Chondrosarcoma following synovial chondromatosis.A case study

Synovial chondrosarcoma: a single-institution experience with molecular investigations and review of the literature

AIMS

To evaluate the available diagnostic histological criteria for synovial chondrosarcoma and to screen for the presence of IDH1/IDH2 mutations in a series of cases of this malignant cartilaginous neoplasm.

METHODS AND RESULTS

Ten cases of synovial chondrosarcoma diagnosed at our institute were reviewed. At presentation, all tumours occurred in adults (median age, 62 years). The most common location was the knee joint (five cases), and the size at diagnosis ranged from 30 mm to 170 mm. Eight patients had secondary synovial chondrosarcomas associated with pre-existing/recurrent or concomitant synovial chondromatosis. Five patients had local recurrences and three had lung metastases. All patients with intralesional excisions developed local recurrences, whereas those who underwent wide resections did not. At last follow-up (mean, 91 months), available for nine patients, seven patients were alive and disease-free, one patient had died of disease, and one was alive with paravertebral metastases. Frequent histological features observed included loss of clustering of chondrocytes (nine cases), the presence of variable amounts of myxoid matrix (eight cases), peripheral hypercellularity (eight cases), tumour necrosis (six cases), and spindling of chondrocytes (four cases). Of the seven cases for which it was possible to evaluate bone permeation, six showed infiltration of bone marrow. All seven cases screened for mutations of exon 4 of IDH1 and IDH2 were found to be wild-type.

CONCLUSIONS

Histological criteria in correlation with clinical and radiological features allow the recognition of synovial chondrosarcoma. IDH1/IDH2 mutations were not present in synovial chondrosarcoma. Adequate surgical margins are important for disease control.

Intra- and extracapsular synovial chondromatosis of the temporomandibular joint: Rare case and review of the literature

Synovial chondromatosis is a benign disease which most commonly appears in large joints and only rarely affects the temporomandibular joint. The diagnosis is quite difficult due to the fact that a large swelling in the preauricular area and the radiographic findings may be misdiagnosed as other benign or malignant diseases. We report an unusual case of intra- and extracapsular chondromatosis of 25 osteochondral loose bodies in the right temporomandibular joint.

Malignant Transformation of Synovial Chondromatosis: A Systematic Review

Background:

Synovial chondromatosis (SCh) can undergo malignant transformation. Pathologic diagnosis of secondary synovial chondrosarcoma (SChS) is challenging and misdiagnosis may result in over- or undertreatment.

Method:

A systematic review revealed 48 cases of SChS published in 27 reports since 1957. Data was collected to identify findings indicative of SChS and outcomes of treatment.

Results:

At median follow-up of 18 months, patients were reported as alive (10%), alive without disease (22%), alive with disease (15%), dead of disease (19%), dead of pulmonary embolism (4%), and unknown (29%). Initial diagnosis of SChS (grade: low/unknown 48%, intermediate/high 52%) was after biopsy in 58%, local resection in 29%, and amputation in 13%. Seventy-four percent of patients underwent 1.8 (mean) resections. Patients treated prior to 1992 were managed with amputation in 79% of cases compared to 48% after 1992. Symptoms were present for 72 mos prior to diagnosis of SChS.

Synovial chondrosarcoma demonstrated symptom progression over several months (82%), rapid recurrence after complete resection (30%), and medullary canal invasion (43%). The SChS tumor dimensions were seldom quantified.

Conclusion:

Malignant degeneration of synovial chondromatosis is rare but can necessitate morbid surgery or result in death. Pathognomonic signs for SChS including intramedullary infiltration are present in the minority of cases. Progression of symptoms, quick local recurrence, and muscle infiltration are more suggestive of SChS. Periarticular cortical erosion, extra-capsular extension, and metaplastic chondroid features are non-specific. Although poorly documented for SChS, tumor size is a strong indicator of malignancy.

Biopsy and partial resection are prone to diagnostic error. Surgical decisions are frequently based on size and clinical appearance and may be in conflict with pathologic diagnosis.

Synovial chondrosarcoma

BACKGROUND

Synovial chondrosarcoma (SCH) is a very rare tumor arising in the intra-articular cavity. In the majority of literature reports it is described as a malignant transformation of a pre-existing synovial chondromatosis (SC). We reported a systematic review of primary and secondary SCH described in the literature with the aim to recollect data from different case-reports and case-series, trying to summarize general aspects of this very rare disease.

METHODS

We collected 42 abstracts in the form of case series and case reports, which reported 67 cases of SCH. Studies were taken into account only if they proved a histological diagnosis of SCH, either primary or secondary, with or without evidence of pre-existing SC.

RESULTS

The average age of SCH was 56.9 years, with prevalence for male sex. The average time of malignant transformation was 11.2 years. The most affected joint was the knee (47.7%), followed by hip (34.3%) and ankle (5.9%). SCH was described as de novo sarcoma only in 13 cases (19%). Surgery ended up with amputation in 59.7% of cases. Local recurrence rate was 28.3%.

CONCLUSIONS

We concluded that prognosis of SCH is worse than conventional one and we speculated this is due to the difficult site of the tumor (intraarticular), diagnostic delay and inappropriate previous treatments. We consider that a rapid deterioration of a SC or rapid recurrence after synoviectomy should be considered suspicious of malignant transformation and should be treated in a reference center.

Primary synovial chondromatosis: a reassessment of malignant potential in 155 cases

OBJECTIVE

Primary synovial chondromatosis (PSC) is a rare disorder characterised by cartilage formation in synovium-lined joints, tendon sheaths and bursae. It is thought that PSC cartilage arises from the proliferation of mesenchymal cells, which exhibit cartilaginous metaplasia in subintimal connective tissue. There are reports of transformation of PSC to chondrosarcoma, although the precise incidence and nature of this complication is uncertain. In this study we carried out a retrospective review PSC to determine the incidence of sarcomatous change in this condition, in addition to the clinical, radiological and pathological features that characterise this complication

MATERIALS AND METHODS

We reviewed 155 cases of PSC and identified 4 cases (3 in the hip joint; 1 in the elbow joint) of aggressive behaviour and chondrosarcoma-like histology.

RESULTS

Radiologically, these cases were all reported as showing features consistent with PSC and aggressive extra-articular soft tissue/bone involvement. Histologically, in addition to typical features of PSC, there was morphological evidence of peri-articular soft tissue and, in 2 cases, bone involvement by an infiltrating cartilaginous tumour. These tumours all behaved as locally aggressive neoplasms and did not give rise to metastasis.

CONCLUSION

Our findings show that chondrosarcoma arises infrequently in PSC (approximately 2.5 %), and that this complication occurs most commonly in the hip joint (approximately 11 % of cases of hip PSC). These tumours behaved mainly as low-grade, locally aggressive tumours analogous to atypical cartilaginous tumour of bone/grade 1 chondrosarcoma of bone.

Primary tumours of the synovium. A report of four cases of malignant tumour

Four patients who developed malignant synovial tumours are described; one with chondromatosis developed a synovial chondrosarcoma and three with pigmented villonodular synovitis developed malignant change. The relevant literature is discussed.

Imaging of Synovial Chondromatosis with Radiologic-Pathologic Correlation

Primary synovial chondromatosis represents an uncommon benign neoplastic process with hyaline cartilage nodules in the subsynovial tissue of a joint, tendon sheath, or bursa. The nodules may enlarge and detach from the synovium. The knee, followed by the hip, in male adults are the most commonly involved sites and patient population. The pathologic appearance may simulate chondrosarcoma because of significant histologic atypia, and radiologic correlation to localize the process as synovially based is vital for correct diagnosis. Radiologic findings are frequently pathognomonic. Radiographs reveal multiple intraarticular calcifications (70%-95% of cases) of similar size and shape, distributed throughout the joint, with typical "ring-and-arc" chondroid mineralization. Extrinsic erosion of bone is seen in 20%-50% of cases. Computed tomography (CT) optimally depicts the calcified intraarticular fragments and extrinsic bone erosion. Magnetic resonance (MR) imaging findings are more variable, depending on the degree of mineralization, although the most common pattern (77% of cases) reveals low to intermediate signal intensity with T1-weighting and very high signal intensity with T2-weighting with hypointense calcifications. These signal intensity characteristics on MR images and low attenuation of the nonmineralized regions on CT scans reflect the high water content of the cartilaginous lesions. CT and MR imaging depict the extent of the synovial disease (particularly surrounding soft-tissue involvement) and lobular growth. Secondary synovial chondromatosis can be distinguished from primary disease both radiologically (underlying articular disease and fewer chondral bodies of variable size and shape) and pathologically (concentric rings of growth). Treatment of primary disease is surgical synovectomy with removal of chondral fragments; recurrence rates range from 3% to 23%. Malignant transformation to chondrosarcoma is unusual (5% of cases) and, although difficult to distinguish from benign disease, is suggested by multiple recurrences and marrow invasion. Recognizing the appearances of primary synovial chondromatosis, which reflect their underlying pathologic characteristics, improves radiologic assessment and is important to optimize patient management.

Synovial Chondromatosis of the Temporomandibular Joint With Skull Base Extension

Synovial chondromatosis is a benign pathologic lesion that is considered to be a metaplastic process. This disease is rarely encountered in the temporomandibular joint (TMJ). In this article, a 72-year-old patient with synovial chondromatosis of the TMJ extending to the infratemporal fossa is presented and the literature is reviewed.

Synovial chondromatosis of the temporomandibular joint with condylar extension

Synovial chondromatosis is a benign disease that rarely affects the temporomandibular joint (TMJ). It can be seen commonly in the superior joint space and presents with various signs and symptoms according to the stage of progression. Sometimes it presents as a large swelling in the preauricular area with or without cranial extension, and the clinical and radiographic findings may be misdiagnosed as other benign or malignant diseases of TMJ. Therefore, we report an uncommon case of synovial chondromatosis presenting as a large preauricular mass arising from the inferior joint space of the TMJ with bony resorption of the mandibular condyle, which mimicked osteochondroma.

Vertebral synovial chondromatosis. Report of two cases and review of the literature

Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium, most commonly affecting large joints. Its involvement with the spine is rare; only six cases have been reported. The authors describe two patients with synovial chondromatosis involving the cervical spine. In the first case, synovial chondromatosis arose from the left C1-2 facet joint. This patient underwent a two-stage procedure including a posterior approach for tumor resection and occipitocervical fusion as well as a transmandibular circumglossal approach to the anterior craniocervical junction to complete the tumor removal. Interestingly, on histopathological examination, scattered foci of low-grade chondrosarcoma were intermixed within the synovial chondromatosis. To the authors' knowledge, this is the first report of secondary low-grade chondrosarcoma arising in vertebral synovial chondromatosis. In the second case, synovial chondromatosis involved the left C4-5 facet joint. Tumor resection and cervical fusion were performed via a posterior approach. In this report, the authors describe the clinical presentation, radiographic findings, operative details, histopathological features, and clinicoradiological follow-up data obtained in these two patients and review the literature pertaining to this rare entity.

Synovial chondromatosis of the hand: Three case reports and literature review

Synovial chondromatosis is a rare condition that is probably caused by synovial connective tissue metaplasia. It is very rare in the hand and wrist and because of its low prevalence and nonspecific symptoms, synovial chondromatosis can present diagnostic difficulties for the hand surgeon and may lead to a delay in treatment. We review the literature and report three additional cases of synovial chondromatosis in the hand.

Synovial chondromatosis of the metacarpophalangeal joint

We describe a case of synovial chondromatosis in a metacarpophalangeal joint with invasion of local structures. The degree of local tissue involvement was not demonstrated on the preoperative MRI scans. This case highlights that synovial chondromatosis can be invasive and that even the best preoperative imaging may not demonstrate this.

Recurrent synovial chondromatosis of the index finger--case report and literature review

We report a case of synovial chondromatosis of the proximal interphalangeal joint of the dominant right index finger with a follow-up of four years. The lesion recurred within a year of complete excision of the fibrous sac containing cartilaginous nodules. Despite early recurrence and extensive calcification around the proximal phalanx, no malignant changes were noted on histological examination. The patient remains asymptomatic for two years after the second operation.

Synovial chondromatosis of the left temporomandibular joint superficially resembling chondrosarcoma: a case report

A 25 year-old woman was referred to the clinic complaining of pain in the left temporomandibular joint (TMJ) and trismus. According to the x-ray images, a solitary mass was observed in the anterior pouch of the lower joint cavity. The mass was removed by means of a synovectomy and a diskectomy. Upon light microscopic examination, the tissue removed showed high cellular activity. As a differential diagnosis, we had to consider the possibility of chondrosarcoma based on the histopathological features; however, since no invasive nor metastatic finding was recognized, we made a diagnosis of synovial chondromatosis despite its rare existence. Although there has been no sign of recurrence at present, we plan to carefully follow up with the patient.

Fine-needle aspiration diagnosis of synovial chondromatosis of the tibiofibular joint

We report a case of synovial chondromatosis of the tibiofibular joint in a 25-year-old woman that was diagnosed by fine-needle aspiration (FNA). The patient presented with pain in the left knee and a mass in the popliteal fossa. Synovial chondromatosis usually presents with joint symptoms and is often associated with intra-articular loose bodies, whereas presentation as a soft tissue mass is unusual and may raise the clinical suspicion of malignant neoplasm. The diagnosis is commonly confirmed by histopathologic examination of biopsy or excision of the specimen. To the best of our knowledge, this is the first case of synovial chondromatosis of a large joint successfully diagnosed by FNA. Two cases of synovial chondromatosis of the temporomandibular joint have been reported in which the diagnosis was suspected on the basis of FNA. In both these cases, the final diagnosis was established by histopathology of the excised specimens.

Synovial osteochondromatosis of the retrocalcaneal bursa: a case study

A 42-year-old man presented with synovial osteochondromatosis (SO) of the retrocalcaneal bursa with intraosseous lesions in the calcaneum, leading to significant pain and consequent disability. Simple x-rays, computed tomography, and magnetic resonance imaging were performed preoperatively. The patient has remained asymptomatic, clinically and radiographically, without recurrent lesions for 18 months postoperatively.

Synovial chondromatosis of the temporomandibular joint with intracranial extension

An unusual case of synovial chondromatosis of the temporomandibular joint with intracranial extension, which resulted in complete dehiscence of the floor of the middle cranial fossa, is reported. An overview of the current literature and a discussion of the diagnosis and surgical management of synovial chondromatosis are presented.

Primary synovial chondromatosis: a clinicopathologic review and assessment of malignant potential

This is a clinicopathologic review of 53 cases of primary synovial chondromatosis covering a period of 30 years. The average age at presentation was 41 years (range, 17 to 64 years) with a male/female preponderance of 1.8:1. The condition was always monarticular, the most common site being the knee joint (70%) followed by the hip (20%). Degenerative joint disease was well established in three patients (5%), all occurring in the hip. Nine patients suffered recurrences (15%), including three that became malignant. There was no relationship between the age and site of the lesion, nor between the degree of cellularity of the cartilage and age or site. However, there was an association between cellularity of the cartilage and the extent of calcification and ossification--highly cellular lesions were poorly calcified and ossified, but heavily calcified lesions were usually of relatively low cellularity. There was no relationship between extent of calcification and ossification and the age of the patient. Three patients suffered malignant change representing a relative risk of 5%, much higher than that quoted in other series. This suggests that primary synovial chondromatosis has a significant potential for malignant change.

Recurrent synovial chondromatosis treated with meniscectomy and synovectomy

Synovial chondromatosis is a rare benign intraarticular metaplasia of synovium. This process may result in the production of detached particles of highly cellular cartilage in the involved joint spaces. It is most often reported in the larger joints of the body including the knee, hip, elbow, and ankle. Since Axhausen in 1993 reported the first case affecting the temporomandibular joint, several articles have been listed in the literature regarding the presentation, diagnosis, and management of this form of an arthropathy. This is a case of a recurrent synovial chondromatosis that was approached with a meniscectomy and a complete synovectomy.

Synovial osteochondromatosis of the distal radio-ulnar joint

Synovial osteochondromatosis is an uncommon lesion characterized by cartilagenous and osseous metaplasia of joint synovium. It is typically monarticular, affecting large joints such as the knee and hip, although it has also been described in the ankle, elbow and shoulder. It is exceptionally rare in the hand, but has been reported involving the tenosynovium of the digits and the wrist. We report a rare case of synovial osteochondromatosis involving the distal radio-ulnar joint in a 16-year-old man.

Uptake of pentavalent technetium-99m dimercaptosuccinic acid in idiopathic synovial chondromatosis

We reported two Tc-99m(V) DMSA scintigrams in patients with idiopathic synovial chondromatosis which affected the metacarpo-phalangeal joint and shoulder joint. Tc-99m(V) DMSA accumulated markedly and diffusely in the tumor. Tc-99m(V) DMSA scintigraphy would be valuable for deciding the optimal site for biopsy.

Synovial osteochondromatosis of the temporo-mandibular joint

A rare case of synovial osteochondromatosis of the temporo-mandibular joint is presented. Important diagnostic information can be obtained by CT, MRI, 99m Tc bone scan and aspiration biopsy. Observation using a light microscope showed mild cellular atypia, but the hallmarks characteristic of chondrosarcoma were not found. Observation using an electron microscope showed the mature chondrocytes contained a well-developed rough endoplasmic reticulum. Histological evaluation indicated that the present case was benign synovial osteochondromatosis in an early stage.

Asymptomatic, radiologically detected chondrometaplasia in the temporomandibular joint

Asymptomatic loose bodies were detected in the temporomandibular joint of a 62-year-old woman during an examination before comprehensive dental care. The radiologic interpretation was synovial chondrometaplasia (synovial osteochondromatosis). A histologic diagnosis was not obtained, because surgery was unwarranted in view of the lack of symptoms and the benign differential diagnosis. Review of the literature revealed 62 reported cases of temporomandibular joint chondrometaplasia, all of which included one or more of the following: swelling, pain, joint noise, and limited mandibular movement. These reports have described this entity as a rare lesion, but the rate of reports has increased, perhaps because of greater practitioner awareness and increased sensitivity of diagnostic tests.

Chondrosarcomas of the synovium

Chondrosarcoma of the synovium, either primary or secondary to synovial chondromatosis, is rare. Ten cases of synovial chondrosarcoma were studied (four from the Mayo Clinic files and six from the authors' consultation files). Two were considered primary. In five cases there was evidence of preexisting synovial chondromatosis, and in the remaining three, there was a suggestion of preexisting disease. Several histologic features were found that were helpful to diagnose malignancy. The most important ones were loss of the "clustering" growth pattern typical of synovial chondromatosis, myxoid change in the matrix, areas of necrosis, and spindling at the periphery of chondroid lobules. Pulmonary metastasis developed in five of nine patients; three of these patients died.

Reconstruction of the triangular fibrocartilage complex after surgery for treatment of synovial osteochondromatosis of the distal radioulnar joint

Synovial osteochondromatosis of the hand is uncommon, except for tenosynovial chondromatosis of the digits. It is even more rare in the wrist joint. A patient with synovial osteochondromatosis of the distal radioulnar joint that involved the triangular fibrocartilage complex is described. At operation, synovectomy, excision of osteochondral bodies, and removal of the entire triangular fibrocartilage complex was done. The triangular fibrocartilage complex was reconstructed using part of the extensor carpi ulnaris tendon. One year after operation, the patient had regained almost full range of motion and is without pain.

Synovial chondromatosis with intracranial extension. A case report

A case of unilateral synovial chondromatosis of the temporomandibular joint with intracranial extension is presented. Extracapsular extension of these lesions is rare, and few cases have previously been reported. The case presentation will also reflect the inadequacy of routine preoperative temporomandibular joint x-ray films to reflect the extent of the lesion. Despite the benign nature of the lesion, excision was done because of the clinical aggressive behavior.

Synovial chondromatosis of the temporomandibular joint. Review of the literature and case report

Synovial chondromatosis is an uncommon, benign condition of unknown etiology which affects articular joints. Foci of cartilage develop through metaplasia in the underlying connective tissue of the synovial membrane. These foci of cartilage enlarge with time into cartilage fragments, and may be detached from the affected synovium and released into the joint cavity. These cartilaginous foci and fragments may undergo calcification and ossification. The literature is reviewed and an additional case reported.

Synovial chondromatosis of the temporomandibular joint

Synovial chondromatosis of the temporomandibular joint is a rare, benign condition of metaplastic change of the synovium. A case is reported and the world literature is reviewed.

Synovial chondromatosis of the temporomandibular joint

An illustrative case of synovial chondromatosis in the temporomandibular joint (TMJ) region is presented, and 36 cases reported earlier are reviewed. The present patient, a 35-year-old woman, had been suffering from swelling and pain in the TMJ area as well as limited mandibular movements for 7 years. The condition had been treated with various conservative methods without any relief of the symptoms. Finally, radiological examination revealed calcified nodules within the joint space and a surgical exploration was performed. In all, 27 loose particles were removed from the joint in connection with the extirpation of the perforated and deformed disk. The result of surgical therapy has been favourable during the follow-up period of 18 months. Although synovial chondromatosis is rare in the TMJ, it should be kept in mind as one possible disease when treating patients suffering from symptoms similar to those of mandibular dysfunction syndrome.

Chondrosarcoma. I. A selected literature review

More than 200 articles and texts relating to chondrosarcoma in the general skeleton, in the head and neck area, and in extraskeletal soft tissues, were reviewed and summarized. In the interest of space conservation and avoidance, to the extent possible, of distracting referential interjections in the text, the entire list of materials reviewed has not been referenced. For example, articles that contribute essentially nothing more than single case reports are not included in the list of references. Effort has been made, however, to include articles of historical significance, articles reporting series of cases, and articles exploring ideas and concepts. The authors believe this review to be a comprehensive summary of the chondrosarcoma literature. An analysis of 37 cases of chondrosarcoma of the jaws will be published as Part II.

Synovial chondromatosis of the temporo-mandibular joint. Report of three cases and a review of the literature

Synovial chondromatosis of the temporo-mandibular joint is a rare affection, characterized by the formation of cartilage particles in the synovial membrane. These particles can break through and enter the joint compartments. The diagnosis must be considered for patients who complain of slowly progressive swelling, pain, and crepitus in the region of the temporo-mandibular joint. When the changes are not visible on plain X-rays due to absence of ossification, important diagnostic information can be obtained by a technetium 99m (99m Tc) bone scan and a computerized tomography (CT) sialogram. The diagnosis can be established only by histopathologic examination of surgically removed particles or resected synovial membrane. Discussed are 25 cases of histopathologically verified chondromatosis of the temporo-mandibular joint reported in the literature, as well as 3 new cases seen and treated at the University Hospital Groningen since 1970. A good clinical result can be obtained by removal of all particles and synovectomy. Condylectomy is seldom required.

Unusual aspects of synovial chondromatosis of the elbow

A 60-year-old man suffered locally from a rather aggressive chondromatosis of the elbow. Clinically the presentation was rather uncommon, with some radiological aspects (juxta-articular bone rarefaction) differing from those of ordinary chondromatosis. Neither the pathologist nor the radiologist recognized signs of malignancy. Regional osteoporosis, although rarely described in synovial chondromatosis, was considered as the diagnosis in this patient, but a low grade primitive chondrosarcoma must be sought in such cases.

Synovial chondrometaplasia of the hand: case report and review of the literature

A case of synovial chondrometaplasia of the hand is described. Histologic differentiation from chondrosarcoma may be difficult. Recurrences are common, but no instance of malignant change is known. Nonetheless, adequate surgical excision of the lesion is recommended.

Myxoid chondrosarcoma of the synovial tissue. A clinicopathologic, histochemical, and ultrastructural analysis

The first case of a myxoid chondrosarcoma, originating in the synovia of the joint and tendon sheaths of the ankle in a 37-year-old man, is reported. Light microscopically the tumor was similar to extraskeletal myxoid chondrosarcoma as previously described. The chondromatous nature of the tumor was further indicated by the histochemical analysis, which revealed the presence of chondroitin 4- and 6-sulphate in the tumor matrix. Ultrastructurally, chondroblast-like cells with dilated rough endoplasmic reticulum, abundant glycogen, some lipid droplets and numerous microvilli-like projections of the cytoplasm dominated. Also mitochondria-rich cells were observed as well as intermediate cell forms. Based on the observations in this case, the frequent occurrence of synovial chondromatosis, the assumed synovial origin of extraskeletal chondromas and the wide morphologic and functional spectrum synovial intima cells may cover, it is suggested that the myxoid chondrosarcoma originated from the synovial intima cells.