some authors have pointed out that periosteal reaction, marrow edema, and perilesional soft tissue edema on MRI are potentially misleading features seen in a large number of patients with chondroblastoma and is not indicative of an aggressive lesion and occurs due to surrounding hyperemia. , Chondroblastoma also demonstrate characteristic histological findings [Table 2]. ,,,
Chronic infections, eosinophilic granuloma, lymphoma, giant cell tumor, osteoblastoma, enchondroma, and chondromyxoid fibroma should be considered in the differential diagnosis. The low to intermediate heterogeneous signal intensity, lobular internal architecture, and fine lobular margins is not known to occur in chronic infections, eosinophilic granuloma, lymphoma, giant cell tumor, or osteoblastoma. These features help to distinguish chondroblastoma from other lesions, which may occasionally be associated with marrow edema. Intralesional calcification essentially excludes giant cell tumor. In addition, enchondroma, chondromyxoid fibroma, and giant cell tumor are not likely to be associated with marrow and/or periosteal reaction. ,
Irradiation, used in the past for treatment of chondroblastoma has largely been discarded (except for in surgically inaccessible areas) due to the risk of sarcomatous transformation after irradiation. , Enbloc excision of the bone, curettage, curettage with adjuvant local phenol washing, bone grafting, or cryotherapy are currently being used for treatment. Curettage with bone grafting or cryosurgery shows lower recurrence rates (25%) as compared to curettage alone (60%).  Bone graft mainly acts as filler, aids in healing, and prevents pathological fractures. In our case, we combined curettage and iliac crest bone grafting with K-wire stabilization to hold the graft in place and to decrease the risk of pathological fracture. Local recurrences occur in 10-45% of cases. , Local recurrences frequently occurred in patients with an open epiphyseal plate,  associated aneurysmal bone cyst, , and in flat bones.  There are no reports of recurrence of chondroblastoma in carpal bones. , Recurrent chondroblastoma can be treated with repeat curettage of the intraosseous portion and marginal excision of any extraosseous components. 
| > Conclusion|| |
The differential diagnosis of rare carpal bone tumors must be kept in mind in young, active individuals with wrist pain. Detection of radiographic abnormalities should be followed-up with advanced imaging like MRI to differentiate chondroblastoma from other similar tumors. We would recommend use of a fixation device along with curettage and bone grafting to decrease the possibility of pathological fracture.
| > Acknowledgement|| |
Authors wish to thank Dr. Hitesh Shah, Additional Professor of Orthopaedics at Kasturba Medical College, Manipal, Karnataka, India for copy editing the final manuscript.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]