CHONDROMYXOID FIBROMA (FIBROMYXOID CHONDROMA) OF

CHONDROMYXOID
FIBROMA
(FIBROMYXOID
A Clinico-pathological
FRITZ
From
the
and
HECTOR
Registrz’
of Boize
SCHAJOWICZ
Lati,z-Americaiz
Histopathologic
Chondromyxoid
1948
it was
as myxoma
lesion,
cases
1954;
Zaeske
and
seem
or
are
1967)
National
are
exceptional
Cancer
cases),
probably
Ref#{232}reizce Ceiztre
Diseases
tumour
variant
of cartilage
entity;
tumour,
or mistaken
bones
fibromas,
of the
and
skeleton.
(Bauer
and
1964; Perou,
myxomas
have
Because
of the
of bone
no counterpart
relative
rarity
The
of
only a small
number
of publications
exist dealing
with more
than
reported
twenty
cases, The Netherlands
Committee
on Bone Tumours
Bone Tumour
Committee
of the Japanese
Orthopaedic
Association
The major
textbooks
cases),
Goidanich
(1957)
of Jaffe (1958)
(twenty-five
(fifteen
cases)
and Aegerter
(1968)
(twenty-one
cases) do not include
precise
statistical
details.
well documented
cases is only a little more than 100.
frequency
ofrecurrences
(Ralph
1962) and the mention
ofa few cases with
(chondrosarcomatous)
for
The
Harell
Kolis,
myxosarcoma.
for
apparently
classified
Kirkpatrick
of reported
In
it was
or myxofibromas
Bullough
and Jaffe
origin,
derivation.
formerly
or
chondromyxoid
for
( W. H.O.)
ofgiant-cell
as myxomas
Kambolis,
ofodontogenic
in other
Internatio,zal
Allied
benign
BONE
ARGENTINA
chondromyxosarcoma
mostly
and
AIRES,
as a distinctive
literature
Marcove,
Center
(1966)
forty-one.
(1965)
(thirty-seven
Lichtenstein
and
1956;
the
azd
common
or a myxomatous
to thejaws
chondromyxoid
fibroma
ten cases.
Dahlin
(1967)
(1966)
eleven,
and The
least
aizd
Tumours
OF
Cases
BUENOS
Pathology
of Boize
Lichtenstein
in the
Stringa
of Thirty-two
GALLARDO,
chondrosarcoma,
recently
Borja
at least
1924)
and
to be peculiar
and
especially
reported
Scaglietti
is the
by Jaffe
(Bloodgood
a malignant
few
Diagizosis
fibroma
described
Study
CHONDROMA)
transformation
(Iwata
and
Coley
1958,
Jaffe
1958,
The
total
malignant
Gilmer
1963,
and Kirkpatrick
1968) induced
us to carry
out a comparative
clinico-pathological
study ofthe
cases filed in our laboratory
during
the last twenty-nine
years, in order to investigate
the possible
causes
of this evolution
and the prognostic
significance
of some
histological
features,
especially
the presence
of the rather
frequent
areas showing
marked
nuclear
atypism.
Aegerter
Thirty-two
in which
cases,
including
twenty-one
sixteen
patients
specimens
could
MATERIAL
After
years
(up
sarcoma
myxoid
a preliminary
to December
review
1969)
or chondromyxosarcoma,
fibroma,
thirty-two
separated
as typical
chondromyxoid
different
orthopaedic
departments
Brazil.
AND
myxomatous
with sufficient
cases
were
especially
for
entire,
at least
One
fibroma
of our
of
our
cases,
for
had
198
examination.
not
been
being
later confirmed
curettage
or resection.
In two
performed
available
cases
amputation
laboratory.
had
The
this
during
the last
myxosarcoma,
variant
of giant-cell
clinico-radiological
study,
of bone.
country
Twenty-three
and
classified
nine
as
been
carried
available
cases
from
were
other
chondrodetails
submitted
Latin-American
chondromyxosarcoma
a homogenous
was
out
specimen
THE
twenty-nine
chondro-
tumour
and
and pathological
JOURNAL
of
bone
obtained
by operation,
and in the remaining
In sixteen
cases the entire
excision
in our
for
year.
laboratory
of myxoma,
calcaneus
and treated
by total excision
and replacement
with
been previously
reported
by Ottolenghi
and Petracchi
(1953).
In seven cases the material
for histopathological
diagnosis
the diagnosis
open biopsy,
were
one
TECHNIQUE
of all cases filed in our
under
the classification
from
countries,
resected
be followed
graft,
by punch
twenty-five
specimen
was
but
the
had
OF
biopsy,
cases
by
available
macroscopic
been
BONE
AND
the
has
study
photographed
JOINT
SURGERY
CHONDROMYXOID
FIBROMA
(FIBR0MYx0ID
CHONDROMA)
199
OF BONE
and radiographs
had been taken of most of the specimen
or of thin slabs.
For routine
histology
formalin-fixed
material
was stained
with haematoxylin
and eosin, completed
by frozen
sections
and Rio Hortega’s
silver
stain for reticular
fibres.
Some
histochemical
studies
were carried
MALES
FEMALES
LU
CD
5-
z
Ui
0
Ui
a-
10
20
30
AGE
FIG.
Age
and
sex
distribution.
(YEARS)
1
Thirty-two
myxoid
TABLE
SITUATION
Upper
chondro-
I
of
Number
Ulna
of
OF TUMOUR
Situation
Upper
cases
fibroma.
end
Percentage
2
62
2
62
9
281
Total
Percentage
4
124
limb
Phalanx
Upper
end
Lower
end
1
31
Upper
end
3
93
Lower
end
3
9.3
Calcaneus
3
9.3
Metatarsus
2
62
Phalanx
1
31
Tibia
Fibula
Lower
limb
Shoulder girdle
Thorax
Cervical spine
Pelvic
girdle
53 B,
NO.
2,
MAY
1
31
Ribs
2
62
1
31
2
62
Third vertebra
Innominate
1971
684
Scapula
Apophysis
bone
out on material
fixed in 10 per cent neutral
formalin
Centigrade),
as well as in Bouin’s
fluid.
Glycogen
periodic
acid-Schiff
stain,
with
and
without
previous
VOL.
22
or 80 per cent
and glycoproteins
digestion
by
alcohol
(both
at 5 degrees
were investigated
with
ptyaline
or
taka-diastase.
F. SCHAJOWICZ
200
AND
H.
GALLARDO
Lipids
were investigated
with Sudan
IV and Sudan
black and metachromasia
with Alcian
blue
or toluidine
blue, with and without
previous
action
of testicular
hyaluronidase.
In five cases
alkaline
and acid
phosphatase
was investigated
following
Gomori’s
technique
on frozen
sections.
CLINICAL
The
incidence
tumour-like
in
lesions
our
filed
series
in our
was
somewhat
laboratory
blastomas
observed
by us in the
As has been stated
by other
were
male
and fifteen
female.
CHARACTERISTICS
and
lower
was
same time period.
authors
there was
Ages
(of twenty-nine
than
1 per
somewhat
cent
less
of
than
all
tumoral
one-half
and
of chondro-
no
sex predominance
: seventeen
patients
patients)
and localisation
(thirty-two
patients)
are shown
in Figure
1 and Table
I. There
was a predilection
for the second
decade
of
life
twenty-one
twenty-five
six years
(thirteen
were
years.
old
patients),
and
aged
between
five
Our youngest
patient
and
the
oldest
patient
and
was
fifty-
eight
years
old.
similar
distribution
This
histograph
has
to that of chondro-
blastoma
number
but
the
of cases
a
in the
second
decade
is evidently
lower
(38 as
opposed
to 63 per cent) and after tewntyfive years
frankly
higher
(26 against
1 l5
per
cent).
The
metaphysial
of
the
from
FIG.
I 5-Boy
aged
end,
2
10.
Antero-posterior
extensive
transradiant
and
lateral radio-
showing
an
lesion located
eccentrically
in the upper metaphysis
of tibia-the
most
frequent
location.
Note the scalloped
margin
of sclerosed
bone on the medullary
side.
A coarse trabeculation
may
be observed.
The
and
cortex
interrupted
is expanded,
on
its
very
postero-Iateral
much
thinned
surface.
mass
and
movement,
in only
bone
local swelling,
increasing
tenderness
but
one
tumours,
there
case.
trauma
to
There
does
no major
was
not
involvement
a history
seem
variable
line, often
distances
in close
it.
The preferred
site was
cases),
generally
at its upper
by the fibula
calcaneus
(three
(six cases)
cases).
and
Surprisingly
Usually
there
was
pain
and
by the presence
of a palpable
tumour
was limping
and slight
limitation
of
of a joint.
of injury
in one
to be related
to the
RADIOGRAPHIC
at
enough
we had no case involving
the femur,
a location
found
by other workers
(Jaffe
1958,
Lichtenstein
1965,
Dahlin
1967).
The
patients’
complaints
were
not
sometimes
accompanied
palpation.
Sometimes
there
was
with
(five
followed
the
specific.
slowly
common
location
was the
region
of a large tubular
bone
lower
limb
the epiphysial
contact
the tibia
Case
graphs
most
A pathological
out
of seven
pathological
fracture
cases
but,
occurred
as in other
process.
FEATURES
The radiographic
aspect
was rather
characteristic
in the cases involving
large limb bones
where
the lesion
appeared
as a transradiant
area of variable
size, located
eccentrically
in the
metaphysis
(Figs. 2, 4, 5, 37, 38, 41 and 42). Only rarely and in advanced
lesions
did the tumour
cross
the epiphysial
line (Figs.
4 and 5).
When
it involved
a small
tubular
bone,
such
as a
rib, fibula
(Fig.
3), metatarsal
or phalanx
(Fig. 6), it generally
occupied
the entire
width
of
the affected
bone
and produced
a fusiform
expansion
and thinning
of both
cortices.
The
internal
border
of the tumour
tended
to be scalloped
and well defined
by a narrow
rim of
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
CHONDROMYXOID
FIBROMA
(FIBROMYXOID
FIG.
CHONDROMA)
13-Woman
aged 32.
Antero-posterior
and lateral
showing a transradiant well-limited
lesion in the upper third
shaft.
FIG.
10-Boy
the upper
partially
destroyed.
Note the triangular
The
resected
colour,
VOL.
53
B,
NO.
2,
MAY
4
aged
7.
metaphysis
specimen
and the
1971
FIG.
Figure
of
4-Radiograph
the fibula.
showing
The
lesion
the eccentrically
periosteal
new
radiographs
of the fibular
5
a large
has
Well demarcated
sclerotic
border
periosteal
bone reaction
at the lower
showing
triangular
BONE
3
Case
Case
in
OF
eccentric
osteolytic
lesion
expanded
the cortex
which is
towards
the medullary
cavity.
border of the lesion. Figure 5-
located
tumour
bone
formation
mass,
at
of
greyish-white
its lower
end (a).
201
F. SCHAJOWICZ
202
bone sclerosis
toward
delimited
by a thinned
formed
periosteal
to
radiological
the
the
marrow
cavity
cortex,
replaced
bone,
often
picture
partially
of
an
AND
H.
GALLARDO
(Figs.
2, 12, 13 and 14). On its outer
in great
part by a thin and blown-up
absent
aneurysmal
(Figs.
4, 5, 8, 37,
bone
conspicuous
cyst.
In
spotty
radiograph
; more
tumour
were
38, 41 and
only one
calcification
often
bone
of
shows
caused
border
the
gross
and
Gross
tunity
Antero-posterior and
lateral
radiographs
showing
a centrally
osteolytic
lesion,
slightly
trabeculated,
first phalanx
of the great
toe.
placed
similar
areas
on
of
the
traversing
the
appearance
40).
However,
microsc3pic
specimen
observed
solitary
(uni-
FINDINGS
the
obtained
numerous
by curettage
of examining
specimen
excision
in
cysts.
pathology-Besides
fragments
22.
very
were
visible
septa
PATHOLOGICAL
aged
it was
of new
that this is usually
only a pseudotrabeculation
by ridges
and corrugations
of the sclerotic
at the inner
surface,
very
similar
to the
pseudotrabeculation
cameral)
bone
25-Man
42),
case
and
producing
a trabecular
seen (Figs.
2, 3, 7, 8, 39 and
a study
Case
surface
shell
irregular
we had
a number
the oppor-
of entire
and large fragments
resulting
of some
tumours
of appreciable
in the
resection
from
wide
size one
.
them
located
in the lnnomlnate
than
10 centimetres.
The
tumour
bone,
was
of
of more
generally
well limited
on its outer
surface
and covered
by a thin shell of new-formed
periosteal
bone
or directly
by the periosteum.
Its eccentric
location
in the metaphysial
region
was evident
in
the large limb bones (Figs. 4 and 5), but sometimes
occupied
the entire width,
and occasionally
the
diaphysis
a fusiform
(Fig.
swelling
3) of a smaller
(Fig. 6).
tubular
bone,
FIG.
Case
The
somewhat
31-Man
cut surface
translucent,
aged
49. Osteolytic,
such
as fibula,
rib
or metatarsus,
producing
7
somewhat
trabeculated
of the ulna.
showed
a solid
tumour
mass
resembling
cartilage,
but only
lesion
of greyish-white
in a few cases
in the upper
end
or bluish-grey
of frankly
mucoid
colour,
aspect
(Fig. 9) with formation
of small cavities
of different
size produced
by cystic
softening
of the
mucoid
tissue
(Figs.
11 to 14).
The consistency
was usually
firm, although
very soft areas
could
be observed,
as well as haemorrhages
and foci of blood
pigment.
Conspicuous
areas
of
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
CHONI)ROMYXOID
calcification
in a rib.
The
of yellowish-white
demarcation
FIBROMA
colour
were
of the tumour
(FIBROMYXOID
found
mass
in only
towards
FIG.
8
FIG.
9
CHONDROMA)
OF
BONE
one case of appreciable
size,
the spongiosa
was generally
203
located
sharp,
Case 18-Girl
aged 13. Figure 8-Unusually
large trabeculated lesion in the ilium with penetration
into the soft parts,
surrounded
in part by a thin shell of new bone.
Figure
9Part of the resected
specimen
showing
typical myxoid
aspect
of the tumour
with large haemorrhagic
areas.
lobulated
and surrounded
small tumour
lobules
were
VOL.
53 B,
NO.
2,
MAY
1971
by a thin,
often
scalloped
border
found
in the spongiosa,
separated
of sclerotic
bones.
Sometimes
from the principal
tumour
mass.
204
We did
a true
F.
not
observe
trabeculation,
Microscopic
in our
resection
nor
penetration
SCHAJOWICZ
specimen
of the
pathology-Histologically
areas
of spindle-shaped
myxoid
or sometimes
AND
H.
bony
GALLARDO
septa
tumour
traversing
into
the tumour
the
the tumour
epiphysis.
of lobulated
is composed
or stellate
cells without
distinct
cytoplasmic
chondroid
intercellular
material
separated
by
tissue,
to cause
or pseudolobulated
border
and abundant
bands
of more
cellular
-U
FIG.
10
Case
19-Girl
aged
6.
distension
of the spinous
FIG.
Figure
process
10-Radiograph
of the third
showing
vertebra,
cervical
11
ballooned-out
suggesting
aneurysmal
bone cyst.
Figure
11-The
cut surface
of the specimen.
tumour is mainly solid, though there are some irregular
cystic
haemorrhagic
an
The
areas.
i-i.
Case 2-Boy
12
FIG.
13
14
FIG.
9. Figure I 2-Antero-posterior
and lateral radiographs
showing a transradiant
lesion located
eccentrically
in the lower metaphysis
of the fibula.
The scalloped
sclerotic
inner border is clearly visible.
Figure
13-Macroscopic
aspect of the specimen
showing
several cystic cavities and some small tumour
lobules separated
by normal
marrow
from the bulk of the tumour.
Figure
14-Radiograph
of the specimen.
aged
tissue,
rich
multinucleated
in
spindle-shaped
or rounded
giant
cells of different
sizes
myxoid
areas
elements
roundish
(Fig. 21)
or ovoid
chondroblastic
were
often
rich
but on many
cells, showing
or histiocytic
in
collagenous
occasions
conspicuous
elements
observed
cells,
(Figs.
intermingled
17 to 20).
fibres
they were
cytoplasmic
The
with
more
a
with
a varying
number
septa
which
separated
fair
number
fibroblastic
cellular
with
predominance
borders,
very similar
to the
in chondroblastomas
THE
of
JOURNAL
(Figs.
OF
BONE
33 and
AND
of
the
of
young
34).
JOINT
This
SURGERY
CHONDROMYXOID
FIG.
FIBROMA
(FIBR0MYx0ID
CHONDROMA)
15
OF BONE
FIG.
16
15-Topographic
photomicrograph
showing
the eccentric
location
of the lesion.
The tumour
is limited by a thinned
distended
cortex,
formation
of cystic
cavities
and
the border
of bone sclerosis
towards
the medullary
cavity.
A small tumour
nodule
separated
by sclerotic
bone from the main neoplasm
is seen (arrowed).
(>‘3.)
Figure
16-Photomicrograph
of the zone
squared
in Figure
15, showing
the sclerosis (a) at the distal border of the tumour
(b). At (c)
part of the growth
cartilage
is observed.
(x 16.)
Case
2.
Figure
FIG.
17
FIG.
18
Photomicrograph
showing
formation
of small irregular
cystic spaces in the tumour,
which shows a well defined
limit towards
a small ring of vascular
loose connective
tissue, separating
the
neoplasm
from the sclerotic
bone border (below). (x 20.) Figure 18-Case
22. Photomicrograph
showing
Figure
2.
17-Case
lobules
VOL.
53B,
NO.
2,
MAY
of myxoid
1971
tissue
partially
separated
by more
cellular
septa.
(>
50.)
205
206
F.
-
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SCHAJOWICZ
AND
H.
GALLARDO
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19
FIG.
Case
18.
multinucleated
Figure
giant
FIG.
19-Photomicrograph
cells.
( - 100.)
of
Figure
cells at higher
cross-section
of
one
of
20-Photomicrograph
magnification.
(x 200.)
---Jt
20
the
septa
showing
containing
some
multinucleated
giant
1
5’
-u1
-.
#{149},5
FIG.
21
FIG.
22
a septum,
composed
of
fusiform elements of fibroblastic aspect, without giant cells. (x 100.)
Figure
22-Case
3.
Photomicrograph
showing
a myxoid
zone with typical
elongated
and stellate
cells.
(‘
400.)
Figure
21-Case
22.
Photomicrograph
showing
the
cellular
aspect
THE
of
JOURNAL
OF
BONE
AND
JOINT
SURGERY
CHONDROMYXOID
FIBROMA
I
.-
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Figure
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CHONDROMA)
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FIG.
(FIBROMYXOID
23
FIG.
23-Photomicrograph
showing
condensation.
On the
is observed.
(:- 100.)
tion of the myxoid
tissue,
surface
the
of the
Figure
periphery
surrounding
of
24-Photomicrograph
with
formation
24
a tumour
lobule
with
bone
increased
osteoclastic
showing
of cavities
cystic
of different
the
degenera-
size.
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#{149}.- #{149}
NO.
#{149}
2,
MAY
1971
V...
,
FIG.
showing
the
area.
(Figure
transition
25, - 100,
ir
f
25
19-Photomicrographs
tissue
53 B,
s
-
:‘
FIG.
VOL.
-
%1
-#{149}
Case
O
#{149}
-,
0-!
#{149}
1P
.S
.
a
I
-
#{149}
p
of
a myxoid
Figure
26,
;-
(above)
400.)
26
into
a chondroid
-
208
F. SCHAJOWICZ
V.
AND
H.
GALLARDO
T.
‘#{149}
a
-.5--
S
I
-.
.4-
-
1-
“Pu
Fw;.
Photomicrographs
no atypical
chondromyxoid
;r
27
FIG.
‘-‘r,-’
“-
#{149}- ‘“
‘
A
“4
5’.
4
-S
#{149}
_\
1I\
8
1I
-%
-5”
5’
-#{149}
\
‘‘
8
-
#{149},
‘,
28
showing
marked
cellular
atypism
with one or more hyperchromatic
nuclei;
mitoses
are observed.
These
cytological
features
are frequently
encountered
in
fibroma
and apparently
have
no prognostic
significance.
Figure
27-Case
8.
(:- 100.)
Figure
28--Case
1. (x400.)
-
S
#{149}
5,.
8.
,
‘5
4
)1
.#{149}“#{149}4#{149}
a
#{149};.#
-
‘l’
4
V
j.f5I’#{149}
,
-,
-
#{149}
FIG.
j.
I#{149}
,
29
Case 7-Photomicrographs
observed
:‘-
in this
FIG.
showing
tumour
30
foci of irregular calcification. These are only rarely
type.
(Figure
29-’<
100. Figure
30< 400.)
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
CHONDROMYXOID
FIG.
Case
5-Photomicrographs
septum
(Fig.
31) and
(FIBROMYXOID
a dense
net of
the
a highly
cells
are
NO.
2,
MAY
1971
cellular
area
very
similar
100. Figure
34-
limiting
to those
>
400.)
2C9
BONE
32
of reticulin
fibres
corresponding
fibres
in a myxoid
zone
(Fig.
FIG.
showing
rounded
(Figure 33-/
53 B,
net
such
33
18-Photomicrographs
OF
FIG.
showing
a much
looser
cytological features of
VOL.
CHONDROMA)
31
FIG.
Case
FIBROMA
to
32).
a cellular
(<400.)
34
a myxoid
lobule.
of chondroblastoma.
The
210
F.
SCHAJOWICZ
AND
H.
GALLARDO
pattern
mediate
was very clear
stages
between
a fourth
case
in three
cases,
with
interone and the other
entity;
in which
it predominated
was included
in our series of chondroblastomas.
giant
were
cells
lacking
were
an
in
only
in a recurrence
almost
two
in one
Multinucleated
of the
and
later
finding
constant
cases,
but
appeared
cases
(Case
22).
A
the lobular
aspect
of the
tumour
borders,
with an evident
increase
of cells
(Figs.
16, 17 and 23), thus distinguishing
this process
from
the myxoma
of the mandible.
Between
this
characteristic
lobular
feature
surface
was
and
the
surrounding
rim
spongiosa
a narrow
zone
loose connective
tissue
was
of richly
a regular
17 and
reticular
stains
a loose
in the myxoid
being
23).
fibres
much
With
was
more
silver
observed
dense
and
of
vascularised,
finding
(Figs.
surrounding
net of
zones,
individual
and histiocytic
elements
of the septa
(Figs.
31 and 32). Some myxoid
lobules
showed
an
increased
collagenisation,
and
areas
of frank
chondroblastic
FIG.
Case 2.
with
35
FIG.
35-Block
replacement
Figure
36-Healing
operation.
The
of
patient
recurrence
with
publication.
36
resection
of tumour
by a portion
of fibular
shaft.
Figure
confused
fifteen
years
one
sufficiently
abundant
septa
generally
shapes
in
particularly
later.
in
case
one
of
conspicuous
FIG.
Case 1 l---Girl
tibia.
Figure
observed
large
hyperchromatic
lesion
one year after
is well and without
chondrosarcoma
In only
were
chondroid
differentiation
with formation
of lobules
of hyaline
cartilage
were
found
in several
cases
(Figs.
25 and 26). In less than
half of the cases we
our
cases
foci
pleomorphic
nucleus
to be visible
vascularised
(Case
I) before
of amorphous
Jaffe
and
calcification
37
in the
cells with
different
radiographs
recent
of the
The
were
or old
upper
found
(Case
THE
JOURNAL
7).
with
OF
BONE
30)
of the
is well sixteen
haemorrhages
29 and
38
metaphysis
patient
and
28),
it to be
Lichtenstein’s
(Figs.
FiG.
and
one or more
sizes
and
the myxoid
areas
(Figs.
27
at its periphery,
which caused
aged 12. Figure
37-Chondromyxoid
fibroma
38-Four
years after curettage
and bone graft.
after operation.
richly
of
The
years
interlobular
abundant
AND
JOINT
blood
SURGERY
CHONDROMYXOID
pigment,
partly
Trabeculae
The
elements
FIBROMA
phagocytised
of new-formed
histochemical
as well
by
bone
showed
a discrete
amount
to ptyalin
digestion,
and
cells
of periodic
were strongly
14.
Figure
of the cortex.
The
and
chondroid
Alcian
were
myxoid
granules
areas.
areas
gave,
common
findings.
material
positive,
many
chondroblastic
multinucleated
giant
in their cytoplasm,
as in other giant-cell
cells
resistant
lesions.
40
of the calcaneus
with
partial
destruction
year after
curettage
and bone
graft.
41
42
FIG.
Figure
expansion
blue, which
in
The
FIG.
lesion
40-One
rather
rarely.
glycogen
of the
211
OF BONE
41-Chondromyxoid
of the cortex.
after
curettage.
in most
disappeared
fibroma
of
42-Recurrence
Figure
parts, a positive
almost
the
upper
two
tibial
years
metachromatic
completely
in the
reaction
myxoid
areas
with
after
digestion.
hyaluronidase
TREATMENT
The
elements,
only
39
39-Large
Figure
after
curettage.
showing
wide
and
myxoid
toluidine
CHONDROMA)
acid-Schiff
positive
acid phosphatase
FIG.
Recurrence
metaphysis
found
demonstrated
stellate
FIG.
Case
histiocytic
were
studies
as in the
(FIBR0MYx0ID
type
in two-thirds
of treatment
of the
cases
occurred
transformation
carried
followed
and
in
out
are
only
AND
PROGNOSIS
case
is shown
in each
shown
one
case,
in Table
located
in Table
In our
in the tibia,
III.
II and
series
the
the
no
results
case
tumour
of
obtained
malignant
recurred
two
years after curettage,
a segmental
resection
being performed
at this stage.
The patient
is well
one year
later
(Figs.
41 and 42).
No case received
radiotherapy.
The low incidence
of
recurrence
in our series is possibly
due to the preference
for a wide excision
or block
resection
in most (523
per cent) of our cases as initial
treatment.
The higher
incidence
of recurrence
reported
in the
curettage
as initial
VOL.
53 B,
NO.
2,
literature
MAY
treatment,
1971
(Ralph
1962)
resection
appears
being
to be the
performed
consequence
only
as a second
of the
surgical
preference
procedure.
for
2 12
F. SCHAJOWICZ
AND
TABLE
CLINICAL
Case
Age
number
(years)
DETAILS
OF THIRTY-Two
Sex
Location
Male
Calcaneus
H. GALLARDO
II
CASES
OF CHONDROMYXOID
Symptoms
FIBROMA
Trauma
Treatment
Progress
Extirpation.
Massive bonegraft
duetocompressior
Well at 14 years
Necrosis
I
10
-
9
Male
Lower
16
Male
First
2
3
metaphysis
fibula
11
Male
finger
Lowerthirdfibula
5
-
Female
Iliac bone
6
--
Female
7
---
Female
Rib
Phalanx
(finger)
8
16
Male
Calcaneus
9
58
Male
Fourth
10
7
Male
graft
Well
at
15 years
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Tumour
Resection
Eight
months:
tumour,
pain
Yes
Resection
Well
at
Four
Yes
Curettage.graft
Well
at 16 years
and
limping
Upperright metaphysis
tibia
tumour
12
9
Female
Upper
Two
months:
pain and swelling
13
32
Female
Upperthirdfibula
14
16
Male
months
:
and pain
15
10
Male
Upper
16
10
Male
First
metatarsal
17
41
Female
Upper
left metaphysis
tibia
Eighteen
tumour
metaphysis
Two
tibia
-
-
Female
calcaneus
at 10 years
-
I2
metaphysis
tibia
-
Well
-
II
right
Resection
-
-
rib
Upper
metaphysis
right
fibula
Left
Resection.
Bone
-
phalanx
index
4
-
of graft
months:
and
pain
months:
tumour
17 years
Curettage.
Bone
graft
Well
at
Resection
Well
at 7 years
I year
Well
at
15
years
Curettage.
Bone
graft
Well
at
15
years
Resection.graft
Well
Bone
at 6 years
Resection
-
pain
at 9 years
Curettage.graft
Bone
-
months:
Well
Bone
Yes
Eight tumour
months:
Six
-
-
DISCUSSION
Chondromyxoid
intermediate
or
fibroma
transitional
is a relatively
stages
with
rare benign
chondroblastoma
bone
tumour.
It is distinctive,
although
do exist,
and sometimes
make
classification
difficult
(Schajowicz
and Gallardo
1970, Dahlin
1956,
1967, Lichtenstein
and
Bernstein
1959,
Lichtenstein
1965).
The clinical
and radiological
features
of chondromyxoid
fibroma
are generally
rather
characteristic,
especially
when
the tumour
is located
in a large
limb
bone.
Our
occurring
found
years
experience
in patients
in chondroblastoma.
old.
However,
confirms
between
the predilection
for the
five and twenty-five
years
Fewer
Scaglietti and
cases
were
Stringa
seen
(1961)
second
of age,
in patients
and
Ralph
and third
compared
decades,
68 per cent
with the 88 per cent
over
years
thirty
(1962)
reported
children
under
ten years,
the youngest
being in a child five years old.
There
is no sex predominance,
in comparison
with chondroblastoma,
64 per cent male preponderance.
THE
JOURNAL
and
in which
OF
BONE
under
several
AND
JOINT
ten
cases in
there
is a
SURGERY
CHONDROMYXOID
FIBROMA
(FIBROMYXOID
TABLE
CLINICAL
Case
number
Age
DETAILS
Sex
CASES
OF CHONDROMYXOID
Symptoms
Trauma
FIBROMA
Treatment
Progress
(years)
I8
13
Female
Left
19
6
Female
Spinous
iliac
bone
20
9
Male
23
Lower
22
Female
third
16
Male
23
32
Female
24
16
Female
25
22
Male
26
54
Male
27
20
Female
28
47
Male
Pain
left
at 2 years
Well
at 4 years
and
tumour
-
-
Resection
-
-
-
Five years:
and tumour
pain
I ) Curettage.
2) Resection
2 years
Yes
right
Phalanx
large
of
Upper
toe
Several
pain
third
Upper
tibia
third
30
19
Female
31
48
Male
Uppermetaphysis
32
30
Male
Upper
-
1) Curettage.
2) Amputation
swelling
Well
at
15
years
-
Swelling
metaphysis
Female
at 2 years
fracture
metatarsal,
left foot
17
Well
Pathological
left ulna
Upper
months:
and
2 years
later
Resection
tibia
right
Recurred
later
Resection
Upperthird
Two
pain
left metaphysis
tibia
:
-
Well
at
1 year
Curettage
Well
at
1 year
year:
One
and
Curettage
Well
at 3 months
Amputation
Well
at 2 months
-
Four
years
tumour
pain
Resection
and swelling
One
ulna
-
years
tibia
Lower
third
left fibula
frequent
common
Well
Resection
-
tibia
Lower
angle
left scapula
First
Resection
fibula
29
most
most
-
metaphysis
right
The
the
tibia
third
left
Upper
-
spine
Upper
21
-
process,
cervical
also
213
OF BONE
Il-continued.
OF THIRTY-Two
Location
CHONDROMA)
:
pain
-
tumour
-
Curettage
year:
Well at
Resection
location
was the upper
metaphysis
site in other
reports
(Jaffe
1958,
of the tibia
Lichtenstein
(31 per cent),
1965, Dahlin
Japanese
and Netherlands
Bone
Tumour
Registries
1966).
In our
frequently
involved
were fibula
(19 per cent) and calcaneus
(9 per cent),
bones
of the foot (9 per cent),
giving
an incidence
of 68 per cent in
surprisingly
we had none
in the femur,
which
most authors
consider
common
locations.
Involvement
of bones
of membranous
origin
seems
2 months
which
1967,
was
The
series
the other
bones
followed
by the long
the lower
limb.
Quite
to be one of the most
to be very uncommon,
only one case having
been reported
one in the mastoid
apophysis
(Jaffe
A rare location in our series was the
in a parietal
bone (Aegerter
and Kirkpatrick
1968) and
1958).
No cases have been reported
in the jaw bones.
spinous
process
of a third cervical
vertebra.
Benson
and
Bass
in which
(1955)
reported
involved.
Because
of the
of the joint
so often
53 B,
VOL.
D
NO.
2,
MAY
a similar
position
seen
1971
case,
of the
tumour
in chondroblastoma,
the
uppermost
part
in the
metaphysis
of large
is lacking.
of the
limb
thoracic
bones,
spine
irritation
was
214
large
F. SCHAJOWICZ
The radiographic
limb bone,
with
tumour
involves
An
picture
is characteristic:
an internal
well defined
a smaller
typical
because
expanding
both
difficult.
AND
tubular
bone,
H. GALLARDO
there
is commonly
an eccentric
location
scalloped
border
of sclerotic
bone.
When
a rib
or fibula,
the lesion
may
extend
throughout
surfaces
and often
making
diagnosis
important
cytological
evident
nuclear
atypism
simulating
a malignant
OF TREATMENT
Number
1
year
2 years
Curettage
I
4
1
Resection
I
1
2
1
pattern
(1948)
in approximately
publication,
was
and the
prognostic
The
the presence
of
or monstrous,
We found
this
of
CASES)
patients
3 years
well
at:
--
5 years
or
more
4 years
1
Total
-
Percentage
1
7
33.3
6
11
523
1
1
1
4.7
-
2
one-third
misdiagnosed
of our cases,
one of which,
as a chondromyxosarcoma.
extreme
rarity
of reported
significance.
presence
of transitional
types
of areas
of chondroid
differentiation
demonstration
of metachromatic
malignant
behaviour
between
is not
III
(TWENTY-ONE
Extirpation
Amputation
appearance
reported
by virtually
all authors,
was
or more hyperchromatic
nuclei,
often globular
However,
mitotic
figures
are exceptional.
TABLE
1-12
months
radiographic
the entire
width
of the affected
bone,
from fibrous
dysplasia
and chondroma
feature,
with one
tumour.
RESULTS
Treatment
the
in a
the
this
and a similar
substances
in
before
Jaffe and
The evolution
confirm
tumour
and
that
this
Lichtenstein’s
of our cases
finding
chondroblastoma,
histochemical
the
myxoid
demonstrated
by others
(Benedetti,
Canepa
and Garcia
indicate
a cartilage
derivation
of this process.
In spite
9
has
the evidence
behaviour,
particularly
and
chondroid
areas,
1962; Scaglietti
of the general
no
the
also
and Stringa
1956, 1961)
agreement
that it belongs
to the
general
group
ofcartilage
tumours,
it is designated
as a “fibroma”,
which in our opinion
appears
to be illogical
; in our opinion
the term
“fibromyxoid
chondroma”
would
be much
more
appropriate.
This was also pointed
out by Aegerter
and Kirkpatrick
(1968).
Although
in a certain
percentage
of cases
chondromyxoid
fibroma
can be cured
by
thorough
from
Dahlin
in young
(block
that
curettage,
per cent
125
the
tumour
the incidence
of recurrence
in Ralph’s
(1962)
review
is relatively
up to the
high, varying
25 per cent of
(1967).
The tendency
to local recurrence
after initial
curettage
seems to be even higher
children
(Scaglietti
and Stringa
1961, Ralph
1962).
A more radical
surgical
treatment
resection
or amputation)
is indicated
in these patients.
In our opinion
it is probable
presence
of small
by the rim ofsclerotic
tumour
bone,
by curettage.
In our opinion
choice.
Malignant
transformation
in our
after this treatment
of the published
cases
series.
Only
isolated
lobules
impedes
block
cases
in the spongiosa,
an adequate
and
resection
should
appears
to be very
have
been
reported
separated
complete
whenever
exceptional,
in the
from
the bulk
extirpation
ofthe
possible
be the
no case having
literature,
such
of the
lesion
treatment
of
been found
as that
of Iwata
and Coley
(1958).
They reported
the case of a seventeen-year-old
boy who had a tumour
in
the upper
fibula which
recurred
one month
after curettage.
A resection
was performed,
which
in order to save the nerve was incomplete,
but six months
later, because
of a second
recurrence,
amputation
transformation.
was
performed.
The same
Histological
tumour,
which
examination
showed
was
did not metastasise,
THE
JOURNAL
a chondrosarcomatous
reported
by Jaffe (1958).
OF
BONE
AND
JOINT
SURGERY
CHONDROMYXOID
Gilmer,
change.
FIBROMA
Higley
and Kilgore
(1963)
This was in a thirteen-year-old
This recurred
the large size
(FIBROMYXOID
and
Gilmer
girl who
six months
after curettage.
of the tumour.
The diagnosis
CHONDROMA)
215
OF BONE
(1963)
describe
another
case
had a tumour
in the lower end
Disarticulation
of the limb was
of chondrosarcoma
was made.
extreme
rarity
of malignant
change,
the statement
“in the twenty-one
cases in our collection,
eight have
of these has metastasised”
is difficult
to understand.
of malignant
of the femur.
done
because
of
In view of the
of Aegerter
and Kirkpatrick
(1968)
shown
features
of chondrosarcoma.
that
One
SUMMARY
I
A series
.
of thirty-two
cases
clinical,
3.
The
rarity
4.
the
5.
the
Excision
or block
resection
is preferred
to curettage
liability
to recurrence
after curettage.
It is suggested
that the designation
“fibromyxoid
usual designation
“chondromyxoid
fibroma”.
The
authors
Mrs
wish
and
Adela
of the
and
fibroma
The
material
radiographic
of chondromyxoid
2.
tumour
to express
permitting
and
their
the
use
M. de Schajowicz
pathological
of malignant
appreciation
of their
and
in this
laboratory
are
change
to all those
cases
is reported.
features
as a method
chondroma”
colleagues
paper.
technician
described.
is stressed.
They
Miss
is more
who
also
Alicia
have
wish
Sens
of treatment,
collaborated
to acknowledge
and
photographer
because
appropriate
than
by sending
the
of
skilful
their
help
Mr Oscar
of
Lobo.
REFERENCES
ACKERMAN,
and
L. V., and SPJUT,
H. J. (1962): Atlas ofTumor
Pathology.
Cartilage,
p. 17. Washington,
D.C. : Armed
Forces
Institute
E., and
AEGERTER,
G.
BENEDETFI,
B.,
B. L.,
C0M0LLI,
E.,
Trabajos
A.
HARELL,
(1954):
Orthopaedic
of Bone.
Journal
ofBone
andJoint
Surgery,
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