Low-Grade Chondrosarcoma of Long Bones Treated with Intralesional Curettage Followed by Application of Phenol, Ethanol, and Bone-Grafting
A common treatment of low-grade cartilaginous lesions of bone is intralesional curettage with local adjuvant therapy. Because of the wide variety of different diagnoses and treatments, there is still a lack of knowledge about the effectiveness of the use of phenol as local adjuvant therapy in patients with grade-I central chondrosarcoma of a long bone.
A retrospective study was done to assess the clinical and oncological outcomes after intralesional curettage, application of phenol and ethanol, and bone-grafting in eighty-five patients treated between 1994 and 2005. Inclusion criteria were histologically proven grade-I central chondrosarcoma and location of the lesion in a long bone. The average age at surgery was 47.5 years (range, 15.6 to 72.3 years). The average duration of follow-up was 6.8 years (range, 0.2 to 14.1 years). Patients were evaluated periodically with conventional radiographs and gadolinium-enhanced magnetic resonance imaging (Gd-MRI) scans. When a lesion was suspected on the basis of the MRI, the patient underwent repeat intervention. Depending on the size of the recurrent lesion, biopsy followed by radiofrequency ablation (for lesions of <10 mm) or repeat curettage (for those of ≥10 mm) was performed.
Of the eighty-five patients, eleven underwent repeat surgery because a lesion was suspected on the basis of the Gd-MRI studies during follow-up. Of these eleven, five had a histologically proven local recurrence (a recurrence rate of 5.9% [95% confidence interval, 0.9% to 10.9%]), and all were grade-I chondrosarcomas. General complications consisted of one superficial infection, and two femoral fractures within six weeks after surgery.
This retrospective case series without controls has limitations, but the use of phenol as an adjuvant after intralesional curettage of low-grade chondrosarcoma of a long bone was safe and effective, with a recurrence rate of <6% at a mean of 6.8 years after treatment.
Available from: Domenico Campanacci
- "After intralesional curettage, local adjuvants on the cavity walls can be used to decrease the risk of local recurrence, although no definitive data are available to support this choice. Phenol plus ethanol [13, 14, 16] and cryosurgery [14–16, 20–22, 31] have been used as local adjuvants in curettage of central low-grade CS, and no significant difference in local control was observed between these different techniques. From previous in vitro studies, phenol appeared to be ineffective on cartilaginous tissue and protective properties of chondroid matrix against the cytotoxic action of phenol had been postulated . "
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Diagnosis and treatment of low-grade chondrosarcoma remain controversial. We performed a review of a single-center series with the aims of assessing the oncologic outcome of these patients, verifying if intralesional curettage can be adequate treatment, and defining clinical criteria to support the surgeon and the oncologist in decision-making for surgery and subsequent follow-up.
Materials and methods
A retrospective review of 85 patients was performed (61 females and 24 males, age range 20–76 years). The site of the lesion was the femur in 35 cases, humerus in 33, tibia in 15, and fibula in 2. Sixty-four patients were treated by intralesional curettage. Twenty-one patients with aggressive radiological patterns were treated with wide resection.
Mean follow-up was 67 months (range 24–206 months). Two patients developed local recurrence, both after intralesional curettage. The difference in incidence of recurrence was not statistically significant between the two groups. No distant metastases were observed. Postsurgical complications were significantly higher in the resection group.
Low-grade chondrosarcoma of the appendicular skeleton without aggressive radiological patterns can be treated with intralesional surgery with good oncological outcome and very low rate of postsurgical complications. Wide resection, following surgical principles of malignant bone tumors, should be considered only when aggressive biologic behavior is evident on imaging.
Available from: Pancras C W Hogendoorn
- "For this reason curettage was supplemented by the use of a local adjuvant, such as phenol, liquid nitrogen or bone cement (poly methyl methacrylate, PMMA). Various studies have demonstrated that by using adjuvant, the results of local therapy have been greatly improved [1-4]. "
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ABSTRACT: Phenol is widely used for years as local adjuvant treatment for bone tumours. Despite its use for a long time, no information is available about the local concentration of phenol that is achieved in an individual patient, and the most sufficient and safe procedure to wash out the phenol after using it as local adjuvant.
1. What is the initial local concentration of phenol in the tissue of the cavity wall after the application of phenol? 2. How quickly is phenol 85% diluted by washing the bone cavity with ethanol 96% solution? 3. Is the degree and speed of dilution influenced by the size of the cavity? 4. How many times should the cavity be rinsed to obtain sufficient elimination of phenol?
A basic science study was performed at respectively 16 and 10 patients, treated by intralesional curettage and adjuvant therapy for low-grade central chondrosarcoma of bone. Test 1:in 16 patients ten samples were collected of the mixture of phenol and ethanol from the bone cavity. Test 2:in ten patients, two biopsy samples were taken from the cavity wall in the bone during surgery.
Phenol concentrations had wide variety in different patients, but all decreased by rinsing with ethanol.
Ethanol 96% is effective to wash out local applicated phenol, by rinsing the bone cavity six times. The local concentration of phenol diminishes to an acceptable concentration of 0.2%. This study provides new insights to safely further improve the surgical technique of intralesional treatment of bone tumours.
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ABSTRACT: Osteosarcoma and chondrosarcoma compose most of the primary malignancies of the shoulder. The literature lacks site-specific comparative analyses of these 2 major shoulder sarcomas. The purposes of this study were to describe the different characteristics of the 2 major sarcomas near the glenohumeral joint, examine differences in treatment outcomes, and evaluate the functional outcomes of limb salvage surgery.Thirty-two patients with osteosarcoma or chondrosarcoma who underwent a wide resection including the glenohumeral joint were enrolled in this study. The characteristics of tumor development and treatment, oncologic and functional outcomes, and factors affecting outcomes were compared between groups and with the literature. The results showed shoulder osteosarcoma developing similarly to the literature reports, whereas chondrosarcoma tended to be of a high histologic grade. Nonetheless, the osteosarcoma group had a poorer overall 5-year survival rate (53.0%) than the chondrosarcoma group (85.7%) or those in previous reports. The osteosarcoma group had a tendency toward a worse 5-year metastasis-free survival rate than the chondrosarcoma group (35.4% vs 75.0%, respectively), although the 5-year local recurrence-free survival rate was not significantly different between the 2 groups (75.0% vs 87.5%, respectively). Histologic grade, surgical stage, and chemotherapy affected the oncologic outcomes in univariate analysis, although not a single factor was independent in multivariate analysis. The functional outcomes were not significantly affected by clinical characteristics or surgical methods in patients who had undergone a wide resection including the glenohumeral joint.
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