Key words: Bone tumors - Spine - Tumor of spine. - Chondrosarcoma - Computed tomography. Chondrosarcoma is a fairly common primary malignant tumor of ...
Skeletal Radiology
Skeletal Radiol (1985) 14:178-183
Chondrosarcoma of the spine: An unusual radiographic presentation George Hermann, M.D. t, Michael Sacher, M.D 1, Charles F. Lanzieri, M.D. 1, Paul J. Anderson, M.D. 2, and Jack G. Rabinowitz, M.D. 1 1 Department of Radiology and 2 Division of Neuropathology, Mount Sinai School of Medicine, City University of New York, USA
Abstract. Chondrosarcoma is a primary malignant tumor arising rarely in the axial skeleton. It usually presents as a destructive lesion with diffuse mottled calcification. We report three patients with chondrosarcoma of the spine. Each patient was evaluated by conventional radiographic technique, computed tomography, and myelography. All of them show radiographically a purely destructive process of the body and in one case the body and lamina. This pattern remains to be documented in the radiologic literature. Key words: Bone tumors - Spine - Tumor of spine - Chondrosarcoma - Computed tomography
Chondrosarcoma is a fairly common primary malignant tumor of the skeleton that characteristically involves the bones of the shoulder and pelvic girdles, the long bones, and the ribs [4]. Its incidence increases in the fourth decade and is second only to myeloma [2]. The tumor usually arises de novo from bone. Secondary lesions that occur within pre-existing solitary enchondromas, osteochondromas, or Paget's disease are less frequent. The occurrence of chondrosarcoma in the vertebral axis is extremely rare [1]. It may arise in the posterior elements of the spine or in the vertebral body [2]. The preoperative diagnosis is based, in most cases, on the clinical and radiological appearance. Our experience with three patients is described. Each patient was evaluated by conventional radiographic techniques, computed tomography (CT),
myelography, and in one instance angiography. Atypical radiographic findings were obtained in all cases.
Case reports Case 1
A 77-year-old female was admitted with a two month history of left hip pain radiating to the left upper thigh. The pain was aggravated by movement or walking, but subsided at rest. She subsequently developed weakness and numbness of the left hip. Her past medical history was non-contributory. Physical examination revealed straight leg raising on the left restricted to 45 ~ a slightly decreased left knee jerk, and left foot drop. She noticed a mild decrease in sensation on the left calf. Electromyography suggested L5 dysfunction. A plain radiograph of the lumbosacral spine demonstrated mild degenerative changes at the level of L4-5, but no sign of a destructive lesion. The patient responded well to conservative therapy. Two months later the symptoms reappeared but the repeated plain radiographs revealed mild degenerative changes with no definite sign of a destructive lesion (Fig. 1). Because of the persistent symptoms, CT was performed and showed extensive destruction of L4 without evidence of calcification, suggesting a metastatic lesion (Fig. 2). However, no primary lesion was detected following complete clinical evaluation. The patient initially refused a biopsy but later consented. Four weeks later, a repeat radiograph of the lumbar spine revealed evidence of bone destruction with depression of the upper endplate of L4. A needle biopsy was performed but was non-diagnostic. The patient refused open biopsy and left the hospital. Several months later she was readmitted with progressive paraparesis and CT revealed further destruction of the body of L4. Myelography demonstrated a ventral extradural block at the superior aspect of L4 (Fig. 3). The patient underwent laminectomy for decompression of the block, and biopsy of L4 demonstrated the presence of chondrosarcoma (Fig. 4).
Case 2 Address requests to: George Hermann, M.D., Department of
Radiology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA
9 1985 International Skeletal Society
A 39-year-old female was admitted to the hospital because of neck pain and progressive weakness of the right hand. Gradual-
Fig. 1. Case 1. Lateral view of the lumbar spine: Degenerative changes involve the facet joints of L4-$1. There is a mild pseudospondylolysthesis at the same level. Note the slight straightening of the anterior aspect of the body of L4. No sign of definitive destruction Fig. 2. CT section through the level of the body of L4. There is an extensive destruction of the left half of the body of L4. The mass protrudes into the spinal canal (arrow) Fig. 3. Myelography demonstrates a complete extradural block at the superior aspect of L4. Note the severe destruction of L4
Fig. 4. Histologic sections stained with hematoxylin-eosin showed a moderately cellular cartilagenous matrix containing cells with large, hyperchromatic nuclei and abundant polyhedral, coarsely vacuolated cytoplasm. Binucleate cells were common and occasional mitoses are seen. The pathologic diagnosis was chondrosarcoma (magnification x 135)
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Fig, 5A, B. Case 2. There is a destruction of the body of C6 on the lateral view (A). Note the involvement of the body and the right posterior element on CT (B) Fig. 6. Metrizamide myelography reveals an epidural defect in the right side of the contrast column at the level of C6. Note the destruction of the body and part of the right pedicle (arrows)
ly increasing neck pain and stiffness had begun two years prior to admission. Plain X-ray of the cervical spine at that time was interpreted as showing no definite pathologic process. These symptoms resolved spontaneously but returned abruptly following a motor vehicle accident after which the symptoms progressed to include pain in the right upper extremity. Radiologic examination revealed a lytic lesion involving the body and right lamina of the sixth cervical vertebra (Fig. 5A). CT scan confirmed the destructive process (Fig. 5 B). There was no sign of associated soft tissue mass or calcification. Myelography demonstrated a small epidural mass (Fig. 6).
Laminectomy was performed and a 3 x 2 x 2 cm mass was removed from the right posterior arch. Histologically the tumor proved to be chondrosarcoma showing a high degree of cellularity with large multinucleated cells (Fig. 7).
Case 3 A 30-year-old male was admitted for treatment of severe subluxation of C1-2. His clinical history revealed that 18 months previously he had been struck by a car and thrown to the
G. Hermann et al. : Chondrosarcoma of the spine
~81 Fig. 7, Histologic sections stained by hematoxylin-eosin exhibited a moderately cellular cartilagenous matrix composed of plump, rounded cells with eccentrically placed hyperchromatic nuclei and abundant polyhedral, vacuolated cytoplasm. Binucleate cells were common. Occasional mitoses were encountered. The pathologic diagnosis was chondrosarcoma (magnification x 76) Fig. 8A, B. Case 3. There is destruction of the body of C2 on lateral view with evidence of subluxation of C1-2 on lateral view (A). CT myelography reveals an extensive destruction of the body of C2 (B). Evidence of soft tissue mass in the spinal canal
ground sustaining a hyperflexion injury. He had severe head and neck pain at the time of the accident but suffered no loss of consciousness. X-rays revealed a fracture of C2 which was interpreted as pathological in nature, secondary to possible underlying aneurysmal bone cyst. The patient refused surgical treatment at that time. One year later he reinjured his neck but no changes in the radiologic findings were detected. At the present admission physical examination showed no significant neurologic findings. On the plain lateral view of the cervical spine, a lytic lesion of C2 was observed with severe subluxation of C1-C2 (Fig. 8A). CT demonstrated a destructive lesion in the body of C2 (Fig. 8 B). The patient was placed in cervical traction to 20 lb. Preoperative angiography showed faint vascularity anterior to C2. Consequently, the spine was
fused posteriorly for stabilization. 4 x 3 cm tumor was removed from the body of C2. Histology showed chondrosarcoma.
Discussion
Primary malignant tumors of the spinal column are relatively uncommon lesions, comprising at most about 6-7% of all chondrosarcomas [5, 6, 10]. When compared to the incidence of metastatic disease Torma [12] found only 11 cases of clhondrosarcoma in a series of 250 histologically verified
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Fig. 9. Histologic sections stained with hematoxylin-eosin disclosed a moderately cellular tumor composed of plump cells with compressed, eccentrically positioned nuclei and abundant granular cytoplasm. Occasional "cartilage-like" columns of tumor cells were observed; mitoses were rare. The pathologic diagnosis was chondrosarcoma (magnification x 74)
malignant tumors of the axial skeleton. According to the Memorial Hospital Tumor Registry of New York, only 19 cases of primary vertebral chondrosarcomas have been recorded there during the past 30 years [2]. Our series of three cases is probably one of the larger series recorded. Although the number of reported cases is small, chondrosarcomas have been found at every level of the vertebral column but occur most commonly in the thoracic area [12]. Pain and swelling are the usual presenting symptoms. The tumor is slow growing, with clinical symptoms sometimes developing over 4 to 5 years [3]. In one instance a tumor was known to be present for more than 20 years [2]. Vertebral location is more common in a younger age group. The neurologic abnormalities may vary from paresthesias to paraplegia. In a few instances extradural block has been described at the time of onset of clinical symptoms. When spinal cord compression occurs the tumor usually arises from the posterior arch [13]. The radiologic appearance as described in the majority of cases is fairly characteristic. The tumor shows a large area of bone destruction associated with irregularly mottled calcifications. Sclerotic margins may often be recognized. The tumor can extend from one spinal level to another. When it extends into the soft tissue it always contains calcification [1-3, 9]. Although it is quite common for chondrosarcoma to appear lytic in the peripheral skeleton, we were unable to find a documented
case of purely lytic chondrosarcoma of the spine, although it has been described without radiologic documentation [8]. Each of our three cases presented as a lytic process of the vertebral body and in one case also of the lamina. The lesions in our series were relatively limited and not significantly expansile. N o flocculent calcifications or soft tissue masses were found. Computerized tomography is invaluable in demonstrating the extent of the pathologic process. It is essential to evaluate the degree of spinal canal involvement. The occurrence of an extradural block in the absence of a significant paraspinal mass (Case 3) has not, to our knowledge, been reported previously in primary chondrosarcoma of the spine. In many instances, CT is able to demonstrate the soft tissue extent into the spinal canal, and thereby myelography can be avoided [7]. In our first case the initial plain radiographs were virtually normal and only CT revealed a lytic lesion. The radiologic appearance of the destructive process was indistinguishable from aneurysmal bone cysts, metastases, myeloma, and lymphoma. Chondrosarcoma must be considered in the differential diagnosis of tumorous spinal lesions in the younger age group before undertaking biopsy. The primary spinal tumors have a less favorable prognosis than lesions in the appendicular skeleton [5]. Complete removal of the tumor is essential in order to achieve a high cure rate. This is often technically difficult because the proximity
G. Hermann et al. : Chondrosarcoma of the spine
of vital structures prevents total excision. Therefore, a high probability exists that residual tumor cells will eventually become responsible for recurrence. Histologically, chondrosarcoma may be classified as low, average, or high grade depending on the morphology of the nuclei and the cell differentiation. However, to differentiate low grade chondrosarcoma from benign chondroma may be difficult because of the subtle changes in cellularity [4, 11]. In some cases the radiologic evidence of lack of invasion may be helpful in diagnosing benign conditions [6]. Clear cell chondrosarcoma, a histopathologically different entity has been described recently. Roentgenographically these tumors appear predominantly lytic and in most instances involve the proximal femur and the humerus. Involvement of the vertebral lamina in one instance has been described. While metastasis is uncommon, local recurrence is frequent [4]. Chondrosarcoma may grow at the site of biopsy since it is almost impossible to prevent neoplastic cells spilling into the wound [2]. Therefore, the tumor must be widely excised at the time of the definitive surgery together with the biopsy site. In order to ensure an en bloc removal of the lesion, the surgeon must be aware of the size and extent of the tumor when curative surgery is planned.
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