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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 3  |  Page : 719-721

Chondrosarcoma third metacarpal: Diagnosis and management options


1 Department of Orthopedics, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh, India
2 Department of Pathology, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh, India
3 Department of Pediatrics, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh, India

Date of Web Publication12-Jun-2018

Correspondence Address:
Dr. Seema Sharma
H. No. 23, Type 5, Block B, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.175429

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 > Abstract 


Chondrosarcoma is a rare malignant tumor of cartilage commonly arising in the pelvis, proximal femur, and humerus, but quite uncommon in the small bones of the hand. Although limited surgical procedures such as curettage are mentioned as a management option in low-grade chondrosarcomas, they tend to have a high rate of recurrences. Hence, wide excision is recommended as a treatment option even in low-grade chondrosarcomas of the hand.

Keywords: Amputation, chondrosarcoma, curettage


How to cite this article:
Sharma V, Verma L, Chander B, Sharma S. Chondrosarcoma third metacarpal: Diagnosis and management options. J Can Res Ther 2018;14:719-21

How to cite this URL:
Sharma V, Verma L, Chander B, Sharma S. Chondrosarcoma third metacarpal: Diagnosis and management options. J Can Res Ther [serial online] 2018 [cited 2022 Aug 10];14:719-21. Available from: https://www.cancerjournal.net/text.asp?2018/14/3/719/175429




 > Introduction Top


Chondrosarcoma is a common malignant bone tumor of the fifth and sixth decade.[1] It accounts for the 9% of the malignant bone tumors, males being commonly affected. Although benign cartilage tumors are frequent in the small bones of the hand and feet, malignant lesions are rare at these sites.[1] We describe a 23-year-old patient with chondrosarcoma of the middle finger (third metacarpal), a rare representation considering the site and age of the patient.


 > Case Report Top


A 23-year-old male presented to us with swelling over dorsum of the left third metacarpal for the past 4 months. There was no history suggestive of trauma or underlying systemic disease. Clinical examination revealed a swelling 3 cm × 3 cm in dimension, distally and dorsally located over head and neck region of third metacarpal with well-defined margins, a firm consistency and tenderness on palpation. Swelling was fixed to underlying structures. Overlying skin was stretched but freely mobile. Range of motion at metacarpophalangeal joint was full and pain free [Figure 1]. Radiograph showed expanded distal third metacarpal with multiple lytic lesions and thinned out cortices [Figure 2].
Figure 1: Clinical photograph of the lesion distal third metacarpal

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Figure 2: (a) Anteroposterior X-ray left hand - lobulated expansile lesion distal third metacarpal, (b) after ray resection (arrow)

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Magnetic resonance imaging (MRI) showed lobulated expansile altered signal intensity lesion 27 mm × 15 mm × 16 mm with postcontrast enhancement involving the distal metaphyseal region of the third metacarpal. Curvilinear and few punctuate calcification were also noted within the lesion. There was cortical destruction of the dorsal surface of the third metacarpal with mass exophyting to the surrounding subcutaneous tissue. There was displacement and partial encasement of the extensor tendon by the mass. A skip lesion 8 mm × 5 mm × 6 mm in the base of third metacarpal with swelling of overlying cortex was also noted [Figure 3]. The possibility of enchondroma or chondrosarcoma was entertained. Histopathological evaluation reported chondrosarcoma with polychromatic two or more nuclei in one lacuna with mild to moderate nuclear pleomorphism. Metastatic workup of the lesion was normal [Figure 4]. The patient and his attendants were educated about the tumor spread, treatment plan, and recurrence rate. After detailed informed consent, ray amputation was planned. Postoperative recovery was uneventful. The patient is on regular follow-up and 5 months after ray resection, our patient has no signs of local recurrence or metastasis.
Figure 3: Magnetic resonance imaging showing lobulated expansile lesion with cortical destruction, skip lesion in base of metacarpal (arrow)

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Figure 4: Pleomorphic cells with more than one chondrocyte per lacuna with tumor giant cells

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 > Discussion Top


Chondrosarcoma is a malignant tumor of proliferating cartilage tissue.[1],[2],[3] It may arise as a primary lesion or occur secondarily at the site of a previous benign lesion such as enchondroma or osteochondroma. Primary chondrosarcoma in the hand are very rare with an incidence ranging from 1.5% to 3.2% with chondrosarcoma of metacarpals being still rarer.[4]

Pain in the absence of pathological fracture is the main feature which distinguishes enchondroma from the low-grade chondrosarcoma; however in our case, pain was not the presenting complaint of the patient.[2]

Both enchondroma and chondrosarcoma arise from the medullary cavity, but chondrosarcoma has a more aggressive behavior. Histologically, chondrosarcomas are composed of malignant cells with abundant cartilaginous matrix, hypercellularity, plump nuclei, binucleate cells, and entrapment of bony trabeculae.[1],[2],[3] Based on nuclear size, nuclear staining (hyperchromasia), and cellularity, chondrosarcoma is divided into low, intermediate, and high grades; higher grades predicting more chances of metastasis.[5]

In the present case, histopathological examination showed the cartilaginous material with plump hyperchromatic two or more nuclei in one lacuna. The nuclei showed the mild to moderate nuclear pleomorphism, the features being consistent with well-differentiated chondrosarcoma.

Some well-differentiated chondrosarcomas present a clinicopathological overlap with enchondroma resulting in a misdiagnosis. A study reported an 85-year-old male with a small swelling in 4th and 5th digit of the right hand, lytic in nature and suspected to be an enchondroma on histopathology. The patient refused further treatment. Fifteen years later, he presented with a rapid increase in the size of the swelling at the same site with features of malignancy on radiography. Histopathology reported chondrosarcoma which was managed by ray amputation.[6] Another study reported a a a 70-year-old woman who presented with swelling and pain at the index finger of the right hand managed by excisional curettage. Histopathology reported it to be an enchondroma. Seven months later, the patient reported recurrence at the same site. This time, the tumor was found to be transformed into an intermediate grade (Grade II) chondrosarcoma, and amputation of the finger was performed.[7] Hence, histopathology alone may not be sufficient enough to provide a final diagnosis of the lesion. Instead, it should be viewed in light of clinicoradiological behavior of the lesion. The present patient was a histopathologically confirmed case of well-differentiated chondrosarcoma, but locally aggressive clinicoradiological features such as rapid growth of the lesion, cortical breach with partial encasement of extensor tendons, and a satellite lesion in the base of the third metacarpal on MRI-guided us toward ray amputation as the definitive surgical procedure instead of other conservative surgical options.

Chondrosarcomas of the hand behave differently from chondrosarcomas elsewhere in that even high-grade chondrosarcomas have a lower incidence of metastasis tempting us all the more toward conservative surgery.[8] However small size of the hand and resulting possibility of spread of tumor from one compartment to another precludes the use of excision and curettage in chondrosarcoma in the hand. Moreover such surgeries need to be linked with a close follow-up for local recurrence.[3] Ray amputation or wide excision and reconstruction are the preferred treatment options to gain adequate tumor clearance and avoid the risk of local recurrence or metastasis.[4],[7],[9]

Initially, in the present case, resection and reconstruction with fibular graft were planned restoring hand function thereby. Detection of a skip lesion in the base of the same metacarpal on MRI guided our decision toward ray amputation.


 > Conclusion Top


Differentiating benign from low-grade malignant cartilage tumors is a challenge requiring thorough evaluation before arriving at a definitive diagnosis. Small hand compartments encourage local tumor spread, radical surgeries, or wide resections score over more conservative surgeries for making the patient free of disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Teo HEL, Peh WCG. Primary bone tumors of adulthood. Cancer Imaging 2004;4:74-83.  Back to cited text no. 1
    
2.
Thanigai S, Douraiswami B. Chondrosarcoma of metacarpal – A rare presentation. J Clin Orthop Trauma 2013;4:85-8.  Back to cited text no. 2
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3.
Hatori M, Watanabe M, Kotake H, Kokubun S. Chondrosarcoma of the ring finger: A case report and review of the literature. Tohoku J Exp Med 2006;208:275-81.  Back to cited text no. 3
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4.
Müller PE, Dürr HR, Wegener B, Pellengahr C, Maier M, Jansson V. Solitary enchondromas: Is radiographic follow-up sufficient in patients with asymptomatic lesions? Acta Orthop Belg 2003;69:112-8.  Back to cited text no. 4
    
5.
Evans HL, Ayala AG, Romsdahl MM. Prognostic factors in chondrosarcoma of bone: A clinicopathologic analysis with emphasis on histologic grading. Cancer 1977;40:818-31.  Back to cited text no. 5
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6.
Sridhar H, Vijaya M, Clement W, Srinivas C. Chondrosarcoma arising in an enchondroma of the metacarpal bone – A case report. J Clin Diagn Res 2014;8:142-3.  Back to cited text no. 6
[PUBMED]    
7.
Demireli P, Cavdar DK, Vural S, Ovali GY, Ozalp T. Secondary chondrosarcoma arising from a solitary enchondroma at the index finger of the right hand – A case report. Turk J Pathol 2006;22:53-6.  Back to cited text no. 7
    
8.
Miyake A, Morioka H, Yabe H, Anazawa U, Morii T, Miura K, et al. A case of metacarpal chondrosarcoma of the thumb. Arch Orthop Trauma Surg 2006;126:406-10.  Back to cited text no. 8
[PUBMED]    
9.
Gohla T, van Schoonhoven J, Prommersberger KJ, Lanz U. Chondrosarcomas of the hand. Handchir Mikrochir Plast Chir 2004;36:328-32.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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