Chondromyxoid fibroma of the distal clavicle

Chondromyxoid fibroma of the distal clavicle

Pathology ISSN: 0031-3025 (Print) 1465-3931 (Online) Journal homepage: http://www.tandfonline.com/loi/ipat20 Chondromyxoid fibroma of the distal cla...

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Pathology

ISSN: 0031-3025 (Print) 1465-3931 (Online) Journal homepage: http://www.tandfonline.com/loi/ipat20

Chondromyxoid fibroma of the distal clavicle Nuttaya Pattamapaspong, Wilfred C. G. Peh, Man Hong Tan, Jacqueline S. G. Hwang & Puay Hoon Tan To cite this article: Nuttaya Pattamapaspong, Wilfred C. G. Peh, Man Hong Tan, Jacqueline S. G. Hwang & Puay Hoon Tan (2006) Chondromyxoid fibroma of the distal clavicle, Pathology, 38:5, 464-466 To link to this article: https://doi.org/10.1080/00313020600922439

Published online: 06 Jul 2009.

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In conclusion, it is imperative that a histological diagnosis is made on any ovarian lesion showing iodine uptake on a I-131 scan for assessment of disease status in thyroid carcinoma. The differential diagnosis includes an incidental struma ovarii and a metastatic deposit of thyroid carcinoma, both of which are rare occurrences but which would have differing prognostic implications for the patient. The ovary should be thoroughly sampled and should be reviewed in conjunction with any relevant previous histology. Lydia Ng Barbara Brennan Department of Histopathology, PathWest Laboratory Medicine WA, Women’s and Children’s Health Service Site, King Edward Memorial Hospital, Subiaco, Western Australia Contact Dr B. Brennan. E-mail: [email protected] ACKNOWLEDGEMENTS The authors would like to thank Dr Colin Stewart, St John Of God Pathology, Subiaco, Western Australia and Professor Peter Russell, Mayne Health Laverty Pathology, Department of Anatomical Pathology, Royal Prince Alfred Hospital, and Department of Pathology, University of Sydney, Sydney, New South Wales.

1. Mancuso A, Triolo O, Leonardi I, DeVivo A. Struma ovarii: a rare benign pathology which may erroneously suggest malignancy. Acta Obstet Gynecol Scand 2001; 80: 1075–6. 2. Makani S, Kim W, Gaba AR. Struma ovarii with a focus of papillary thyroid cancer: a case report and review of the literature. Gynecol Oncol 2004; 94: 835–9. 3. Devaney K, Snyder R, Norris HJ, Tavassoli FA. Proliferative and histologically malignant struma ovarii: a clinicopathologic study of 54 cases. Int J Gynecol Pathol 1993; 12: 333–43. 4. Griffiths AN, Jain B, Vine SJ. Papillary thyroid carcinoma of struma ovarii. J Obstet Gynaecol 2004; 24: 92–102. 5. Hemli JM, Barakate MS, Appleberg M, Delbridge LW. Papillary carcinoma of the thyroid arising in struma ovarii- report of a case and review of management guidelines. Gynecol Endocrinol 2001; 15: 243–7. 6. Loizzi V, Cappuccini F, Berman ML. An unusual presentation of struma ovarii mimicking a malignant process. Obstet Gynecol 2002; 100: 1111–2. 7. Bhansali A, Jain V, Rajwanshi A, Lodha S, Dash RJ. Follicular carcinoma in a functioning struma ovarii. Postgrad Med J 1999; 75: 617–8. 8. Sussman SK, Kho SA, Cersosimo E, Heimann A. Coexistence of malignant struma ovarii and Graves’ disease. Endocr Pract 2002; 8: 378–80. 9. Szyfelbein WM, Young RH, Scully RE. Struma ovarii simulating ovarian tumours of other types – a report of 30 cases. Am J Surg Pathol 1995; 19: 21–9. 10. Young RH, Jackson A, Wells M. Ovarian metastasis from thyroid carcinoma 12 years after partial thyroidectomy mimicking struma ovarii: report of a case. Int J Gynecol Pathol 1994; 13: 181–5. 11. Logani S, Baloch ZW, Snyder PJ, Weinstein R, LiVolsi VA. Cystic ovarian metastasis from papillary thyroid carcinoma: a case report. Thyroid 2001; 11: 1073–5. 12. Tollefsen HR, DeCosse JJ, Hutter RVP. Papillary carcinoma of the thyroid. A clinical and pathological study of 70 fatal cases. Cancer 1964; 17: 1035–44.

DOI: 10.1080/00313020600922405

Pathology (2006), 38(5), October

Chondromyxoid fibroma of the distal clavicle Sir, Chondromyxoid fibroma is a rare benign cartilaginous tumour that comprises less than 1% of osseous neoplasms.1 Classically, this tumour usually arises in long tubular bones, with the proximal tibial metaphysis being the most common location. Chondromyxoid fibroma of the clavicle is extremely rare. To our knowledge, only three cases of chondromyxoid fibroma occurring at this site have been previously documented.2–4 We report the clinical presentation, imaging and pathological findings of an additional patient with this rare tumour in this very unusual location. A 23-year-old Chinese man noticed swelling of his left distal clavicle that had slowly increased in size over 6 months. The swelling was associated with a constant dull pain. He initially attributed this pain to carrying of a laptop computer that was often slung over his left shoulder. He then consulted his family physician and was referred to our institution. He had no medical history of note. On physical examination, a bony, hard mass was palpable over the acromioclavicular joint. The overlying skin was normal. The range of shoulder movement was slightly restricted due to pain. No other abnormality was detected on general physical examination. All laboratory tests (including full blood count, electrolytes, erythrocyte sedimentation rate, C-reactive protein) were within normal limits. Radiographs showed an expanded osteolytic lesion at the distal end of left clavicle (Fig. 1). The lesion had welldefined margins with internal septa. No periosteal reaction or associated soft tissue mass was present. Tc-99m MDP bone scintigraphy showed focal tracer uptake corresponding to the left distal clavicle lesion. There was early increased tracer uptake in the blood pool phase and moderately increased tracer uptake on delayed images. There was no abnormal tracer uptake elsewhere in the skeleton. Computed tomography (CT) showed an expanded osteolytic lesion at the distal end of the left clavicle. It had a thin sclerotic rim and endosteal scalloping, and measured 262 cm. The margins of the lesion were preserved except

Fig. 1 Frontal radiograph of the left shoulder shows an expanded osteolytic lesion at the distal end of the clavicle. It has well-defined margins and multiple internal septations.

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Fig. 2 Reconstructed coronal CT images show erosion of the inferior margin of the expanded lesion. The left acromioclavicular joint is intact. Note endosteal scalloping corresponding to macroscopic tumour lobulation.

for its inferior aspect which was eroded. The acromioclavicular joint was not involved. Reconstructed coronal CT images were helpful in improved demonstration of some features, such as the inferior cortical erosion. No calcification or associated soft tissue mass were present (Fig. 2). Based the imaging findings and clinical features, the preoperative diagnosis was a benign bony tumour such as an aneurysmal bone cyst or giant cell tumour. Open biopsy was carried out, with frozen section rendering a diagnosis of a chondroid lesion without overt malignancy but deferring the final decision to paraffin histology. The lesion was curetted until it was completely removed and the cavity was packed with synthetic processed bone graft. Histologically, the tumour showed a lobulated architecture, and was composed of chondroid and fibromyxoid areas. There were areas of chondroid differentiation, fibroblastic stroma and fibromyxoid zones. There were eosinophilic spindle cells juxtaposed with the chondroid areas, and scattered osteoclastic-type giant cells. The diagnosis was chondromyxoid fibroma (Fig. 3). The patient made an uneventful post-operative recovery. He has been followed up for 37 months to date, with no evidence of recurrence. Chondromyxoid fibroma is a rare benign tumour that is derived from cartilaginous-forming connective tissue. It was first described by Jaffe and Lichtenstein in 1948 as a benign lesion with variable proportions of cartilaginous, myxoid and fibrous components that could occasionally be confused with chondrosarcoma.5 This tumour occurs with an approximately equal sex ratio.2,4 The patient age is variable, ranging from 6 to 87 years. Approximately 50% of cases present in the second and third decades of life, with mean age of 31.1 years.2 A case of congenital chondromyxoid fibroma has been reported by Mendoza et al.6 The most common clinical presentation of this tumour is pain and swelling. There may also be some restriction of movement, as was seen in our case. Most chondromyxoid fibromas measure more than 3 cm in size at clinical presentation. On radiographs, they are usually seen as well-circumscribed osteolytic lesions. They may sometimes cause bony expansion. Most cases demonstrate scalloping with a thin sclerotic rim. When the lesion grows large, disruption of cortex or ‘cortical bite’ without periostitis is considered to be a characteristic feature.7 Soft tissue extension of tumour may occur but is unusual.2 Despite the unusual site, our patient had most of the radiographic features of chondromyxoid fibroma. Typically, these tumours arise in the medullary canal of the metaphysis or metadiaphysis. Isolated epiphyseal or

A

B Fig. 3 Photomicrographs of the excised chondromyxoid fibroma. (A) The tumour is lobulated in appearance (H&E, 640). (B) Eosinophilic spindle cell areas are juxtaposed with the chondroid areas (H&E, 6200).

diaphyseal located tumours are very rare.1,2 A feature of this tumour is that its long axis is often parallel to the long axis of the host bone. As seen in our case, there may be septa that represent bone ridges. Pathologically, these bone ridges do not cross the entire width of the tumour but instead represent linear peripheral endosteal scalloping.1 The endosteal scalloping was well shown on CT in our patient, and corresponded to the linear ‘septa’ seen on radiographs. Chondroid matrix calcification is an uncommon radiographic feature. CT is the best modality for evaluating lesion margin integrity and radiographically faint calcification. Despite this, CT is able to detect only 12.2% of calcified matrix in tumour, while microscopically, calcification is detected in up to 34.1% of cases.8 Bone scintigraphy typically demonstrates marked increased uptake of radionuclides. The purpose of bone scintigraphy is to exclude multiple lesions which would suggest an alternative diagnosis. Chondromyxoid fibromas are almost invariably solitary,1 typically occurring in the metaphysis of long bones of the lower extremities. In a series of 278 cases of chondromyxoid fibroma, Wu et al. reported the distribution of these tumours in long bones in 46.9%, flat bones in 30.3%, small tubular bones of hand and feet in 17.3%, and the skull and facial bones in 5.4%.2

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The most frequently affected long bone is the proximal tibia.1,2,4 Bone tumours of the clavicle are rare, approximately 80% of which are malignant.9 Chondromyxoid fibroma of the clavicle is extremely rare. To our knowledge, only three cases have been previously mentioned in the English language literature. In 278 cases of chondromyxoid fibroma in the Mayo Clinic series, there was one case affecting the clavicle,2 while another case was found in a series of 36 cases from the Albert Einstein College of Medicine.4 There is one previous case report of chondromyxoid fibroma of the clavicle.3 Nakazora et al. reported a 34-yearold Japanese woman who had a tumour arising in the diaphysis of the left clavicle.3 Radiographs, CT and magnetic resonance imaging suggested a preoperative suspicion of a malignant bone tumour and wide excision was performed. The diagnosis was only made on histological examination of the resected specimen.3 Our case had similar features to that reported by Nakazora et al. Our patient was also a young adult but the tumour was located at the distal end of the clavicle. There was partial involvement of the inferior cortex of the clavicle by an expanded osteolytic lesion. However, the well preserved fat plane and the lack of features of an aggressive bone lesion, such as soft tissue mass or periosteal reaction, led us to an initial diagnosis of a benign rather than malignant bone tumour. Our final diagnosis depended on histological examination of the biopsy material. The clavicle is classified as a flat bone. It has a unique development process, with almost the entire clavicle developing by intramembranous ossification. However, the sternal and acromial ends are preformed in cartilage, known as endochondral ossification. Chondromyxoid fibroma arises from cells related to the epiphyseal cartilage.10 Therefore, the location of tumour in this case may be explained by the endochondral ossification at the acromial (or distal) end. Pathologically, chondromyxoid fibromas are usually small tumours that are well-demarcated from the surrounding bone. On microscopic examination, the tumour fundamentally consists of distinct chondroid areas but myxomatous and fibrous zones are present in varying amounts. The tumour shows a lobulated pattern of growth, with lobules having a hypocellular center and hypercellular periphery. The tumour cells are spindle-shaped or stellate and arranged in a myxoid matrix. Multinucleated giant cells are commonly seen scattered at the periphery of cartilaginous lobules. Because they frequently have cellular pleomorphism, without radiographic and clinical correlation, chondromyxoid fibroma may potentially be misinterpreted as chondrosarcoma.11 En-bloc resection is considered the best form of treatment. As curettage alone is associated with a 25% risk of recurrence, bone grafting is recommended after curettage to decrease chances of recurrence. In our case, intraoperative frozen section consultation was unable to arrive at the definitive diagnosis, and curettage was performed instead. Malignant transformation has been reported but it is very rare, with malignant fibrous histiocytoma, fibrosarcoma and chondrosarcoma described. Malignant transformation can occur spontaneously or in post-irradiated tumours.2,4,12

Pathology (2006), 38(5), October

In conclusion, we report a case of chondromyxoid fibroma occurring in the distal clavicle of a young man. This is a rare benign tumour located at an extremely rare site. The imaging findings alone are non-specific, and the diagnosis relies on pathological examination combined with the knowledge of clinical and imaging features. Nuttaya Pattamapaspong* Wilfred C. G. Peh*§ Man Hong Tan{ Jacqueline S. G. Hwang{ Puay Hoon Tan{ Departments of *Diagnostic Radiology, {Orthopaedic Surgery, and {Pathology, Singapore General Hospital, and §Programme Office, Singapore Health Services, Singapore Contact Dr P. H. Tan. E-mail: [email protected]

1. Giudici MA, Moser RP, Kransdorf MJ. Cartilaginous bone tumours. Radiol Clin North Am 1993; 31: 237–59. 2. Wu CT, Inwards CY, O’Laughlin S, Rock MG, Beabout JW, Unni KK. Chondromyxoid fibroma of bone: a clinicopathologic review of 278 cases. Hum Pathol 1998; 29: 438–46. 3. Nakazora S, Kusuzaki K, Matsumine A, Seto M, Fukutome K, Uchida A. Case report: chondromyxoid fibroma arising at the clavicular diaphysis. Anticancer Res 2003; 23: 3517–22. 4. Zillmer DA, Dorfman HD. Chondromyxoid fibroma of bone: thirty-six cases with clinicopathological correlation. Hum Pathol 1989; 20: 952–64. 5. Jaffe HL, Lichtenstein L. Chondromyxoid fibroma of bone: a distinct benign tumour likely to be mistaken especially for chondrosarcoma. Arch Pathol 1948; 45: 541–51. 6. Mendoza M, Gonzalez I, Aperribay M, Hermosa JR, Nogues A. Congenital chondromyxoid fibroma of the ethmoid: case report. Pediatr Radiol 1998; 28: 339–41. 7. Resnick D, Kyriakos M, Greenway G. Tumours and tumour-like lesions of bone: imaging and pathology of specific lesions. In: Resnick D, editor. Diagnosis of Bone and Joint Disorders. 3rd ed. Philadelphia: Saunders. 1989; 3628–938. 8. Yamaguchi T, Dorfman HD. Radiographic and histologic patterns of calcification in chondromyxoid fibroma. Skeletal Radiol 1998; 27: 559–64. 9. Gerscovich EO, Greenspan A, Szabo RM. Benign clavicular lesions that may mimic malignancy. Skeletal Radiol 1991; 20: 173–80. 10. Steiner GC. Ultrastructure of benign cartilaginous tumours of intraosseous origin. Hum Pathol 1979; 10: 71–86. 11. Bahk WJ, Mirra JM. Pseudoanaplastic tumours of bone. Skeletal Radiol 2004; 33: 641–8. 12. Sehayik S, Rosman MA. Malignant degeneration of a chondromyxoid fibroma in a child. Can J Surg 1975; 18: 354–60.

DOI: 10.1080/00313020600922439

A case of dermatopathic lymphadenitis diagnosed by fine needle aspiration Sir, Dermatopathic lymphadenitis (DL) is a well described histological entity which presents as a reactive nodal hyperplasia, usually secondary to a skin disorder characterised by itching and scratching. It is a T-cell response to skin antigens presented and processed by interdigitating dendritic cells.1 This benign condition frequently mimics Hodgkin’s lymphoma, mycosis fungoides, Langerhans cell histiocytosis and even malignant melanoma.2–5 It is