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Abstract

Purpose:

The aim of this study is to report the clinical and radiological outcomes following surgical treatment of chondroblastoma by means of an extended intralesional curettage using high-speed burr, with phenol as a local adjuvant which is followed by the implantation of synthetic bone graft, aiming to lower the recurrence rate of this tumor.

Patients and Methods:

This retrospective study included 20 patients with chondroblastoma lesions during the period between 2000 and 2015.

Results:

Fifteen males and five females were followed up for a mean of 63.35 (26–144) months with average age at the time of presentation was 20.8 (range: 12–32) years. Nineteen patients (95%) were complaining of pain at the time of presentation, and the lesion was discovered accidently in one patient. The mean operative time was 138.5 min (75–250). At the most recent follow-up, all patients had regained full physical function without pain at the operation site.

Conclusion:

The aggressive treatment of chondroblastoma by an extended intralesional curettage using high-speed burr with phenol as a local adjuvant seems effective in lowering the incidence of local recurrence and secondary more aggressive surgeries. Implantation of the bone defects that result from curettage with the synthetic bone substitutes is a good alternative due to rapid restoration of the mechanical strength with good remodeling.

Keywords

chondroblastoma extended curettage local adjuvant phenol

Introduction

Benign chondroblastoma was first identified by Jaffe and Lichtenstein to confirm the cartilaginous origin of this tumor to differentiate it from other epiphyseal lesions such as giant cell tumor (GCT) of bone.¹ Chondroblastoma is a rare locally aggressive benign bone tumor that accounts for approximately 1–2% of all benign bone tumors, with a higher frequency in males as compared to females.^2

–9 It is primarily observed in adolescents and young adults.^1,10

Patients suffering from this condition usually complain of pain and local tenderness at the time of presentation, followed by swelling and limitation of motion of the adjacent joints.⁵ Chondroblastoma lesions arise from the secondary ossification centers and commonly involve the epiphyses or apophyses of long bones.^2,7,11
–13 Less commonly, they can arise in metaphyseal regions.¹⁴ Furthermore, they commonly affect the hip, shoulder, and knee regions. However, no part of the skeleton can be excluded in this regard.¹⁵

The surgical strategies adopted for the treatment of chondroblastoma include curettage, either alone or in combination with filling the bone defect using autogenous or allogeneic bone grafts or both.^{3
–5,10,15,16} Packing the bone defects with polymethylmethacrylate^11,14 or calcium phosphate cement (CPC)¹⁷ or using cryosurgery⁸ is the other reported treatment modality. The reported postoperative recurrence rates after treatment pertaining to these procedures range from 10% to 36%.^{7,11,14
–16} Moreover, rare cases with pulmonary metastasis have been described.^7,10 The reported risk factors for postoperative recurrence include tumor location in the hip or pelvis, an open growth plate, inadequate resection, and/or aggressive behavior of the lesion.^{2,3,5,12,14,18}

The aim of this study is to report the clinical and radiological outcomes following surgical treatment of chondroblastoma by means of an extended intralesional curettage using high-speed burr, with phenol as a local adjuvant which is followed by the implantation of a synthetic bone graft, aiming to lower the recurrence rate of this tumor.

Patients and methods

This retrospective study included 20 patients with chondroblastoma who underwent surgical treatment by extended curettage with phenol as a local adjuvant, followed by the implantation of a synthetic bone graft during the period between 2000 and 2015 (Table 1).

Table 1.

Characteristic details of patient.

No.	Age and gender	Tumor site	Stage	Adjacent physis	Previous treatment at another hospital	Synthetic substitute	Operative time (minutes)	Follow-up (months)	Radiological outcomes
1	15/M	Proximal humerus	Aggressive	Closing	No	β-TCP	180	46	Consolidation
2	22/F	Proximal humerus	Aggressive	Closed	No	β-TCP	155	144	Consolidation
3	26/M	Calcaneus	Aggressive	Closed	No	β-TCP	75	82	Consolidation
4	12/F	Proximal tibia	Active	Open	No	β-TCP	85	32	Consolidation
5	22/M	Proximal femur (head, neck)	Active	Closed	No	β-TCP	150	37	Consolidation
6	27/M	Patella	Active	Closed	No	β-TCP	85	48	Consolidation
7	22/F	Acetabulum	Aggressive	Closed	No	α-TCP	250	56	No recurrence
8	31/M	Distal femur	Active	Closed	No	β-TCP	150	26	Consolidation
9	32/M	Proximal femur (trochanter)	Active	Closed	No	β-TCP	95	127	Consolidation
10	16/M	Proximal femur (trochanter)	Active	Closed	No	α-TCP	150	35	No recurrence
11	28/M	Proximal femur (trochanter)	Active	Closed	No	β-TCP	210	133	Consolidation
12	24/M	Talus	Active	Closed	No	α-TCP	90	92	No recurrence
13	16/F	Distal femur	Active	Closed	No	α-TCP	166	63	No recurrence
14	14/M	Proximal tibia	Active	Closing	No	α-TCP	88	73	Recurrence
15	21/M	Proximal femur (trochanter)	Active	Closed	No	α-TCP	156	43	No recurrence
16	15/F	Proximal humerus	Active	Closing	No	α-TCP	82	96	No recurrence
17	20/M	Proximal femur (trochanter)	Active	Closed	No	α-TCP	131	34	No recurrence
18	15/M	Proximal femur (head, neck)	Aggressive	Closing	Yes	α-TCP	157	39	No recurrence
19	23/M	Proximal tibia	Active	Closed	No	α-TCP	128	27	No recurrence
20	15/M	Acetabulum	Aggressive	Closing	No	β-TCP	186	34	Recurrence

α-TCP: alpha tricalcium phosphate; β-TCP: beta tricalcium phosphate; F: female; M: male.

Age at the time of presentation, sex, presenting symptoms, tumor location, and imaging findings were reviewed. The diagnosis was based on radiological findings and histopathological evaluation of surgical specimens. Radiological staging was made depending on the following criteria. Inactive or latent lesions were identified as intraosseous location with a complete, well-defined reactive, sclerotic rim. Active lesions were intraosseous lesions with a thin and incomplete sclerotic rim or ones contained within the reactive periosteal bone. Aggressive lesions had poorly defined edges and cortical destruction, with minimal or no sclerotic rim, and the extraosseous component not being contained by reactive periosteal bone.¹⁵

The status of the adjacent physis was classified on plain radiographs as being either open, closing, or closed. The physis was considered to be open if it was wide and clearly apparent, to be closing if it appeared as a thin irregular epiphyseal plate, and to be closed if radiolucency was lost and an epiphyseal scar was visible.⁵

Radiography of the lesion and chest, computed tomography (CT), and magnetic resonance imaging (MRI) were performed for all patients; but in patients with aggressive lesions or when malignancy was suspected, CT of the chest and technetium-99m and thallium-201 bone scintigraphy were indicated. Ethical approval was obtained from the Institutional Review Board of the Kanazawa University and written informed consent was granted by all patients.

Surgical procedure

The choice of the surgical approach and positioning of the patient depended on the anatomical location of the lesion. The affected region was screened under the image intensifier to confirm that the lesion could be identified both in the anteroposterior and lateral views. After approaching the lesion, a cortical window was created. A biopsy was obtained for the frozen section to confirm the provisional diagnosis of chondroblastoma before a definitive surgical procedure was performed. If the frozen section diagnosis was not confirmed, the surgical procedure was performed in another stage, after definitive diagnosis was obtained.

The cortical window should be large enough to allow adequate exposure with straightforward visualization of the entire tumor cavity. Through the cortical window, extended intralesional curettage of the lesion was performed. The major intraosseous bulk of the tumor was removed using a hand curette back to the normal-appearing bone. Then, the high-speed burr (of 90,000 rounds per minute) was used under direct vision to enlarge the tumor cavity in all directions, allowing removal of an additional 1–5 mm of the cavity lining. In addition to the thorough removal of tumor tissue using this technique, the high-speed burr also adds a thermal component to the eradication of the tumor.

After complete extended curettage, phenol (Liquefied phenol 91%; NIKKO Pharmaceutical company, Gifu, Japan) was used as a local adjuvant to destroy any remaining tumor cells. According to the size of the tumor cavity, 2–4 ml of phenol was applied to the cavity walls for 3–5 min using soaked swabs. Then, the cavity was rinsed with 99.5% ethanol (as dehydrated ethanol; Yoshida Pharmaceutical Company, Saitama, Japan), and this was performed by filling the cavity by ethanol and left in situ for 2–3 min. The volume of ethanol differed depending on the size of the cavity. Then, this mixture of phenol and ethanol was extracted by suction. Finally, irrigation of the tumor cavity with isotonic saline was performed. This cycle may be repeated two or three times.

Thereafter, implantation of the synthetic bone substitute was performed (Figure 1). Packing the bone defects with alpha tricalcium phosphate (α-TCP) was performed in 10 patients and beta tricalcium phosphate (β-TCP) in the remaining patients (Figure 2). Internal fixation was performed in one patient with a dynamic hip screw because the lesion was presented with a preoperative impending pathological fracture of the proximal femur.

Figure 1.

Case presentation representing a 20-year-old male with chondroblastoma of the greater trochanter of the right femur treated by extended curettage with phenol as a local adjuvant followed by implantation of α tricalcium phosphate. (a) Anteroposterior radiograph of the pelvis showing chondroblastoma of the left greater trochanter. (b) Postoperative radiograph showing the lesion after curettage and implantation of α tricalcium phosphate. (c) and (d) Radiographs taken at final follow-up (2 years after surgery).

Figure 2.

Case presentation representing a 15-year-old female with chondroblastoma of the greater tuberosity of the left humerus treated by extended curettage with phenol as a local adjuvant followed by implantation of α tricalcium phosphate. (a) Radiograph of the proximal humerus showing the chondroblastoma lesion, (b) CT of the lesion, (c) MRI of the lesion, (d) intraoperative photo after curettage, and (e) postoperative radiograph showing the lesion after curettage and implantation of α tricalcium phosphate. CT: computed tomography; MRI: magnetic resonance imaging.

Patients had follow-ups, with serial radiographs taken at approximately 6 weeks, every 3 months for the first 2 years, then every 6 months for until 5 years, and once each year thereafter. For the lower extremity lesions that were reconstructed using α-TCP, gradual weight bearing was allowed 1 week after surgery when the α-TCP achieved maximum strength. While, for β-TCP cases weight bearing was delayed for 4–6 weeks depending upon the site and size of the lesion. Local recurrence was suspected if the symptoms recurred, if abnormalities were detected on plain radiographs at the operative site, or if cortical destruction and bone marrow edema were apparent on MRI.

Results

There were 15 males and 5 females. The average age at the time of presentation was 20.8 (12–32) years. They were followed up with for a mean period of 63.35 (26–144) months. Eight patients (40%) were in the second decade of age. Nineteen patients (95%) were complaining of pain at the time of presentation, and the lesion was discovered accidentally in one patient.

The pathological diagnoses were primary chondroblastoma in 19 patients and recurrent chondroblastoma in 1 patient after previous treatment with curettage in another hospital. The most common site was the proximal femur in seven patients (35%), followed by the proximal humerus in three (15%), the proximal tibia in three (15%), the distal femur in two (10%), and the acetabulum in two (10%). There was one case each involving the patella, the talus, and the os calcis. The adjacent physis was open in 1 patient (5%), closing in 5 patients (25%), and closed in 14 patients (70%). The lesions were radiologically active in 14 patients (70%) and aggressive in 6 patients (30%).

The mean operative time was 138.5 (75–250) min. At the most recent follow-up, all patients had regained full physical function without pain at the operation site. Local tumor recurrence was observed in two patients (10%) with chondroblastoma of the acetabulum and proximal tibia 7 months after the index surgery. The lesions were active in one patient and aggressive in the other. Both lesions were treated with recurrtage and implantation of α-TCP within the bone defect, and they regained full physical function by the final follow-up. No postoperative infection nor fracture was observed.

Discussion

Chondroblastoma is a rare locally aggressive benign bone tumor that accounts for approximately 1–2% of all benign bone tumors.^2,3,5,7 Similar to what has been reported in the literature,^5,6,9,12 chondroblastoma lesions in our series have higher frequency in male patients and in the epiphyses or apophyses of long bones. The male to female ratio in our study is 3:1. The previous studies reported higher frequency in adolescent patients but, in our study, adolescent patients represent only 40% of the cases.

In the present study, the common presenting symptom of the patients was pain as reported in the literature.^5,6,9 The proximal tibia and the proximal humerus have been reported as being the most commonly involved locations.^1,2 In the current study, the proximal femur was the most frequent site of involvement, followed by the proximal humerus and the proximal tibia.

The activity of chondroblastoma varies among previous reports in the literature. Springfield et al.³ reported that 33% of the lesions were aggressive, 53% were active, and 14% were latent in their study, which included 70 cases of chondroblastoma. Suneja et al.⁵ founded that aggressive lesions were 13%, active lesions were 85%, and latent lesions were 3% in their study of 53 cases. Atalar et al.⁶ reported that 46.5% were aggressive, 46.5% were active, and 7% were latent. Garin and Wang⁴ reported that aggressive lesions were 30%, active lesions were 30%, and latent lesions were 40%. In our study, the lesions were aggressive in 30% and were active in 70% of the cases.

There is controversy regarding the standard treatment for chondroblastoma. There are several options for surgical treatment, including curettage either alone or combined with filling the defect with bone graft, polymethylmethacrylate, or CPC. Cryosurgery using liquid nitrogen as a local adjuvant has been described.^{3,5,9,11,14,17,19} Percutaneous radiofrequency heat ablation and marginal resection^13,19,20 are other treatment options.

Some authors thought that a less aggressive approach is more convenient for the surgical treatment of chondroblastoma as they were afraid of growth plate injury which may result in physeal growth arrest. But a less aggressive approach is associated with a high recurrence rate, and it is not known if the physeal damage is caused directly by chondroblastoma lesion or due to surgical curettage.^8,19 Tomić et al.²¹ observed a high recurrence rate (up to 30%) with surgical management using simple curettage, and they considered it as an unacceptable option, especially for aggressive lesions. They stated, “Aggressive disease requires an aggressive management strategy.” Suneja et al.⁵ believed that extended curettage can be performed with proper care as the physis is somewhat resilient; they considered that aggressive curettage may be a curative method in most cases. Hsu et al.¹¹ also recommend extended curettage using high-speed burr, especially for aggressive lesions, as they believed that it was an effective method.

Adjuvant treatment, such as cryosurgery or cementation, has been reported in the hope that the freezing or heat of polymerization will destroy the residual tumor cells. Although these adjuvants may be useful, they carry the risk of growth plate or articular cartilage damage. These adjuvants should be used with caution to avoid injury of the adjacent soft tissues and neurovascular structures, otherwise significant injury to surrounding soft tissues and adjacent bone rim or cartilage may result leading to a secondary fracture, skin necrosis, and neuropraxia.^22,23

In our study, we performed an extended intralesional curettage using high-speed burr with phenol as a local adjuvant, as we believe that primary aggressive treatment is essential to lower the recurrence rate and the need for second more aggressive surgery. Mashhour and Abdel Rahman advised aggressive surgical treatment at the time of the first surgery to prevent recurrence and a second, more aggressive surgery with possible growth plate and articular cartilage injury.⁸

Phenol as a local adjuvant causes denaturation and coagulation of the cellular proteins and DNA damage, resulting in the actual destruction of the cells and tissue necrosis. By this process of coagulative necrosis, phenol can cause destruction of about 1–1.5 mm of tumor tissue.²⁴ Dürr et al. reported that phenol is an effective and safe local adjuvant in the management of GCT. They did not observe any significant differences in recurrence rates for curettage, phenolization, and bone grafting compared to other published studies using cryosurgery or cementation.²⁵ Other studies revealed that phenol is an effective local adjuvant in the surgical treatment of low-grade chondrosarcoma.^26,27 Zekry et al. reported the use of phenol as a local adjuvant in the management of GCT and chondroblastoma lesions of proximal femur with satisfactory outcomes.²⁸

Ethanol was used mainly in our study as a rinsing agent for phenol, but it also has an antitumor effect, as it causes necrosis of tumor tissues by denaturation of the cellular proteins, degeneration of the cellular cytoplasm, and production of a thromboembolic effect on the small vessels that supply the tumor. Moreover, the adverse effects of ethanol on the surrounding tissues are minimal.²⁴

For reconstruction of the bone defects after curettage, we used either α-TCP or β-TCP depending on the size of the lesion and age of the patient. β-TCP granules were preferable for small lesions and in adolescent patients because it acts as a scaffold for new bone formation, while α-TCP or CPC was used for larger, recurrent, or aggressive lesions to restore the mechanical strength in a short time.

The reported recurrence rates range from 10% to 36%,^2,5,12,14,18 and the reported risk factors were chondroblastoma location around the hip joint, aggressiveness of the lesion, associated aneurysmal bone cyst components, young age, and inadequate surgical treatment.^{2,3,5,12,14,18} In our study, there were two cases (10%) of posttreatment recurrence (one acetabulum and one proximal tibia). The lesion of acetabulum was aggressive, while that of the proximal tibia was active. Both were treated again by extended curettage with phenol and ethanol as local adjuvants, followed by the implantation of α-TCP and, finally, with follow-ups to ensure that they achieved good function. This lower rate of postsurgical recurrence in our study was explained by the combined efficacy of intralesional extended curettage and local adjuvants (phenol and ethanol).

Because most of the chondroblastoma lesions are epiphyseal in location, complications, such as limb-length discrepancy, angular deformities, and osteoarthritic changes, may be observed after the surgical treatment of these lesions. For the management of these complications, secondary surgical interference may be required, such as limb lengthening, deformity correction, or arthroplasty procedures. However, these complications were not reported in our study. So, we believe that primary aggressive treatment of chondroblastoma is a safe procedure.

This study has some limitations. It is a level-IV evidence retrospective study with a limited number of patients. Therefore, a larger study may be needed in the future.

Conclusion

The aggressive surgical treatment of chondroblastoma by an extended curettage using high-speed burr with phenol and ethanol as local adjuvants seems effective in lowering the incidence of local recurrence and secondary more aggressive surgeries with possible injury of articular cartilage and growth plate. Implantation of the bone defects that result from curettage with the synthetic bone substitutes is a good alternative due to rapid restoration of the mechanical strength with good remodeling.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Karem M Zekry

Akihiko Takeuchi

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