rare pathologic entity, accounting for approximately 3% of all chondromas.8 ... Chondroma of spine may be derived from a hyperplasia of immature spinal ...
International Journal of Spine Surgery Enchondroma protuberans of transverse process of D8 vertebra extending to 7th and 8th ribs - rare case report --Manuscript Draft-Manuscript Number:
IJSSURGERY-D-17-00087
Full Title:
Enchondroma protuberans of transverse process of D8 vertebra extending to 7th and 8th ribs - rare case report
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Article
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Other and Special Categories
Keywords:
Enchondroma protuberans; Magnetic resonance imaging (MRI); osteochondroma; enchondroma; chondrosarcoma; periosteal chondroid tumours
Corresponding Author:
Subbaiah Goli, MS Ortho (Spine) STAR Hospitals Hyderabad, INDIA
Corresponding Author Secondary Information: Corresponding Author's Institution:
STAR Hospitals
Corresponding Author's Secondary Institution: First Author:
Murahari Penkulinti, MS Ortho
First Author Secondary Information: Order of Authors:
Murahari Penkulinti, MS Ortho Harshavardhan Raorane, MS Ortho Vinayak Santosh Kalakata, MS Ortho Satish Kumar Vemuri, MSc Rajkiran Reddy Banala, MSc, PhD Subbaiah Goli, MS Ortho (Spine)
Order of Authors Secondary Information: Abstract:
Background: Enchondroma protuberans (EP) is rare benign cartilaginous bone tumour, arising from intramedullary cavity of long bones which usually protrudes beyond the cortex with an exophytic growth pattern resembling osteochondroma. To report a rare case of enchondroma protuberans arising from transverse process of D8 vertebra extending to adjacent 7th, 8th ribs and paraspinal tissues. Methods: 45 year old female patient came with complains of upper back pain radiating up to left costal margin since 6 months, no paraesthesia and there was no history of any sensory or motor symptoms. On physical examination there was midline and left paraspinal tenderness over D6 - D8 region. Anterio-poserior and lateral X-ray images revealed well defined oval ossific mass lesion over lateral aspect of D8 vertebra extending to 7th and 8th ribs on left side, multiple bridging osteophytes noted. CT scan showed ossific mass lesion arising from D8 transverse process with extension to adjacent 7th and 8th ribs, margins well defined with no periosteal reaction. Magnetic resonance imaging showed well defined expansile mass lesion arising from transverse process of D8 vertebra matrix was isointense with adjacent marrow with no evidence of calcifications or vascular flow voids, no encroachment into the spinal canal. Results Complete resection of mass lesion with adjacent part of 7th and 8th ribs with intramedullary curettage performed and sent for histopathological examination. Histopathology showed bony trabeculae with normal mucosal elements, a mild Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
hypercellularity with binucleation. Chondrocytes in myxoid matrix located in round lacunae, compatible with enchondroma with no evidence of atypia. Post operative period was uneventful and after 12 months there were no signs of recurrence noted in CT scan. Conclusion Enchondroma protuberans is rare presentation in dorsal spine; should be considered in the differential diagnosis of osteochondroma, enchondroma, chondrosarcoma and periosteal chondroid tumours. Additional Information: Question
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We wish to report a rare case of Enchondroma protuberans of dorsal spine spreading to the adjacent ribs.
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Enchondroma protuberans of transverse process of D8 vertebra extending to 7th and 8th ribs - rare case report Murahari Pǂ, Harshavardhan Raorane, Vinayak Santosh K, Rajkiran Reddy Banala, Subbaiah ᵻ GPV 1. Spine department, Star Hospitals, Road No 10, Banjara Hills, Hyderabad-500032
Corresponding author: ᵻ Dr GPV Subbaiah*
Spine department Star Hospitals Banjara Hills, Hyderabad Telangana.
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Introduction Enchondroma protuberans (EP) is rare benign cartilaginous bone tumour, arising from intramedullary cavity of long bones which usually protrudes beyond the cortex with an exophytic growth pattern resembling osteochondroma. Only a few cases of EP have been reported in phalanges and metacarpals. To the best of our knowledge no case of spinal Enchondroma protuberans originating from transverse process extending to the ribs has been reported so far. We report a case report of 45 yrs old female patient of EP originating from the transverse process of D8 vertebra extending to corresponding 8th and 7th ribs and paraspinal tissue. Case report - 45 year old female patient came with complains of upper back pain radiating up to left costal margin since 6 months, no paraesthesia and there was no history of any sensory or motor symptoms. Not associated with fever and any other constitutional symptoms. On physical examination there was midline and left paraspinal tenderness over D6 - D8 region, no regional deformity, overlying skin was normal, neurological examination was normal. Anterio-poserior and lateral X-ray images revealed well defined oval ossific mass lesion over lateral aspect of D8 vertebra extending to 7th and 8th rib on left side, multiple bridging osteophytes noted. Paraspinal shadow was normal CT scan showed ossific mass lesion arising from D8 transverse process with extension to adjacent 7th and 8th ribs, margins well defined, no periosteal reaction ,vertebral bodies and posterior elements were normal. Magnetic resonance imaging showed well defined expansile mass lesion arising from transverse process of D8 vertebra matrix was isointense with adjacent marrow with no evidence of calcifications or vascular flow voids, no encroachment into the spinal canal.
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Complete resection of mass lesion with adjacent part of 7th and 8th ribs with intramedullary curettage performed and sent for histopathological examination. Histopathology showed bony trabeculae with normal mucosal elements, a mild hypercellularity with binucleation. Chondrocytes in myxoid matrix located in round lacunae, compatible with enchondroma with no evidence of atypia. Post operative period was uneventful and after 12 months there were no signs of recurrence noted in CT scan. Discussion Enchondroma protuberans (EP) is rare benign cartilaginous tumour of long bones, arising from intramedullary cavity, which usually protrudes beyond the cortex. Chondromas in the spine are rare pathologic entity, accounting for approximately 3% of all chondromas.8 There are only few reported cases of the EP and all were located in the hands, ribs, and humerus regions. Chondroma of spine may be derived from a hyperplasia of immature spinal cartilage with migration outside the vertebral axis or from metaplasia of the connective tissue in contact with the vertebra or the annulus fibrosus 6. Enchondroma almost always appears as a well-defined osteolytic lesion that is usually located within the metadiaphysis of long bone. Due to bone expansion the cortex may appear thin, but usually remains intact. Expansion of enchondroma through the cortex is rare, and if accompanied by a cortical defect, will result in EP.
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Radiologically, EP is presented as a well-defined intramedullary osteolytic lesion and may be accompanied by fine matrix calcification, cortical expansion and cortical defect, and round welldefined soft-tissue expansion 5. Radiologically, EP resembles osteochondroma; however osteochondroma can be excluded on the basis of presence of cartilage cap with underlying trabecular bone. EP also has geographic intramedullary osteolytic lesion 9. It is important to distinguish EP and osteochondroma when planning surgical treatment to prevent potential chondrosarcomatous transformation. In the case of osteochondromas, the regions containing cartilage are generally confined to the cap; therefore excision of cap is sufficient7. Whereas in the case of EP, however deposits of cartilage are found not only in the protruded tumor but also with in the adjacent underlying medulla of the host bone. Thus EP should be treated with the combination of resection of cartilage containing protrubence and intermedullary curettage 9. The typical presentation of enchondroma protuberans in MR images is as a well-defined intramedullary lesion with low signal intensity in T1-W image and high signal intensity in T2-W and STIR sequences accompanied by cortical expansion and cortical defect. Although this benign tumour is usually diagnosed by conventional radiography (X-ray)
2,3
and
sometimes conventional X-ray alone is not sufficient for diagnosis 2. The conventional radiographs may not detect protruding mass or cortical expansions. MR images can reveal the Connection between the intramedullary portion and the exophytic protrusion can be revealed better by MR images than conventional radiography. Also MR images can clearly delineate the cortical defect, which is essential in the diagnosis of enchondroma protuberans
1,4
. Magnetic
resonance imaging studies of our case report was similar to the previously reported cases of enchondroma protuberans.
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It is essential to consider Enchondroma protuberans in the differential diagnosis of osteochondroma,
Enchondroma,
and
periosteal
chondroid
tumours,
chondrosarcoma.
Osteochondroma is continuous with the bone, originating in the bone and consist of a dense osteoid formation in the cortex and medulla. Periosteal chondroma is benign cartilaginous tumour of periosteal origin, which occurs in young adults. Malignant transformations of benign enchondroma to chondrosarcomas were reported, but so far no malignant transformations for EP were reported 10. Conclusion - Enchondroma protuberans is rare presentation in dorsal spine; should be considered in the differential diagnosis of osteochondroma, enchondroma, chondrosarcoma and periosteal chondroid tumours. References 1. Beytemur O, Adanir O, Oncu M, Tetikkurt US. A rare cartilaginous tumor in the phalangeal bone: enchondroma protuberans. Acta Orthop Traumatol Turc. 2014; 48(3):379–81. 2. Dagum AB, Sampson SP. Enchondroma protuberans: a case report. J Hand Surg. 1998; 23(2):338–41. 3. Caballes RL. Enchondroma protuberans masquerading as osteochondroma. Hum Pathol. 1982; 13(8):734–9. 4. An YY, Kim JY, Ahn MI. Enchondroma protuberans of the hand. AJR Am J Roentgenol. 2008; 190(1):40–4.
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5. Ceulemans LJ, Verheyen L, Vanhoenacker FM. Enchondroma protuberans of the rib. JBRBTR Organe Soc R Belge Radiol SRBR Orgaan Van K Belg Ver Voor Radiol KBVR. 2011; 94(6):354. 6. Lozes G, Fawaz A, Perper H. Chondroma of the cervical spine. Case report. J
Neurosurg.
1987; 66(1):128-30. 7. Slesarenko YA, Sampson SP, Gould ES. Recurrent enchondroma protuberans: a case report. J Hand Surg. 2005; 30(6):1318–21. 8. Erten SF, Kocak A, Mizrak B. An end-plate chondroma mimicking calcified lumbar disc herniation. A case report and review of the literature. Neurosurg Rev. 1999; 22(2–3):145–8. 9. Crim JR, Mirra JM. Enchondroma protuberans. Report of a case and its distinction from chondrosarcoma and osteochondroma adjacent to an enchondroma. Skeletal Radiol. 1990; 19(6):431-4. 10. Müller PE, Dürr HR, Nerlich A. Malignant transformation of a benign enchondroma of the hand to secondary chondrosarcoma with isolated pulmonary metastasis. Acta Chir Belg. 2004; 104(3):341-4.
Figure
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Figure 1(A & B): CT Scan image of axial and saggital section showing ossific process extending to 7th and 8th rib left side indicated by bold orange arrow. 1C: 3D reconstruction CT scan mass arising from D8 transverse process extending to adjacent ribs
Figure 2 (A & B): T2W image s well defined expansile mass lesion arising from transverse process of D8 vertebra with matrix isointense to adjacent marrow C STIR Image showing well defined expansile mass heterogenous in signal intensity arising from transverse process of D8 vertebra
Figure 3(A&B) : Gross specimen of mass of enchondroma with part of 7th and 8th rib, C&D: Histopathology showing chondroid lesion peripherally rimmed by osteoid, chondrocytes in myxoid matrix located in round lacunae, compatible with enchondroma
Figure 4: Axial CT scan image of D8 vertebra with adjacent ribs showing no growth post one year after surgery, indicated by bold red arrow.
