Chondroblastoma

Original Editors - Drew Cecil & Chance Chadwick  from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors -

Definition/Description

Chondroblastoma refers to a benign bony tumor that is caused by the rapid division of chondroblast cells which are found in the epiphysis of long bones. They have been described as calcified chondromatous giant cell tumors[1]. The most frequently involved body regions are the hip, knee, and shoulder. Although usually benign, chondroblastoma metastasizes on rare occasions, with fatal results[2].

Prevalence

Chondroblastoma is a relatively rare, benign cartilaginous tumor, accounting for approximately 1% of the benign tumors of bone. The peak incidence is in the second decade of life and is slightly more common in males than females[3]. In addition to long bones, chondroblastoma also occurs in the acetabular region of the pelvis, scapula, spine, and ribs. It can also occur in the patella, tarsal bones, and occasionally in craniofacial bones.

Metaphyseal origin is rare but has been reported. Rare cases of multifocal chondroblastoma with synchronous involvement of several typical sites have also been documented. A small number of cases have reported chondroblastomas that are exclusively found in soft tissue[4].

Recurrence of the tumor happens in about 20% of cases, and seems to depend on the location of the initial tumor and the surgical intervention selected to treat it. Recurrence is most common in tumors of the hip and lumbar spine[5].

Characteristics/Clinical Presentation

Clinically, patients present with the following signs and symptoms in early stages of tumor development[5]:

  • Pain
  • Swelling around the joint
  • Limited range of motion secondary to pain
  • Palpable mass at the sight of the lesion
  • Antalgic gait patterns secondary to pain and decreased range of motion[4].


In later stages of tumor development the following signs and symptoms may become evident:

  • Synovitis
  • Joint effusion
  • Periostitis


Histologically, the tumour is built up of round or polygonal chondroblasts surrounded by reticulin fibers. The matrix is pinkstained chondroid, with occasional focal calcification. Scattered osteoclast-type multi-nucleated cells are often present. Dystrophic (chicken-wire) calcification is occasionally present but is not necessary for a diagnosis[6].


The following is a link to a video which discusses the histological components of a chondroblastoma:


Associated Co-morbidities

No associated co-morbidities were found to be related to condroblastoma.

Medications

There is currently no evidence that supports the pharmacological management of chondroblastoma. Over the counter medications such as nonsteroidal anti-inflammatory drugs (Ibuprofen) and acetaminophen (Tylenol) are commonly used for the management of pain as needed.

Diagnostic Tests/Lab Tests/Lab Values

Biopsy
In cases that appear to be atypical upon imaging, a needle or incisional biopsy of the tumor may be required before further surgical intervention can take place.

Radiographic Imaging
The appearance of chondroblastomas in radiographic imaging are reflected by the benign, slow-growing nature of the lesions. They are usually revealed as round or oval, lucent lesions with sharply marginated borders. Radiographs may also be useful in differentiating chondroblastoma from other benign bony tumors when periostitis is present[7]

Magnetic Resonance Imaging
MRI can be useful in depicting the extent of the tumor when a chondroblastoma extends to the metaphysis of long bones. The stroma of the bony tumor provides a low signal intensity on T1-weighted images and variable signal intensity on T2-weighted images. The signal intensities of other bony tumors (endochondromas, osteochondromas, etc.) tend to be very high in T2 weighted images, a characteristic that is not seen in chondroblastomas. In some cases, MRI and radiographic images may have contradicting results. In this situation, the diagnosis of chondroblastoma should be made based off of radiographic images.

Nuclear Imaging
Nuclear imaging involves the uptake of a radionuclide agent that is absorbed by the bone. This type of imaging has proven to be useful as the agent is absorbed by the highly vascularized area surrounding the tumor. Nuclear imaging is not typically used to diagnose chondroblastoma, rather, it can be used to rule in other bony tumors that are typically multifocal in nature such as endochondromas and osteochondromas.

Angiography
Angiography is not typically used as a diagnostic intervention, however, it can be useful in planning for surgical removal of the tumor. Angiograms rarely reveal any serious vascular abnormality, but there have been reports of vascular displacement in cases where large tumors are present. Periosteal reactions and neovascularization of nearby cortical bone have been reported in some angiographic imaging cases.

Computed Tomography
CT scanning is rarely used as a diagnostic tool in patients with chondroblastoma. This imaging modality is usually reserved for more severe or recurrent tumors. CT scans can depict matrix mineralization, extension of the tumor into soft tissue, and erosion of cortical bone. Coronal and sagittal reconstructions can be used to assess extension of the tumor across the epiphyseal plate into the metaphysis of the bone.

[8]

The following is a link to a video which depicts CT scan results of a chondroblastoma in the proximal tibia:


Etiology/Causes

Chondroblastomas occur when a single chondroblast cell begins to divide at an abnormally high rate. This typically occurs in the epiphyseal region of long bones. The cause of the high rate of cell division is unknown. There is currently no evidence that links chondroblastoma to a faulty or abnormal gene. Chondroblastoma has also been found to have no association with repeated joint trauma. [9]

Systemic Involvement

Musculoskeletal

  • Joint pain
  • Decreased range of motion
  • Atrophy of muscle
  • Pathological fracture


Integumentary

  • Elevated temperature of the overlying skin
  • Swelling at location of the tumor


Neurologic

  • Bowel and bladder dysfunction
  • Sexual dysfunction
  • Numbness/weakness in lower extremity


Cardiopulmonary

  • Possibility of metastasizing to lungs

[10]

Medical Management (Current Best Evidence)

Most patients undergo curettage and bone grafting surgery when the tumor is present, high speed burring can also be included in the surgery[6]. Other treatments vary in the type of replacement after the curettage. These types of fillings can include polymethylmethacrylate, and fat implantation. Long term follow-up is needed because of the tumors ability for late recurrence[2].

Radiofrequency ablation is also used to treat this type of tumor. According to the Mayo Clinic radiofrequency ablation is a treatment in which the doctor inserts a thin needle through the skin and into the tumor, guided by imaging techniques. High-frequency electrical energy delivered through this needle heats and destroys the tumor. Months after the procedure, dead cells turn into a harmless scar.

Physical Therapy Management (Current Best Evidence)

Although physical therapy does not have a direct role on the treatment of chondroblastoma, it does have have an important role in maintaining the well-being of the patient. Physical therapists have the ability to screen for non- musculoskeletal involvement by recognizing red-flags that may be associated with chondroblastoma. Therapist can refer patients to the proper healthcare provider if such a discovery is made.

Physical therapy will be involved in treating any impairments, functional limitations, or disabilities that can occur secondary to chondroblastoma. Increasing the patient’s quality of life and allowing the patient to maintain and independent lifestyle are the main goals of physical therapy for patients. The treatment will focus on improving mobility, allowing the patient to return to their prior level of function, and reducing pain. Cardiovascular fitness will also be an important aspect of treatment. Improving this will help the patient’s energy levels and tolerance for activities of daily living.

[11]

Differential Diagnosis

Differential diagnosis is important for both the physician and the physical therapist. The physician must differentiate between different bony tumor disease processes using appropriate imaging and histological findings. The physical therapist, especially in a direct access situation, must be able to rule out articular or soft tissue injuries in order to refer the patient to the proper practitioner. Below, is a list of possible differential diagnoses seen with chondroblastoma:

  • Giant cell tumor
  • Chondrosarcoma
  • Endochondroma
  • Osteochondroma
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Juvenile Rheumatoid Arthritis
  • Periarticular Soft Tissue Injury
    Anatomy.jpg


[10][9]

Case Reports/ Case Studies

Title
Chondroblastoma Of A Metacarpal Bone Mimicking an Aneurysmal Bone Cyst: A Case Report And Review Of The Literature

Authors

Takuya Kudo, Kyoji Okada, Yoshinori Hirano and Masato Sageshima

Abstract
Chondrobalstoma of the metacarpal bone is rare. This study talk about a case where a 21 year old male developed a chondroblastoma of the first metacarpal bone on the right hand. Radiographs showed an expansile osteolytic lesion with a multilocular appearance. In the MRI the lesion showed low-intensity in T1 and high intensity in T2-weighted images with multiple fluid levels. These MRI findings resemble an aneurismal bone cyst (ABC). The tumor was recognized as a chondrobalstoma from the pathological findings. 

Examination
The 21-year-old male had experienced swelling of his right thenar region. The physical examination revieled swelling tenderness and a well-defined tumor with bony hard consistence in the right thenar region of the right hand. Excursion of the metacarpophalangeal joint and carpometacapal joint was limited. The patient did not have any history of trauma and laboratory data was unremarkable.
Radiographs showed thinning and ballooning of the bone cortex of the entire right first metacarpal bone, except in its distal end. In the medullary region of the metacarpal bone, and osteolytic lesion having multilocular septa was found. Sclerotic change of the rim of the lesion was prominent in the radial distal site.

Summary of findings
A benign bone tumor such as ABC or giant cell tumor with ABC-like change was suspected. Histologically, low power magnification showed a number of large and small cystic spaces filled woth blood, suggesting and ABC. Based on the presence of pink-stained chrondroid foci and a coffee-bean appearance of the nuclei of the cells, chondrobalstoma with ABC-like change of the first metacatpal bone was diagnosed.

Intervention
Complete resection of the tumor was performed, leaving only the distal end of the metacarpal bone. A columnar shaped iliac bone was used to replace the bony tumor that was resected, and fixed through the carpometacarpal joint.

Outcome
The patient was followed up with until the 27th month post-op, there was no sign of local recurrence in physical and radiological examination, and bone union was in satisfactory condition.

Discussion
In summary, this is a rare case of chondroblastoma. In the imaging diagnosis, it appeared to be an ABC or giant cell tumor with ABC-like change. The resection and subsequent bone graft provided a good clinical outcome. The authors stressed that chondroblastoma rarely occur in metacarpal bone, and may show imaging features similar to those of ABC.

Recent Related Research (from Pubmed)

References

  1. Bain LG, Sun QF, Zhao WG, Shen JK, Tirakotai W, Bertalanffy H. Temporal bone chondroblastoma: A review. Neuropathology 2005; 25, 159–164.
  2. 2.0 2.1 Atalar H, Basarir K, Yildiz Y, Erekul S, Saglik Y. Management of chondroblastoma: retrospective review of 28 patients. J Orthop Sci. 2007; 12, 334–340.
  3. Elek E, Grimer R, Mangham D, Davies A, Carter S, Tillman R. Malignant chondroblastoma of the os calcis. Sarcoma. 1998; 2, 45-48.
  4. 4.0 4.1 Kang LC, Chamyan G, Barness-Gilbert E. Pathology teach and tell: chondroblastoma. Pediatr Pathol Mol Med. 2002; 21, 71-74.
  5. 5.0 5.1 Ramappa A, Lee F, Tang P, Carlson J, Gebhardt M, Mankin H. Chondroblastoma of bone. J Bone Joint Surg. 2000; 82(8), 1140-1145.
  6. 6.0 6.1 Hsu CC, Wang JW, Chen CE, Lin JW. Results of curettage and high-speed burring for chondroblastoma of the bone. Chang Gung Med J. 2003; 23(10), 761-766.
  7. Brower A, Moser R, Kransdorfl M. The frequency and diagnostic significance of periostitis in condroblastoma. Am J Roentgenol. 1990; 154, 309-314
  8. Fine BP and Stacy GS. Chondroblastoma Imaging. Medscape Reference. http://emedicine.medscape.com/article/388632-overview#a01. Last Edited May 25, 2011. Accessed on April 3, 2012.
  9. 9.0 9.1 Damron TA and Morgan HD. Chondroblastoma. Medscape Reference. http://emedicine.medscape.com/article/1254949-overview. Last Edited February 6, 2012. Accessed on April 3, 2012
  10. 10.0 10.1 Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.
  11. Cancer Treatment Center of America. Oncology Rehabilitation. http://www.cancercenter.com/complementary-alternative-medicine/physical-therapy.cfm. Accessed April 2, 2011.