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Non-invasive diagnostic tools in the field of head and neck oncology : A liquid biopsy for head and neck cancers

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Enchondroma and atypical cartilaginous tumors : Enchondroma Atypical enchondroma† (chondrosarcoma in situ) Chondrosarcoma in situ Low-grade chondrosarcoma Intermediate-grade chondrosarcoma High-grade chondrosarcoma Dedifferentiated chondrosarcoma

Enchondroma

Atypical enchondroma† (chondrosarcoma in situ)

Chondrosarcoma in situ

Low-grade chondrosarcoma

Intermediate-grade chondrosarcoma

High-grade chondrosarcoma

Dedifferentiated chondrosarcoma

http://www.smbs.buffalo.edu/ortho/tumorarticles/cartilagetumors.pdf



Radiologic follow-up of untreated enchondroma and atypical cartilaginous tumors in the long bones:

Background and Objectives

Both enchondroma and atypical cartilaginous tumors (ACT) are not considered malignant, so inactive and asymptomatic tumors might not need surgery. To the best of our knowledge, this is the first study that has been done to evaluate the natural course of conservative-treated enchondroma and ACT in the long bones.

Methods

For this retrospective study, we analyzed the results of patients in whom we refrained from surgery and only regularly performed radiological follow-up of the tumor. Minimal follow-up after initial diagnosis was 24 months.

Results

Forty-nine patients were included in this study. Eight out of forty-nine cases received surgical treatment during follow-up of the tumor. The reasons for this surgery were radiologic growth of the tumor in two cases, pain in one case, patient request in three cases, another indication for surgery in the same limb in two cases.

Conclusion

In this small series of conservatively treated enchondroma and ACT, only 6% of the patients had a medical indication for surgery. This study shows that indication for surgery should be discussed more thoroughly. Based on our results, we would recommend annual radiologic follow-up for asymptomatic enchondroma or ACT in the long bones, irrespective of tumor size. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.




Journal of the American Academy of Orthopaedic SurgeonsCartilaginous neoplasms are relatively
common tumors that can
involve almost any bone.1 These
tumors vary in presentation and can
range from a latent enchondroma to
a high-grade or dedifferentiated
chondrosarcoma. The major dilemma
facing the surgeon is clinically and
radiologically differentiating an enchondroma
from a low-grade chondrosarcoma.
Occasionally, even the
histologic diagnosis can be difficult.
The diagnosis and treatment options
for these tumors are dependent on a
combination of clinical, radiologic,
and histologic findings.
Most musculoskeletal surgeons,
radiologists, and pathologists can
readily distinguish an enchondroma
from a high-grade chondrosarcoma.
Enchondromas are benign
intramedullary tumors that are
usually asymptomatic and do not
metastasize.1 They are most commonly
located in the short tubular
bones in the hands but are also
found in long bones. Radiographs
usually demonstrate a small (<5 a="" an="" and="" appearances="" are="" asymptomatic="" atypia="" be="" beyond="" bone.="" bones="" by="" calcifications="" can="" cartilage="" cartilaginous="" cells="" characterized="" chondrosarcomas="" clinically="" clinicopathologic="" cm="" commonly="" control="" cortical="" demonstrates="" destruction="" discrete="" distinct="" distinguish="" does="" each="" easily="" elements.="" enchondroma="" enchondromas="" endosteal="" entity="" excision.="" excision="" exhibit="" extension.1-4="" extension.="" extremely="" femur="" figures="" findings="" from="" have="" high-grade="" histologically.="" histologically="" however="" humerus="" hyaline="" in="" incidence="" including="" intralesional="" intramedullary="" involvement="" is="" islands="" lamellar="" larger="" lesion="" local="" located="" long="" low-grade="" low.4="" malignant="" marked="" metaphyses="" metastasize.5-9="" mitotic="" most="" multinucleated="" necessary="" neoplasms="" not="" observation.="" obtain="" occasionally="" of="" often="" one="" or="" other.="" other="" painful.="" painful="" radiographic="" radiologic="" radiologically="" range="" rare.="" recur="" recurrence="" require="" resemble="" scalloping="" significant="" soft-tissue="" some="" spindle="" surrounded="" symptomatic="" that="" the="" these="" they="" thickening="" this="" tibia="" to="" treated="" treatment="" tumor="" tumors.="" used="" usually="" which="" wide="" with="" without="">5 cm)
than an enchondroma. Endosteal
scalloping and lysis are common.2,10
Cortical thickening, expansion, or
disruption and soft-tissue masses
are uncommon findings.10,11 Because
low-grade chondrosarcomas
can have cytologic features similar
to those of enchondromas, histologic
evaluation is important.12,13
Dr. Marco is Assistant Professor of Surgery,
M.D. Anderson Cancer Center, Houston. Dr.
Gitelis is Professor of Orthopaedic Surgery,
Rush Medical College, Chicago. Dr. Brebach is
Instructor in Orthopaedic Surgery, Rush
Medical College. Dr. Healey is Professor of
Orthopaedic Surgery, Weill/Cornell University
and Memorial Sloan-Kettering Cancer Center,
New York.
Reprint Requests: Dr. Gitelis, Suite 440, 1725
W. Harrison Street, Chicago, IL 60612.
Copyright 2000 by the American Academy of
Orthopaedic Surgeons.
Abstract
The proper treatment of cartilaginous tumors is dependent on the clinicopathologic
and radiologic findings. Enchondroma is a benign tumor that is usually
asymptomatic and thus should be treated nonoperatively. Symptomatic
enchondromas are often treated by intralesional excision. Intramedullary lowgrade
chondrosarcoma is a malignant tumor that is usually painful. The treatment
of low-grade chondrosarcoma may range from intralesional excision with
or without adjuvant therapy to wide excision. Although intralesional excisions
have a higher bone and joint preservation rate than wide excisions, they may be
associated with a higher local recurrence rate. Intermediate- and high-grade
chondrosarcomas are treated with wide excisions. The treatment of these cartilaginous
lesions should involve a multidisciplinary team including a musculoskeletal
surgeon, a radiologist, and a pathologist.
J Am Acad Orthop Surg 2000;8:292-304
Cartilage Tumors: Evaluation and Treatment
Rex A.W. Marco, MD, Steven Gitelis, MD, Gregory T. Brebach, MD, and John H. Healey, MD
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 293
Low-grade chondrosarcomas
rarely metastasize, but frequently
recur if inadequate surgery is performed.
7-9 Most authors therefore
recommend a wide excision to eradicate
a low-grade chondrosarcoma,
although some have advocated
intralesional therapy. Wide excisions
are associated with low local
recurrence rates, whereas intralesional
excisions are associated with
high local recurrence rates. Intralesional
excisions combined with
adjuvant therapy, however, are
associated with low mortality and
local recurrence rates in carefully
selected patients with low-grade
chondrosarcomas.14 Intralesional
excisions preserve the adjacent bone
and joint surfaces, which probably
improves the functional outcome.
The primary dilemma is determining
which intramedullary lowgrade
chondrosarcomas can be
treated by intralesional excision
rather than wide excision. A thorough
evaluation of the clinical presentation,
radiographic findings,
and histologic appearance is necessary
to determine the most appropriate
treatment (Table 1).
Clinical Presentation
Enchondroma involving a metacarpal
or phalanx of the hand may present
as pathologic fracture in a
young adult. Enchondromas involving
long bones are usually
asymptomatic and are commonly
an incidental finding identified on a
radiograph obtained to evaluate the
chest or an adjacent joint. Regional
pain about an enchondroma is more
frequently related to a nearby joint
or a local soft-tissue disorder than to
the tumor itself and may be the
cause for incidental discovery of an
asymptomatic enchondroma.
A common scenario is a patient
with shoulder pain in whom there
is a completely intramedullary cartilaginous
lesion in the proximal
humerus, which could represent an
enchondroma or a low-grade chondrosarcoma.
A thorough history
and physical examination are necessary
to evaluate the shoulder for
other causes of the pain. Subacromial
or acromioclavicular injection
of a local anesthetic agent can help
identify the origin of the pain. If
Table 1
Characteristics of Cartilage Tumors and Treatment Recommendations
Adaptive or
Aggressive Radio-
Tumor Type Pain logic Changes* Bone Scan Histology Treatment
Enchondroma − − − Enchondroma Observation
Atypical enchondroma†
(chondrosarcoma in situ) + − +/− Enchondroma Observation or intralesional
excision
Chondrosarcoma in situ +/− − +/− Grade I Observation, intralesional
chondrosarcoma excision, or (occasionally)
wide excision
Low-grade
chondrosarcoma + + + Grade I Wide excision
chondrosarcoma
Intermediate-grade
chondrosarcoma + + + Grade II Wide excision
chondrosarcoma
High-grade
chondrosarcoma + + + Grade III Wide excision
chondrosarcoma
Dedifferentiated
chondrosarcoma + + + Dedifferentiated Wide excision
chondrosarcoma
* Adaptive radiologic changes include cortical thickening and expansion. Aggressive changes include cortical disruption and the presence
of a soft-tissue mass.
† Synonymous with grade 0.5 chondrosarcoma, low-grade I chondrosarcoma, or borderline chondrosarcoma.
Cartilage Tumors
294 Journal of the American Academy of Orthopaedic Surgeons
the pain resolves, it was likely secondary
to an inflammatory syndrome
in the shoulder, rather than
being due to the proximal humerus
lesion. The shoulder disorder
should be treated appropriately,
and the lesion, which is likely an
enchondroma, should be periodically
monitored for the development of
clinical or radiographic signs or
symptoms of tumor progression. If
the pain persists despite appropriate
treatment of the presumed
shoulder disorder, the symptoms
may be from the lesion, which can
be either an enchondroma or a lowgrade
chondrosarcoma, necessitating
further evaluation to differentiate
between them.
Most patients with chondrosarcoma
have pain.9,10,12,14 In a study
of 58 patients with intramedullary
low-grade chondrosarcoma, Marco
et al14 found that 60% (35) had rest
or night pain, 21% had vague
regional pain, and 19% had lesions
that were detected incidentally.
Nearly 80% of patients with intermediate-
or high-grade chondrosarcoma
have pain.6 Pathologic fractures
occur in 3% to 8% of patients
with chondrosarcoma.6,9,14
Radiologic Findings
Enchondromas (Fig. 1) and lowgrade
intramedullary chondrosarcomas
(Fig. 2) of long bones can
have similar radiologic appearances.
Both types of tumors demonstrate
stippled calcifications, and
both may display endosteal scalloping
on plain radiographs.1,15
They are commonly located in the
metaphysis of the humerus, femur,
or tibia. Calcification is manifested
by punctate mineralization or popcornlike
calcification. The margins
of the tumor should be examined
for osteolysis and endosteal scalloping.
The extent and degree of
endosteal scalloping correlate with
the likelihood of the lesion being
a chondrosarcoma.10 In one study,
Murphey et al10 found that 71 (75%)
of 95 patients with chondrosarcoma
had endosteal scalloping of
more than two thirds of the cortical
thickness, compared with 8 (9%) of
92 patients with enchondroma.
Chondrosarcoma can demonstrate
adaptive and aggressive radiologic
signs. Cortical expansion and
thickening are adaptive changes, and
cortical disruption and soft-tissue
masses are aggressive changes associated
with chondrosarcoma.1,10
Rosenthal et al15 summarized the
plain-radiographic and computed
tomographic (CT) findings in lowand
high-grade chondrosarcoma.
Low-grade features include (1) dense
calcifications forming rings or spicules,
(2) widespread or uniformly
distributed calcifications, and (3) eccentric
lobular growth of a soft-tissue
mass. High-grade features include
(1) faint amorphous calcification,
(2) large noncalcified areas, and
(3) concentric growth of a soft-tissue
mass. Lysis within a previously calcified
area may be a sign of tumor progression.
The primary exception to
these radiologic findings is enchondroma
in a short tubular bone of the
hand, which frequently demonstrates
marked endosteal scalloping, large
areas of lysis, and cortical expansion.
A technetium-99m diphosphonate
whole-body bone scan can
provide some useful information
about an intramedullary cartilaginous
lesion. A whole-body bone
scan with a high degree of radionuclide
uptake within the lesion compared
with an internal standard,
such as the anterior superior iliac
spine or acromioclavicular joint, is
more consistent with chondrosarcoma
than enchondroma.10 Murphey
et al10 graded radionuclide uptake
from grade 1 to grade 3, with grade
1 indicating uptake less than that in
the anterior iliac crest; grade 2, uptake
similar to that in the anterior
iliac crest; and grade 3, uptake
greater than that in the anterior iliac
Figure 1 A, Anteroposterior radiograph of the left proximal humerus and shoulder of an
82-year-old man without any pain. Note the calcified lesion without evidence of cortical
erosion. B, T1-weighted (repetition time, 350 msec; echo time, 12 msec [350/12]) MR
image of the left humerus shows tumor lobules present, with multiple satellites. The
tumor did not destroy bone and was consistent with an enchondroma. Follow-up plain
radiographs showed no evidence of progression.
A B
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 295
crest. In their study of 51 patients
with chondrosarcoma, 42 (82%) had
grade 3 uptake, compared with 14
of 67 patients (21%) with enchondroma.
However, most enchondromas
demonstrate some activity on
bone scan; therefore, that finding
alone is not particularly worrisome.
The bone scan can also help identify
polyostotic disease.
Axial imaging with CT or magnetic
resonance (MR) imaging can
be helpful in evaluating the depth
of endosteal scalloping and the size
of the lesion and its soft-tissue component.
Computed tomography is
the study of choice to evaluate the
osseous architecture for endosteal
scalloping and bone disruption.
Magnetic resonance imaging is particularly
useful in determining the
nonmineralized intramedullary
extent of the tumor and soft-tissue
extension. The axial and coronal
images accurately demonstrate
marrow replacement by tumor,
providing measurements that can
guide the surgeon when either an
intralesional or a wide excision is
performed. The relationship of a
soft-tissue mass to important paraosseous
structures, such as the joint
capsule and the neurovascular bundle,
is accurately demonstrated on
MR images. The percentage of medullary
fill of the lesion visualized on
MR imaging is also useful information.
Medullary fill greater than 90%
is predictive of chondrosarcoma.11
Noncontiguous foci of cartilage, or
satellites (Fig. 1, B), are predictive of
enchondroma if the medullary fill is
less than 90%. Finally, a chest radiograph
and usually a CT scan of the
chest are obtained for staging.
Biopsy
The biopsy of a chondrosarcoma
can be performed with closed or
open techniques. Closed biopsy
techniques with fine (20- to 23-
gauge) or core needles are commonly
utilized to confirm the diagnosis
of a cartilaginous tumor that
is clinically and radiographically a
chondrosarcoma. A fine-needle
biopsy directed by fluoroscopy or
CT can be utilized if there is a softtissue
component. Imaging may
not be required if the soft-tissue
mass is palpable. This procedure
primarily yields material for cytologic
and, to a lesser extent, histologic
examination. If the tumor is
located within bone, a core needle
penetrates the bone more readily
than a fine needle. A core-needle
biopsy provides a cylinder of tissue,
which can be examined both cytologically
and histologically. Biopsy
specimens should be taken from
the areas of most concern, such as
areas of bone destruction and those
demonstrating a high degree of
endosteal scalloping and lysis.
Experienced musculoskeletal
pathologists can usually diagnose a
high-grade chondrosarcoma if malignant
cartilaginous cells are noted.
A major drawback of needle-biopsy
techniques, however, is sampling
error due to tumor heterogeneity.
16,17 A high-grade cartilaginous
tumor often contains low-grade or
benign hyaline cartilage material.
Figure 2 A, Anteroposterior radiograph of the left proximal humerus of a 43-year-old man with progressively increasing shoulder pain,
which was present at rest. Note the calcification with minimal endosteal scalloping. B, T2-weighted (3,500/16) MR image of the lesion in
the proximal humerus. Biopsy revealed a low-grade chondrosarcoma. C, The patient was treated with intralesional excision, cauterization
with phenol, and insertion of methylmethacrylate. The pain resolved completely.
A B C
Cartilage Tumors
296 Journal of the American Academy of Orthopaedic Surgeons
The final pathologic study could conceivably
reveal a chondrosarcoma
despite a needle-biopsy diagnosis of
enchondroma. Differentiating an
enchondroma from a low-grade
chondrosarcoma is often difficult, if
not impossible, with the small
amount of material obtainable by
needle biopsy.
An open biopsy usually provides
adequate tissue for diagnosis
but is associated with surgical-site
contamination and other complications
associated with open procedures
and general anesthesia. Confirmation
of the viability of the
tumor and the adequacy of the tissue
sample should be obtained by
frozen-section diagnosis at the time
of the procedure.
Symptomatic intramedullary cartilaginous
tumors that display neither
adaptive radiologic changes
(cortical thickening or expansion)
nor aggressive radiologic changes
(cortical disruption or soft-tissue
mass) are likely to be enchondromas
or low-grade chondrosarcomas. If
the clinical presentation warrants
further evaluation, a biopsy is recommended
before definitive treatment.
If an intermediate- or a highgrade
cartilage tumor is identified
on the basis of frozen-section analysis,
the procedure should be terminated,
and treatment deferred until
a final pathology report is made. If
the frozen section is consistent with
an enchondroma or a low-grade
chondrosarcoma, some surgeons
would proceed with intralesional
excision with or without adjuvant
therapy.
Performing a simultaneous intralesional
excision can obviate a
second operative procedure, provide
curative treatment, and minimize
bleeding with subsequent
seeding of tumor cells within the
incision.15 However, the patient
must be counseled preoperatively
that the tumor grade (and thus the
optimal treatment) may change
with the final diagnosis on permanent
sections. Definitive treatment
should be based on the highest grade
of tumor present. If the diagnosis is
an enchondroma or a low-grade
chondrosarcoma, close observation
is appropriate. If intermediate- or
high-grade chondrosarcoma is
identified within any portion of the
tumor, a secondary wide excision
may be required. To minimize local
contamination of the tissues by
chondrosarcoma cells, it is important
to protect the surrounding tissues
during the curettage and
achieve meticulous hemostasis after
intralesional treatment. If the biopsy
and intralesional excision are
performed properly, the definitive
oncologic procedure and outcome
should not be adversely affected if
more aggressive surgical intervention
is required.
Although simultaneously performing
a biopsy and an intralesional
excision for an intramedullary
cartilaginous tumor has advantages,
most surgeons prefer to wait
for the final pathologic diagnosis
before further treatment. An intralesional
or wide excision with removal
of the entire biopsy track
and previously exposed tissue is
then performed. However, the
pathologist may identify highergrade
tumor in the specimen removed
at the definitive excision
than was originally found at biopsy.
Delaying the definitive treatment
while waiting for a final biopsy
diagnosis does not completely
avoid the possibility that a change
in the preoperative diagnosis may
occur once the entire specimen is
examined.
Some authors have advocated not
obtaining biopsy specimens of cartilaginous
tumors that are clinically
and radiographically chondrosarcomas,
although this is not a widely
held opinion.18 These chondrosarcomas
are painful and may have an
associated soft-tissue mass. A high
degree of endosteal scalloping and
adaptive and aggressive radiologic
findings are seen. Although these
tumors can be low-grade chondrosarcomas,
they are more often
intermediate- or high-grade chondrosarcomas.
Chondrosarcomas
demonstrating these clinical and
radiographic signs should be treated
with wide excision. Some tumor
surgeons would proceed with a
wide excision without performing a
biopsy, thereby avoiding the inevitable
contamination of the biopsy
site with tumor cells. The specimen
is then sent for final gross and histologic
diagnosis. However, although
this procedure is theoretically better,
only a very experienced tumor surgeon
should make these decisions.
Clinicopathologic
Grading
Chondrosarcomas are graded on
the basis of the cytologic and histologic
appearance8,12,13,15,19 (Fig. 3),
combined with the clinical and radiologic
presentation. Most authors
grade chondrosarcomas from grade
I to grade III.8,12,13,15,19 The diagnosis
of grade II (intermediate-grade)
and grade III (high-grade) chondrosarcoma
can usually be made on
the basis of either cytologic or histologic
features.12,13 Grade I (lowgrade)
chondrosarcoma, however,
has cytologic features similar to
those of enchondroma. Therefore,
histologic criteria must be combined
with clinical and radiologic findings
to differentiate enchondroma (Fig. 4)
from low-grade chondrosarcoma.12,13
Histologically, both enchondromas
and low-grade chondrosarcomas are
composed of hyaline cartilage cells.
A low-grade chondrosarcoma should
be suspected if there are (1) many
cells with plump nuclei, (2) more
than an occasional binucleate cell,
and (3) giant cartilage cells with
large nuclei or with clumps of chromatin.
19 Further differentiation
between an enchondroma and a
low-grade chondrosarcoma is then
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 297
possible by examining the tissue
pattern of the cartilage cells and the
lamellar bone, as described by Mirra
et al.12 The enchondroma pattern
consists of nodules of hyaline cartilage
that are encased by lamellar
bone. These nodules are separated
from each other by normal marrow.
The low-grade chondrosarcoma
pattern consists of cartilage cells
that permeate marrow spaces and
completely replace the marrow fat.
The cartilage cells directly abut and
surround the lamellar bone in the
chondrosarcoma pattern. Other histologic
findings of chondrosarcoma
include (1) malignant bands of
fibrosis, (2) chondrosarcomatous
invasion of marrow fat, (3) malignant
invasion of the haversian system,
and (4) a soft-tissue mass.
Occasionally, a painful cartilaginous
lesion in a long bone has the
radiologic appearance of a lowgrade
chondrosarcoma (e.g., lytic
areas or high-grade endosteal scalloping
without adaptive or aggressive
radiographic changes) and the
histologic appearance of an enchondroma.
This lesion is referred to as a
grade 0.5 chondrosarcoma by some
authors; others may describe it as a
borderline chondrosarcoma, low
grade 1 chondrosarcoma, grade 0
chondrosarcoma, painful enchondroma,
or atypical enchondroma.
We prefer the term “chondrosarcoma
in situ,” which implies that the
lesion is benign and should not
metastasize unless there is malignant
transformation. We also believe
that tumors with both the
radiologic and the histologic appearance
of a low-grade chondrosarcoma
should be considered chondrosarcomas
in situ because these
lesions do not metastasize if treated
properly.4,14,20,21
Cartilaginous lesions in the hand
and pelvis behave differently than
intramedullary cartilaginous lesions
of the long bones with similar
histologic appearances.1 Enchondromas
of the short tubular bones
in the hand frequently have multinucleated
cells, as well as increased
cellularity that resembles the appearance
of grade 1 chondrosarcoma. Although
these tumors occasionally
recur after intralesional treatment,
they do not metastasize. However,
most patients with a histologically
similar lesion in the pelvis will have
a local recurrence after intralesional
excision.21-23
Staging
Chondrosarcomas are staged according
to the system described by
Enneking.24 Nonmetastatic lowgrade
chondrosarcomas are considered
stage I neoplasms. Nonmetastatic
intermediate- and high-grade
chondrosarcomas are stage II. Metastatic
chondrosarcomas are stage
Figure 3 A, Low-grade chondrosarcoma (hematoxylin-eosin, original magnification ×100). This tumor is well-differentiated. Hypercellularity
is noted, but the cartilage matrix may be easily identified. There are numerous binucleate cells within lacunae and few atypical
cells. B, Higher-magnification view of the same tumor (hematoxylin-eosin, original magnification ×250). Mild pleomorphism and
hyperchromatism are apparent, and binucleate cells are seen. The tumor had a well-differentiated cartilage matrix. C, Intermediategrade
chondrosarcoma (hematoxylin-eosin, original magnification ×250). The tumor displays distinct pleomorphism, with some very
large hyperchromatic cells.
A B C
Figure 4 Enchondroma (hematoxylineosin,
original magnification ×100). Note
the hypocellularity of the lesion and the
uniformity in size and staining features of
the cells. The hyaline cartilage matrix is
readily apparent.
Cartilage Tumors
298 Journal of the American Academy of Orthopaedic Surgeons
III. Tumors are then subclassified as
either stage A or stage B on the basis
of whether they are located within
the bone or extend outside the bone.
For example, a low-grade intramedullary
chondrosarcoma without
metastases is stage IA, whereas a
high-grade nonmetastatic chondrosarcoma
with an associated softtissue
mass is stage IIB.
Enchondromas may be staged by
using the Enneking staging system
for benign tumors.24 In that system,
a stage 1 tumor is latent (i.e., a
tumor that does not progress or that
heals spontaneously). A stage 2
tumor is active (i.e., it progresses
but respects natural barriers, such as
the bone cortex). A stage 3 tumor is
aggressive (i.e., it progresses and
will ultimately destroy natural barriers).
Enchondromas are usually
stage 1 but are occasionally stage 2.
Types of Surgical Excisions
Enneking24 defined surgical margins
for bone tumors. An intralesional
excision is a procedure that
enters the tumor during removal.
Intralesional excisions may be
planned or inadvertent (i.e., those
that occur during attempted wide
excision). A planned intralesional
excision grossly debulks the tumor
through a large cortical window,
which conceivably leaves microscopic
and macroscopic tumor in
the tumor bed. Intralesional margins
can be extended by use of an
adjuvant, such as phenol or liquid
nitrogen. A marginal excision passes
through the reactive zone around
the tumor, which probably contains
microscopic satellite lesions of the
tumor. These microscopic deposits
remain in the excision bed. A wide
margin includes a cuff of normal tissue
completely encircling the tumor.
Wide excisions remove the reactive
zone with its microscopic satellites.
The margin definitions are the same
for limb salvage and amputation.
Treatment of
Enchondromas
Enchondroma is a benign latent
lesion or, at worst, an active lesion
that does not metastasize and rarely
undergoes malignant degeneration.
Enchondromas can be treated nonoperatively
unless they are symptomatic
or enlarging or unless there is
an impending or existing fracture.
Most patients with an enchondroma
are asymptomatic and are best followed
up by sequential clinical
assessments and radiographic evaluations
(i.e., a set of orthogonal plain
radiographs) in 3 months. If there is
no clinical or radiographic change at
that time, another set of radiographs
is obtained 6 months later. In the
absence of progressive changes (e.g.,
increased endosteal scalloping or
osteolysis), obtaining repeat clinical
and radiographic examinations once
a year is reasonable. Patients are told
to return for examination if symptoms
develop. Bone scanning, CT,
and MR imaging are usually not necessary
for the evaluation of wellcalcified
lesions. Extensive noncalcified
or lytic areas should be followed
with serial MR imaging studies.
A few patients with enchondromas
present with vague regional
pain about the involved bone. The
pain is usually related to joint or
soft-tissue pathologic changes.
Nonoperative measures, such as
physical therapy and differential
injections, can be used. If the pain
persists or worsens despite nonoperative
treatment or if there is radiographic
evidence of tumor progression,
the pain may be originating
from the lesion.
The most worrisome symptoms
are rest pain and night pain (often
termed “nonmechanical pain”), which
are considered an ominous sign suggesting
the presence of a malignant
neoplasm. Patients with these symptoms
or lesional progression should
undergo further evaluation with
axial imaging and a biopsy.
Enchondromas involving the
short tubular bones of the hand usually
present as pathologic fractures.
If a fracture is present, the digit is
immobilized until union occurs. If
the lesion is large and another pathologic
fracture is expected, an intralesional
excision and reconstruction
with autogenous or allograft
bone can be performed. Local recurrence
is unusual. Some surgeons
prefer to treat the fracture and the
tumor at the time of presentation.
Occasionally, internal fixation is
required to help stabilize the fracture.
Adjuvant therapy may help
decrease local recurrence rates but is
not routinely utilized.
Treatment of
Chondrosarcomas in Situ
The treatment of low-grade chondrosarcomas
without adaptive or
aggressive radiologic changes is controversial.
Most authors recommend
a wide excision for treatment of lowgrade
chondrosarcoma. In three
studies,6,7,22 wide excisions were associated
with lower local recurrence
rates compared with intralesional
excisions. However, the authors of
those studies combined low-grade
and high-grade chondrosarcomas, as
well as axial and appendicular chondrosarcomas,
in their analyses of the
surgical margin.
There is a subset of patients with
low-grade chondrosarcomas that
can be treated with intralesional
excision with adjuvant therapy
without compromise of the oncologic
outcome.4,14,20,21 Adjacent bone and
joint preservation and improved
function are the major advantages
of an intralesional excision compared
with a wide excision, which
usually requires bone and joint sacrifice.
These patients have intramedullary
low-grade chondrosarcoma
(stage IA) of the appendicular
skeleton, which can demonstrate a
high degree of endosteal scalloping
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 299
but not adaptive or aggressive radiologic
signs (Fig. 2). These tumors
are usually painful. They are histologically
low-grade chondrosarcomas
and do not metastasize when
treated properly. Thus, they are
more appropriately described as
chondrosarcomas in situ.
In a large retrospective review of
the data on 58 patients with intramedullary
low-grade chondrosarcoma
of a long bone treated with
intralesional excision with or without
adjuvant therapy, Marco et al14
demonstrated low local recurrence
rates. There were no local recurrences
or metastases in the 57 patients
who met criteria for the diagnosis
of chondrosarcoma in situ
after a minimum follow-up interval
of 5 years. The only local recurrence
developed in a patient with cortical
disruption, thickening, and expansion,
as well as a soft-tissue mass.
By definition, this patient did not
have a chondrosarcoma in situ. The
joint was preserved in 92% of the
patients when it was in jeopardy.
Bauer et al20 reported on 22 patients
with intramedullary lowgrade
chondrosarcoma (chondrosarcoma
in situ) of a long bone treated
by an intralesional excision. One patient
had a local recurrence, and
there were no metastases.
Schreuder et al4 treated 9 patients
with intramedullary low-grade
chondrosarcoma (chondrosarcoma
in situ) with intralesional excision
plus adjuvant liquid nitrogen. They
had no local recurrences at a mean
follow-up interval of 26 months.
Marcove et al21 reported on intralesional
excision plus cryosurgery
for low- and medium-grade
chondrosarcoma. There were no
local recurrences in the four patients
who met criteria for the diagnosis
of chondrosarcoma in situ of a
long bone. Recurrences were seen
in three of nine patients with grade
II chondrosarcoma of a long bone
or a grade I or grade II tumor of the
axial skeleton.
The combined local recurrence
rate in these studies was 1% (1 of 92
patients) for patients with tumors
that met the criteria for diagnosis of
chondrosarcoma in situ. None of
these patients had metastases or
died of disease.
It should be noted that chondrosarcoma
in situ can demonstrate
malignant behavior. Lee et al5 noted
that 2 of 16 patients with atypical
enchondroma had metastases, and 1
patient died of the disease. Chondrosarcoma
in situ is thus an appropriate
designation for a symptomatic
intramedullary cartilaginous
tumor without adaptive or aggressive
radiologic changes but with histologic
findings consistent with an
enchondroma or a low-grade chondrosarcoma.
The term implies that
the tumor is a premalignant lesion
that will not metastasize if properly
treated. Appropriate intervention
and follow-up are justified, yet the
patient is not given the diagnosis of
a malignant condition.
Technique for Intralesional
Excision
Intralesional excisions may be
used in carefully selected individuals.
The exposure is limited initially
until the biopsy has been performed.
Sponges are used to protect the
exposed muscle and soft tissues
from contamination with tumor
cells. A high-speed burr is used to
open the humerus. Alternatively, a
trephine can be used to procure a
sample that preserves the interface
between the tumor and the cortical
endosteum. Care should be taken to
minimize spillage. Biopsy specimens
are obtained from the most
worrisome areas with a curette. A
frozen section is also obtained. The
surgeon should discuss the case
with the pathologist before the biopsy
to factor in the clinical and
radiologic features. If the frozensection
findings are consistent with
an intermediate- or high-grade chondrosarcoma,
the defect is filled with
bone wax or methylmethacrylate to
prevent tumor spillage, and the
wound is closed after meticulous hemostasis
has been established. After
the final pathologic diagnosis, the
definitive procedure is performed. If
the frozen section is consistent with
an enchondroma or a low-grade
chondrosarcoma, the surgeon can
stop and wait for the final pathologic
diagnosis or proceed with an intralesional
excision.
The intralesional excision requires
a slightly more extensile
exposure than the biopsy. Sponge
protection is augmented to cover all
exposed muscle and soft tissue,
which helps prevent implantation
of sarcoma cells. Avoiding unnecessary
dissection and exposure is
critical so that a salvage procedure
can be performed if the final diagnosis
warrants a wide excision. A
burr is used to unroof the tumor
cavity. Another technique is to connect
multiple drill holes with an
osteotome. A Kerrison rongeur is
effective in enlarging the hole until
there is complete visualization of
the entire cavity. The lesion is
excised with progressively smaller
instruments until all gross tumor
has been removed. Internal burring
is then performed throughout the
cavity, thereby extending the margins
by another millimeter. A fiberoptic
light is used for direct visualization
of the entire tumor cavity.
Adjuvant Therapy
Most authors believe that adjuvant
therapy is required to kill remaining
microscopic foci of tumor.
3,4,14,21 Some prefer to cauterize
the cavity with both electrocautery
and phenol. A phenol and glycerol
solution is dabbed on the bone with
a cotton-tipped applicator. Phenol
percentages as high as 80% are
used. The phenol is removed by
lavaging the cavity with absolute
alcohol. Further lavage with a highpressure
pulsatile system is then
performed.
Cartilage Tumors
300 Journal of the American Academy of Orthopaedic Surgeons
An alternative to phenol cauterization
is cryosurgery.21 Cryosurgery
effectively extends the margin
of resection beyond that achieved
by mechanical curettage and burring.
This method kills tumor cells
by mechanically disrupting the cell
membrane with intracellular ice
crystals and poisoning them by creating
intracellular electrolyte imbalances.
Cryosurgery also causes capillary
scarring, which necroses both
tumor cells and host bone. It is
most effective when the lesion is
frozen rapidly and thawed slowly.
One treatment consists of three
cycles in succession. The depth of
freeze is governed by the size of the
defect, the volume of liquid nitrogen
delivered, the effectiveness of
local heat-exchange mechanisms
(e.g., blood flow) in dissipating the
cold, and the duration of the freeze.
Some surgeons monitor the depth of
the freeze with multiple temperature
probes around the lesion.
Freezing can usually be assessed on
the basis of the amount of frost or
the size of the ice ball created.
For selected stage IA chondrosarcomas
(chondrosarcomas in
situ), successful local control is
obtained after freezing the bone
until the periosteum starts to
frost.14,21 The general technique is
as follows: Hemostasis is obtained
by using a tourniquet when possible;
alternatively, electrocautery,
argon-beam laser, or a thin layer of
bone wax may be used. The bone
cavity should be kept horizontal to
avoid spillage of the liquid nitrogen.
The soft tissues are retracted
widely so that the skin is not inadvertently
frozen. Liquid nitrogen is
instilled rapidly by pouring it in the
cavity or by using a spray gun. The
liquid is then allowed to evaporate.
The bone window must not be occluded,
because nitrogen embolization
can occur when trapped nitrogen
expands during its conversion
from liquid to gas. Ice or frozen
blood bubbles are broken up to release
captured nitrogen. The bone
is thawed slowly, and the process is
then repeated twice. In selected
cases, two cycles may be sufficient.25
The remaining shell of bone contains
some necrotic bone, which is
left in place as autogenous graft.
The cortical defect weakens the
bone. The use of adjuvant cryotherapy
may cause increased fracture
rates during the revascularization
phase of bone healing compared
with untreated intralesional defects.
Protection of the bone during the
remodeling and revascularization
phase is recommended to decrease
the risk of pathologic fractures.
Defect reconstruction and activity
modification help protect the bone.
Partial weight bearing with crutches
is utilized to protect lower-extremity
bone defects. Avoidance of twisting
of both upper and lower extremities
is also recommended. Most sporting
activities are prohibited for 2
years to allow remodeling and revascularization.
Although most patients
feel that they can resume normal
activity, they must be reminded
that the bone will be weak for as
long as 2 years after the procedure.
Reconstruction After
Intralesional Excision
Although an intralesional excision
usually preserves the adjacent joint
and most of the bone cylinder, reconstruction
is required to prevent fractures
through the weakened bone.
Methylmethacrylate reconstruction
provides immediate stability, avoids
the morbidity of autogenous bone
graft, facilitates the postoperative
radiologic evaluation for signs of recurrence,
and may kill residual microscopic
tumor cells with thermotherapy.
The cement is molded into
the cavity, creating a smooth cortical
margin. If the osseous defect is large,
internal fixation with threaded pins
embedded into the cement can be
added. Alternative reconstructions
include autogenous or allogeneic
bone graft or bone-graft substitutes
(Fig. 5). Plate-and-screw fixation
may be used to reinforce this reconstruction.
Although long intramedullary
devices may decrease the risk
of fracture, this type of fixation may
spread tumor cells within the bone
and adjacent soft tissue. The wound
is closed in the usual manner over
closed suction.
Gentle, early range-of-motion exercises
of the joint are encouraged.
The fracture rate ranges from 10% to
20% after intralesional excision.14,25
Patients should therefore modify
their activity until the bone strength
is restored, which may require up to
2 years of bone remodeling.
Final Diagnosis and Follow-up
The final diagnosis and tumor
grade are determined after the
pathologist has evaluated the entire
specimen. Proper treatment is dictated
by the highest grade of tumor
present in the excised tissue. If a
diagnosis of chondrosarcoma in situ
is rendered, careful follow-up with
clinical and radiologic examinations
is recommended to monitor for
local recurrence or distant metastases.
If an intermediate- or highgrade
tumor is seen, wide excision is
recommended. If the intralesional
excision was done properly, so as to
minimize tumor contamination, a
wide excision with limb preservation
can then be performed.
Treatment of
Chondrosarcomas With
Adaptive or Aggressive
Radiologic Changes
Several studies have demonstrated
that adequate surgical margins
lower the risk of local recurrence in
patients with chondrosarcoma.5,7-9,23
Gitelis et al7 reported a 6% local
recurrence rate if adequate margins
were achieved, compared with a
69% local recurrence rate in patients
with inadequate surgical margins.
Although an intralesional excision
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 301
with adjuvant therapy provides adequate
margins in patients with chondrosarcoma
in situ, this method
does not provide adequate margins in
most patients with higher grades of
chondrosarcoma. A wide excsion is
thus recommended for intermediateand
high-grade chondrosarcomas of
long bones.
Marcove et al21 reported a 33%
local recurrence rate in nine patients
with intermediate-grade chondrosarcoma
in a long bone treated with
intralesional excision plus cryosurgery.
Metastases developed in one
of these patients, and only one remained
disease-free after a subsequent
wide excision. Wide margins
are probably required to obtain adequate
local control even in the case
of low-grade chondrosarcomas in
long bones with adaptive or aggressive
radiologic findings (Fig. 6).
Marco et al14 reported that one
patient with a low-grade chondrosarcoma
with cortical expansion,
thickening, and disruption, as
well as a soft-tissue mass, had a local
recurrence after an intralesional
excision combined with cryosurgery.
The local recurrence was a
dedifferentiated chondrosarcoma.
Wide excisions of chondrosarcomas
involving the axial skeleton are
associated with lower local recurrence
rates (13% to 25%)26,27 compared
with intralesional procedures
(67% to 100%).21-23 Tsuchiya et al22
treated two patients with borderline
chondrosarcoma (chondrosarcoma
in situ) of the pubis. One
patient underwent an intralesional
A B C D
Figure 5 A, Lateral radiograph of the right proximal tibia of a 43-year-old woman with leg pain shows a calcified lesion in the tibial diaphysis,
as well as mild endosteal erosion associated with the tumor. B, T2-weighted (1,900/80) MR image demonstrates mild endosteal
erosion and the full extent of the tumor. C, Postoperative radiograph after biopsy and excision of a low-grade chondrosarcoma (grade I,
stage IA). The bone was cauterized with phenol and filled with a bone-graft substitute (calcium sulfate). D, Radiograph obtained 2 years
postoperatively shows bone repair with dense ossification. The patient’s pain had resolved.
Figure 6 Anteroposterior (A) and lateral (B) radiographs of the right proximal femur of a
41-year-old man with a painful right hip show adaptive changes of cortical thickening and
expansion. The grade I chondrosarcoma was treated by wide resection.
A B
Cartilage Tumors
302 Journal of the American Academy of Orthopaedic Surgeons
excision without adjuvant therapy,
and one patient underwent a marginal
excision. Recurrent disease
developed in both patients, and one
patient died of the disease.
Ozaki et al26 had a 67% local recurrence
rate in nine patients with
low-grade chondrosarcomas of the
pelvis and sacrum that had been
contaminated intraoperatively during
an attempted wide excision.
Soft-tissue extension was noted in
eight of these patients.
Marcove et al21 treated two patients
with intermediate-grade
chondrosarcoma of the sacrum and
pelvis with intralesional excisions
combined with cryosurgery. Both
patients had local recurrences.
Wide excisions are also recommended
for chondrosarcomas involving
the ribs, the proximal fibula,
or the distal clavicle, because
resection of these bones can be
accomplished without significant
morbidity.
Wide excisions create intercalary
or articular defects. This type of
procedure requires major reconstruction
(Fig. 7). The options for
intercalary reconstruction include
allograft, autograft, vascularized
autograft, and implant. The options
for joint reconstruction include
arthrodesis with autograft or allograft,
arthroplasty with a modular
oncology prosthesis, allograft prosthetic
composite, and osteoarticular
allograft.26,28,29
Major intercalary or joint reconstruction
after a wide excision is
associated with very significant
morbidity and functional limitations.
The reported complications
include infection, allograft nonunion,
allograft fracture, allograft
dissolution, implant fracture, and
implant loosening.14 Most oncologic
surgeons permanently restrict
the function of their patients after
major joint reconstruction. Patients
are usually limited to low-impact
stress to improve the durability of
the replaced joint.
Summary
The diagnosis and treatment of cartilaginous
tumors is dependent on the
clinical presentation, the location of
the lesion, the radiologic findings,
and the histologic grade of the tumor.
Redefining the current diagnostic terminology
should help determine the
proper treatment for these tumors.
The term enchondroma should be
utilized to describe an asymptomatic
intramedullary cartilaginous lesion.
In the hand, an enchondroma can
exhibit cortical expansion, lysis, and
endosteal scalloping. Enchondroma
A B
C D
Figure 7 A, Anteroposterior radiograph of the left proximal humerus of a 74-year-old
man with a painful shoulder. Note the calcified lesion involving the humeral metaphysis.
There is marked endosteal scalloping and some bone destruction. B, CT scan of the
humerus demonstrates a large area of lysis and cortical thinning. C, Technetium bone scan
reveals intense uptake in the proximal humerus. D, Postoperative radiograph of the proximal
humerus after wide excision of a low-grade (grade I) chondrosarcoma. There was cortical
breakthrough by tumor (stage IB). The proximal humerus was replaced by an
osteoarticular allograft.
Rex A. W. Marco, MD, et al
Vol 8, No 5, September/October 2000 303
ation pattern. A wide excision is recommended
for these lesions.
Intermediate, high-grade, and
dedifferentiated chondrosarcomas
are more aggressive tumors. They
are associated with higher local recurrence
and mortality rates. These
tumors are usually painful and demonstrate
adaptive and aggressive
radiologic changes. A soft-tissue
mass is often seen. The cytologic and
histologic features are readily distinguished
from those of enchondroma
and low-grade chondrosarcoma. A
wide excision is recommended to
minimize the risk of local recurrence.
Limb salvage with reconstruction is
possible in most cases.
Cartilaginous lesions in the pelvis
and sacrum are worrisome. These
tumors frequently recur after intralesional
procedures even if the histologic
appearance is benign or suggestive
of a low-grade neoplasm.
Therefore, wide excisions are recommended
for nearly all cartilaginous
tumors of the pelvis and sacrum.
The diagnosis and treatment of
cartilaginous tumors can be complex.
Ideally, treatment involves a
multidisciplinary team composed of
a musculoskeletal surgeon, a radiologist,
and a pathologist.
in a long bone can exhibit some
endosteal scalloping but should not
demonstrate lysis, cortical expansion,
thickening, disruption, or associated
soft-tissue masses. Histologically, enchondromas
are composed of islands
of hyaline cartilage encased by lamellar
bone. Most are treated appropriately
by periodic observation.
Chondrosarcoma in situ is a
symptomatic, intramedullary cartilaginous
tumor of a long bone without
radiologic evidence of either
adaptive changes (cortical expansion
or thickening) or aggressive
changes (cortical disruption or softtissue
mass) and with the histologic
features of an enchondroma or a
low-grade chondrosarcoma (stage
IA). Occasionally, a chondrosarcoma
in situ is asymptomatic but has a
high degree of endosteal scalloping
or medullary fill.
Chondrosarcoma in situ is a premalignant
lesion that warrants close
observation with clinical and radiographic
evaluation. Patients with
persistent pain or progressive radiologic
findings can be treated with intralesional
excision combined with
adjuvant therapy. This procedure
preserves the joint and provides improved
functional outcome potential
compared with wide excision.
Chondrosarcoma in situ does not
metastasize or recur if treated properly.
This designation is preferable
to grade 0.5 chondrosarcoma, low
grade 1 chondrosarcoma, or borderline
chondrosarcoma because those
terms imply that the patient has a
malignant condition rather than a
premalignant one. We also prefer
the term chondrosarcoma in situ to
the term atypical enchondroma
because the latter implies benignity,
which can downplay the necessity
for treatment or long-term followup.
Careful follow-up for 10 years is
recommended to monitor for local
recurrence.
A cartilaginous tumor of a long
bone that is histologically a lowgrade
chondrosarcoma and exhibits
a soft-tissue mass or cortical expansion,
thickening, or disruption is designated
a low-grade chondrosarcoma.
Such tumors are commonly
located in the long bones and pelvis.
They rarely occur in the hand.
Cytologically, low-grade chondrosarcomas
resemble enchondromas.
Histologically, however, they exhibit
the criteria described by Mirra
et al.12 The most common finding
is the chondrosarcomatous perme-
References
1. Unni KK: Dahlin’s Bone Tumors: General
Aspects and Data on 11,087 Cases, 5th ed.
Philadelphia: Lippincott-Raven, 1996.
2. Geirnaerdt MJ, Hermans J, Bloem JL,
et al: Usefulness of radiography in
differentiating enchondroma from
central grade 1 chondrosarcoma. AJR
Am J Roentgenol 1997;169:1097-1104.
3. Quint U, Pingsmann A: Surgical treatment
of enchondroma in long tubular
bones: Preservation of function versus
extensive excision in the humerus. Arch
Orthop Trauma Surg 1995;114:352-356.
4. Schreuder HWB, Pruszczynski M,
Veth RPH, Lemmens JAM: Treatment
of benign and low-grade malignant
intramedullary chondroid tumours
with curettage and cryosurgery. Eur J
Surg Oncol 1998;24:120-126.
5. Lee FY, Mankin HJ, Fondren G, et al:
Chondrosarcoma of bone: An assessment
of outcome. J Bone Joint Surg Am
1999;81:326-338.
6. Pritchard DJ, Lunke RJ, Taylor WF,
Dahlin DC, Medley BE: Chondrosarcoma:
A clinicopathologic and statistical
analysis. Cancer 1980;45:149-157.
7. Gitelis S, Bertoni F, Picci P, Campanacci
M: Chondrosarcoma of bone:
The experience at the Istituto Ortopedico
Rizzoli. J Bone Joint Surg Am
1981;63:1248-1257.
8. Evans HL, Ayala AG, Romsdahl MM:
Prognostic factors in chondrosarcoma
of bone: A clinicopathologic analysis
with emphasis on histologic grading.
Cancer 1977;40:818-831.
9. Bjornsson J, McLeod RA, Unni KK,
Ilstrup DM, Pritchard DJ: Primary
chondrosarcoma of long bones and
limb girdles. Cancer 1998;83:2105-2119.
10. Murphey MD, Andrews CL, Flemming
DJ, Temple HT, Smith WS, Smirniotopoulos
JG: From the archives of the
AFIP: Primary tumors of the spine—
Radiologic pathologic correlation.
Radiographics 1996;16:1131-1158.
11. Colyer RA, Sallay P, Buckwalter K, Van
Bastelaer F: MRI assessment of chondroid
matrix tumours, in Limb Salvage:
Current Trends—Proceedings of the 7th
International Symposium. Singapore:
International Symposium of Limb
Salvage, 1993, pp 89-93.
12. Mirra JM, Gold R, Downs J, Eckardt JJ:
A new histologic approach to the differentiation
of enchondroma and
Cartilage Tumors
304 Journal of the American Academy of Orthopaedic Surgeons
chondrosarcoma of the bones: A clinicopathologic
analysis of 51 cases. Clin
Orthop 1985;201:214-237.
13. Sanerkin NG: The diagnosis and grading
of chondrosarcoma of bone: A
combined cytologic and histologic
approach. Cancer 1980;45:582-594.
14. Marco RAW, Lane J, Huvos A, Kawai
A, Healey JH: Intralesional excision of
intramedullary low grade chondrosarcoma
of the extremity. Presented at the
67th Annual Meeting of the American
Academy of Orthopaedic Surgeons,
Orlando, Fla, March 15-19, 2000.
15. Rosenthal DI, Schiller AL, Mankin HJ:
Chondrosarcoma: Correlation of radiological
and histological grade. Radiology
1984;150:21-26.
16. Tunç M, Ekinci C: Chondrosarcoma
diagnosed by fine needle aspiration
cytology. Acta Cytol 1996;40:283-288.
17. Ayala AG, Ro JY, Fanning CV, Flores
JP, Yasko AW: Core needle biopsy and
fine-needle aspiration in the diagnosis
of bone and soft-tissue lesions. Hematol
Oncol Clin North Am 1995;9:633-651.
18. Barnes R, Catto M: Chondrosarcoma of
bone. J Bone Joint Surg Br 1966;48:729-764.
19. Lichtenstein L, Jaffe HL: Chondrosarcoma
of bone. Am J Pathol 1943;19:553-574.
20. Bauer HCF, Brosjö O, Kreicbergs A,
Lindholm J: Low risk of recurrence of
enchondroma and low-grade chondrosarcoma
in extremities: 80 patients
followed for 2-25 years. Acta Orthop
Scand 1995;66:283-288.
21. Marcove RC, Stovell PB, Huvos AG,
Bullough PG: The use of cryosurgery
in the treatment of low and medium
grade chondrosarcoma: A preliminary
report. Clin Orthop 1977;122:147-156.
22. Tsuchiya H, Ueda Y, Morishita H, et
al: Borderline chondrosarcoma of long
and flat bones. J Cancer Res Clin Oncol
1993;119:363-368.
23. Ozaki T, Lindner N, Hillmann A, Rödl
R, Blasius S, Winkelmann W: Influence
of intralesional surgery on treatment
outcome of chondrosarcoma.
Cancer 1996;77:1292-1297.
24. Enneking WF: A system of staging
musculoskeletal neoplasms. Clin
Orthop 1986;204:9-24.
25. Aboulafia AJ, Rosenbaum DH, Sicard-
Rosenbaum L, Jelinek JS, Malawer
MM: Treatment of large subchondral
tumors of the knee with cryosurgery
and composite reconstruction. Clin
Orthop 1994;307:189-199.
26. Ozaki T, Hillmann A, Lindner N,
Blasius S, Winkelmann W: Chondrosarcoma
of the pelvis. Clin Orthop 1997;
337:226-239.
27. Kawai A, Healey JH, Boland PJ, Lin PP,
Huvos AG, Meyers PA: Prognostic factors
for patients with sarcomas of the
pelvic bones. Cancer 1998;82:851-859.
28. Eriksson AI, Schiller A, Mankin HJ:
The management of chondrosarcoma
of bone. Clin Orthop 1980;153:44-66.
29. van Loon CJM, Veth RPH, Pruszczynski
M, Wobbes T, Lemmens JAM, van
Horn J: Chondrosarcoma of bone: Oncologic
and functional results. J Surg
Oncol 1994;57:214-221.

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1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

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5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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