Chondroma is a benign neoplasm consisting of cells of mature cartilage (usually hyaline). It can develop on any bones, but most often the tubular bones of the hand are affected. It is prone to slow growth, the current is favorable. At the initial stages, the clinic is scarce or absent, so small chondromas often become an accidental find when conducting radiography for another reason. With growth, deformation occurs, when located in the joint area, arthralgias are possible, less often synovitis. The diagnosis is made on the basis of X-ray examination and biopsy data. Surgical treatment – excision of the tumor.
D16 Benign neoplasm of bones and articular cartilage
Chondroma is a benign tumor consisting of mature cartilage cells. It usually grows slowly, and may remain asymptomatic for a long time. Symptoms usually appear when the anatomical structures located nearby are compressed. The course is favorable, however, degeneration into a malignant tumor (chondrosarcoma) is possible, therefore surgical removal is required. Treatment is carried out as planned in a hospital setting. Tumors are prone to recurrence.
In the practice of specialists in the field of orthopedics and traumatology, chondromas are quite common. They make up about 10-12% of the total number of skeletal neoplasms. Mostly young patients (from 10 to 30 years old) suffer, the peak incidence is 11-16 years old.
The causes of development are unknown. Usually chondromes are solitary (single). In the presence of dysplastic processes, the formation of multiple secondary tumors is possible. The source of chondroma may be normal cartilage (sprout, articular), areas of dystopian (located in an atypical place) cartilage or foci of embryonic non-ossified cartilage.
Most often, chondroma occurs on the bones of the phalanges of the fingers, metacarpal bones of the hand and metatarsal bones of the foot. Of the long tubular bones, the femur is most often affected, less often the humerus and shin bones. It can also develop on flat bones, in soft tissues, cartilage of the larynx and paranasal sinuses. It is particularly dangerous when formed in the area of the base of the skull, since it compresses the brain structures when placed intracranially.
When localized in the nasal sinuses, it causes difficulty in nasal breathing, with the formation of tubular bones in the epiphysis area, it can cause synovitis. In some cases, pathological fractures are possible. The chondromes of the proximal parts of the humerus and femur, as well as the chondromes of the sternum, scapula and pelvis are quite often subjected to malignant degeneration. At the same time, the malignancy of chondromes of short tubular bones (feet, hands) is extremely rare and is considered a casuistic case.
Depending on the location of the chondroma in relation to the bone, two types of tumors are distinguished in orthopedics and clinical oncology:
- Enchondroma. It forms inside the bone. In the process of growth, the enchondroma deforms the bone, as if bursting it from the inside.
- Ecchondroma. It forms on the outer surface of the bone, grows towards soft tissues.
The clinical course largely depends on the localization of neoplasia. As a rule, the disease is asymptomatic in the initial stages. The extremely slow growth characteristic of this neoplasm leads to the fact that several years or even decades may pass from the moment of chondroma formation to the appearance of the first signs of the disease. However, there may be exceptions (when located in the trachea, paranasal sinuses, the base of the skull, etc.), because with such localization, chondromes begin to squeeze anatomical formations located nearby early.
When localized in the area of small tubular bones (hand, foot) during palpation, in some cases, a small painless thickening is detected. Pain can occur in cases when the neoplasm reaches a significant size and begins to squeeze the nerve trunks located on the lateral surfaces of the fingers. With the formation of chondroma in the metaphyso-diaphyseal and metaphyso-epiphyseal regions of long tubular bones, there are also no symptoms at the initial stages. As the tumor grows, passing arthralgias appear (joint pain without signs of inflammation). If the chondroma reaches a sufficiently large size, synovitis may develop.
When the chondroma is localized in the chest area, 90% of the ribs are affected. In the overwhelming majority of cases, chondroma is formed at the site of the transition of the bony part of the rib to the cartilaginous one and is most often found in the region of the II-IV rib. In the initial stages, the course is asymptomatic. As the tumor grows, a cosmetic defect first occurs, and after some time (sometimes several years), a pain syndrome joins. Despite the fact that chondroma is a benign tumor, it shows a tendency to germinate the inner leaf of the periosteum and pleura. When the pleura is involved in the process, the patient has chest pain, which increases with breathing.
Increasing in size, the chondroma can germinate a significant part of the diameter of the bone. At the same time, strong bone tissue is replaced by softer and more delicate cartilage, so large tumors, regardless of their localization, can cause pathological fractures. The characteristic signs of such fractures are sharp pain, crepitation and pathological mobility in the area of injury in the absence of injury or after a minor injury.
Chondromes growing from the base of the skull and located in its cavity begin to squeeze the brain early. The tumor increases slowly, so the symptoms of compression occur gradually. Dizziness, headaches, movement coordination disorders (vestibular ataxia), paralysis and paresis of the extremities are possible. The growth of chondroma in the paranasal sinuses causes difficulty breathing through the nose.
Diagnostics is carried out by oncologists and orthopedic traumatologists. Due to the meager and non-specific symptoms, additional instrumental studies are the main method of diagnosing chondromes. Endochondromes in the skeletal bones (except for the base of the skull) can be detected during a routine X-ray examination. To diagnose exochondroma, as a rule, it is necessary to use other techniques, since the cartilaginous tumor is not radiopaque and is not visible against the background of soft tissues.
Endochondroma in the area of short tubular bones (hands, feet) is characterized by limited homogeneous illumination, which often occupies the entire diameter of the bone. On radiographs of long tubular bones, chondromes look like oblacoid lumen of irregular shape, sometimes with calcification shadows. The X-ray picture of the chondroma in some cases may resemble a single-chamber bone cyst, a localized focus of fibrous dysplasia and a giant cell cystic tumor. It is also necessary to exclude signs of chondroma malignancy. To clarify the diagnosis, a biopsy is performed followed by a histological examination of the material.
A typical chondroma of hyalinous cartilage tissue consists of lacunae, in the center of which lie single cells separated by normal, myxomatous or edematous matter. When the intercellular substance changes, cells often have a stellate or fusiform shape. Foci of calcification are usually found in the intercellular substance.
The nuclei of benign tumor cells are small, slightly rounded. One cell usually contains one nucleus. With malignant degeneration, the nuclei become larger, “plump”, round or acquire an irregular shape. The number of binuclear cells increases. At the initial stages of malignancy, foci of unchanged cartilage cells remain in the chondrome, therefore, if a malignant degeneration of the tumor is suspected, it is recommended to take a biopsy in several sites. Magnetic resonance imaging and computed tomography with tumor biopsy are used to detect exochondromes.
When detecting chondromes of the base of the skull and the paranasal sinuses, radiography is also uninformative, so CT or MRI is used in such cases. Before starting an instrumental diagnosis, a neurologist or neurosurgeon conducts a neurological examination to clarify the localization of the lesion. During CT scans of the skull and MRI of the brain, the exact location of the chondroma, its shape, size and relationship to neighboring organs and tissues is determined. In conclusion, a biopsy is performed to clarify the diagnosis (if possible at this location of the chondroma).
The treatment is operative, carried out as planned in a specialized department (usually oncological). The tactics and scope of surgical intervention are determined taking into account the localization of the tumor and its effect on neighboring organs and tissues. Chondromes located in the area of short tubular bones of the foot and wrist are removed within healthy tissues. If necessary, the bone defect is plasticized with a homo- or allograft. Chondromes in the area of long tubular bones, as well as the sternum, scapula and pelvis, must be removed radically, following the principles of surgical treatment of patients with malignant neoplasms (chondrosarcomas), since in this case the risk of tumor malignancy is high enough.
The tactics of treating chondroma in the area of the base of the skull is chosen taking into account its localization, size, relation to neighboring tissues, the presence of concomitant diseases, the general condition of the patient and the risk of complications. The standard is surgical treatment. Traditional surgical removal of the skull bone tumor, minimally invasive surgical intervention (using an endoscope inserted through the nasal passages) or radiosurgical surgery is possible.
Radiation therapy can also be used in the treatment of chondroma of the base of the skull. It is usually used at the stage of preparation for surgery to reduce the size of the neoplasm or in the postoperative period to completely destroy tumor cells that could remain after surgery. At the same time, in some cases, radiation therapy becomes the main method of treatment of chondroma of the base of the skull. This happens in the presence of contraindications and surgical intervention, for example, in the presence of serious somatic diseases or severe general condition of the patient.
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