- Email: [email protected]
Chondroblastoma of the thoracic vertebra
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observed microscopically. More radical removal of surrounding brain containing infiltrative tumour cells should be performed to prolong survival. Giant cell glioblastoma may have a more favourable prognosis than common glioblastoma multiforme.1,7,9,11,13 However, cases with a shorter survival time have been reported.14 Our patient had a relatively long survival period of 34 months, which was longer than that for glioblastoma multiforme. Radiotherapy can achieve cessation of bleeding due to spinal metastasis with rapid clinical improvement.4 Our patient may have survived longer if radiation of spinal lesions and ventriculoperitoneal shunting had been performed.
REFERENCES 1. 2. 3. 4. 5.
6. 7. 8. 9.
10.
11. 12. 13. 14.
Rubinstein LJ. Tumors of the Central Nervous System. Armed Forces Institute of Pathology, 1972: 72–74. Russel DS, Rubinstein LJ. Pathology of Tumours of the Nervous System. 5th ed. Edward Arnold, 1990: 237–240. Zülch KJ. Brain Tumors – Their Biology and Pathology. Springer-Verlag, 1986: 323–325. Lossos A, Siegal T. Spinal subarachnoid hemorrhage associated with leptomeningeal metastases. J Neurooncol 1992; 12: 167–171. Papo I, Balint K, Slovik F, Scarpelli M, Ranaldi R. Subarachnoid haemorrhage due to widely metastatising malignant ependymoma. Neurochirurgia (Stuttg) 1985; 28: 243–245. Tarlov IM, Keener EB. Subarachnoid hemorrhage and tumour implants from spinal sarcoma in an infant. Neurology 1953; 3: 384–390. Becker DP, Benyo R, Roessmann U. Glial origin of monstrocellular tumour. Case report of prolonged survival. J Neurosurg 1967; 26: 72–77. Hadfield MG, Silverberg SG. Light and electron microscopy of giant-cell glioblastoma. Cancer 1972; 30: 989–996. Margetts JC, Kalyan-Raman UP. Giant-celled glioblastoma of brain. A clinicopathological and radiological study of ten cases (including immunohistochemistry and ultrastructure). Cancer 1989; 63: 524–531. Schiffer D, Giordana MT, Soffietto R, Tarenzi L, Bertolotto A. On the nature of the so-called monstrocellular sarcoma of the brain. Neurosurgery 1980; 6: 391–397. Garcia-Bengochea F, Collins GH. Monstrocellular sarcoma of the brain: 6-year post operative survival: Case report. J Neurosurg 1969; 31: 686–689. Lim V, Sobel DF, Zyroff J. Spinal cord pial metastases: MR imagings with gadopentetate dimeglumine. AJR 1990; 155: 1077–1084. Burger PC, Vollmer RT. Histologic factors of prognostic significance in the glioblastoma multiforme. Cancer 1980; 46: 1179. Hitselberger WE, Kernohan JW, Uihlein A. Giant cell fibrosarcoma of the brain. Cancer 1961; 14: 814–852.
Chondroblastoma of the thoracic vertebra
Keywords: chondroblastoma, spine, thoracic vertebra, bone tumour Received 7 January 2000 Accepted 15 February 2000 Correspondence to: Dr Ayhan Attar, Ankara Üniversitesi TOp Fakültesi Beyin Cerrahisi Klinigai SamanpazarO/Ankara/Turkey. Tel.: ;(312) 310 33 33 / 2627, ;(312) 2129207; Fax: ;(312) 309 43 40; E-mail: [email protected]
INTRODUCTION Chondroblastoma is a benign bone tumour arising most often in the epiphyses of long bones. A few primarily metaphyseal chondroblastomas have been reported. Although a reticuloendothelial origin for the cells of this tumour has been suggested, the consensus is that they derive from cartilage germ cells or cells of epiphyseal cartilage. The location of these tumours in descending order are proximal end of humerus, distal end of femur, proximal end of femur, proximal end of tibia, talus and innominate bone. Vertebral involvement is extremely rare. Male patients are affected slightly more often than females. Almost all patients are between five and twenty-five years old. Chondroblastomas in some of the unusual sites tend to involve older people. Pain is the most common symptom.1–4 We report a chondroblastoma involving the second thoracic vertebral body and adjacent structures.
CASE REPORT A 48-year-old man suffering from interscapular pain for one year was admitted to our clinic. He had been operated for thoracic mass at the thoracic surgery department five years previously. There were no significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) revealed a mass infiltrating the second thoracic vertebra and adjacent structures as well as narrowing the epidural space. An operation was planned, and sternotomy was performed through an anterior approach. The tumour was grey-brown, bloody and seemed to be infiltrative. The second thoracic vertebra and adjacent tumoural structures were excised, and anterior stabilisation was achieved with mesh and acrylic. One week after the first operation posterior stabilisation was performed using a cervical 6 and thoracic 4 vertebrae sublaminar, pedicular, and transverse hook-rod system and sublaminar wiring. There were no neurological complications following either operation. Pathological diagnosis was benign chondroblastoma.
A. Attar1 MD, H. Ç. Ugaur1 MD, Y. S. Çagalar1 MD, A. Erdogan1 MD, N. Ozdemir2 MD Ankara University, School of Medicine, Departments of 1Neurosurgery and 2 Thoracic Surgery, Ankara, Turkey
Summary A 48-year-old patient with interscapular pain was admitted to our clinic. MRI revealed a mass infiltrating the second thoracic vertebra and adjacent structures. No other clinical manifestations were observed in general examination. The patient underwent surgery and subtotal removal was achieved while anterior and posterior stabilisations were performed. Diagnosis was pathologically confirmed. As thoracic chondroblastoma cases are not frequent, we decided to present this case. © 2001 Harcourt Publishers Ltd Journal of Clinical Neuroscience (2001) 8(1), 59–60 © 2001 Harcourt Publishers Ltd DOI: 10.1054/jocn.2000.0780, available online at http://www.idealibrary.com on
© 2001 Harcourt Publishers Ltd
Fig. 1 MRI revealing the tumour infiltrating the T2 vertebra and adjacent structures.
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in the thoracic spine. The lesion may occur at any age, but the vast majority occur in the second decade of life.1 Atypical localisation is noted in older patients such as in our case who was 48 years old. Sometimes the pathological diagnosis is mistaken to be malignant bone tumour, chondromyxoid fibroma, or giant cell tumour.3,5 Curettage or resection are the primary treatments of choice. Curettage effects cure about 90% of chondroblastomas. Occasional tumour recurrence indicates the necessity for complete removal which requires adequate exposure of the lesion. In our case the operative approach permitted adequate exposure of the lesion, but because of the tendency to local infiltration to paravertebral tissues, complete excision was not achieved. Regarding spinal chondroblastomas, following surgical excision, stabilisation of the vertebral column is needed. Because of the important vascular structures in the upper thoracic region during anterior approach, an anterior stabilisation procedure did not provide sufficient and precise stability, therefore, it was combined with posterior stabilisation. Recurrent chondroblastomas can be treated with repeated curettage and radiation therapy. Some studies have shown that chondroblastomas are sensitive to radiation therapy, but in some cases the tumour can progress to sarcoma after radiation therapy. As a result radiotherapy should be employed only at recurrence and/or when a surgical approach is impossible.1,3,4 Due to recurrence and subtotal removal of the tumour, radiotherapy was employed in our case. REFERENCES 1. Dahlin D, Ivins JC. Benign chondroblastoma. Cancer 1972; 30(2): 401–413. 2. Hoeffel JC, Brasse F, Schmitt M, Plenat F, Vignaud JM, Czorny A, Montaut J, Marchal AL. About one case of vertebral chondroblastoma. Pediatr Radiol 1987; 17: 392–396. 3. Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M. Chondroblastoma. J Bone Joint Surg 1985; 67-A(5): 748–755. 4. Wisniewski M, Toker C, Anderson PJ, Huang P, Malis LI. Chondroblastoma of the cervical spine. J Neurosurg 1973; 38: 763–766. 5. Bruder E, Zanetti M, Boos N, Von Hochstetter AR. Chondromyxoid fibroma of two thoracic vertebrae. Skeletal Radiol 1999; 28: 286–289. Fig. 2 Plain radiograph revealing the stabilisation system following operations.
Schwannoma of the suprascapular nerve presenting with atypical neuralgia: case report and review of the literature Rewati Raman Sharma MS DNB, Sanjay J. Pawar MS MCH, Audumbar S. Netalkar MCH The National Neurosurgical Centre, Khoula Hospital, Post Box 90, Postal Code 116, Mina-al-Fahal, Muscat, Sultanate of Oman
Fig. 3 Pathological examination revealed that the tumour contains sheets of chondroblasts with rounded uniform nuclei and polygonal pale cytoplasm. Chondroid eosinophilic material as seen upper left (double large arrows) of the figure, there is also an osteoclast type giant cell (small arrow).
DISCUSSION Chondroblastoma is an uncommon tumour accounting for approximately 1 per cent of primary benign bone tumours. Although benign in nature, a tendency to local recurrence is a well recognised feature of this tumour in any location.1,4 It is rarely located Journal of Clinical Neuroscience (2001) 8(1)
Summary Compressive lesions of the suprascapular nerve produce weakness and atrophy of the supra- and infraspinatus muscles and a poorly defined aching pain along the posterior aspect of the shoulder joint and the adjacent scapula. Entrapment neuropathy of the suprascapular nerve is fairly common whereas tumorous lesions are rare; among the latter ganglion cysts are frequently seen. An isolated solitary schwannoma of the suprascapular nerve presenting with atypical neuralgic pain is exceptional. The location of a schwannoma under the firm deep cervical fascia in the posterior
© 2001 Harcourt Publishers Ltd
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Chondroblastoma of the thoracic vertebra 59
observed microscopically. More radical removal of surrounding brain containing infiltrative tumour cells should be performed to prolong survival. Giant cell glioblastoma may have a more favourable prognosis than common glioblastoma multiforme.1,7,9,11,13 However, cases with a shorter survival time have been reported.14 Our patient had a relatively long survival period of 34 months, which was longer than that for glioblastoma multiforme. Radiotherapy can achieve cessation of bleeding due to spinal metastasis with rapid clinical improvement.4 Our patient may have survived longer if radiation of spinal lesions and ventriculoperitoneal shunting had been performed.
REFERENCES 1. 2. 3. 4. 5.
6. 7. 8. 9.
10.
11. 12. 13. 14.
Rubinstein LJ. Tumors of the Central Nervous System. Armed Forces Institute of Pathology, 1972: 72–74. Russel DS, Rubinstein LJ. Pathology of Tumours of the Nervous System. 5th ed. Edward Arnold, 1990: 237–240. Zülch KJ. Brain Tumors – Their Biology and Pathology. Springer-Verlag, 1986: 323–325. Lossos A, Siegal T. Spinal subarachnoid hemorrhage associated with leptomeningeal metastases. J Neurooncol 1992; 12: 167–171. Papo I, Balint K, Slovik F, Scarpelli M, Ranaldi R. Subarachnoid haemorrhage due to widely metastatising malignant ependymoma. Neurochirurgia (Stuttg) 1985; 28: 243–245. Tarlov IM, Keener EB. Subarachnoid hemorrhage and tumour implants from spinal sarcoma in an infant. Neurology 1953; 3: 384–390. Becker DP, Benyo R, Roessmann U. Glial origin of monstrocellular tumour. Case report of prolonged survival. J Neurosurg 1967; 26: 72–77. Hadfield MG, Silverberg SG. Light and electron microscopy of giant-cell glioblastoma. Cancer 1972; 30: 989–996. Margetts JC, Kalyan-Raman UP. Giant-celled glioblastoma of brain. A clinicopathological and radiological study of ten cases (including immunohistochemistry and ultrastructure). Cancer 1989; 63: 524–531. Schiffer D, Giordana MT, Soffietto R, Tarenzi L, Bertolotto A. On the nature of the so-called monstrocellular sarcoma of the brain. Neurosurgery 1980; 6: 391–397. Garcia-Bengochea F, Collins GH. Monstrocellular sarcoma of the brain: 6-year post operative survival: Case report. J Neurosurg 1969; 31: 686–689. Lim V, Sobel DF, Zyroff J. Spinal cord pial metastases: MR imagings with gadopentetate dimeglumine. AJR 1990; 155: 1077–1084. Burger PC, Vollmer RT. Histologic factors of prognostic significance in the glioblastoma multiforme. Cancer 1980; 46: 1179. Hitselberger WE, Kernohan JW, Uihlein A. Giant cell fibrosarcoma of the brain. Cancer 1961; 14: 814–852.
Chondroblastoma of the thoracic vertebra
Keywords: chondroblastoma, spine, thoracic vertebra, bone tumour Received 7 January 2000 Accepted 15 February 2000 Correspondence to: Dr Ayhan Attar, Ankara Üniversitesi TOp Fakültesi Beyin Cerrahisi Klinigai SamanpazarO/Ankara/Turkey. Tel.: ;(312) 310 33 33 / 2627, ;(312) 2129207; Fax: ;(312) 309 43 40; E-mail: [email protected]
INTRODUCTION Chondroblastoma is a benign bone tumour arising most often in the epiphyses of long bones. A few primarily metaphyseal chondroblastomas have been reported. Although a reticuloendothelial origin for the cells of this tumour has been suggested, the consensus is that they derive from cartilage germ cells or cells of epiphyseal cartilage. The location of these tumours in descending order are proximal end of humerus, distal end of femur, proximal end of femur, proximal end of tibia, talus and innominate bone. Vertebral involvement is extremely rare. Male patients are affected slightly more often than females. Almost all patients are between five and twenty-five years old. Chondroblastomas in some of the unusual sites tend to involve older people. Pain is the most common symptom.1–4 We report a chondroblastoma involving the second thoracic vertebral body and adjacent structures.
CASE REPORT A 48-year-old man suffering from interscapular pain for one year was admitted to our clinic. He had been operated for thoracic mass at the thoracic surgery department five years previously. There were no significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) revealed a mass infiltrating the second thoracic vertebra and adjacent structures as well as narrowing the epidural space. An operation was planned, and sternotomy was performed through an anterior approach. The tumour was grey-brown, bloody and seemed to be infiltrative. The second thoracic vertebra and adjacent tumoural structures were excised, and anterior stabilisation was achieved with mesh and acrylic. One week after the first operation posterior stabilisation was performed using a cervical 6 and thoracic 4 vertebrae sublaminar, pedicular, and transverse hook-rod system and sublaminar wiring. There were no neurological complications following either operation. Pathological diagnosis was benign chondroblastoma.
A. Attar1 MD, H. Ç. Ugaur1 MD, Y. S. Çagalar1 MD, A. Erdogan1 MD, N. Ozdemir2 MD Ankara University, School of Medicine, Departments of 1Neurosurgery and 2 Thoracic Surgery, Ankara, Turkey
Summary A 48-year-old patient with interscapular pain was admitted to our clinic. MRI revealed a mass infiltrating the second thoracic vertebra and adjacent structures. No other clinical manifestations were observed in general examination. The patient underwent surgery and subtotal removal was achieved while anterior and posterior stabilisations were performed. Diagnosis was pathologically confirmed. As thoracic chondroblastoma cases are not frequent, we decided to present this case. © 2001 Harcourt Publishers Ltd Journal of Clinical Neuroscience (2001) 8(1), 59–60 © 2001 Harcourt Publishers Ltd DOI: 10.1054/jocn.2000.0780, available online at http://www.idealibrary.com on
© 2001 Harcourt Publishers Ltd
Fig. 1 MRI revealing the tumour infiltrating the T2 vertebra and adjacent structures.
Journal of Clinical Neuroscience (2001) 8(1)
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12/9/00 11:46 AM
Page 60
Sharma et al.
in the thoracic spine. The lesion may occur at any age, but the vast majority occur in the second decade of life.1 Atypical localisation is noted in older patients such as in our case who was 48 years old. Sometimes the pathological diagnosis is mistaken to be malignant bone tumour, chondromyxoid fibroma, or giant cell tumour.3,5 Curettage or resection are the primary treatments of choice. Curettage effects cure about 90% of chondroblastomas. Occasional tumour recurrence indicates the necessity for complete removal which requires adequate exposure of the lesion. In our case the operative approach permitted adequate exposure of the lesion, but because of the tendency to local infiltration to paravertebral tissues, complete excision was not achieved. Regarding spinal chondroblastomas, following surgical excision, stabilisation of the vertebral column is needed. Because of the important vascular structures in the upper thoracic region during anterior approach, an anterior stabilisation procedure did not provide sufficient and precise stability, therefore, it was combined with posterior stabilisation. Recurrent chondroblastomas can be treated with repeated curettage and radiation therapy. Some studies have shown that chondroblastomas are sensitive to radiation therapy, but in some cases the tumour can progress to sarcoma after radiation therapy. As a result radiotherapy should be employed only at recurrence and/or when a surgical approach is impossible.1,3,4 Due to recurrence and subtotal removal of the tumour, radiotherapy was employed in our case. REFERENCES 1. Dahlin D, Ivins JC. Benign chondroblastoma. Cancer 1972; 30(2): 401–413. 2. Hoeffel JC, Brasse F, Schmitt M, Plenat F, Vignaud JM, Czorny A, Montaut J, Marchal AL. About one case of vertebral chondroblastoma. Pediatr Radiol 1987; 17: 392–396. 3. Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M. Chondroblastoma. J Bone Joint Surg 1985; 67-A(5): 748–755. 4. Wisniewski M, Toker C, Anderson PJ, Huang P, Malis LI. Chondroblastoma of the cervical spine. J Neurosurg 1973; 38: 763–766. 5. Bruder E, Zanetti M, Boos N, Von Hochstetter AR. Chondromyxoid fibroma of two thoracic vertebrae. Skeletal Radiol 1999; 28: 286–289. Fig. 2 Plain radiograph revealing the stabilisation system following operations.
Schwannoma of the suprascapular nerve presenting with atypical neuralgia: case report and review of the literature Rewati Raman Sharma MS DNB, Sanjay J. Pawar MS MCH, Audumbar S. Netalkar MCH The National Neurosurgical Centre, Khoula Hospital, Post Box 90, Postal Code 116, Mina-al-Fahal, Muscat, Sultanate of Oman
Fig. 3 Pathological examination revealed that the tumour contains sheets of chondroblasts with rounded uniform nuclei and polygonal pale cytoplasm. Chondroid eosinophilic material as seen upper left (double large arrows) of the figure, there is also an osteoclast type giant cell (small arrow).
DISCUSSION Chondroblastoma is an uncommon tumour accounting for approximately 1 per cent of primary benign bone tumours. Although benign in nature, a tendency to local recurrence is a well recognised feature of this tumour in any location.1,4 It is rarely located Journal of Clinical Neuroscience (2001) 8(1)
Summary Compressive lesions of the suprascapular nerve produce weakness and atrophy of the supra- and infraspinatus muscles and a poorly defined aching pain along the posterior aspect of the shoulder joint and the adjacent scapula. Entrapment neuropathy of the suprascapular nerve is fairly common whereas tumorous lesions are rare; among the latter ganglion cysts are frequently seen. An isolated solitary schwannoma of the suprascapular nerve presenting with atypical neuralgic pain is exceptional. The location of a schwannoma under the firm deep cervical fascia in the posterior
© 2001 Harcourt Publishers Ltd