Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : EC20 - EC26 Full Version

Concordance between Radiological Features and Histopathological Diagnosis of Cartilaginous Lesions of Bone among Patients at a Tertiary Care Centre, Trivandrum, Kerala


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57352.17141
Jayasree Kattoor, Balaji Radhakrishnan, Sindhu Nair, M Venugopal

1. Professor and Head, Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India. 2. Assistant Professor, Department of Pathology, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India. 3. Assistant Professor, Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India. 4. Professor and Head, Department of Radiology, Regional Cancer Centre, Trivandrum, Kerala, India.

Correspondence Address :
Balaji Radhakrishnan,
68 E/4, RV Street, Alagesan Nagar, Chengalpattu-603001, Tamil Nadu, India.
E-mail: balajir11@srmist.edu.in

Abstract

Introduction: Cartilaginous tumours comprise a large, heterogeneous group of mesenchymal neoplasms. They pose a challenge in terms of accurate diagnosis and management. Histopathological findings have direct implications for treatment outcomes.

Aim: To determine the concordance between the radiological features and the histopathological diagnosis of cartilaginous lesions of bone.

Materials and Methods: This was a retrospective study conducted in the Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India, among 109 patients with histopathologically proven benign and malignant cartilaginous tumours, received in the laboratory between January 2012 and December 2021 for a duration of 10 years, were analysed. The study was conducted between September 2019 and January 2022. The demographic data for the study, including age, tumour site, clinical findings, and radiological diagnosis, were obtained from medical records. The cases were histopathologically graded based on the World Health Organisation 2020 classification of tumours of soft tissue and bone. The concordance between histopathological diagnosis and radiological features was assessed. The Chi-square test was used to find the association between two categorical variables, and the Independent sample t-test was used to find the difference between two groups with respect to mean and standard deviation.

Results: There were a total of 109 cases of cartilaginous tumours, out of which 82 cases (75.22%) were diagnosed as malignant and 27 cases (24.77%) were diagnosed as benign. Among benign neoplasms, chondroblastoma and osteochondroma were the most common, with 10 cases (37.03%) each. Among malignant chondroid tumours, 73 (89.02%) were diagnosed as conventional chondrosarcoma. There were five cases (6.09%) of secondary chondrosarcomas (malignant transformation of a benign cartilaginous lesion). Among the secondary chondrosarcomas, three cases (60%) were malignant transformation in osteochondroma, 1 (20%) in enchondroma, and 1 (20%) in synovial chondromatosis. Among the 91 cases for which radiology was available, 86 (94.50%) had a concordance between radiological and histopathological diagnosis. Five cases (5.49%) had a discordant radiological diagnosis.

Conclusion: For histologically benign tumours, the radiological findings in the study were identical and concordant. For histologically malignant tumours, there were discrepancies with radiological findings in this study when the lesion had an associated cyst, absence of cortical destruction, or absence of a clear cartilaginous component and extra cortical expansion. For histologically suspicious cases in the study, the final diagnosis was made based upon radiological findings, with a particular interest in cortical destruction.

Keywords

Benign tumours, Chondroblastoma, Cortical destruction, Imaging, Osteochondroma

Bone tumours are uncommon, accounting for only 0.5% of total cancer incidence worldwide (1). Cartilaginous neoplasms are defined as lesions that produce a cartilaginous matrix (2). They are subclassified into benign and malignant lesions. Benign cartilaginous tumours behave indolently, and hence treatment is necessary only for symptomatic patients (3). Grade I chondrosarcomas are treated with extensive intralesional excision with curettage, adjunctive burring, and bone void augmentation, whereas grade II and grade III lesions need extensive resection with reconstruction surgeries (4). Small biopsy samples without radiological correlation can mislead in differentiating low-grade and high-grade tumours, which have entirely different management protocols.

Osteochondroma is the most common benign bone tumour, and chondrosarcoma is the third most common primary malignant bone tumour after myeloma and osteosarcoma. Chondroblastoma is the rarest, with a 1% incidence among benign bone lesions (5). Certain benign cartilaginous neoplasms do not affect life expectancy, but certain lesions like osteochondromatosis have a higher risk of malignant transformation (6). In the case of chondrosarcomas, a few factors like the site and grade influence the prognosis of the patient. Particular importance must be given to identifying areas of dedifferentiation since they carry a poor prognosis compared to their well-differentiated counterparts.

The present study is limited only to cartilaginous lesions with concordant radiological assessment, similar studies are rare (7). Hence, aim of the present study was to determine the concordance between the radiological features and the histopathological diagnosis of cartilaginous lesions of bone.

Material and Methods

This retrospective study was conducted in the Department of Pathology at Regional Cancer Centre, Trivandrum, Kerala, India, from September 2019 to January 2022 with data included from 1st January 2012 to 31st December 2021. The present study was conducted after obtaining ethical clearance from the Institutional Ethical Committee (IEC-IRB No.09/2019/01 dated 27.09.2019).

Sample size calculation: Sample size was calculated by applying the formula:

N=4 pq/e2

Where ‘p’ is the prevalence. The prevalence of cartilaginous tumours among bone tumours was taken as 67% (6).

So, p=67; q=(1-p) and e=allowable error (13% in the present study). Thus, the final sample size (N) calculated was 53. A total of 109 cases of histologically diagnosed cartilaginous tumours were analysed.

Inclusion criteria: All the core needle, excision, and amputation specimens obtained from patients of all age groups, reported at the histopathology department as cartilaginous tumours, including benign, intermediate, and malignant tumours as classified under the World Health Organisation (WHO) 2020 classification (8).

Exclusion criteria: Apart from cartilaginous lesions, all other tumours and inflammatory conditions of bone were excluded from the present study.

Study Procedure

The demographic data for the study, including age, tumour site, clinical findings, and radiological diagnosis, were obtained from medical records. The cases were histopathologically graded based on the WHO 2020 Classification of Tumours of Soft Tissue and Bone (8). The concordance between histopathological diagnosis and radiological features was assessed.

Statistical Analysis

R-programming was used to analyse the empirical data. Categorical data was presented by frequency and percentage, whereas continuous numerical data was presented by mean and standard deviation. The Chi-square test was used to find the association between two categorical variables, and the Independent sample t-test was used to find the difference between two groups with respect to mean and standard deviation. The agreement between histopathological findings and radiological findings was assessed through sensitivity, specificity, positive predictive value, and negative predictive value. A level of significance of 5% is considered statistically significant.

Results

In the present study, there were 109 cases of cartilaginous neoplasms, out of which 82 cases (75.22%) were diagnosed as malignant and 27 cases (24.77%) were diagnosed as benign. The male:female ratio was 1:1 with 54 males (49.54%) and 55 females (50.46%). The age of patients with benign cartilaginous neoplasms ranged from 7-65 years, and malignant cartilaginous neoplasms ranged from 8-76 years (Table/Fig 1).

Among the benign neoplasms, there were 10 (37.03%) cases of chondroblastoma and osteochondroma each, 3 (11.11%) enchondromas, and 2 (6.89%) cases each of chondromyxoid fibroma and synovial chondromatosis.

Among the 10 chondroblastomas, 7 (70%) were male and 3 (30%) were female, with an age range of 7-56 years. The most common radiological presentation was a well circumscribed lesion with preserved cortical lining (Table/Fig 2). Microscopically, clusters of round to polyhedral chondroblasts with abundant cytoplasm and well-defined cell borders were noted (Table/Fig 3). The most common site was the skull, with three cases (30%), followed by the humerus and tibia, with two cases (20%) each. Five cases (50%) were associated with a secondary aneurysmal bone cyst.

Among 10 cases of osteochondroma, 4 (40%) were males and 6 (60%) were females, with an age range of 7-43 years. Radiologically, only one case showed a sessile architecture with a cartilaginous cap (Table/Fig 4). The most common site was the femur, with six cases (60%). One of the osteochondroma cases had developed multiple lesions in the femur, tibia, scapulae, right second and fifth ribs. The femoral lesion later transformed into chondrosarcoma.

Among the three cases of enchondromas, two were males and one was female, and the sites of occurrence were in the hand, foot, and humerus. Two (7.40%) of the benign cartilaginous neoplasms were chondromyxoid fibromas. One in a male and the other in a female with lesions in the tibia and fibula, respectively. Radiologically, a well-defined eccentrically located lytic lesion was found in both cases (Table/Fig 5). Histologically, lobules of benign spindle cells in a background of chondromyxoid stroma was noted. (Table/Fig 6). Two (7.40%) of the benign cartilaginous neoplasms were diagnosed as synovial chondromatosis (Table/Fig 7), with one case each in a male and female, both in the knee joints. Histologically, both cases had lobules of hyaline cartilage lined by benign chondrocytes with absent atypia (Table/Fig 7).

Out of total, 73 cases (89.02%) of malignant cartilaginous neoplasms were diagnosed as conventional chondrosarcoma and 36 (49.31%) were males and 37 (50.69%) were females, with a male-female ratio of 1:1. The most common site was the humerus, with 13 cases (17.80%), followed by the femur with 12 cases (16.43%) (Table/Fig 8).

One patient had a lesion both in the tibia and fibula. According to WHO, 24 cases (32.87%) were grade I, 42 cases (57.53%) were grade II, and 7 cases (9.58%) were grade III. 68 cases (93.15%) were primary chondrosarcomas. Radiologically, the most common finding was a large lytic lesion with thickened cortex, cortical erosion, and cartilaginous calcifications (Table/Fig 9). Histologically, varying degree of cellularity, atypia, and mitotic activity was noted depending upon the chondrosarcoma grade. There were five cases (6.09%) of secondary chondrosarcomas (malignant transformation of a benign cartilaginous lesion). There were three cases (60%) of malignant transformation in osteochondroma, one case (20%) of multiple enchondromatosis, and one case (20%) of synovial chondromatosis among the secondary chondrosarcomas.

There were three cases (3.66%) of mesenchymal chondrosarcoma, two of which presented in the skull while the other was in the femur. Histologically, all cases had a small round cell component with interspersed areas of cartilage (Table/Fig 10).

There were four cases (4.88%) of dedifferentiated chondrosarcoma, with three cases having an osteosarcoma component. The other case had an undifferentiated spindle cell sarcoma component. Three of the cases presented in the pelvis, with one case in the femur. Radiologically, an aggressive bone lesion with adjacent soft tissue calcification was noted. (Table/Fig 11) Histologically, interspersed islands of malignant osteoid lined by round to spindle cells with hyperchromatic nuclei and nuclear atypia were noted (Table/Fig 12).

There were two cases (2.43%) of clear cell chondrosarcoma, in the femur and humerus, respectively. Histologically, clear cell chondrosarcoma showed sheets of round to polygonal cells with clear cytoplasm, one case also showed a giant cell reaction (Table/Fig 13).

Radiological details were available for 91 cases. Eighty six (94.50%) of the 91 cases had a concordance between radiological and histopathological diagnosis. Five cases (5.49%) had histopathological and radiological discordance (Table/Fig 14). The statistical significance value (p-value=0.406) of gender reveals that there was no statistically significant difference in the male-female ratio among the patients with benign and malignant conditions. However, age was statistically different among the patients with benign and the patients with malignant (p-value=0.001) (Table/Fig 15). In other words, patients with malignancy were older than patients with benign conditions.

It was concluded that 93.75$ of the patients with malignancy shall had positive result in radiological diagnosis (sensitivity). Whereas, 100% of the patients with benign lesion will had negative results in radiological diagnosis (specificity) (Table/Fig 16). Positive Predictive Value (PPV) indicated that if the patient’s radiological diagnosis was malignant, there is a 100% chance that the patient really had malignancy, whereas Negative Predictive Value (NPV) indicated that if the patient’s radiological diagnosis was benign, there was a 87.1% chance that the patient really had a benign lesion.

Discussion

Cartilaginous tumours form the second largest group of primary bone tumours. The presentation of cartilaginous tumours differs according to site, location, and age group. Subclassifying the cartilaginous tumours as benign, malignant, and locally aggressive (intermediate) is important since treatment protocols differ for each category (4).

Benign Cartilaginous Tumours

Osteochondroma: Osteochondroma is the most common benign tumour of the bone (2). In the present study, osteochondromas and chondroblastomas were the most common benign tumours. According to the literature review, the most common site of involvement of osteochondromas are in the lower extremities (9), which is also the same in the present study, with the femur being the most common site with six cases. [60%] 15% of osteochondromas occur as multiple lesions in the context of hereditary multiple osteochondromas (10). The percentage of solitary osteochondromas undergoing malignant transformation is 1-2%, while for multiple osteochondromas the risk of transformation is between 1% and 25% (11),(12),(13). One [10%] of the 10 cases in the current study presented in multiple sites and the femoral lesion of the same patient had undergone malignant transformation. Two of the 10 cases had a cartilaginous cap thickness of more than 2 cm [3.5 and 3.2 cm]. Cap thickness greater than 2 cm is a high-risk indicator for transformation (13). Radiologically, there is a stalk-like extension and the cortex and medulla are continuous with the underlying bone (14). In the index study, nine cases were diagnosed radiologically as osteochondroma and 1 case was diagnosed as a benign cartilaginous lesion with no evidence of bone expansion, cortical thickening, or destruction. This case had a sessile architecture with absent stalk formation. There was 100% concordance between radiology and histopathology. In their retrospective study Bernard SA et al., had found that Computed Tomography (CT) imaging had a sensitivity and specificity of 100% and 95% in distinguishing chondrosarcoma (15), which mirrors in the present study. One of the differential diagnoses to be considered for osteochondroma is paraosteal osteochondromatous proliferation, also called Nora’s lesion (2). Histologically, Nora’s lesion shows hypercellular cartilage with atypia. All the osteochondromas in the study had organised bland hyaline cartilage, and hence diagnosis was straightforward after radiological correlation.

Chondroblastoma: Chondroblastoma is rare and accounts for less than 1% of all primary bone tumours. However, in the present study, it was the most common along with osteochondroma. The literature review shows the average age range is 19-23 years (16), which is the same as in the present study with the exception of three cases in which two were above 30 years and one was 56 years old. The outcome is the same in adults and children, with the exception that the most common sites in adults are small tubular bones like the talus and calcaneum, as opposed to long tubular bones in children (17),(18). However, in the index study the most common site involved was temporal bone. Chondroblastoma presents as a solitary lesion. All cases in this study were solitary lesions. Chondroblastoma is commonly associated with secondary aneurysmal bone cyst (16) and is the most common cartilaginous neoplasm to be associated with secondary aneurysmal bone cyst (19). Five cases (50%) in the current study were presented with secondary aneurysmal bone cyst. Malignant transformation in chondroblastomas is rare, with only three cases reported in the literature so far (20). One of the temporal bone chondroblastomas had multiple recurrences at the same site and is symptom-free now. The typical radiological finding in chondroblastomas is a radiolucent lesion with well-defined borders and a sclerotic rim (3). In the present study, seven cases were diagnosed radiologically as chondroblastoma, correlating with the younger age of these patients. Two cases were diagnosed as benign cartilaginous lesion. One case was diagnosed as an aneurysmal bone cyst, the reason being a large cyst in radiology with a small cartilaginous component. All cases were diagnosed as benign radiologically, and there was 100% concordance.

All cases histologically showed classical round chondroblasts in a background of chondroid matrix, and hence the histopathological diagnosis was straightforward.

Enchondroma: Enchondroma is a medullary bone lesion that arises from the diaphyseal shaft. The most common site is the small bones of the hands (21). The sites of the lesion in the present study were the humerus, hand, and foot, with one case each.

Radiologically, enchondromas are well demarcated and central in location (3). In the present study, two of the cases were diagnosed as enchondroma, considering the location in the metatarsal and metacarpal, respectively. One was diagnosed as a benign chondromatous lesion, probably an osteochondroma, considering the location in the humerus. However, no stalk was visualised, and probably a sessile type was considered. Hence, all cases were diagnosed as benign, and hence there was 100% concordance between radiology and histopathology. In their study, Vidoni et al., found that out of 9 chondroblastomas diagnosed by imaging, 8 had concordant histological diagnosis. One case was diagnosed histologically as an osteoblastoma (22). Histologically, the closest differential diagnosis for enchondroma is low-grade chondrosarcoma. Because enchondromas can also show increased cellularity and atypia, especially in the small bones of the hand and feet, bone permeation is the definitive feature for diagnosing a lesion as chondrosarcoma (23). One of the three cases, which was a needle biopsy in the present study, showed atypical features such as myxoid change and increased cellularity. Cortical destruction or permeation of bone spicules was absent. It was difficult to categorise in needle biopsies and radiological correlation was essential for proper categorisation.

Chondromyxoid fibroma: Chondromyxoid fibroma represents less than 1% of all tumours of bone (24). It has a wide age range, from 3-70 years (24). The long bones are most commonly affected, with the tibia being the most common site (25), which is in correlation with the present study, with one case in the tibia and the other in the fibula.

Radiologically, chondromyxoid fibroma is an expansile lytic lesion with internal septations and sharply demarcated borders (3). In the current study, both the cases radiologically showed an eccentric defect with thinned out cortex, sclerotic borders, and absent cortical destruction, and hence were diagnosed as benign cartilaginous lesions with a differential diagnosis of chondromyxoid fibroma. There was 100% concordance between radiology and histopathology. It is difficult to differentiate chondromyxoid fibroma from chondrosarcoma in small biopsies, since chondromyxoid fibroma can show a haphazard arrangement. Altering hypocellular and hypercellular areas seen in excision specimens can be missed in small biopsies. One case was excision, and the diagnosis was straightforward. The second case was difficult to diagnose on needle biopsy because of nuclear atypia and haphazard arrangement. Subsequent excision biopsy proved it to be a chondromyxoid fibroma.

Synovial chondromatosis: Synovial chondromatosis is rare and affects the third to fifth decade of life (25). The most common site is the knee (26), which is in concurrence with the present study. Radiologically, the involved joint shows calcified bodies and can cause marginal bone erosion. Non-calcified bodies are usually visualised on a CT scan (26). In this study, one lesion that presented in the knee joint had joint distention and intra-articular bodies with varying mineralisation radiologically and hence was diagnosed as synovial chondromatosis. The other case was localised in the tibia with associated joint effusion and arthritis. A diagnosis of benign cartilaginous lesion with joint effusion was given. Malignancy was ruled out. Histology of both cases showed lobules of hypercellular hyaline cartilage and clustering of chondrocytes. There was 100% concordance between radiology and histopathology.

Malignant Cartilaginous Tumours

Chondrosarcoma-conventional type: Conventional chondrosarcoma occurs in older patients with a peak incidence between the 5th and 7th decades (27). However, the mean age group of conventional chondrosarcomas in this study was 46 years, with seven (9.58%) cases younger than 25 years. Some authors suggest that chondrosarcomas at a younger age tend to have a worse prognosis compared to adults (28). Other authors, however, claim that there is no difference in prognosis between adults and younger patients (29),(30). In the present study, none of the cases under 25 years of age were diagnosed as grade III. Conventional chondrosarcoma can involve any bone, with the most common site of involvement being the femur, followed by the humerus, which is in concurrence with this study. Histologically, all cases had bone permeation, which is the pathognomic feature for diagnosing chondrosarcoma. Radiologically, conventional chondrosarcoma shows a mixed lytic and sclerotic pattern with ring and arc type of calcification. Differentiating between atypical borderline lesions and malignant tumours is the most trickiest with both pathologists and radiologists having high interobserver variability (7). These are the five cases that had discordance between radiological and histopathological diagnosis.

Case 1: The patient was a 50-year-old male who presented with a painful swelling in the femur. Radiology revealed a predominant cystic component with an eccentrically located radiolucent lesion with non sclerotic margins. Based on the age, site and cystic component, a radiological diagnosis of giant cell tumour was given. The histology sections showed an extensive cystic component and a minor malignant moderate grade cartilaginous component and was diagnosed as grade II chondrosarcoma.

Case 2: The patient was a 23-year-old male who presented with a lesion in the femur. Radiology revealed a hyperattenuating large solid mass with cortical destruction and a probable diagnosis of primitive neuroectodermal tumour was given. Literature shows that a large solid mass with aggressive bone destruction is the classical presentation of the Ewing/PNET family of tumours (31). The histology sections showed entirely atypical cartilaginous islands and was diagnosed as grade II chondrosarcoma. No round cell component was noted.

Case 3: The patient was a 56-year-old female who presented with a lesion in the lower femur. Imaging showed an expansile lesion involving bone and an adjacent soft tissue component. A probable diagnosis of tumour with neural origin was given. Histology was given as grade II chondrosarcoma. No neural component was noted in the sections studied.

Case 4: The patient was a 49-year-old female who presented with a lesion in the scapula. Radiology showed a cartilaginous lesion with thinned out, mild endosteal scalloping and intact cortex. No cortical destruction or extension into adjacent soft tissue was noted. Hence, a diagnosis of chondroma was given radiologically. Histologically, most of the islands were benign, with a single focus exhibiting higher grade cartilage being noted, hence it was diagnosed as grade II chondrosarcoma. Increased tumour length was considered as a parameter to distinguish grade I chondrosarcoma from enchondroma (32). Recent research, however, indicates that tumour length is insignificant in distinguishing enchondroma from grade I chondrosarcoma (33).

Case 5: The patient was a 58-year-old male who presented with a swelling in the humerus. Radiologically, a well-defined lesion with chondroid calcification and an intact cortex was noted. Similar to case 4, it was diagnosed as a benign cartilaginous lesion, but histologically turned out to be a grade II chondrosarcoma with evidence of adjacent bone permeation. In their retrospective study, Miwa S et al., found that endosteal scalloping and cortical defect had high sensitivity (96.7% and 86.7%, respectively). Whereas, periosteal reaction and extraskeletal mass involvement had very high specificity [100%] in diagnosing atypical cartilaginous tumour/chondrosarcoma (34).

Chondrosarcomas are graded based on cellularity, pleomorphism, and necrosis. In the present study grade I, grade II, and grade III were 32.87%, 52.53%, and 9.58%, respectively. Aggerholm-Pedersen N et al., claim that grade I was more common than grades II and III (46%, 29%, and 25%, respectively) (35). Within conventional chondrosarcomas, grade I had an 89% five year survival rate compared to 57% for grade II and grade III (27).

Five cases (6.09%) in the present study were secondary chondrosarcomas, which is less compared to other studies in which secondary chondrosarcomas made up to 15% of conventional chondrosarcomas (27). Three of the secondary chondrosarcomas had an osteochondromatous precursor component. As shown in various studies, solitary osteochondroma is the most common pre-existing benign lesion (36),(37).

Dedifferentiated chondrosarcoma: Dedifferentiated chondrosarcoma is a distinct subtype of chondrosarcoma showing a cartilaginous tumour with an abrupt transition to a higher-grade non cartilaginous tumour. The age of presentation is a decade older than conventional chondrosarcomas (21). However, in the present study, only one patient was older than sixty years, with the remaining patients under 50 years. The most common sites of involvement are the femur and pelvis (38). Out of the four cases in the current study, one was in the femur and the other three in the pelvis. The most common dedifferentiating malignant component is a high-grade spindle cell sarcoma, mostly an undifferentiated high-grade sarcoma (21). However, in some studies, the most common dedifferentiated component is osteosarcoma (39), which is in concurrence with the present study, which had three out of four cases with an osteosarcoma component. The other case had an undifferentiated spindle cell sarcoma. Radiologically dedifferentiated chondrosarcoma shows a cartilaginous neoplasm with an associated aggressive lytic component invading into the adjacent soft tissues (40). In the present study, radiologically, three cases (75%) were diagnosed as malignant chondrosarcoma. Histologically, all the cases were diagnosed as dedifferentiated chondrosarcoma, with the percent of dedifferentiated areas being 11%, 16%, and 24%, respectively. One case (25%) was diagnosed radiologically as osteosarcoma. This case histologically had a dedifferentiated component of osteosarcoma. The percentage of the dedifferentiated osteosarcoma component was 43%. The percent of dedifferentiated component ranges from 2-98% (41). However, the associated cartilaginous component was low grade. With the above findings and the age of the patient being 69 years, a diagnosis of dedifferentiated chondrosarcoma with an osteosarcoma component was given. There was 100% concordance between radiology and histopathology.

Mesenchymal chondrosarcoma: Mesenchymal chondrosarcoma has an age range of 10-20 years. In the present study, two of the three patients were younger than 10 years. One patient presented at the age of 65 years. The most common site of involvement is the craniofacial region, especially the mandible and maxilla (27). In the current study, two cases of mesenchymal chondrosarcoma were in the skull and the other in the femur. In the current study, all three cases were diagnosed as malignant chondrosarcoma both radiologically and by histology. There was 100% concordance between histopathology and radiology.

Clear cell chondrosarcoma: Clear cell chondrosarcoma has a very good prognosis with >80% 5-year survival, and dedifferentiated chondrosarcoma has a very bad prognosis with 10% five year survival (27). Clear cell chondrosarcoma involves the long bones, which is the same in the present study, with the femur and humerus being the sites involved in the two cases. Radiologically, both cases were diagnosed as chondrosarcoma with cortical expansion and destruction. A histopathological diagnosis of clear cell chondrosarcoma was made since the major component in the tumour had clear or ground glass cytoplasm. Because neither case had any additional conventional chondrosarcoma components, the diagnosis was simple. There was 100% concordance between radiology and histopathology.

There is a low reliability for the grading of cartilaginous lesions in long bones, even among specialised and experienced pathologists and radiologists (10). Slightly improved agreement was observed for lesions that had MRI imaging available compared to plain radiographs and computed tomography scans alone. (10). The positive predictive value and negative predictive value in the present study were 0.93, and 1.00, respectively. Feldman et al., [PPV-1.00 NPV-0.95], Korukian M et al., [PPV 0.95, NPV 0.94] had similar predictive values of the current study (42),(43).

Limitation(s)

Even though histopathology is the gold standard for diagnosing cartilaginous tumours, the limitations of the study were that tests like immunohistochemistry and molecular genetic testing were not performed.

Conclusion

Benign histological diagnoses in the study had no discordance with radiological findings. However, a few malignant histological diagnoses were classified as benign lesions whenever radiologically there was an associated large cyst or absence of cortical destruction or extracortical expansion. For core needle biopsies with suspicious atypical areas, the radiological correlation was the key to clinching the diagnosis. The utility of core needle biopsies in dedifferentiated sarcomas to represent the entire spectrum is questionable, and hence radiological correlation is mandatory. Prospectively, we believe that combined radiological and histomorphological efforts might play a significant role in subtyping the cartilaginous tumours, which may help to refine treatment protocols.

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DOI and Others

DOI: 10.7860/JCDR/2022/57352.17141

Date of Submission: Apr 26, 2022
Date of Peer Review: May 23, 2022
Date of Acceptance: Oct 12, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
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