on serial radiographs of myositis ossificans. Calcification may occur in the soft tissues in conditions such as scleroderma,. Raynaud disease, and systemic lupus.
1263
Soft-Tissue
Michael B. Philip H. Lander1 Louis R. Begin2 Alexander Hadjipavlou3
Chondromas
Soft-tissue
chondromas are benign, relatively rare lesions. The clinicopathologic and features in six cases are presented and the literature is reviewed. Five of six cases had calcifications. Peripheral curvilinear calcification was seen in two cases, multiple nnglike areas characteristic of cartilage in one, and discrete ossification in another. Histopathologically, they were diverse, ranging from an immature pattern with a preponderance of chondroblasts to a more mature form with chondrocytes. Although these lesions resemble a wide variety of other soft-tissue Iesions, they can usually be differentiated by their small size, characteristic location in the extremities, the nature of their calcifications, and the histopathologic features. The importance of this lesion is that it is benign. It must be distinguished from more aggressive soft-tissue neoplasms such as soft-tissue chondrosarcoma so as to spare the patient unnecessary radical therapy. radiologic
Benign soft-tissue cartilaginous tumors are relatively uncommon. Somewhat fewer than 200 cases have been described in the literature. In 1 883 Baumuller [1] first reported on an ossifying chondroma of the skin of the dorsum of the foot. In 1 887 Paget [2] reported that cartilage tumors arising in the soft tissues are usually benign. Recently, there have been two comprehensive reports in the pathologic literature. In 1 974 Dahlin and Salvador [3] reported 70 cases in the hands and feet, from the Mayo Clinic. In 1 978 Chung and Enzinger [4] reported 1 04 cases from the Armed Forces Institute of Pathology, also mainly in the hands and feet. However, only two radiographs were published in both these larger series. While there have been scattered reports of small numbers of cases elsewhere [5-10], the radiologic spectrum of this lesion has not been adequately characterized. A review of the Sir Mortimer B. Davis Jewish General Hospital’s experience with these tumors is presented.
Received October 12, 1984; accepted vision 1
February Department
after re-
8, 1985. of
Radiology,
McGill
University,
and Sir Mortimer B. Davis Jewish General Hospital, 3755 Cote St. Catherine Rd., Montreal, Quebec H3T 1 E2, Canada. Address reprint requests to P. H. Lander. 2 Department
of Pathology,
and Sir Mortimer
B. Davis Jewish
Montreal,
Quebec
Department and Sir Mortimer 3
McGill General
McGill University,
B. Davis Jewish
General
1985
C American Roentgen Ray Society
A survey of the records of the radiology and pathology departments uncovered six cases of soft-tissue chondroma from 1978 to 1983. Clinical and surgical records and gross and microscopic pathology were reviewed in all six cases. Excision had been performed in all cases. Plain radiographs in six cases and a computed tomographic (CT) scan in one case (case 2) were assessed. Follow-up information ranging from 1 month to 3 years was obtained.
Hospital,
of Orthopedics,
AJR 144:1263-1267, June 0361 -803X/85/1 446-1263
and Methods
University,
H3T 1 E2, Canada.
Montreal, Quebec H3T 1E2, Canada.
Materials
Hospital,
Results
Six cases of soft-tissue chondroma were studied. Three tumors were located in the fingers, two in the toes, and one in the proximal tibia. The patients were 1373 years old; there were four females and two males. The tumors measured 0.52.2 cm. Clinical, radiologic, and pathologic findings are detailed in the case reports.
1264
ZLATKIN
ET AL.
AJR:144, June 1985
24
.
‘..
-
I
.
.
Fig. 1 -Case 1 . Anteropostenior (A) and lateral (B) radiographs of left index finger. Large anterolateral soft-tissue mass with dense inhomogeneous calcification. Entire mass is calcified with well defined curvilinear border of calcification. Adjacent bone and joint are uninvolved. C, Plump cells with abundant eosanophihc cytoplasm and eccentric nuclei, characteristic of chondroblasts, are embedded within hyaline chondroid matrix (x250).
S
‘:‘‘
A
B
Fig. 2.-Case
2.
C
of
mass adjacent to proximal right tibia, with incompletely circumscribed (arrowhead). B, CT scan of this region. Peripheral rim of calcification (arrowhead). No evidence of bony involvement. C, Mature and pyknotic nuclei within chondroid Iacunae (x250).
Case
A, Radiograph
right knee. Soft-tissue
Reports
Case 1
A 73-year-old woman had progressive swelling of the distal left index finger for 2 years. Physical examination revealed a large, firm, tender mass of the terminal phalanx of this finger. The distal interphalangeal joint was entirely normal. There were no other subcutaneous masses.
peripheral chondrocytes
curvilinear
calcification
with little cytoplasm
Plain radiographs revealed an anterolateral soft-tissue mass, with dense inhomogeneous calcification and a well defined curvilinear calcified border (figs. 1A and 1B). There was no bone erosion or periosteal reaction. A 1 .2 cm well circumscribed, subcutaneous, slightly lobulated lesion was excised. The cut surface was firm, gritty, blue white, and glistening. Microscopic examination revealed confluent lobules of hyaline cartilage with a variable degree of cellularity, mainly chondro-
AJR:144,June
SOFT-TISSUE
1985
CHONDROMAS
Fig. 3.-Case 3. Anteropostenor (A) and lateral (B) films of right index finger. Lesion ventral to tuft of distal phalanx is incompletely calcified. Terminal sclerosis. No bony erosion. C. Chondroid-stromal interface displays granulomalike multinucleated giant cell proliferation. Fibrocartilage on right (xiOO).
1265
tuft
blasts. A few multinucleated giant cells were concentrated at the stromal chondroid interface. Calcification was present as coarse granular deposits or perilacunar ringlets (fig. 1C).
Case 2
A 19-year-old man had pain and a focal swelling below the right knee for 18 months. A firm, tender mass was present on the medial aspect of his right proximal leg. The knee joint was intact, with no limitation of motion. A small soft-tissue mass adjacent to the proximal aspect of the right tibia showing incomplete peripheral curvilinear calcification was seen on a radiograph of the knee (fig. 2A) and on a CT scan (fig. 2B). A firm, multilobulated, well circumscribed 2.2 x 2.0 cm mass was excised. The lesion was located below the capsular insertion and was not adherent to periosteum. The cut surface was blue white and glistening. Microscopic examination revealed a pure matrix of hyaline cartilage with mature chondrocytes (fig. 2C). There was a central cavitary space of cystic degeneration and an incomplete peripheral shell of calcification and/or ossification.
Case 3
Fig. 4.-Case 4. Anteropostenior film of right great toe. Soft-tissue mass with multiple punctate and ringlike calcifications. Underlying bone uninvolved.
A 58-year-old woman had had a fixed hard lump in the pulp space of the distal right index finger for 1 year. A small calcified lesion ventral to the tuft of the distal phalanx of the right index finger was seen on plain-film examination. Terminal tuft sclerosis was noted without adjacent bone erosion (figs. 3A and 3B). A 0.7 x 0.6 cm well circumscribed lesion was excised, displaying a firm, gritty, gray, and glistening cut surface. Microscopic examination displayed a mixed hyaline and fibrocartilaginous matrix with intervening
stromal
areas.
The
vascular core, with condensation
latter
were
characterized
of fibroblasticlike
by a fibre-
or chondroblastic-
like cells mixed with multinucleated giant cells at the stromal-chondroid interface (fig. 3C). The cellularity was variable, and a geographic
pattern of fine calcification
was present.
Case 4
A 61 -year-old woman had a 4 month history of swelling in her right great toe. Physical examination revealed a tender, firm nodule in the subcutaneous tissue just proximal to the interphalangeal joint. A soft-tissue mass proximal to the interphalangeal joint, with multiple areas of punctate and ringlike calcifications, was seen on plain radiographs (fig. 4). A 2.2 cm lesion was excised and had a cut surface similar to that of case 1 Microscopic examination showed confluent lobules of hyaline cartilage with marked variation in degree of cellularity, includ.
ZLATKIN
1266
ET AL.
AJR:144, June 1985
feet are the predominant site, with up to 80% in the fingers [13]. Clinically they present as a slow-growing mass, occasionally causing pain or tenderness. They are usually less than 3 cm in size, and, on palpation, firm or rubbery, well defined, and often mobile. Malignant transformation has not been reported in the English literature. Chung and Enzinger [4] reported 56 cases in which followup information was available for 1 year or more. Ten patients had recurrence after initial excision. In the 54 cases of Dahlin and Salvador [3], there was recurrence in eight during an observation period of 1 -1 0 years. Therefore, recurrence is a potential problem. In our series, follow-up examinations from 1 month to 3 years showed four of the patients (cases 1 3, 5, and 6) to be asymptomatic, and follow-up radiographs in three cases showed no recurrence. One patient (case 2) had a recurrent mass at the site of surgical excision but was asymptomatic and repeat biopsy was not performed. Case 4 showed no recurrence after 1 month of follow-up. The histopathologic appearance of this neoplasm is variable, ranging from an immature pattern dominated by chondroblasts (resembling osseous chondroblastoma) to a mature profile with chondrocytes (resembling osseous enchondroma). The matrix can be hyaline, fibrous, or fibrohyaline. A granulomalike reaction with multinucleated giant cells can be seen within the stroma, as in two of our cases. This was observed in about 15% of cases studied by Enzinger and Weiss [1 3]. The variable cellularity in conjunction with cellular immaturity and atypia could mislead one to a malignant pathologic interpretation. However, soft-tissue chondroma is unlikely to display tumor cells in cords and rows within a myxoid matrix, as found in extraskeletal myxoid chondrosarcoma, or the primitive round-cell pattern and hemangiopericytoid vascularity characteristic of extraskeletal mesenchymal chondrosarcoma [13]. The radiographic findings include a well demarcated, extraosseous, soft-tissue mass. Often, they are located near a joint, which may be related to a synovial origin. Previous authors have reported calcifications in 33%-70% [3, 4]. In our series, five of six cases had calcifications with a rim of peripheral curvilinear calcification in two. One case had multiple punctate and ringlike areas of calcification characteristic of cartilage and another discrete ossification. Other less common findings mentioned in previous reports are extrinsic bone erosion or sclerosis [3, 4, 1 3]. One of our cases (case 6) showed minimal bony erosion and one case (case 3) showed terminal sclerodactyly. The lesion should be differentiated from benign intraarticular and juxtacortical calcified lesions. The lesions of synovial chondromatosis are usually multiple and located within the synovial membrane or bursae of largejoints, such as the knee and elbow. Solitary intraarticular chondromas, as described by Milgram and Dunn [1 4], may be distinguished by their location within the joint capsule and large size, although there is controversy as to whether they are a distinct entity. Juxtacortical (penosteal) chondroma [1 3, 1 5-1 8] arises within and beneath periosteum and shows characteristic cortical erosion. ,
Fig. 5.-Case 5. Anteropostenor radiograph of left great toe. Calcified softtissue lesion, separate from bone, characterized by ossification within it.
ing
solid
geographic
groups
of
i
calcification,
0 to i 5 chondrocytes. mostly peripheral.
There were areas of
Case 5
A 45-year-old woman had severe pain in her foot for 2 months. At physical examination a firm mass, tender to palpation, was felt on the plantar surface at the metacarpophalangeal joint of the left great toe. An ossified mass in the soft tissues of the plantar surface of the foot was seen adjacent to the metacarpophalangealjoint on plain film examination (fig. 5). A 2 cm mass with an osseous core, completely separate from the adjacent bone, was excised. Microscopically, there was a peripheral shell of hyaline cartilage merging with fibrous tissue. Partly infarcted cancellous lamellar bone was present at the center.
Case 6
A 13-year-old boy developed a tender, firm mass at the radial aspect of the base of the proximal phalanx of the left third finger. Radiographs (not shown) demonstrated soft-tissue swelling without calcification, with minimal erosion of the underlying bone. A 0.5 x 0.3 cm subcutaneous nodule was excised, showing a gross and microscopic appearance similar to that seen in case 2, with absence of ossification and cystic changes.
Discussion
Soft-tissue chondromas are benign tumors of cartilaginous tissue that may arise adjacent to normal bony or cartilaginous structures. Dahlin and Salvador [3] suggested a synovial origin. Others considered them to be developmental faults or metaplasia [1 1 1 2]. These tumors are found in a wide age range, as evidenced by our cases. However, most have been found to occur around 30-60 years of age. The hands and ,
SOFT-TISSUE
AJR:144, June 1985
Malignant soft-tissue tumors showing calcification should be distinguished. The soft-tissue margins of synovial sarcoma may be indistinct, the calcification spotty and less frequent, and bone destruction or adjacent osteoporosis commonly seen. Extraosseous chondrosarcoma [1 1 1 3, 1 9] is uncommon in the hands and feet, tends to be large, shows secondary bony involvement, and the calcification is more irregular. Extraosseous osteosarcoma [20-22] is larger, often shows ossification, and is common in the thighs. Crystal deposition within paraarticular soft tissue occurs in gout, calcium pyrophosphate deposition disease, or hydroxyapatite deposition disease. The calcification tends to be amorphous, nodular, or multilobulated. Tumoral calcinosis may show fluid levels. Myositis ossificans is rare in the hand and foot [23]. Occasional periosteal reactions associated with this entity are never seen with soft-tissue chondromas, and there is rapid evolution on serial radiographs of myositis ossificans. Calcification may occur in the soft tissues in conditions such as scleroderma, Raynaud disease, and systemic lupus erythematosus. These are usually well circumscribed and multiple. There is most often a well defined clinical history and other characteristic radiographic findings. ,
.
weichen
2. Paget Green, 3. Dahlin of the 4. Chung
6. Dellon AL, Weiss SW, Mitch WE. Bilateral extraosseous chondromas of the hand in a patient with chronic renal failure. Am Soc Surg Hand 1978;3: 139-1 41 7. Hoeffel JE, Chameux F, Bretagne MC, Metle M, Floquet J. Les chondromes extraosseux du dolt. J Radiol 1980;61:293-296 8. Holmes HS, Bovenmeyer DA. Cutaneous cartilaginous tumour. Arch Dermatol
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12. Uehara H, Becker FP. Extraskeletal Surg 1960;80:319-326
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Milgram JW, Dunn EJ. Para-articular chondromas and osteochondromas. Clin Orthop 1980;i48: 147-1 51 15. Fornasier VL. Periosteal chondroma. Clin Orthop 1977;124:233-
236 16. Jaffe HL. Juxtacortical
chondroma.
Bull Hasp J Dis Orthop
Inst
1956;1 7:20-29
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der
J. Lectures in surgical pathology. London: Longmans, 1970:498 DC, Salvador AH. Cartilaginous tumors of the soft tissues hands and feet. Mayo Clin Proc 1974;49:72i-726 EB, Enzinger FM. Chondroma of soft parts. Cancer 1978;4i :1414-1424 5. Cooper M, Courniotes JH, Fethiere DA, Grovit M. Soft tissue chondroma with cytological atypia. J Am Podiatry Assoc 1980;70:36i -363
cartilaginous
13. Enzinger FM, Weiss SW. Cartilaginous tumors and tumor-like lesions of soft tissues. In: Soft tissue tumors. St. Louis: Mosby, 1983:698-705
18. B. Em Fall von ossificerendein
1976;1 12:839-840
9. Lichtenstein L, Goldman AL. Cartilage tumours in the soft tissues particularly in the hand and foot. Cancer 1964;i7:i203-i208 10. Rosenfeld N, Kurzer A. Soft tissue chondroma of the hand. Hand 1980;i2: 189-i 92 ii Smith MT, Farinacci CJ, Carpenter HA, Bannayan GA. Extraskeletal myxoid chondrosarcoma, a clinicopathological study. Cancer 1976;37:821 -827
a distinctive be1952;34:691-697 Rockwell MA, Salter ET, Enneking WF. Penosteal chondroma. J Bone Joint Surg [Am] 1972;54:i02-i08 Angerval L, Enerback L, Knutson H. Chondrosarcoma of soft tissue origin. Cancer 1973;32:507-5i3 Allan CJ, Soule EH. Osteogenic sarcoma of the somatic soft tissues. Cancer 1971;27:i121-1i33 Das Gupta TK, Hajdu SI, Foote FV. Extraosseous osteogenic sarcoma. Ann Surg 1968;i 68:1011-1022 Shahin W, Chaimoff C, Dintsman M. Extraosseous osteogenic sarcoma. Report of 2 cases. Clin Orthop 1974;1 01:151-153 Johnson MK, Lawrence JF. Myositis ossificans in the soft tissues of the hand. J Bone Joint Surg [Am] 1975;57:999-i000 nign cartilage
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CHONDROMAS
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