Outcome of conservative and surgical treatment of enchondromas and atypical cartilaginous tumors of the long bones: retrospective analysis of 228 patients

Abstract

Background Sufficient data on outcome of patients with clinically and radiologically aggressive enchondromas and atypical cartilaginous tumors (ACT) is lacking. We therefore analyzed both conservatively and surgically treated patients with lesions, which were not distinguishable between benign enchondroma and low-grade malignant ACT based upon clinical and radiologic appearance. Methods The series included 228 consecutive cases with a follow-up > 24 months to assess radiological, histological, and clinical outcome including recurrences and complications. Pain, satisfaction, functional limitations, and the musculoskeletal tumor society (MSTS) score were evaluated to judge both function and emotional acceptance at final follow-up. Results Follow-up took place at a mean of 82 (median 75) months. The 228 patients all had comparable clinical and radiological findings. Of these, 153 patients were treated conservatively, while the other 75 patients underwent intralesional curettage. Besides clinical and radiological aggressiveness, most lesions were histologically judged as benign enchondromas. 9 cases were determined to be ACT, while the remaining 7 cases had indeterminate histology. After surgery, three patients developed a recurrence, and a further seven had complications of which six were related to osteosynthesis. Both groups had excellent and almost equal MSTS scores of 96 and 97%, respectively, but significantly less functional limitations were found in the non-surgery group. Further sub-analyses were performed to reduce selection bias. Sub-analysis of histologically diagnosed enchondromas in the surgery group found more pain, less function, and worse MSTS score compared to the non-surgery group. Sub-analysis of smaller lesions (< 4.4 cm) did not show significant differences. In contrast, larger lesions displayed significantly worse results after surgery compared to conservative treatment (enchondromas > 4.4 cm: MSTS score: 94.0% versus 97.3%, p = 0.007; pain 2.3 versus 0.8, p = 0.001). The majority of lesions treated surgically was filled with polymethylmethacrylate bone-cement, while the remainder was filled with cancellous-bone, without significant difference in clinical outcome. Conclusion Feasibility of intralesional curettage strategies for symptomatic benign to low-grade malignant chondrogenic tumors was supported. Surgery, however, did not prove superior compared to conservative clinical and radiological observation. Due to the low risk of transformation into higher-grade tumors and better functional results, more lesions might just be observed if continuous follow-up is assured.

Curettage and cryosurgery for enchondroma and atypical cartilaginous tumors of the long bones: Oncological results of a large series

“…Our oncological results after curettage and cryosurgery of enchondroma and ACT are excellent and comparable with other studies. [13][14][15] We found a recurrence-free survival of 97% which is in line with the literature (mean recurrence-free survival, 93%; range, 77%-100%). 6 Two cases initially diagnosed as ACT after biopsy and curettage and cryosurgery recurred with radiologic aggressive characteristics.…”

“…Our oncological results after curettage and cryosurgery of enchondroma and ACT are excellent and comparable with other studies 13‐15 . We found a recurrence‐free survival of 97% which is in line with the literature (mean recurrence‐free survival, 93%; range, 77%–100%) 6 …”

“…With the current knowledge of the behavior of ACT in the long bones, the negative side effects of operative treatment should be considered before opting for surgery 13,26 …”

“…With the current knowledge of the behavior of ACT in the long bones, the negative side effects of operative treatment should be considered before opting for surgery. 13,26 Further research should define criteria regarding which specific cartilaginous tumors require surgical intervention.…”

CT radiomics-based machine learning classification of atypical cartilaginous tumours and appendicular chondrosarcomas

“…Curettage is the standard of care [3] , but its effectiveness in preventing transformation into higher-grade chondrosarcoma has not been demonstrated. Hence, given the similarity to benign enchondroma on both imaging [28] and histology [8] , watchful waiting has been proposed as an alternative strategy to prevent overtreatment and morbidity associated with surgery [29] , [30] , [31] . An accurate differentiation from higher-grade chondrosarcomas requiring wide resection is thus necessary for treatment planning, and currently based on a multidisciplinary approach combining clinical presentation with imaging and biopsy [3] .…”