Exostoses, enchondromatosis and metachondromatosis; diagnosis and management

We describe a 5 years old girl who presented to the multidisciplinary skeletal dysplasia clinic following excision of two bony lumps from her fingers. Based on clinical examination, radiolographs and histological results an initial diagnosis of hereditary multiple exostosis (HME) was made. Four years later she developed further lumps which had the radiological appearance of enchondromas. The appearance of both exostoses and enchondromas suggested a possible diagnosis of metachondromatosis. Genetic testing revealed a splice site mutation at the end of exon 11 on the PTPN11 gene, confirming the diagnosis of metachondromatosis. While both single or multiple exostoses and enchondromas occur relatively commonly on their own, the appearance of multiple exostoses and enchondromas together is rare and should raise the differential diagnosis of metachondromatosis. Making this diagnosis is important as the lesions in metachondromatosis may spontaneously resolve and therefore surgical intervention is often unnecessary. We discuss the diagnostic findings, genetic causes, treatment and prognosis of this rare condition of which less than thirty cases have previously been reported.

Maffucci Syndrome. An Interesting Case and a Review of the Literature

Maffucci syndrome, a rare sporadic form of enchondromatosis, is characterized by hemangiomas and multiple enchondromas, benign cartilaginous tumors that arise near growth plates. Previous studies demonstrate that individuals diagnosed with Maffucci syndrome have approximately 100% lifetime risk of malignant transformation. Identification of Maffucci syndrome by surgical excision and pathological diagnosis can be life-saving due to its high malignant potential relative to other subtypes of enchondromatosis such as Ollier's disease. We report a case of a 58-year-old man with enchondromatosis who experienced malignant transformation of the enchondroma in his distal femur into a chondrosarcoma. He underwent a right distal femoral replacement without complications. Two years later, new masses were identified in his left hand and excised following progressive growth, pain, and functional limitation. Pathology confirmed these to be hemangiomas, and he was diagnosed with Maffucci syndrome. At last follow-up, patient reported additional nodular tumor growths occurring unilaterally on the left side. For patients with Maffucci syndrome, continual follow-up and careful surveillance of these masses is crucial as these lesions can cause fractures, deformities, pain, and undergo malignant transformation. Our report reviews the literature and outlines the treatment and management plans for patients with this rare and potentially dangerous disorder.

Ollier Disease: Pathogenesis, Diagnosis, and Management

Ollier disease (Spranger type I) is a rare bone disease that is characterized by multiple enchondromatosis with a typical asymmetrical distribution and confined to the appendicular skeleton. The pathogenesis of enchondromatosis is not clearly understood. Recently, heterozygous mutations of PTHR1, IDH1 (most common), and/or IDH2 genes have been suggested by various authors as genetic aberrations. Genomic copy number alterations and mutations controlling many vital pathways are responsible for the pathogenesis of Ollier disease. A comprehensive description of all genetic events in Ollier disease is presented in this article. Clinically, Ollier disease has a wide variety of presentations. This article describes the plethora of clinical features, both common and rare, associated with Ollier disease. Multiple enchondromas are most commonly seen in phalanges and metacarpals. Radiologically, Ollier disease presents with asymmetrical osteolytic lesions with well-defined, sclerotic margins. In this article, various radiological features of Ollier disease, including radiographs, computed tomography, and magnetic resonance imaging, are also discussed. Gross pathology, cytological, and histological features of both Ollier disease and its malignant transformation are outlined. Although treatment is conservative in most cases, different possible treatment options for difficult cases are discussed. In the literature, there is a paucity of data about the disease, including diagnosis, management, prognostication, and rehabilitation, necessitating a comprehensive review to further define all of the possible domains related to this disease.

Five polyostotic conditions that general orthopedic surgeons should recognize (or should not miss)

General orthopedic surgeons frequently encounter patients with conditions affecting multiple bones. It is important to recognize common polyostotic diseases. This article describes five polyostotic conditions: Multipe Enchondromatosis (Ollier Disease and Maffucci syndrome), Multiple Hereditary Exostosis (Diaphyseal Aclasis), Fibrous Dysplasia (McCune-Albright syndrome and Mazabraud syndrome), Paget's Disease of bone (Osteitis Deformans), and Skeletal Metastases. This is a survey of the clinical, pathologic and radiographic features that assist in diagnosing these conditions. Also, an overview of the laboratory findings, treatment, follow-up, and prognosis is presented. Recognizing these diseases will aid in prompt and accurate diagnosis and appropriate referral and therapy.

[Hereditary multiple exostosis. Case report and differential diagnosis of enchondromatosis]

The enchondromatosis include a heterogeneous group of congenital disorders characterized by the presence of multiple enchondromas associated with musculoskeletal malformations and the main complication is the risk of malignant transformation to chondrosarcoma. The hereditary multiple exostosis is an entity with autonomus dominant inheritance pattern, characterized by having multiple exostosis capped benign cartilage and heterogeneous clinical manifestations. Mutations of EXT1 and EXT2 genes have been cloned and are responsible for over 80% of the cases. We report a case of a six years old female with a diagnosis of hereditary multiple exostosis, that has been multidisciplinary assessed at our institution being the second case study in the Medical Genetics Unit of the Universidad de Los Andes; the clinical and genetic aspects, the differential diagnosis with Oilier disease and Maffucci syndrome were reviewed.

Early-onset childhood sarcoidosis with incidental multiple enchondromatosis

The triad of rash, arthritis, and uveitis seems to be characteristic for early-onset childhood sarcoidosis. We describe an interesting case of early-onset childhood sarcoidosis coexisting enchondromatosis, which clinically masquerade as Langerhans cell histiocytosis. A 33 months old girl presented with skin rash, subcutaneous nodules with polyarthritis, and revealed the involvement of lymph nodes as well as spleen during work-up. She also presented with multiple osteolytic lesions which pathologically proven enchondromatosis. Oral prednisone was prescribed at 2 mg/kg/day for 2 months until when subcutaneous nodules and joint swellings almost disappeared, and then slowly tapered over a period of 5 months. We report an unusual case of early-onset childhood sarcoidosis presented with osteolytic bone lesions which were irrelevant to sarcoidosis.

[A woman with multiple masses on her left hand]

We describe a 66-year-old woman who presented with firm masses on her left hand, which had recently increased in size, and multiple haemangiomas. A diagnosis of Maffucci syndrome was established. Renewed growth of enchondromas during adulthood is suspicious for malignant transformation. Therefore, curettage with adjuvant fenolisation was performed in our patient. Clinical and radiological follow-up was required concerning local recurrence.

MAFFUCCI SYNDROME: A RARE AND IMPORTANT DIFFERENTIAL DIAGNOSIS FOR LUMPY HANDS

Maffucci syndrome belongs to a group of disorders known as enchondromatoses. First described in 1881, it features multiple enchondromas and vascular abnormalities, mainly haemangiomas. The syndrome is a variant of Ollier's disease, which consists solely of multiple enchondromas. This case serves to highlight important features of a rare condition.

[Increasing leg length discrepancy in multiple enchondromatosis]

BACKGROUND

Ollier's disease (multiple enchondromatosis) is a rare non-hereditary condition characterised by the occurrence of multiple enchondromas, usually unilateral and asymmetrically distributed in the metaphyseal regions of the long bones and in the phalanges of the hand and foot.

CASE DESCRIPTION

A 10-year-old girl visited our outpatients' department with growth retardation of the left leg. Radiographic examination showed reduced growth and deformities in the femur and tibia, confirmed by MRI and bone scan. Since the aetiology of the deformities was not clear, we consulted the Netherlands Committee on Bone Tumours who diagnosed Ollier's disease (multiple enchondromatosis).

CONCLUSION

The pathogenesis of Ollier's disease possibly involves abnormalities in the signalling pathways controlling the differentiation of chondrocytes. Treatment is surgical and may consist of curettage and grafting of lesions, osteotomy, or Ilizarov fixation to correct deformities and length difference. Patients have a 5-50% risk of malignant transformation to chondrosarcoma, necessitating lifelong follow-up.

Chondrosarcomas of the base of the skull in Ollier's disease or Maffucci's syndrome--three case reports and review of the literature

Ollier's disease is a rare disease characterized by constitutional bone dysplasia with multiple enchondromas. The combination of haemangioma and chondromatoses is known as Maffucci's syndrome. Malignant degeneration of bone dysplasia into chondrosarcoma is a well-known complication, but a lesion of the base of the skull is exceptional. It is a slowly growing low-grade malignant tumour. Three new cases of chondrosarcoma of the base of the skull occurring in one patient with Marfucci's syndrome and two patients with Ollier's disease are reported and these cases are discussed in the light of the literature. A multidisciplinary approach, comprising surgery and radiotherapy, achieved good results.

The association between intracranial tumours and multiple dyschondroplasia (Ollier's disease or Maffucci's syndrome): do children and adults differ?

In Ollier's disease (OD) and Maffucci's syndrome (MS), there is deforming dysplasia of cartilage, primarily but not exclusively involving the metaphyses and diaphyses of long bones. In a minority of patients with either of these rare syndromes, dysplasia can lead to sarcomatous degeneration, producing chondrosarcomas. There also appears to be an association with other neoplasms, which can include intracranial tumours. The primary objective of the current paper was to compare children/adolescents who have either OD or MS and an intracranial malignancy with their adult counterparts. All relevant cases in the medical literature were identified by electronically searching PubMed, SciSearch, Scientific Commons, Springer Link, and Google. Translate DotNet and Babelfish were used to translate non-English text. Non-parametric Pearson chi-square analyses were used to compare youths versus adults with respect to gender and geographic distribution (by continent), tumour histology and site of lesion, and the underlying enchondromatosis syndrome (OD vs. MS). All tests were 2-tailed, and P < 0.05 represented a statistically-significant difference. Forty-six patients with 47 intra-cranial malignancies were identified, with nine of the patients being 18 years old or less and categorized as youths. The incidence of intracranial chondrosarcomas peaked in the fourth decade of life, in parallel with the peak number of MS cases; conversely, both non-sarcomas and OD peaked in the third decade of life. Six of nine youths (67%) versus 17 of 36 adults with gender data (47%) were female (P = 0.30). There was no difference in geographic distribution by continent (P = 0.82). Four youths (44%) versus 16 adults (43%) had a chondrosarcoma (P = 0.95), and there was no statistically significant difference by tumour site (P = 0.42). However, seven (77%) of the youths had Ollier's disease as their underlying enchondromatosis syndrome, versus just 17 (46%) of the adults, a difference that approached statistical significance (P = 0.086). The association between enchondromatosis and intracranial malignancy seems to be roughly the same in youths versus adults, though Ollier's disease cases appear to predominate among youths.

Clinics in diagnostic imaging (124). Multiple enchondromatosis in Ollier disease

A three-year-old girl presented with slow-growing swellings at the left foot and upper right humerus. Radiographs show multiple enchondromas in both feet, proximal humeri and scapulae, as well as at multiple sites in the hands, distal forearm bones and pelvis, in keeping with multiple enchondromatosis in Ollier disease. The clinical presentation and imaging features of enchondromas and the different types of enchondromatosis are discussed.

Hemangiomas: Their uses and abuses

Hemangiomas are vascular tumors, and are distinct from vascular malformations. The term "hemangioma" is frequently misapplied by various medical specialists. This article briefly summarizes the main types of hemangiomas: infantile, rapidly involuting, and noninvoluting types. More complex conditions are also reviewed, such as hemangiomas of the liver and PHACES. The discussion then focuses on common vascular misnomers and proper descriptive terminology for hemangiomas: solitary (small, large, or diffuse) and multifocal. It is concluded that the term "segmental hemangioma" is imprecise, ill-advised, misguided, and should be abandoned.

[Maffucci syndrome: an historical case]

We report a case of Maffucci syndrome in a 24-year-old patient, diagnosed thanks to the data of the clinical examination, the imagery and the histology. The clinical, radiological and evolutionary aspects are discussed, as well as the various therapeutic means.

[Venous malformations: clinical characteristics and differential diagnosis]

Venous malformations (VM) are localized defects of blood vessels that are due to vascular dysmorphogenesis. These slow-flow lesions can affect any tissue or organ. Clinically, a cutaneous VM is characterized by a bluish mass that is compressible on palpation. Phleboliths are commonly present. Symptoms depend on location and size. VM are often sporadic and isolated, however, they can be associated with other malformations and be part of a syndrome; Klippel-Trenaunay (capillary-lymphatico-venous malformation with limb hypertrophy) is the most common. Glomuvenous malformation (GVM) is another type of venous anomaly. In contrast to VM, GVM is often painful on palpation and not compressible. Clinical diagnosis of VM is often made in the presence of a bluish cutaneous lesion: however, other lesions can mimick VM. The most frequent anomalies are a blue naevus, a hemorrhagic lymphatic malformation, a sub-cutaneous hemangioma or even the presence of dilated superficial normal veins due to underlying venous stenoses. This chapter will detail the clinical characteristics of venous anomalies and their differential diagnosis.

Les malformations lymphatiques : aspects cliniques et évolution

Lymphatic malformations (LM) are the most frequent vascular malformations. There are three types of lesions involving lymphatic development that must be included in LM: vascular anomalies and knots (truncal malformations [TLM]); cystic anomalies, superficial or deep, uni- or multicystic (extratruncal malformations [ETLM]) and hemolymphatic anomalies which combine venous, arterial, or capillary malformations with LM. ETLM can be ubiquitously distributed but most are located in the cervical or axillary regions. Most ETLM are diagnosed at birth and in 80-90% of the cases before the age of 2. The clinical aspects are extremely variable: superficial ETLM (vesicular) and deep ETLM, localised or diffuse, mono- or multicystic. TLM are generally located on a lower limb with neonatal lymphatic oedema (often in a polymalformation context). All forms of the hemolymphatic combination can be identified. They are generally located on the limbs and are often unilateral. They are usually sporadic but can also be can be found in polymalformation syndromes (Klippel-Trénaunay, Parkes-Weber, Protée, Maffucci). ETLM generally tend to increase in volume and spread with age with stabilisation at puberty. They do not tend to spontaneously regress. Specific local complications can have serious consequences. They are linked to haemorrhaging, infections and compression phenomena. There can also be complications such as skeletal and soft tissue hypertrophy.

[Surgical treatment of hand deformities in multiple enchondromatosis: a case report]

Multiple enchondromatosis (Ollier's disease) is a rare disease characterized by widespread enchondromas. In general, the short tubular bones of the hand are involved, with progressive lesions resulting in cosmetic problems and functional deformities. Diaphysectomy and reconstruction with structural autografts or allografts are usually recommended in the treatment of extensive enchondromas involving the fingers. Curettage and grafting and ray amputation are other surgical procedures that can be applied depending on the severity of involvement. A 25-year-old woman with enchondromatosis presented with severe swelling and deformities on her fingers in both hands. The majority of the lesions were managed by diaphysectomy and reconstruction with structural grafts; ray amputation, curettage and grafting were performed for more severe lesions. During a long-term follow-up (left hand 6 years, right hand 5.5 years) cosmetic and functional results were acceptable.

A "reverse" Maffucci's syndrome: case report and short review of the literature

Maffucci's syndrome is a congenital, non-hereditary mesodermal dysplasia associated with multiple enchondromas and after some years accompanied by hemangiomas. We describe a rare case of "reverse" Maffucci's syndrome in a 42-year-old woman who has suffered from multiple hemangiomas for the last 24 years. The last two years she complained for heel pain. Bone scintigraphic examination showed abnormal findings in the left calcaneal bone. The scintigraphy, radiology and histology findings revealed multiple enchondromas, so the diagnosis was changed into Maffucci's syndrome. After one year, the left calcaneal bone showed sarcomatous transformation.

[Maffucci's syndrome. Case reports and literature review]

Maffucci syndrome is a rare, congenital disease, which is associated with the appearance of multiple enchondromas (possibility of malignant transformation in 20 to 100%), soft tissue hemangiomas and other mesenchymatous injuries. Case 1 is a 33-year-old female who presented with multiple nodules predominantly in upper extremities. Upon examination, there was deformity in articulation and nodules on the hands, which were soft and moveable. There were bony shavings in the second and fourth fingers of the left hand (enchondromas and atypical cells associated with hemangioma esclerosante). Maffucci syndrome was diagnosed. Later, excision of subcutaneous nodules in superior extremities was performed along with excision of nodules in both hands and hypochondrium (enchondroma injuries of left hand and hypochondrium, hemangioma in right hand). There was dysarticulation of the second finger at the metacarpal level of the phalanges of the left hand (chondrosarcoma). The patient is being followed up currently. Case 2 is a 26-year-old female. The patient had a history of subcutaneous abdominal tumor, exostosis, nodules and nodule in right breast. Upon examination, a tumor was found in the right breast, exostosis of right tibia, injury to the right wrist and left thyroid nodule. A simple mastectomy and axillary dissection was performed (fibroadenoma to intracanalicular and 14 negative lymph nodes). Later, left thyroidectomy and lumpectomy in right wrist were performed (hyperplasia to nodular thyroid and hemangioma cavernous). There was injury in the carpus of the right hand and elbow (hemangioma cavernous and synovial tissue with fibrosis and enchondroma). A diagnosis was made of Marffucci syndrome associated with mesenchymatous tumors. The patient was in poor general health and did not survive this hospitalization.

Maffucci's syndrome with extensive gastrointestinal involvement

A 10-year-old girl with cutaneous, oral and gastrointestinal vascular lesions was referred for consideration of laser treatment of her skin lesions. She was noted to have multiple venous malformations predominantly affecting the hands and feet, some of which had been present from birth. Her right hand was deformed by multiple venous malformations, and X-rays of this hand revealed enchondromata within metacarpal and phalangeal bones. She was known to have extensive involvement of her gastrointestinal tract by venous malformations, resulting in refractory iron-deficiency anaemia. In view of the multiple cutaneous and gastrointestinal vascular lesions, a diagnosis of blue rubber bleb naevus syndrome had been made many years earlier. However, after recognition of the characteristic enchondromata, this diagnosis has been revised to Maffucci's syndrome. In addition to her ongoing dermatological and paediatric follow up, she has now been referred to the orthopaedic surgeons for surveillance of her skeletal lesions.

A case of Maffucci 's syndrome with pleural effusion: ten-year follow-up

INTRODUCTION

Maffucci 's syndrome (MS) is a congenital non-hereditary mesodermal dysplasia characterised by numerous mesenchymal neoplasias in the form of enchondromas with secondary bone deformities and multiple soft tissue haemangiomas that may have phlebolitis.

CLINICAL PICTURE

A 23-year-old male patient presented with non-productive cough, dyspnoea, chest pain and back pain. Chest X-ray showed unilateral pleural effusion and multiple enchondromas of the ribs. On physical examination, there were mobile, multiple, bluish-coloured lesions probably cavernous haemangiomas on bilateral chest walls. In addition, there were multiple nodular lesions on the extremities especially accumulated on the fingers. The patient was diagnosed as Maffucci 's syndrome according to computed tomography (CT) of the thorax, conventional radiography of the skeletal system, magnetic resonance (MR) imaging, Th4-Th11 intercostal and right upper extremity angiography and physical examination findings.

TREATMENT

As the patient rejected any diagnostic intervention, he was monitored with CT.

OUTCOME

During the last 6 years of follow-up, the lesion that was detected on the rib adjacent to the basal segments of the left lung showed significant progression and was accepted as chondrosarcoma.

CONCLUSION

To our knowledge, this is the first case of Maffucci ' s syndrome with pleural effusion. In this case report, the probable mechanism of pleural effusion was discussed.

Desmoid tumor of bone with enchondromatous nodules, mistaken for chondrosarcoma

Desmoid tumor of bone, also termed desmoplastic fibroma or aggressive fibromatosis, is a rare, locally aggressive fibroblastic tumor. We present a 16-year-old male with a huge desmoid tumor involving the iliac wing. It was associated with enchondromatous nodules mimicking malignancy. The tumor in this patient was mistaken for chondrosarcoma and hemipelvectomy was performed. To our knowledge, such a case has not previously been documented fully in the English literature. The radiographic and pathologic findings and a possible mechanism of enchondromatous nodule formation in fibrous bone tumors are discussed.

Maffucci lymphangioma syndrome: an unusual variant of Ollier's disease, a case report and a review of the literature

A case of Maffucci's syndrome in an 18-month old boy is presented, in which the vascular malformation consists of lymphangioma. This is a rare variant of Maffucci's syndrome. So far only six other cases have been reported in which lymphangiomas featured. We believe that the case described here is only the second case to be reported for which a lymphangioma is the only vascular malformation in the syndrome. The literature of the other six cases was reviewed and various features identified enabling this particular disease to be classified as a distinct variant of Maffucci's syndrome.

[Multiple enchondromatosis: Ollier's disease]

In contrast to solitary enchondroma,patients with multiple enchondromatosis of bone (Ollier's disease) get affected in childhood by bone swelling and growth retardation. In adults, the main problem is the risk of malign transformation up to 40%.Pain, increasing local tumor and thinning of the corticalis are the typical clinical and radiological signs of transformation to a low grade chondrosarcoma. There is no need for a regular radiological screening. If a malign transformation occurs,marginal or wide resection of the lesion should be performed.

[Parapharyngeal chondrosarcoma and Ollier's disease: a case report and review of the literature]

OBJECTIVES

Ollier's disease is a constitutional pathology of unknown etiology. It is characterized by bone dysplasia generating numerous enchondromas. The malignant degeneration of this dysplasia is well known. The aim of this article is to study the diagnostic, therapeutic and prognostic characteristics of these lesions.

MATERIAL AND METHODS

We report a case of parapharyngeal chondrosarcoma extended to the base of the skull in a patient with Ollier's disease. The treatment was a surgical removal by a cervicotransoral incision combined with a preauricular incision and with a mastoidectomy. It was therefore possible to control the skull base, the parapharyngeal space, the infratemporal fossa and the major neurovascular structures. The removal of the lesion was completed at the level of the clivus and sphenoid with optics (30 and 70 degrees ). We discuss this treatment and the follow up on the bases of literature data.

RESULTS

The neoplastic degeneration of enchondromas is estimated between 25 to 50% of cases. The most frequent location is the pelvic bones. Chondrosarcomas are slow growing tumors and their metastatic potential is less significant as we note it in our case report. Their diagnostic is essentially based on histological criteria's and their treatment is surgical.

CONCLUSION

Chondrosarcomas of the ENT area occurring with Ollier's disease is rare. Their prognostic is good if the surgical treatment is well done.

[Association of ovarian juvenile granulosa cell tumor with Maffucci's syndrome]

The authors report a rare case of the ovarian juvenile granulosa cell tumor associated with Maffucci's syndrome (enchondromathosis + hemangiomas), no heriditary mesodermal dysplasia. Sarcomatous changes of chondromas are encountered most frequently; however other various typed neoplasma have been reported: ovarian juvenile granulosa cell tumor may occur not infrequently in female patients with Maffucci's syndrome in the first or second decades. Sarcomatous changes of choromas established prognosis of the Maffucci's syndrome.

Natural history of chondroid skull base lesions--case report and review

Long-term follow-up reports on chondroid lesions of the skull base are rarely presented in the literature. There are virtually no data on natural growth rates of these tumors based on MRI obtained over a period of 10 years or longer. We followed a patient who has had such a lesion for more than 12 years. A non-progressive, slight abducens palsy has been the only associated symptom so far. Even though the patient was operated on for an additional intracranial arterio-venous malformation, clinical features and chromosomal testing excluded Maffucci's syndrome. The MRI follow-up in this case provides an extraordinary perspective on the natural history of chondroid skull base tumors.

Maffucci syndrome: a case report

The multiple enchondromas and hemangiomas of Maffucci syndrome affect the skin and skeletal systems. The disease develops slowly, with enlargement of enchondromas and hemangiomas occurring during the first 2 decades of life. Effects of the disease range from those requiring minor adjustments in activities of daily living to almost total incapacitation.

Maffucci's syndrome: clinical and radiological features of a rare condition

Maffucci's syndrome is a rare congenital non-inherited condition, characterized by multiple enchondromata, cutaneous haemangiomata and more recently spindle-cell haemangioma-endotheliomata. It is associated with an increased risk of malignancy including intracranial chondrosarcomas. Early diagnosis is crucial; screening patients with Ollier's disease is recommended. The treatment of choice for these intracranial cartilaginous tumours is complete surgical excision but this is often difficult to achieve due to difficult access and relationships with neurovascular structures. An alternative treatment is proton-beam therapy. We report a case of Maffucci's syndrome; illustrating the typical clinical and radiological features as well as the known complications of the condition.

Enchondroma and chondrosarcoma

Enchondroma and chondrosarcoma are two of the most commonly encountered primary bone lesions in the typical radiology practice. The purpose of this article is to review the clinical, radiological, and pathological features that distinguish conventional chondrosarcoma from enchondroma. Chondrosarcoma is almost always associated with pain and tends to present in the axial skeleton of middle aged adults. Enchondroma tends to present in young adults in the appendicular skeleton, particularly the hands, and is often an incidental finding. Although both lesions have characteristic radiographic appearances, difficulty separating these two entities most often occurs when a lesion is seen in the long tubular bones. The judicious use of computed tomography, magnetic resonance imaging, and nuclear medicine in conjunction with appropriate clinical data allows the radiologist to establish the correct diagnosis of benign or malignant medullary chondroid lesion in the majority of cases.

Benign chondroid neoplasms of bone

Benign cartilage lesions discussed in this article include osteochondroma (solitary, epiphyseal, and multiple), chondroblastoma, periosteal chondroma, and chondromyxoid fibroma. These lesions often demonstrate imaging appearances strongly suggesting the above diagnosis, particularly the "ring and arc" mineralization characteristic of cartilage lesions, which reflects their underlying pathology. This article emphasizes the imaging spectrum of these lesions with a multimodality approach.

Surgical treatment of a massive chondrosarcoma in the skull base associated with Maffucci's syndrome: a case report

BACKGROUND

A successfully treated massive chondrosarcoma in the skull base associated with Maffucci's syndrome is presented. The purpose of this report is to discuss the surgical approach to the tumor and reconstruction of the skull base.

CASE DESCRIPTION

A 36-year-old woman who had a history of multiple enchondromas and subcutaneous hemangiomas presented with decreased right visual acuity and left papilledema. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a mass in the skull base. The tumor occupied the nasal and paranasal cavities, and extended to the anterior, middle, and posterior intracranial spaces. The midline skull base structures and the left middle cranial base were destroyed. Using a combined anterior craniofacial and left orbitozygomatic approach, the tumor was totally resected. The large skull base defect was reconstructed with a vascularized outer table parietal bone graft attached to a bipedicled temporoparietal galeal flap. The postoperative course was uneventful except for decreased left visual acuity, and temporary diplopia and facial hypesthesia. In 40 months of follow-up there was no recurrence. CONCLUSIONSA skull base approach should be selected to perform total resection of an extensive skull base tumor. The bipedicled temporoparietal galeal flap and vascularized calvarial bone was useful for simultaneous reconstruction.

Hemangiosarcoma of the left hand in a patient with the rare combination of Maffucci's and Stewart Treves syndrome

We describe a patient with the previously unseen combination of Maffucci's and Stewart Treves syndrome who presented with an angiosarcoma of the hand. Maffucci's syndrome is characterized by the presence of multiple enchondroma and soft tissue hemangioma. The syndrome is a rare nonhereditary condition with a usual onset in childhood. Malignant transformations are a common feature of this syndrome. In 1948, Stewart and Treves first described six cases of lymphangiosarcoma after radical mastectomy. This syndrome is an unusual form of angiosarcoma occuring as a complication of lymphedema. Chronic lymphedema and lymphangiectasia preceding lymphangiosarcoma may not only be induced by radical mastectomy with axillary lymph node dissection and postoperative radiation therapy. Posttraumatic, congenital or spontaneous chronic lymphedema may also be associated with lymphangiosarcoma. A time interval of many years seems to be required before malignant transformation develops. Generally the syndrome has a very poor prognosis. Both syndromes described above are of a rare frequency. We report this case because of prior unknown coincidence of both syndromes.

Swelling of the dorsum of the hand and/or foot can be a first sign of Maffucci syndrome

The cardinal feature of Maffucci syndrome is the coexistence of enchondromatosis and vascular anomalies. The patients are usually normal at birth, the disease becoming evident at any time up to puberty. Association of soft-tissue swelling has been described in this syndrome but has not been listed as a sign or symptom. We report three cases in which the initial sign was diffuse swelling of the dorsum of the hand and/or foot. This was noticed at birth in cases 1 (girl) and 3 (girl) and at the age of 1 month in case 2 (boy), who otherwise appeared normal except for case 3 who had a rectovestibular fistula. The pathology of the swollen soft tissue was adipose tissue associated with various degrees of thickened and fibrotic septum containing dilated lymphatic channels. These dilated channels within the septum were so subtle that they were initially overlooked in cases 1 and 2. Awareness that swelling of the dorsum of the hand or foot can be the sole sign and symptom of Maffucci syndrome before the typical indications become evident helps the physician establish an early diagnosis of this condition.

Is Ollier's disease an understaging of Maffucci's syndrome?

Ollier's disease and Maffucci's syndrome are similar multiple enchondromatous conditions. Other co-existing pathologies, particularly other primary malignancies, have been described sporadically in both conditions but more so in Maffucci's syndrome. Maffucci's syndrome is distinguished from Ollier's disease by the presence of haemangiomas in the former. In this report, a patient believed to have Ollier's disease for 44 years was subsequently found to have large splenic haemangiomas on magnetic resonance imaging (MRI). In the light of this, we recommend that any patient diagnosed with Ollier's disease to have total body MRI to search for haemangiomas that will alter the diagnosis to Maffucci's syndrome and hence the prognosis. MRI also screens for the presence of other associated malignancies.

[Hemangioma and superficial arteriovenous malformations]

Haemangiomas are different from true superficial vascular malformations. The haemangiomas, mainly affecting the newborn and small babies, will, after a phase of progression, sometimes regress completely. Therapeutic abstention is the rule except in high risk angiomas when steroid therapy may be effective. Visceral involvement poses problems. Superficial vascular malformations, on the other hand, arise at all ages and may affect any blood vessel. Each type has a specific clinical presentation, complementary investigations and appropriate treatment. Some are slowly progressive, for example capillary, venous and lymphatic malformations. Others are haemodynamically active, such as the arteriovenous malformations. Capillary malformations are flat angiomas with aesthetic consequences, apart from the Sturge-Weber-Krabbe syndrome. Cold, blue venous malformations confirmed by ultrasonography and magnetic resonance imaging, when necessary, require treatment adapted to their site and size: compression, embolisation, surgery or abstention. Lymphatic malformations may be cystic or tissular: the cystic lymphangioma, a soft swelling of often healthy skin, with compartments separated by septa on ultrasound scan, is usually treated by ethibloc embolisation. Arteriovenous malformations, warm and pulsatile, demonstrated at arteriography, may progress rapidly and treatment by surgery or embolisation, when necessary, has to be complete. Finally, there are complex vascular malformations which pose very difficult problems of management.