Hand Surgery Source

CHONDROBLASTOMA

Introduction

Chondroblastomas are benign, rare, yet aggressive tumors that typically grow at the ends of the body’s long bones, close to the epiphysis (joints). Chondroblastomas have been observed in the lunate5 triquetrum and hamate4. Although not malignant, chondroblastomas will grow if left untreated, possibly destroying surrounding bone and making movement painful. In extremely rare cases, the tumor can metastasize to the lungs or other organs. Delays in diagnosis result from the lack of typical clinical and radiologic presentation; findings in both cases are nonspecific. Surgery is always the preferred treatment, unless the tumor cannot be removed due to its location or size.

Pathophysiology

  • The cause of chondroblastomas is not known.
  • In children, they are thought to arise from the cartilaginous growth plates, just as the plates start to close.
  • The tumors comprise many cells that resemble fetal cartilage.
  • One hypothesis about the aggressive growth of chondroblastomas suggests an aneurysmal bone-cyst component.
  • Chondroblastomas contain "coffee bean" shaped chondroblasts, multinucleated giant cells and a chondroid matrix5.

Related Anatomy

  • A large percentage of chondroblastomas occur at the knee joint (34%), at the ends of the femur or tibia, or in the shoulder at the proximal humerus (20%).
  • Less common locations include the pelvis, hip, and heel.
  • In the shoulder, the chondroblastoma is called “Codman’s tumor.”

Incidence

  • Chrondroblastomas are rare and account for only 1% of all bone tumors.
  • Approximately 80% of patients are aged <25 years.
  • Males are twice as likely as females to develop chondroblastomas.
  • Chondroblastomas are extremely rare in the hand and wrist.

Differential Diagnosis

  • Aneurysmal bone cyst
  • Clear-cell chondrosarcoma
  • Enchondroma
  • Eosinophilic granuloma
  • Giant cell tumor
  • Infection of the bone (osteomyelitis)
  • Osteoblastoma
ICD-10 Codes

CHONDROBLASTOMA

Diagnostic Guide Name

CHONDROBLASTOMA

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
CHONDROBLASTOMA, BENIGN NEOPLASM, BONE        
- SHORT BONES OF UPPER LIMB (FOREARM, WRIST, HAND, FINGERS, THUMB)   D16.12 D16.11  

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Swelling with visible and/or palpable mass
Pain (also present at rest)
Joint stiffness
Muscle atrophy
Typical History

The patient is most likely a young male under the age of 25.  The main presenting symptom is pain. If the carpal bones are involved, then the patient may describe worsening wrist pain that is exacerbated with ulnar deviation and lifting heavy objects. The patient will not have seen or felt a mass, because the tumor is within the bone. If presentation is delayed, swelling, stiffness, and tenderness may accompany the pain.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Remove the tumor and prevent recurrence
Conservative
  • All treatments require interventional therapies.
Operative
  • Cryotherapy
  • Radiofrequency ablation
  • Curettage of the tumor with filling of the defect with autogenous graft, allograft or bone cement.
  • Curettage of the tumor may be augmented with phenol or adjuvant intralesional cryotherapy which has been report to provide lower recurrence rates (7%).
  • En block resections may require reconstruction with internal fixation and/or implants to stabilize the bone or replace the joint.
  • For metastasis, resection of both the metastasis and the surrounding soft tissue should be done.
Complications

SURGICAL COMPLICATIONS

  • Damage to growth plate
  • Fracture of bone at treated area
  • Hamate excision could have important implications for finger and wrist biomechanics
  • Infection
  • Recurrence of tumor  
Outcomes
  • Prognosis is good after complete surgical removal of the affected bone.
  • Tumors recur in 10–35% of patients; thus, regular follow-up examinations and X-rays are necessary for 3 to 4 years.
  • Patients may develop osteoarthritis over time.
    • Satisfactory outcomes have been observed after endoscopically assisted decompression and mini-open decompression.
Key Educational Points
  • Chondroid differentiation (95% of cases) or calcification must be identified for the histologic confirmation of chondroblastoma.
  • A chondroblastoma is easily misdiagnosed as an aneurysmal bone cyst (ABC) because it mimics ABC both clinically and radiographically.
  • One third of chondroblastoms contain a secondary aneurysmal bone cyst (ABC).
  • Filling the bony deficit after curettage is controversial: some prefer cementation; others recommend autogenous or allograft bone.
References

New Articles

  1. American Academy of Orthopedic Surgeons. Chondroblastoma. 2016. Accessed October 31, 2016 at http://orthoinfo.aaos.org/topic.cfm?topic=A00609
  2. Mashhour MA, Abdel Rahman M. Lower recurrence rate in chondroblastoma using extended curettage and cryosurgery. Int Orthop 2014;38(5):1019-24. PMID: 24248272
  3. Wu CT, Chen AC, Wang CJ, et al. Chondroblastoma of the triquetrum. Pediatr Neonatol 2013;54(4):278-80. PMID 23597548
  4. Rhee PC, Novais EN, Shives TN, Shin AY. Chondroblastoma with secondary aneurysmal bone cyst of the hamate: Case report. J Hand Surg 2012;37A:538–42. PMID: 22284749
  5. Tountas CP and Cobb SW. Chondroblastoma of the lunate: A case reort. J hand Surg 1992;17A (3):466-467.

Case Reports

  1. Krishnappa A, Shobha SN, Shankar SV, Aradhya S. Fine needle aspiration cytology of chondroblastoma: A report of two cases with brief review of pitfalls. J Cytol 2016;33(1):40-2. PMID: 27011442
  2. Rhee PC, Novais EN, Shives TN, Shin AY. Chondroblastoma with secondary aneurysmal bone cyst of the hamate: Case report. J Hand Surg 2012;37A:538–42. PMID: 22284749

Classics

  1. Jaffe HL, Lichtenstein L. Benign chondroblastoma of bone: a reinterpretation of the so-called calcifying or chondromatous giant cell tumor. Am J Pathol 1942;18(6):969-91. PMID: 19970672
  2. Shanmuga Sundaram TK, Benign chondroblastoma. J Bone Joint Surg 1966;48B(1):92-104. PMID: 5909069