149
Original Article
Grade 1 Chondrosarcoma of Bone: A
Diagnostic and Treatment Dilemma
R. Lor Randall, MD, and William Gowski, MD, Salt Lake City, Utah
Key Words
Chondrosarcoma, low grade, diagnosis, dilemma, enchondroma,
treatment
Abstract
Cartilaginous lesions of bone are relatively common and cover a
large spectrum from latent enchondroma to aggressive dediffer-
entiated chondrosarcoma. Differentiating among these lesions, par-
ticularly benign enchondroma and low-grade chondrosarcoma, can
be challenging. Differentiating involves assimilation and interpre-
tation of clinical, radiographic, and histologic criteria. Molecular
techniques to assist in distinguishing among the various subtypes are
being developed, but these techniques have not yielded any clini-
cally significant contribution. As a result of an imperfect diagnostic
schema, a consensus on treatment algorithms has been elusive. This
review highlights the specific clinical, radiographic, and histologic
criteria currently used clinically to differentiate between benign en-
chondroma and low-grade chondrosarcoma. We discuss the prom-
ise of emerging molecular technologies. Finally, we provide a review
of the available literature on treatment outcomes, along with a dis-
cussion of our own particular preferences. (JNCCN 2005;3:149–156)
Cartilaginous tumors can be found in any bone in the hu-
man body and cover a spectrum of lesions that range from
completely benign to dangerously aggressive.1 Although the
radiographic characteristics that are typical of cartilaginous
bone lesions can be consistent, specialists are often chal-
lenged when differentiating among the different varieties.
Though difficult, making these distinctions is crucial in
determining appropriate treatment.
From the Department of Orthopedics, Huntsman Cancer Institute &
Primary Children’s Medical Center, University of Utah, Salt Lake City,
Utah.
Submitted November 25, 2004; accepted for publication January 4, 2005.
The authors have no financial interest, arrangement, or affiliation with
the manufacturers of any products discussed in the article or their com-
petitors.
Correspondence: R. Lor Randall, MD, FACS, Sarcoma Services, Huntsman
Cancer Institute, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT
84112-5550. E-mail: r.lor.randall@hsc.utah.edu
© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005
Enchondromas, by definition, are benign in-
tramedullary cartilage tumors that do not metastasize.
They are typically found incidentally. Most commonly,
they are found in the metacarpals and their adjacent pha-
langes, but they may occur in the long bones also.
Radiographically, they appear as small cartilage nests (usu-
ally less than 5 cm in diameter) with multiple intrale-
sional calcifications. Occasionally, very mild endosteal
scalloping will occur; however, true cortical invasion and
the involvement of adjacent soft tissues are rare.1 His-
tologically, islands of normal hyaline cartilage (Figure 1)
are found surrounded by lamellar bone. On rare occa-
sions, enchondromas will become symptomatic or lead
to pathologic fracture and will require surgical treatment.
More concerning are the malignant cartilaginous le-
sions, or chondrosarcomas, the lower grade variants of
which can often be quite difficult to differentiate from be-
nign lesions. These are classified in several ways, includ-
ing histologic grade (I–III plus dedifferentiated); location
within the bone and body (peripheral vs. central, axial
skeleton vs. appendicular skeleton); whether the lesion
is primary or secondary (arising de novo vs. secondary to
a premalignant lesion such as an osteochondroma); or
whether it fits into a specific histologic subtype (clear
cell, mesenchymal, base of skull, soft parts).
To date, the single most important factor in evaluat-
ing the malignant potential of a chondrosarcoma is its
histologic grade.2–5 These tumors are divided into three his-
tologic grades based on microscopic appearance. Grade
I (“low-grade”) tumors most resemble normal hyaline car-
tilage, but may surround areas of lamellar bone (a feature
not seen in benign lesions) or show mild cellular atypia
including binucleate forms. Grade III (“high-grade”) tu-
mors have significant areas of marked pleomorphism,
large cells with hyperchromatic nuclei, occasional giant
cells, and abundant necrosis. Grade II (“intermediate-
grade”) tumors lie somewhere in the middle and may have
150 Original Article
Randall and Gowski
Figure 1 Low power photomicrograph of an enchondroma demon-
strating extensive extracellular chondroid matrix with sparse benign
chondrocytes.
some aspects of each of those.6 The fourth histologic
subtype, known as dedifferentiated, is less common. It
is typically thought of as arising from one of the other
three histologic subtypes or from a benign precursor.
Dedifferentiated chondrosarcomas have malignant
spindle cells (with no identifiable cartilage origin) ad-
jacent to areas of neoplastic chondrocytes.
Chondrosarcomas are then staged using either the
method of Enneking et al.1,7 or the AJCC method.8,9
The majority of chondrosarcomas are low-grade le-
sions. They are typically seen in adults between the
third and sixth decades of life and are more common
in men than in women. The most common locations
are (in order of decreasing frequency) the pelvis, femur,
ribs, humerus, scapula, and tibia. Chondrosarcomas
are found most commonly in the metaphysis, but
diaphyseal tumors can occur as well. In general, the
prognosis for low-grade lesions is very good, with a
very low rate of local recurrence and pulmonary
metastasis if adequate resection is performed.
Metastases as late as 9.8 years, although rare, have
been reported.2
Distinguishing between low-grade chondrosar-
coma and benign enchondroma is perhaps one of the
most challenging endeavors in the field of muscu-
loskeletal oncology. Even with diligent clinical prac-
tice and advanced radiographic and histologic
technologies, the diagnosis may still prove elusive. It
is the purpose of this review is to highlight some of the
difficulties in making this distinction, with a particu-
lar focus on the significant clinical, radiographic, and
histologic features that can assist. A review of man-
© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005
agement options and the salient points of the deci-
sion tree will be presented.
History and Physical
Most patients with a chondrosarcoma will have
pain.10–13 Marco et al.13 reported on 58 cases of grade
I chondrosarcoma and found that 60% had night
pain or rest pain, 21% had vague regional pain, and
only 19% had lesions that were encountered inci-
dentally in the absence of pain. This is in contrast to
individuals with benign cartilaginous lesions (who
rarely have pain that can be attributed to the le-
sion14) and patients with grade II or III chondrosar-
coma (who will have pain in up to 80% of cases15).
Patients will present with pathologic fracture in a
relatively small number of cases (3%–8%) of low-
grade chondrosarcoma.10,13,15
Subtle clinical findings to be cognizant of include
antalgic gait, decreased range of motion at adjacent
joints, and mild atrophy of the affected extremity.
Rarely, a mild increase in the Westergren erythrocyte
sedimentation rate will be seen, but the remainder of
laboratory findings will be normal.
When the lesion arises in the proximal humeral
metaphysis, a very common site, the clinician must
very carefully differentiate between signs and symp-
toms arising from the lesion and those arising from
rotator cuff arthropathy. Both can potentially cause
pain at night. The patient’s presenting interview and
examination must be meticulously documented, be-
cause symptoms may change with invasive procedures
such as biopsy and may obscure both the patient and
physician’s understanding of the disease.
Radiologic Findings
Differentiating between the radiographic findings of
benign cartilaginous lesions and grade I chondrosar-
coma can be challenging. Both can show the classic
stippled calcified appearance of cartilaginous bony
lesions (Figure 2). Endosteal scalloping can be a hint
toward the increasing likelihood that the lesion has
malignant potential, but it is not necessarily confir-
matory. Murphey et al. published on 95 cases of chon-
drosarcoma, in which 75% had endosteal scalloping
of more than two thirds of cortical thickness versus
92 cases of enchondroma in which 9% had similar
findings.11
 Original Article 151

Grade 1 Chondrosarcoma of Bone

ing polyostotic disease. Using the method of Murphey

et al.,11 lesions seen on bone scan can be compared
with internal controls. Those lesions showing a higher
degree of uptake are more likely to be of higher his-
tologic grade. However, most enchondromas exhibit
some amount of uptake, and some will uptake sufficient
label to erroneously appear as malignancy. Great cau-
tion therefore should be used in drawing conclusions
from bone scan results, but these results can add to
the overall clinical picture and better inform the de-
cision making process.
Axial computed tomography (CT) can assist in de-
termining the extent of bony destruction and in bet-
ter delineating bony architecture. CT will also help in
better understanding intralesional calcifications. As
with plain radiographs, disappearance or change in
the nature of calcifications with repeat scanning can
suggest malignancy.
Magnetic resonance imaging (MRI) can be help-
ful in differentiating between benign and malignant
lesions in several ways. First, the degree of medullary
fill that is exhibited can be helpful (Figure 3). Greater

Figure 2 AP radiograph of the left proximal femur reveals a calcified

lesion with circumferential bony rarefaction. This could represent an
enchondroma or a low grade chondrosarcoma.

Telling signs of malignancy include a variety of

adaptive and aggressive radiographic features. Adaptive
changes often cited include cortical expansion or
thickening, whereas aggressive features include corti-
cal disruption and soft tissue expansion.11,16 Features
typical of grade I lesions include dense calcifications
appearing in rings or spicules, uniformly distributed
calcifications, and eccentric lobular growth of a soft
tissue mass. Findings suggestive of higher grade in-
clude faint amorphous calcifications, large areas lack-
ing calcifications, and a concentrically growing soft
tissue mass.
Perhaps the most reliable radiographic finding
when differentiating between benign and malignant
lesions is the recognition of radiographic change
with time. In particular, increases in endosteal scal-
loping and cortical destruction or decreases in in-
tralesional calcifications can be telling of malignant
potential.
A technetium-99m diphosphonate bone scan of
Figure 3 Sagittal T2 weighted MRI of the distal femur show extensive
the entire body can be helpful in differentiating be- intramedullary involvement, anterior cortical attenuation and ex-
tween benign and malignant lesions and in identify- tramedullary extension highly suggestive of chondrosarcoma.

© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005
152 Original Article

Randall and Gowski

than 90% medullary involvement can be suggestive of

chondrosarcoma, whereas in the absence of 90%
medullary involvement, non-contiguous foci of carti-
lage can be suggestive of enchondroma.17 Secondly,
the presence of septal enhancements on MRI can
elucidate the presence of intralesional fibrotic bands, a
histologic finding often associated with grade I and II
chondrosarcomas. Finally, the timing and progression
of gadolinium enhancement patterns can help steer a
clinician toward or away from a diagnosis of malig-
nancy.18 Early enhancement (within 10 seconds of
arterial enhancement) was seen in chondrosarcoma
but not in enchondroma.
Furthermore, many surgeons consider MRI crit-
ical for surgical planning. Its contributions can in- Figure 4 High power photomicrograph shows malignant
clude identifying marrow replacement, showing chondrocytes of intermediate grade chondrosarcoma.
proximity to important neurovascular or paraosseous
structures, and delineating the non-mineralized ex-
changes and highly degenerative areas may make iden-
tent of the tumor.
tification impossible.1
Fluorine-18 fluorodeoxyglucose positron emis-
Sanerkin21 showed that the diagnosis and grading
sion tomography (FDG PET) may have a role in tu-
of chondrosarcoma of bone is best established by a
mor grading in chondrosarcoma.19,20 The standard
complementary study of its cytology and of its tissue
uptake value (SUV) may prove to be a useful param-
structure and relationship to the host bone. Mirra et
eter for tumor grading and prediction of outcome in
al.12 refined the methods of Sanerkin. Collectively,
chondrosarcoma patients, allowing identification of
their work introduces the notion that islands of hya-
patients at high risk for local relapse or metastatic
line cartilage surrounded by plates of lamellar bone
disease.
and bone marrow, called an “enchondroma encase-
ment pattern,” can be distinguished from the chon-
drosarcomatous pattern of hyaline or myxoid cartilage
Biopsy permeating lamellar bone, replacing marrow fat, and
Macroscopically, chondrosarcomas tend to reveal a infiltrating the Haversian system. This latter appear-
clear distinction between normal host tissue and the ance has been referred to as a “chondrosarcomatous
malignancy, though with increasing grade, more ag- permeative pattern.”
gressive margins may be fleshier and have infiltrating Ranty et al.22 showed that low-grade chondrosar-
satellite components. Chondrosarcomas will exhibit comas tend to exhibit regions of hyalin and/or myx-
heterogeneous gross properties, including lobulated oid cartilage invading spaces around the tumor, host
areas of chalky calcific admixture, regions of firm lamellar bone trabeculae surrounded by cartilage on
translucent unmineralized gray cartilage, and rela- all sides, and tumoral resorption of bony trabeculae.
tively low vascularity. They tend to have areas of necro- Intracytopasmic hyalin globules were more likely to be
sis and degenerative material as well.1 seen in malignant lesions, whereas tenascin matrix
Lower grade chondrosarcomas will exhibit in- immunoreactivity was more likely to be found in be-
creasing amounts of relatively acellular heavily calci- nign neoplasms.
fied areas as well as regions of increased activity Fine needle biopsy may be attempted in easily ac-
exhibiting immature cartilage cells with multiple nu- cessible lesions with soft tissue components, whereas
clei. By contrast, higher-grade lesions tend to harbor core needle techniques may be required to access in-
regions of densely packed hyperchromatic malignant tramedullary lesions requiring bony penetration.14
looking cells (Figure 4). Sometimes there may be dif- Given the great heterogeneity in both higher and
ficulty in determining that these cells are truly of car- lower grade lesions, sampling error inherent in limited
tilaginous origin. In some regions, myxomatous biopsy techniques may make differentiating between

© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005

Grade 1 Chondrosarcoma of Bone
benign and malignant lesions improbable. Therefore,
biopsy of suspected low-grade chondrosarcoma re-
mains controversial. Lesions that are clinically and
radiographically of a higher grade can often, however,
be confirmed using these less invasive techniques.3
Because both benign and malignant cartilage le-
sions share certain clinical and histologic character-
istics, pathologists often consider the patient’s history
when interpreting specimens. Definitive treatment
should be rendered based on the areas of highest his-
tologic concern. Resection methods should adhere to
sound surgical oncologic principles. Surrounding tis-
sues should be protected from exposure to tumor ma-
terial, and meticulous hemostasis should be gained to
prevent local contamination with remaining micro-
scopic disease. Postoperative evacuation with intra-
operatively placed drains is recommended when feasible.
Lesions appearing more aggressive clinically and ra-
diographically can be widely resected without biopsy
to avoid contamination of healthy tissue, but this
choice remains a matter of surgeon preference.
Molecular Biology
With the advent of improved molecular techniques,
several genotypic and phenotypic markers have been
tested to see if they assist in determining tumor grade
and therefore better predict patient prognosis.
Unfortunately, most are not independent of histologic
grade. Additional independent markers, therefore,
would be highly valuable for selecting treatment al-
gorithms.
Bridge23 cytogenetically analyzed 120 non-neo-
plastic, benign, and malignant cartilaginous lesions
from 103 patients using fluorescent in situ hybridiza-
tion (FISH) techniques. Trisomy of chromosome 7
was seen only in malignant tumors. The correlation of
chromosome aberrations and increasing histologic
grade was seen, and complex aberrations were noted
nearly exclusively in high-grade tumors.
Aigner24 evaluated biologic markers for various
chondrocytic phenotypes by histochemical and im-
munohistochemical techniques in a large series of en-
chondromas and chondrosarcomas. Collagen types II
and X and the proteoglycan aggrecan suggested a low-
grade neoplastic phenotype and better prognosis. The
presence of collagen type I, together with cell spin-
dling, indicated a transition to a higher-grade pheno-
type. The data indicated, however, that these markers
© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005
Original Article 153
are to a large extent the biologic basis of the conven-
tional grading, rather than representing independent
prognostic indicators.
Soderstrom et al.25 analyzed 12 chondrosarcomas
for expression of various connective tissue compo-
nents and SOX9, an important regulator of normal
chondrocyte differentiation. As well, they screened
for additional changes in gene expression using cDNA
array analysis. Grade 3 chondrosarcomas exhibited
the highest levels of SOX9 mRNA and pro-alpha
1(IIA) collagen. Results of the cDNA array analyses
confirmed the heterogeneous nature of chondrosar-
coma, because no individual transcript was up- or
downregulated in all tumors analyzed. Interestingly,
upregulation of decorin mRNA was noted in 7 of the
10 tumors analyzed, suggesting that decorin may play
a role in pathogenesis.
Sjogren et al.26 used a combination of chromo-
some banding, spectral karyotyping, and FISH to char-
acterize the chromosomal pattern in 18 benign and
malignant cartilage tumors. The karyotypic findings
in the chondrosarcomas were more complex than those
in the benign tumors, but they were unable to iden-
tify any consistent abnormalities.
Immunohistochemical detection of telomerase
has indicated increased expression during malignant
transformation in Ewing family tumors.27 A coopera-
tive trial that opened December 1, 2004 (Combined
SWOG S0344/ACOSOG Z9041: A Phase II Surgical
Trial of Intralesional Resection of Low-Grade In-
tracompartmental Chondrosarcoma of Bone) per-
forms a similar analysis of chondrosarcoma specimens
to determine the presence or absence of a similar trans-
formation associated with recurrence and metastasis.
The same study will analyze cDNA microarrays of
those same specimens to better understand chon-
drosarcoma biology as well as look at telomerase ex-
pression.
Treatment
Suggested treatment of an enchondroma involves
clinical reassessment and sequential radiographs 3,
6, and then 12 months apart, assuming no progressive
changes either clinically or radiographically at any
point in time. Symptomatic lesions can be treated
with intralesional curettage and bone grafting.
Pathologic fracture can be treated with either con-
current or staged treatment of both the fracture and
154 Original Article
Randall and Gowski
the lesion if there is concern over the risk of recur-
rent pathologic fracture.
Treatment of chondrosarcomas depends on deter-
mining both the clinical and histologic characteristics
of the lesion, and, despite much attention in the lit-
erature, remains somewhat controversial.
Chemotherapy may offer some benefit in a very
small subset of patients with high-grade chondrosar-
coma3 (healthy patients under the age of 60 with a
dedifferentiated subtype). However, no conclusive
data exist to suggest that this should be standard of
care.28 In metastatic disease, chemotherapy may assist
in slowing the growth of lesions, but a cure is not
likely.3
High-dose irradiation may be of some benefit in
cases in which wide surgical margins are not possible.
Spinal lesions in particular, though very rare, can be
quite challenging to resect. Marginal resection can be
augmented with doses of radiation greater the 60 Gy
and may be helpful in treating microscopic disease.29,30
To date, studies have not shown adjuvant treat-
ments such as chemotherapy or radiation to have any
significant impact on patient morbidity or mortality
in the majority of isolated primary lesions.2–4 Because
these adjunctive modalities are of benefit in only a
small minority of cases, the burden of a cure falls on
the surgeon.
Historically, wide resection was considered the
methods of choice for all chondrosarcomas. Un-
fortunately, these tumors are frequently found in re-
gions such as the pelvis or proximal long bones, where
aggressive surgical management may endanger adja-
cent vital organs and structures or compromise the limb
significantly.1,4 As a result, less aggressive approaches
such as marginal excision and intralesional excision
with margin expansion using adjuncts such as phenol
or cryotherapy have received increasing attention.
In 1977, Marcove et al.4 sought to determine
whether cryosurgery techniques could be successfully
implemented in cases of low and moderate grade chon-
drosarcomas in surgically inaccessible areas. The study
followed up 18 patients for an average period of 5 years,
and showed no recurrence or metastasis in 17 indi-
viduals. The last patient had a presumed but not yet
confirmed metastasis. More recent studies, however,
have called into question whether a 5-year follow-up
is adequate to draw conclusions from these data.2
In 1999, Lee et al.2 compiled data on 86 grade I and
141 combined grade II and III chondrosarcomas treated
© Journal of the National Comprehensive Cancer Network | Volume 3 Number 2 | March 2005
over a 25-year period at a single institution. All pa-
tients received wide, marginal, or intralesional resec-
tion without local margin expansion techniques. They
showed remarkably improved survivorship in patients
who had a wide resection, versus those who had either
a marginal or intralesional resection. All 19 patients
with a marginal resection of a high-grade lesion died
of their disease. They did not have large enough num-
bers, however, to comment on the survivorship or rates
of metastasis in those individuals with grade I disease
treated in the same manner, nor did they describe the
manner in which these procedures were performed.
Further confounding interpretation of the results was
the inclusion of histologic grade II tumors within the
“high grade” classification, a distinction that has more
recently been called into question.5
Intralesional curettage can be effective.31 Bauer
et al.31 studied 40 patients with enchondroma and 40
with low-grade chondrosarcoma of the extremities for
an average of 7 years. Twenty-three patients from each
group were treated by intralesional curettage. The cal-
culated 10-year local recurrence rate was 0.04 in the
enchondroma group and 0.09 in the chondrosarcoma
group, and metastases were non-existent.
Schreuder et al.32 managed 3 chondroblastomas,
14 enchondromas, and 9 grade I chondrosarcomas
with curettage, cryosurgery, and bone grafting. No re-
currences were seen, although, regrettably, short fol-
low-up (average 26 months) and the small number of
included cases of malignancy hamper the interpreta-
tion of this study. However, the results lend a modicum
of credibility to intralesional curettage with margin
expansion techniques for low-grade disease.
Ozaki et al.33 treated 26 chondrosarcoma (14
grade I, 8 grade II, 4 grade III) with intralesional ex-
cision, and followed them for a mean of over 12
years. The 20-year overall survival rate for grade I dis-
ease was 68% despite 93% recurrence over that same
time period. The overall survival rates for the pa-
tients with tumors of histologic grade I was 85%
compared with 44% for those of grade II or III. This
study highlighted the fact that local relapse does not
always result in metastases and death. This group,
however, did not employ margin expansion tech-
niques and showed clear bias toward marginal or
wide excision for all cases in which either was tech-
nically feasible.
One ongoing prospective multi-institutional trial
(SWOG S0344/ACOSOG Z9041) seeks to determine
 Original Article 155

Grade 1 Chondrosarcoma of Bone

Table 1 Schema to Differentiate and Outline Treatment for Benign and Malignant Cartilage Lesions
Lesion Clinical Radiology Histopathology Treatment
Enchondroma Mostly 9% will have endosteal Enchondroma Surveillance,
asymptomatic, scalloping encasement pattern intralesional excision
incidentally if symptomatic
recognized
Grade I 60% are painful Up to 75% with endosteal Chondrosarcomatous Controversial:
Chondrosarcoma (Marco 9,10,12,14) scalloping, calcifications permeative pattern Intralesional excision
in rings or spicules, uniform with margin expansion
calcifications, eccentric vs. wide resection
lobular growth
Grade II Up to 80% painful Up to 75% with endosteal Mixture of grade I Marginal vs. wide
Chondrosarcoma (Marco 6) scalloping, potentially and grade III resection
more aggressive and characteristics
adaptive changes
Grade III Up to 80% painful Up to 75% with endosteal Densely packed Wide resection.
Chondrosarcoma (Marco 6) scalloping, faint amorphous hyperchromatic Possible adjunct XRT
calcifications, malignant looking cells, and CTX with
large areas without cells of questionable selected cases
calcifications, concentrically cartilaginous origin,
growing soft tissue mass myxomatous changes,
highly degenerative areas

whether low-grade lesions can be treated exclusively
with intralesional resection and local adjuvant ther-
apies, thereby improving patient functionality and de-
creasing overall morbidity without compromising
overall survivorship.
Chondrosarcomas arising in the pelvis deserve
special mention here. Because pelvic tumors can be
particularly difficult to access and even harder to en-
sure adequate surgical margins for, they tend to be as-
sociated with significantly increased rates of local
recurrence compared with lesions of similar grade aris-
ing in the axial skeleton.10 Most authors therefore rec-
ommend wide resection of all cartilaginous lesions of
the pelvis.10,14,33,34
Although specific centers may have their own in-
dividualized criteria and algorithms for the surgical
decision making process when treating cartilaginous
lesions, strict evidence-based criteria are elusive. In
general, there is consensus that benign lesions should
be conservatively addressed, while aggressive malig-
nancies should be respected and completely resected.
Optimal treatment for low-grade chondrosarcoma re-
mains, however, a surgical dilemma.
Summary
Cartilaginous lesions of the human skeleton exist on
a continuum spanning from the completely benign
embryonic inclusion to the dangerously aggressive
neoplastic process. To determine the appropriate
treatment for each unique lesion, the practitioner must
take into account the clinical, radiographic, histo-
logic, and soon the microbiologic personality of the tu-
mor (Table 1). Even then, the lack of a consensus can
make choosing optimum surgical management a chal-
lenge. The musculoskeletal specialist must develop a
strong understanding of each lesion while maintain-
ing a firm grasp of the evolving treatment options. As
more advanced molecular tools for predicting tumor
behavior are developed and more conclusive evidence
regarding treatment outcomes revealed, it is likely that
more definitive treatment recommendations will be
agreed upon.
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