Working Diagnosis:
Chondrosarcoma

Treatment:
The patient was admitted to the hospital and treated with a radical resection of the femur and megaprosthesis reconstruction. Case Photo #4 Case Photo #5 Case Photo #6

Outcome:
The patient began physical therapy. She has an early prognosis 50-70 percent 5-year survival rate and will require ongoing follow-up and monitoring.

Author's Comments:
Chondrosarcomas are rare tumors and were therefore appropriately low on the differential. Chondrosarcomas carry a prognosis of increased mortality with advanced differentiation and metastasis. In our patient, the tumor was quickly recognized and aggressively managed. While it may be easy to narrow differential diagnoses when a patient presents with common symptoms, this case serves as a reminder that it is important to keep differential lists broad. Rare and life threatening conditions can and will present with similar initial complaints. In this instance a low threshold for imaging carried minimal cost and led to rapid diagnosis.

Editor's Comments:
Chondrosarcoma is a cartilage forming neoplasm. Pain is the most common presenting symptom. On radiographs, chondrosarcomas have a heterogeneous appearance with cortical thickening, expansion, or thinning. Most also show some cartilaginous mineralization. Lower grade lesions are often smaller and intraosseous. Higher grade lesions are frequently large, destructive lesions with cortical expansion and a soft tissue mass.

The location of the chondrosarcoma can suggest the chance of metastases. More peripherally located chondrosarcomas are less likely to metastasize and those that are more proximal, such as the pelvis, have a higher chance of metastasizing. Skeletal and/or lung metastases present at diagnosis or within 12-18 months are common and are associated with poor survival. Surgery is required for all chondrosarcomas without metastases. More aggressive lesions of long bones are treated with wide local excision. Regular imaging should be performed after excision to evaluate for local recurrence and/or metastases.

References:
1. Leddy L, Holmes R. Chondrosarcoma of Bone. In Peabody, T.D., Attar, S. Ed. Orthopaedic Onology. 2016. Springer, pp. 117-130.
2. Whelan, JS, Davis LE. Osteosarcoma, Chondrosarcoma, and Chordoma. J Clin Oncol 36:188-193.
3. Giuffrida AY, Burgueno JE, Koniaris LG, Gutierrez JC, Duncan R, Scully SP. Chondrosarcoma in the United States (1973 to 2003): an analysis of 2890 cases from the SEER database. J Bone Joint Surg Am. 2009 May;91(5):1063-72. doi: 10.2106/JBJS.H.00416. PMID: 19411454.
4. Amer KM, Munn M, Congiusta D, Abraham JA, Basu Mallick A. Survival and Prognosis of Chondrosarcoma Subtypes: SEER Database Analysis. J Orthop Res. 2020 Feb;38(2):311-319. doi: 10.1002/jor.24463. Epub 2019 Sep 22. PMID: 31498474.

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