INSTRUCTIONAL COURSE LECTURE
CHROMOSOMAL ABERRATIONS IN
MUSCULOSKELETAL TUMOURS:
CLINICAL IMPORTANCE
ANDERS RYDHOLM
From the University Hospital, Lund, Sweden
Only a generation ago it was a major achievement to count
human chromosomes; in 1956, Tjio and Levan determined
that man has 46 chromosomes. Today, cytogenetics and
molecular genetics are providing important clues about the
genesis of tumours and the gene therapy of cancer is
approaching.
BACKGROUND
As far back as 1910, the German zoologist Theodor Boveri
stated that cancer may develop from somatic alterations in
the genetic material, the so-called somatic mutation theory.
For a long time this theory could not be tested because
mammalian chromosomes, for technical reasons, could not
be visualised in enough detail. Boveri’s theory was not gen-
erally accepted until the 1970s, when special staining tech-
niques allowed chromosomes to be divided into several
bands and each individual chromosome pair to be identified
by its specific banding pattern. This made it possible to
demonstrate the presence of recurrent tumour-associated
chromosomal aberrations.
For chromosomal analysis, karyotyping, fresh tumour
tissue is mechanically or enzymatically disintegrated and
cultured for two to ten days in short-term culture. When
these are rich in mitoses, they are harvested and the mitoses
are arrested in metaphase by Colcemid. The metaphases are
spread on glass slides, the chromosomes are banded by
staining techniques, and are then ready for microscopic
analysis (Fig. 1).
The first association between cancer and a chromosomal
aberration was reported by Nowell and Hungerford in 1960.
They found a small marker chromosome, named the Phila-
delphia (Ph1) chromosome, in cells from patients with
chronic myeloid leukaemia. With the introduction of band-
ing techniques, it was shown that the rearrangement giving
F A. Rydholm, MD, Consultant Orthopaedic Surgeon
University Hospital, Lund, Sweden.
Printed with the permission of EFORT. The article appears in European In-
structional Course Lectures Vol. 2, 1995.
J Bone Joint Surg [Br] 1996;78-B:501-6.
VOL. 78-B, No. 3, MAY 1996
rise to this marker was a translocation between chromo-
somes 9 and 22. This was the first consistent chromosomal
abnormality found in human cancer. The discovery seemed
to confirm Boveri’s theory; it was assumed that the acquired
chromosomal abnormality was the cause of the neoplasm.
Since then it has been generally accepted that cancer is
due to somatically acquired, genetic changes caused by
mutations. Some mutations may be inherited and may pre-
dispose to cancer. At the cellular level, cancer is a genetic
disease; genetic changes are inherited from the neoplastic
cell by all its daughter cells. During tumour progression,
additional aberrations occur through genetic instability. It
was earlier believed that acquired chromosomal aberrations
indicated malignancy but they have now also been found in
several types of benign tumour, one of the most studied
being the common benign lipoma.
Many types of structural rearrangement of chromosomes
have been identified in neoplastic cells, such as deletion,
duplication, inversion, insertion and translocation. Such
rearrangements give rise to loss, gain, and relocation of
genetic material. In addition, numerical aberrations, giving
rise to loss or gain of entire chromosomes, are common.
Three principal effects of chromosomal aberrations have
been identified. Oncogenes are the activated form of normal
genes, so-called proto-oncogenes, and act, in most cases, in
a dominant way. Proto-oncogenes are thought to control cell
proliferation by governing the balance between growth-
stimulating and growth-inhibiting factors. When a proto-
oncogene is activated into an oncogene, this balance is dis-
turbed and growth control is lost. The activation of onco-
genes by chromosomal rearrangements has been
demonstrated in several types of tumour. A well-known
example is seen in Burkitt’s lymphoma. By translocations to
various chromosomes (2, 14 or 22 which contain the various
loci for the immunoglobulin chains), the MYC proto-onco-
gene (on chromosome 8) is brought into contact with one of
the three immunoglobulin loci and thereby activated. Proto-
oncogenes can also be activated by other chromosomal rear-
rangements or, at the molecular level, by point mutations,
which cannot be revealed by chromosomal analysis.
The second mechanism is the formation of a fusion gene,
also known as a chimaeric or hybrid gene, leading to the
production of an abnormal protein. The classic example is
the Philadelphia chromosome in chronic myeloid leukaemia
501
502 ANDERS RYDHOLM
Fig. 1
Metaphase plate and karyotype from a normal human male cell with the karyotype 46,XY.
in which the 9;22-translocation brings two genes into con-
tact and an abnormal hybrid protein is encoded by the
fusion gene. The main consequence of many translocations
is the activation of transcription factors by the formation of
fusion genes. These factors activate genes and this process
t(11;22)(q24;q12)
Fig. 2
Schematic presentation. To the left are the two chromosomes 11 and to the
right the two chromosomes 22. In each pair the chromosome on the left is
normal, whereas that on the right is engaged in the translocation. The distal
parts of the affected chromosomes are exchanged, as indicated by arrows.
New genes are created where translocated material from one chromosome
is fused to the other.
is considered to be important for tumorigenesis. Several
tumour-specific translocations which lead to the formation
of fusion proteins have been identified, not only in haemato-
logical malignancies, but also in sarcomas (Fig. 2) (for
review, see Rabbitts 1994).
The third mechanism is inactivation of a tumour sup-
pressor gene. These are normal genes that regulate cell
growth, and which act in a recessive way at the cellular
level. Inactivation of both alleles may lead to abnormal cell
growth. For example, the loss of both retinoblastoma genes
(RB1) on both chromosomes 13 results in the formation of
retinoblastoma and also plays a role in the development of
osteosarcoma. Constitutional, mutational inactivation of one
of the RB1 genes and somatic mutation of the other leads to
earlier onset and often the bilateral development of retino-
blastoma.
More than 20 000 neoplasms with chromosomal aberra-
tions have been reported; three-quarters of them are in hae-
matological malignancies. The under-representation of solid
tumours is due to earlier technical difficulties with short-
term tissue culturing and chromosomal preparations. There
are three main findings in leukaemias and lymphomas:
1) Various tumour types have different kinds of chromo-
somal aberration, some of which seem to be pathogno-
monic.
2) The parts of the chromosomes that are involved in the
aberrations contain genes that are of importance for tumori-
genesis.
3) The chromosomal aberrations are of clinical importance;
they are useful for diagnosis as well as prognosis.
Most solid tumours are the common epithelial cancers
such as carcinomas of the breast, colon, lung, kidney and
prostate, which cause most cancer morbidity and mortality.
Much less cytogenetic data are available for these tumours,
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 CHROMOSOMAL ABERRATIONS IN MUSCULOSKELETAL TUMOURS: CLINICAL IMPORTANCE 503

partly because of technical difficulties, but also because of Table I. Characteristic cytogenetic and molecular genetic findings in
the highly complex karyotypes with multiple aberrations benign musculoskeletal tumours
that are hard to interpret. Type Cytogenetic findings
Another group of solid malignant tumours is the rare Lipoma 12q13-15 (t(3;12)(q27-28;q13-15)
musculoskeletal tumours, the bone and soft-tissue sarcomas, Hibernoma 11q13-21
which comprise only about 1% of all malignancies although Lipoblastoma 8q11-13
Atypical lipoma Ring chromosomes
they arise from the largest tissue compartment of the body. Spindle-cell/pleomorphic lipoma -13/del(13q) and -16/del(16q)
By contrast, benign musculoskeletal tumours are common, Fibromatosis +8/5q
especially soft-tissue tumours such as the ubiquitous lipoma Neurilemmoma -22, del (22q)
and its variants. Chondroma/chondroblastoma/ 12q13, +5, del (6q)
chondromyxoid fibroma
Earlier technical difficulties with chromosomal prepara- Osteochondroma del (8)(q24)
tions now seem to have been overcome. As a result, an Synovial chondromatosis 1p13,12q13
increasing number of benign and malignant musculoskeletal Tenosynovial giant-cell tumours +5,+7
tumours with chromosomal aberrations are being reported; Molecular genetic data are available only for neurilemmoma with loss of
SCH and lipoma with rearrangement of HMGIC
by now more than 1000 cases have been described. The
Chromosomal aberrations have also been found in one to eight cases each
findings in haematological malignancies seem to hold true of aneurysmal bone cyst, benign fibrous histiocytoma, fibroma, lym-
also for musculoskeletal tumours; the various tumour types phangioma, myxoma, neurofibroma, osteoblastoma and rhabdomyoma.
The cases are too few to reveal specific aberrations
have characteristic chromosomal aberrations, some of

Table II. Characteristic cytogenetic and molecular genetic findings in malignant musculoskeletal tumours
Type Cytogenetic findings Molecular genetics
Osteosarcoma
Classic Complex Loss of RBI (40%) and TP53 (30%), amplification
of MDM2 (30%)
Parosteal Ring chromosomes
Ewing’s sarcoma/PNET t(11;22)(q24;q12) FLI1/EWS (90%)
ERG/EWS (5%)
t(7;22)(p22;q12) ETV1/EWS (<5%)
Chondrosarcoma +7,+20,-10,-6,-13,+5,1q21,12q13
Extraskeletal myxoid t(9;22)(q22;q12) TEC/EWS
Chordoma -3,-4
Clear-cell sarcoma t(12;22)(q13;q12),+8 ATFI/EWS
Dermatofibrosarcoma protuberans Ring chromosomes
Fibrosarcoma
Infants +11,+20,+17,+8
Adults Complex
Giant-cell tumour Telomeric associations
Haemangiopericytoma 12q13-15,3p,7p,11p,19q
Leiomyosarcoma Complex
Liposarcoma
Well-differentiated Ring chromosomes
Myxoid t(12;16)(q13;p11) CHOP/FUS (90%)
CHOP/EWS (<10%)
Pleomorphic Complex
MFH*
Myxoid Ring chromosomes
Storiform-pleomorphic Complex
Neurofibrosarcoma Complex
Rhabdomyosarcoma
Alveolar t(2;13)(p35;q14) (70%) PAX3/FKHR
t(1;13)(p36;q14) (5%) PAX7/FKHR
Embryonal Numerical changes, +2, +8, +20
Synovial sarcoma t(X;18)(p11;q11) SSX1/SYT, SSX2/SYT
Desmoplastic small round-cell tumour t(11;22)(p13;q12) WT1/EWS
* malignant fibrous histiocytoma
Chromosomal aberrations have also been found in one to eight cases each of adamantinoma, alveolar soft-part sarcoma, angiosarcoma, epithelioid-
cell sarcoma, Kaposi’s sarcoma, and malignant mesenchymoma. The cases are too few to reveal specific aberrations

VOL. 78-B, No. 3, MAY 1996

504
12 16
Fig. 3
Translocation t(12;16) in a myxoid liposarcoma. The chromosome on the
left in each pair is normal, that on the right participates in the translocation.
The breakpoints are indicated by arrowheads. The distal segment on chro-
mosome 12 has been translocated to the upper (p) arm of chromosome 16,
whereas the distal segment on chromosome 16 has been translocated to the
lower (q) arm of chromosome 12.
which may be pathognomonic, and many of these result in
specific molecular rearrangements. They can already be
used for diagnostic purposes, but little is known about their
prognostic importance.
CHROMOSOMAL ABERRATIONS
Benign musculoskeletal tumours (Table I). Specific chro-
mosomal aberrations have been found in several benign
tumours. Lipomatous tumours have been investigated, and
despite the monotonous histological appearance of the ordi-
nary solitary lipoma, several cytogenetic subgroups have
been identified (Mandahl et al 1994). Chromosome 12 is
involved in most groups. Ring chromosomes appear in both
atypical lipoma and well-differentiated liposarcoma. If
these tumours were the same, this would explain the pathol-
ogist’s difficulties in differentiating between them. Specific
chromosomal aberrations have also been found in other rare
lipomatous tumours such as hibernoma, lipoblastoma, spin-
dle-cell lipoma and pleomorphic lipoma. Very little is
known about the molecular consequences of the chromo-
somal aberrations in benign tumours, but recently the
involvement of the HMGIC gene in chromosome 12 has
been identified in lipomas.
Malignant musculoskeletal tumours (Table II). Ewing’s
sarcoma, leiomyosarcoma, liposarcoma, malignant
fibrous histiocytoma (MFH), osteosarcoma, rhabdomy-
osarcoma and synovial sarcoma are the most investigated
tumours. Leiomyosarcoma, the highly malignant, stori-
form-pleomorphic variant of MFH, and osteosarcoma all
have complex chromosomal aberrations. Parosteal oste-
osarcoma, the myxoid type of MFH, dermatofibrosarcoma
protuberans, and well-differentiated liposarcoma, all rela-
ANDERS RYDHOLM
tively less malignant, are characterised by supernumerary
ring chromosomes. Ewing’s sarcoma, myxoid liposar-
coma, alveolar rhabdomyosarcoma, and synovial sarco-
mas all have specific translocations, and the genes
involved are known.
On the basis of these findings, benign and malignant
musculoskeletal tumours can be divided into four groups.
Tumours that show consistent chromosomal aberrations
This group includes the ordinary lipoma and several benign
lipomatous tumour variants: atypical lipoma/well-differenti-
ated liposarcoma, lipoblastoma, spindle-cell and pleomor-
phic lipoma, and hibernoma. Among the malignant
lipomatous tumours, myxoid liposarcoma has a characteris-
tic translocation, t(12;16) (Fig. 3). Other tumours in this
group include neurilemmoma, clear-cell sarcoma, extra-
skeletal myxoid chondrosarcoma, desmoplastic small
round-cell tumour, Ewing’s sarcoma, PNET, alveolar rhab-
domyosarcoma, and synovial sarcoma.
Tumours that seem to have consistent chromosomal aberra-
tions. Benign and malignant cartilage tumours, parosteal
osteosarcoma, chordoma, dermatofibrosarcoma protuber-
ans, childhood fibrosarcoma, and haemangiopericytoma
may be characterised by specific chromosomal aberrations.
The number of reported cases, however, is still low.
Tumours with no detectable characteristic patterns. Chro-
mosomal aberrations have been found in several cases of
fibromatosis, fibrosarcoma in adults, giant-cell tumour, leio-
myosarcoma, malignant fibrous histiocytoma, neurofibrosa-
rcoma, osteosarcoma and embryonal rhabdomyosarcoma.
No specific aberrations, however, have been found. The
aberrations in leiomyosarcoma, osteosarcoma and highly
malignant fibrous histiocytoma are very complex and there-
fore impossible to karyotype in detail.
Tumours of which an insufficient number have been ana-
lysed. Since several musculoskeletal tumours have been
analysed in small numbers only, it is not yet possible to
draw any conclusions as to whether they harbour tumour-
specific chromosomal aberrations (see notes to Table I and
II).
The clinical importance of chromosomal aberrations in
musculoskeletal tumours is still limited, but it is rapidly
increasing. Some of the aberrations are already of diagnos-
tic importance. Cytogenetic and in particular molecular
genetic analyses for diagnostic purposes require minute
amounts of tissue; these can be obtained by fine-needle
aspiration.
TUMOUR CLASSIFICATION
The histopathological classification of musculoskeletal
tumours is difficult; there is an ongoing reclassification of
well-known types of tumour and new clinicopathological
entities are still being defined. The tumours are rare; few
pathologists therefore have much experience and they do
not always agree among themselves. Examination by immu-
nohistochemistry and electron microscopy have improved
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 CHROMOSOMAL ABERRATIONS IN MUSCULOSKELETAL TUMOURS: CLINICAL IMPORTANCE 505

Fig. 4b

A 20-year-old man had a lesion of the distal femur which was excised. The
histological findings were evaluated as a benign exostosis. Cytogenetic anal-
yses, however, showed a ring chromosome. Although chromosomal aberra-
tions have been found in benign exostoses they usually involve chromosome
8. The finding of a ring chromosome made the diagnosis of a parosteal oste-
osarcoma more probable. The slides were re-evaluated by several patholo-
gists, without knowledge of the chromosomal aberration, and their diagnosis
was a low-grade parosteal osteosarcoma. The patient had a reoperation with
Fig. 4a a wide excision.

the diagnoses, but there is a need for additional diagnostic
markers. In several cases, cytogenetic findings seem to be of
biological and diagnostic importance. One example is that
of Ewing’s sarcoma and PNET, which share the same and
specific translocation t(11;22). These tumour types are now
regarded as variants of the same neuroectodermal tumour.
The t(11;22) or variants of it have been found in 90% of
Ewing’s sarcomas; the finding of this translocation therefore
favours that diagnosis in cases in which the histopathology
is not clear.
The histopathological diagnosis of synovial sarcoma
may be controversial, especially regarding the monophasic
spindle-cell variant. The finding of t(X;18) in both the mono
and biphasic variants of synovial sarcoma indicates a close
relationship between these types of tumour and strengthens
the diagnosis of synovial sarcoma.
Some 90% of the synovial sarcomas examined carry the
X;18 translocation. It is not clear whether all synovial sarco-
mas have this translocation or may carry other alterations or
whether all tumours with this translocation are indeed syno-
vial sarcomas. This question is also relevant for other sarco-
mas with chromosomal aberrations. Difficulties in the
histological typing of particularly highly-malignant sarco-
mas make it hard to answer this question. If tumours with,
for example, an X;18 translocation have the same biology,
regardless of their different histological appearance, they
could perhaps be classified by the chromosomal aberration
and be called X;18 sarcomas.
VOL. 78-B, No. 3, MAY 1996
The t(12;16) translocation seems to be specific to sub-
groups of liposarcomas; 90% of myxoid tumours have such
an aberration. The finding of this translocation also in
round-cell liposarcomas seems to justify the sometimes
questioned relationship between these types of tumour. The
karyotypic findings in various benign but rare lipomatous
tumours may also be of diagnostic importance.
Extremely low-grade parosteal osteosarcomas may
mimic histologically a completely benign osteochondroma.
These tumours show different karyotypic changes which
can be used for differential diagnosis Fig. 4). When more
data on other types of tumour become available, further spe-
cific chromosomal aberrations will probably be found to
have diagnostic importance.
TISSUE SAMPLING
Diagnosis. Most surgeons consider that open biopsy is nec-
essary for the diagnosis of musculoskeletal tumours. It
does, however, have several disadvantages; wound infec-
tion may delay definitive treatment and a misplaced inci-
sion as well as local tumour spread may complicate later
radical surgery.
In our department we have used fine-needle aspiration
for a long period to diagnose benign and malignant muscu-
loskeletal tumours. We have found this method reliable,
especially for adult soft-tissue sarcoma of which the exact
histotype is of no importance in the surgical management: in
506 ANDERS RYDHOLM

11 22
Fig. 5b

Tumour of the femur in an eight-year-old boy (a). Fine-needle aspiration

showed a small round-cell tumour. Part of the aspirate was cultured for
three days; chromosomal analysis showed an 11;22 translocation (b). The
Fig. 5a diagnosis of Ewing’s sarcoma was confirmed without open biopsy.

most cases a diagnosis of sarcoma suffices. To increase the
diagnostic reliability, we have also used fine-needle aspi-
rates for chromosomal analysis. In a series of 6 osteosarco-
mas and 12 Ewing’s sarcomas, chromosomal aberrations
were found in 2 osteosarcomas and 7 Ewing’s sarcomas, 5
of which had the characteristic 11;22 translocation (Fig. 5).
This finding strongly supported the cytological diagnosis.
Both the PCR (polymerase chain reaction) technique to
detect the hybrid mRNA (used in one of our cases with a
positive result) or the FISH (fluorescence in situ hybridiza-
tion) technique to identify the translocation, may be used on
fine-needle aspirates. These should also be applicable to
other tumour types.
Prognosis. Hitherto, few data have been available concern-
ing the association between chromosomal aberrations and
the prognosis in musculoskeletal tumours. In general, there
seems to be a correlation between increasingly complex
karyotypes and a poor prognosis. Classic osteosarcoma and
malignant fibrous histiocytoma of the storiform pleomor-
phic type, both high-grade malignant tumours, most often
have complex chromosomal aberrations. In contrast, the
presence of supernumerary ring chromosomes may be the
sole structural change found in parosteal osteosarcoma, der-
matofibrosarcoma protuberans, myxoid MFH, and well-dif-
ferentiated liposarcoma/atypical lipoma; they seem to be a
feature of tumours of borderline or low malignancy (Orndal
et al 1992). Preliminary findings in giant-cell tumours of
bone indicate an association between the presence or
absence of chromosomal aberrations and the risk of recur-
rence (Bridge, Neff and Mouron 1992). In chondromatous
tumours, increasingly complex aberrations have been found
to correlate with an increasing grade of malignancy (Bridge
et al 1993).
CONCLUSIONS
Benign and malignant musculoskeletal tumours carry vari-
ous, specific chromosomal aberrations. Several of the genes
involved in these aberrations, especially translocations, have
been identified. The specific chromosomal aberrations can
be used for diagnostic purposes. Preliminary findings indi-
cate that they may also be of prognostic value.
My presentation is based on ten years of close collaboration with Felix
Mitelman, Nils Mandahl and Fredrik Mertens at the Department of Clinical
Genetics in Lund. Cytogenetic data for this article emanate from Heim and
Mitelman (1995) and Mitelman (1994).
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Bridge JA, Bhatia PS, Anderson JR, Neff JR. Biologic and clinical sig-
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Heim S, Mitelman F. Cancer cytogenetics. Second ed. New York: Alan R.
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Mandahl N, Hoglund M, Mertens F, et al. Cytogenetic aberrations in 188
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