Chondroblastoma arising from acromian - a rare site A case report and review of literature

Sudhir Kumar Garg*, Purnima Aggarwal**, R P S Punia*** *Professor and Head

Department of Orthopaedics

**Assistant Professor,
Department of Radiology

***Associate Professor
Department of Pathology Government Medical College & Hospital, Sector 32, Chandigarh

ABSTRACT We report a rare case of Chondroblastoma arising from acromian in a 60 years old female. To our knowledge this is the only such case where chondroblastoma arose from acromian at this age. Keywords : Chondroblastoma, acromian, shoulder, tumors

INTRODUCTION
Chondroblastoma is a rare benign tumour. Up to 80% of these tumours occur between first and third decades of life. In younger age group, it commonly arises from epiphysis of long tubular bones. In an elderly, It is known to arise from atypical sites. However, acromian is a rare site even in elderly patient and thus proved to be a diagnostic problem.

CASE REPORT
A 60 year old female patient came to us complaining of pain in the right shoulder for last 3 years and progressively increasing swelling right acromian region for last 6 months. In the past, she had suffered from pulmonary tuberculosis. On examination, there was a well demarcated firm and tender swelling, about 6.0cms x 8.0cms, arising from the right acromian. Overlying veins were dilated. Shoulder movements were extremely painful. There was no evidence of axillary or cervical lymphodenopathy. There was no evidence of any neurovascular involvement. X-ray right shoulder revealed an expansile lesion of acromian with moderate soft tissue mass. Superiorly, cortex was eroded and there were areas of calcification within this mass (Fig. I).
Corresponding Author : Dr. Sudhir Kumar Garg, Professor and Head Department of Orthopaedics, Government Medical College & Hospital, Sector 32, Chandigarh E-mail : sudhir_ortho@yahoo.com

Fig. 1: Expansile lesion arising from acromian with areas of calcification and eroded superior cortex.

X-rays chest showed evidence of old healed tuberculosis. There was no evidence of any lung primary or metastatic lesion. CT scan of the right shoulder was suggestive of a cartilaginous tumor arising from acromian with areas of calcification (Fig-2). There was no evidence of involvement of the shoulder joint. Because of her age, clinical and radiological findings, a provisional diagnosis of chondrosarcoma was made. Fine

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Chondroblastoma arising from acromian - a rare site

people, it is known to arise from flat bones (1,2,5). Pain is the most common presenting symptom (1,8,9). In few patients, there may be associated soft tissue swelling or mass (9). Radiologically, it usually presents as an eccentric expansile lesion, which may be lobulated, with areas of calcification in about 33% of the cases. At the periphery of the tumor, there is usually a rim of cortical bone (1,6). Curettage alone or in combination with bone grafting is the treatment of choice in most of the cases (3,4,8,9). In patients where expendable bone is involved, wide en-bloc excision is preferred (2). Scapula is a rare site for Chondroblastoma. In a large series of 458 cases by Huvos et al there were fifteen cases involving scapula (4). In only case, which was earlier reported by Wright et al in 1964, acromian was affected (10). In this patient too, swelling was present since the age of 14 years but treatment was sought only at the age of 72 years when it started increasing in size. Thus to our knowledge the case being reported is the only case of such kind where Chondroblastoma arose from the acromian at this age.

Fig. 2: CT Scan of shoulder showing well demarcated artilaginous expansile lesion arising from acromian with areas of calcification.

needle aspiration cytology was carried out which was nondiagnostic. Later on, en-bloc resection with wide margins i.e. partial scapulectomy, excising acromian and superior half of the scapula along with overlying muscles and lateral third of the clavicle, was carried out. Capsule of the shoulder joint was left intact. Postoperative recovery was uneventful. Now after five years of follow-up there is no evidence of recurrence.

REFERENCES
1. 2. Bloem JL,Mulder JD ( 1985) Chondroblastoma: a clinical and radiological study of 104 cases. Skeletal Radiol 14:1-9 Dahlin DC, Ivins JC (1972) Benign chondroblastoma: a study of 125 cases. Cancer 30:401-413. Dahlin DC, Unni KK (1986) Benign chondroblastoma. In: Dahlin DC, Unni KK (eds) Bone tumors: general aspects and data on 8,542 cases. Charles C Thomas, Springfield Illinois USA Fourth ed: 5267. Huvos AG, Marcove RC (1973) Chondroblastoma of bone: a critical review. Clin Orthop 95:300-312. Kurt AM, Unni KK, Sim FH, Mcleod RA (1989) Chondroblastoma of bone: Hum Pathol 20:965-976. Mcleod RA, Beabout JW (1973) The roentgenographic features of chondroblastoma. Am J Roentgenology 118:464-471. Mirra JM (1989) Chondroblastoma. In: Mirra JM, Picci P, Gold RH (eds) Bone tumours: Clinical, radiologic and pathologic correlations. Lea & Febiger, Philadelphia USA Vol. 1:589-623. Springfield DS, Capanna R, Gherlinzoni F, Picci MD, Campanacci M(1985) Chondroblastoma : a review of seventy cases. J Bone Joint Surg (Am) 67A:748-755. Turcotte RE, Kurt AM, Sim FH, Unni KK, Mcleod RA (1993) Chondroblastoma. Hum Pathol 24:944-949.

HISTOLOGY
Cut section revealed a gray which encapsulated tumor with translucent areas. On microscopic examination, lobules of polyhedral chondroblasts were seen. Cells have hyperlobulated nuclei with grooves in some and moderate to abundant amount of pink cytoplasm. Cells were surrounded by lace like hyaline matrix with chicken wire calcification in between these cells. There were areas of necrosis, occasional mitosis and few osteoclastic giant cells. Resected margins were free of tumor. On this histological basis, a final diagnosis of Chondroblastoma was made.
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4. 5. 6. 7.

DISCUSSION
Chondroblastoma is a rare benign cartilaginous tumor that comprises less than 1% of all primary bone tumors (2,3,7,9). Chondroblastoma typically occurs in the second decade of life, however they have been report at all ages. It usually arises from epiphyseal region of the long tubular bones but in elderly
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10. Wright JL, Sherman MS (1964) An unusual chondroblastoma. J Bone Joint Surg (Am) 46-A: 597-600.

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