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Journal of Cancer Research and Therapeutics

April-June 2018 Volume 14 Issue 3

•
Volume 14 •
Issue 3 •
April-June 2018 •
Pages 245-480

Impact Factor® for 2016 Official Journal of

0.75 Association of Radiation Oncologist of India
Correspondence

Chondrosarcoma third metacarpal:

Diagnosis and management options
ABSTRACT Vipin Sharma,
Chondrosarcoma is a rare malignant tumor of cartilage commonly arising in the pelvis, proximal femur, and humerus, but quite Lucky Verma,
uncommon in the small bones of the hand. Although limited surgical procedures such as curettage are mentioned as a management Bal Chander1,
option in low‑grade chondrosarcomas, they tend to have a high rate of recurrences. Hence, wide excision is recommended as a Seema Sharma2
treatment option even in low‑grade chondrosarcomas of the hand.
Departments of
Orthopedics,
1
Pathology and
KEY WORDS: Amputation, chondrosarcoma, curettage 2
Pediatrics,
Dr. Rajendra Prasad
Government Medical
College, Tanda,
INTRODUCTION enhancement involving the distal metaphyseal
Kangra,
region of the third metacarpal. Curvilinear and Himachal Pradesh,
Chondrosarcoma is a common malignant bone few punctuate calcification were also noted India
tumor of the fifth and sixth decade.[1] It accounts within the lesion. There was cortical destruction
For correspondence:
for the 9% of the malignant bone tumors, males of the dorsal surface of the third metacarpal
Dr. Seema Sharma,
being commonly affected. Although benign with mass exophyting to the surrounding H. No. 23, Type 5,
cartilage tumors are frequent in the small bones subcutaneous tissue. There was displacement Block B, Dr. Rajendra
of the hand and feet, malignant lesions are rare and partial encasement of the extensor tendon by Prasad Government
at these sites.[1] We describe a 23‑year‑old patient the mass. A skip lesion 8 mm × 5 mm × 6 mm Medical College,
Tanda, Kangra,
with chondrosarcoma of the middle finger (third in the base of third metacarpal with swelling of
Himachal Pradesh,
metacarpal), a rare representation considering the overlying cortex was also noted  [Figure  3]. The India.
site and age of the patient. possibility of enchondroma or chondrosarcoma was E‑mail: seema406@
entertained. Histopathological evaluation reported rediffmail.com
CASE REPORT chondrosarcoma with polychromatic two or more
nuclei in one lacuna with mild to moderate nuclear
A 23‑year‑old male presented to us with swelling pleomorphism. Metastatic workup of the lesion was
over dorsum of the left third metacarpal for the normal [Figure 4]. The patient and his attendants
past 4 months. There was no history suggestive were educated about the tumor spread, treatment
of trauma or underlying systemic disease. Clinical plan, and recurrence rate. After detailed informed
examination revealed a swelling 3 cm × 3 cm consent, ray amputation was planned. Postoperative
in dimension, distally and dorsally located over recovery was uneventful. The patient is on regular
head and neck region of third metacarpal with follow‑up and 5  months after ray resection, our
well‑defined margins, a firm consistency and patient has no signs of local recurrence or metastasis.
tenderness on palpation. Swelling was fixed
to underlying structures. Overlying skin was DISCUSSION
stretched but freely mobile. Range of motion at
metacarpophalangeal joint was full and pain Chondrosarcoma is a malignant tumor of proliferating
free [Figure 1]. Radiograph showed expanded distal cartilage tissue.[1‑3] It may arise as a primary lesion Access this article online
third metacarpal with multiple lytic lesions and Website: www.cancerjournal.net

thinned out cortices [Figure 2].
Magnetic resonance imaging  (MRI) showed
lobulated expansile altered signal intensity lesion
27 mm × 15 mm × 16 mm with postcontrast
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Cite this article as: Sharma V, Verma L, Chander B, Sharma S. Chondrosarcoma third metacarpal: Diagnosis and management
options. J Can Res Ther 2018;14:719-21.

© 2016 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow 719
 Sharma, et al.: Chondrosarcoma third metacarpal
Figure 1: Clinical photograph of the lesion distal third metacarpal
a b
Figure 3: Magnetic resonance imaging showing lobulated expansile
lesion with cortical destruction, skip lesion in base of metacarpal (arrow)
or occur secondarily at the site of a previous benign lesion such
as enchondroma or osteochondroma. Primary chondrosarcoma
in the hand are very rare with an incidence ranging from 1.5%
to 3.2% with chondrosarcoma of metacarpals being still rarer.[4]
Pain in the absence of pathological fracture is the main
feature which distinguishes enchondroma from the low‑grade
chondrosarcoma; however in our case, pain was not the
presenting complaint of the patient.[2]
Both enchondroma and chondrosarcoma arise from the
medullary cavity, but chondrosarcoma has a more aggressive
behavior. Histologically, chondrosarcomas are composed
of malignant cells with abundant cartilaginous matrix,
hypercellularity, plump nuclei, binucleate cells, and entrapment
of bony trabeculae. [1‑3] Based on nuclear size, nuclear
staining (hyperchromasia), and cellularity, chondrosarcoma is
divided into low, intermediate, and high grades; higher grades
predicting more chances of metastasis.[5]
In the present case, histopathological examination showed
the cartilaginous material with plump hyperchromatic two
or more nuclei in one lacuna. The nuclei showed the mild to
moderate nuclear pleomorphism, the features being consistent
with well‑differentiated chondrosarcoma.
720
a b
Figure 2: (a) Anteroposterior X‑ray left hand ‑ lobulated expansile lesion
distal third metacarpal, (b) after ray resection (arrow)
a b
Figure 4: Pleomorphic cells with more than one chondrocyte per lacuna
with tumor giant cells
Some well‑differentiated chondrosarcomas present a
clinicopathological overlap with enchondroma resulting
in a misdiagnosis. A  study reported an 85‑year‑old male
with a small swelling in 4th and 5th digit of the right hand,
lytic in nature and suspected to be an enchondroma on
histopathology. The patient refused further treatment. Fifteen
years later, he presented with a rapid increase in the size of
the swelling at the same site with features of malignancy on
radiography. Histopathology reported chondrosarcoma which
was managed by ray amputation.[6] Another study reported a
a a 70-year-old woman who presented with swelling and pain
at the index finger of the right hand managed by excisional
curettage. Histopathology reported it to be an enchondroma.
Seven months later, the patient reported recurrence at the
same site. This time, the tumor was found to be transformed
into an intermediate grade  (Grade  II) chondrosarcoma,
and amputation of the finger was performed. [7] Hence,
histopathology alone may not be sufficient enough to provide
a final diagnosis of the lesion. Instead, it should be viewed
in light of clinicoradiological behavior of the lesion. The
present patient was a histopathologically confirmed case of
well‑differentiated chondrosarcoma, but locally aggressive
clinicoradiological features such as rapid growth of the
lesion, cortical breach with partial encasement of extensor
tendons, and a satellite lesion in the base of the third
Journal of Cancer Research and Therapeutics - Volume 14 - Issue 3 - April-June 2018
 Sharma, et al.: Chondrosarcoma third metacarpal
metacarpal on MRI‑guided us toward ray amputation as the
definitive surgical procedure instead of other conservative
surgical options.
Chondrosarcomas of the hand behave differently from
chondrosarcomas elsewhere in that even high-grade
chondrosarcomas have a lower incidence of metastasis
tempting us all the more toward conservative surgery.[8]
However small size of the hand and resulting possibility of
spread of tumor from one compartment to another precludes
the use of excision and curettage in chondrosarcoma in the
hand. Moreover such surgeries need to be linked with a
close follow‑up for local recurrence.[3] Ray amputation or
wide excision and reconstruction are the preferred treatment
options to gain adequate tumor clearance and avoid the risk
of local recurrence or metastasis.[4,7,9]
Initially, in the present case, resection and reconstruction with
fibular graft were planned restoring hand function thereby.
Detection of a skip lesion in the base of the same metacarpal
on MRI guided our decision toward ray amputation.
CONCLUSION
Differentiating benign from low‑grade malignant cartilage
tumors is a challenge requiring thorough evaluation before
arriving at a definitive diagnosis. Small hand compartments
encourage local tumor spread, radical surgeries, or wide
resections score over more conservative surgeries for making
the patient free of disease.
Journal of Cancer Research and Therapeutics - Volume 14 - Issue 3 - April-June 2018
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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