Chondrosarcoma

Chondrosarcoma is a malignant tumour in which neoplastic cells produce cartilage matrix.

It predominantly affects adults.

Common sites include:

Pelvis
Proximal femur
Proximal humerus
Ribs
Scapula

The major biological distinction is between lower grade conventional cartilage tumours and aggressive high grade or specialised chondrosarcoma subtypes.

Histological grade

Grade 1

Low grade tumour with relatively low metastatic potential.

In appendicular sites, some lesions previously termed grade 1 chondrosarcoma are classified as atypical cartilaginous tumour because their metastatic risk is very low.

Grade 2

Intermediate grade, with greater local aggressiveness and metastatic potential.

Grade 3

High grade tumour with substantial metastatic risk.

Important specialised subtypes include:

Dedifferentiated chondrosarcoma
Mesenchymal chondrosarcoma
Clear cell chondrosarcoma

These behave differently from conventional low grade disease.

Plain radiographs: often show a destructive lesion with chondroid matrix mineralisation.
MRI: define medullary extent, soft tissue extension and relation to major neurovascular structures.
CT: particularly useful for matrix calcification and cortical destruction.
CT chest: stage intermediate and high grade disease for pulmonary metastases.
Biopsy should occur only after imaging and multidisciplinary planning.

Sampling error is important because large cartilage tumours can contain areas of differing histological grade. Target the most aggressive appearing component.

Surgery

Surgery is the principal curative treatment for most chondrosarcomas. Conventional chondrosarcoma responds poorly to standard chemotherapy and radiotherapy.

Atypical cartilaginous tumour of an extremity

A small asymptomatic lesion without aggressive radiological features can sometimes be observed.

A symptomatic or progressive lesion can undergo:

Extended intralesional curettage

with:

High speed burr
Local adjunct according to practice
Bone graft or cement reconstruction

This preserves the adjacent joint and generally provides good control for appropriately selected appendicular low grade lesions.

Higher grade conventional chondrosarcoma

Grade 2 and 3 tumours require wide en bloc resection with negative margins.

Do not perform curettage of a high grade lesion.

The operation may require:

Endoprosthetic reconstruction
Pelvic resection
Chest wall reconstruction
Biological reconstruction

Margins have major prognostic importance.

Pelvic and axial chondrosarcoma

Even apparently low grade pelvic cartilage tumours behave more aggressively and are much harder to salvage after recurrence.

Pelvic and axial chondrosarcomas generally require wide surgical excision rather than intralesional treatment.

Dedifferentiated chondrosarcoma

This consists of conventional cartilage tumour adjacent to a high grade noncartilaginous sarcoma.

It has:

High metastatic risk
Poor prognosis
High local recurrence risk

Treatment requires wide resection.

Systemic chemotherapy can be considered, often using osteosarcoma type agents in younger and fit patients, but treatment responsiveness is substantially less predictable than conventional osteosarcoma.

Mesenchymal chondrosarcoma

This rare subtype is more chemotherapy sensitive than conventional chondrosarcoma.

Treatment commonly combines:

Wide resection
Multiagent systemic chemotherapy
Radiotherapy in selected cases

Systemic treatment frequently resembles Ewing sarcoma treatment.

Clear cell chondrosarcoma

Usually lower grade but locally recurrent if inadequately excised.

Treat with wide resection.

Radiotherapy

Conventional chondrosarcoma is relatively radioresistant.

Radiotherapy has a role for:

Unresectable disease
Inadequate margins when reoperation is impossible
Skull base and spinal disease where complete resection is unsafe
Palliation

High precision proton or carbon ion techniques can be valuable in selected axial tumours.

Metastatic disease

Pulmonary metastasectomy can be considered when:

Disease is limited
Primary tumour is controlled
Complete pulmonary resection is achievable

Systemic treatment depends heavily on subtype and molecular findings rather than using one generic chondrosarcoma regimen.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Hepatocellular Carcinoma

Also known as: HCC, Liver cancer

Primary malignancy of hepatocytes, arising overwhelmingly in the context of chronic liver disease, most commonly cirrhosis from chronic hepatitis B, chronic hepatitis C, alcohol related liver disease, and increasingly MASLD.

Hepatitis B carries a unique ability to cause hepatocellular carcinoma even without cirrhosis, through direct viral integration into the host genome, which is why surveillance in high risk hepatitis B carriers begins independent of fibrosis stage in some guidelines (for example, Asian men over 40 and African patients over 20, per the risk thresholds noted in the Hepatitis B entry).

Often detected through surveillance in an asymptomatic patient with known cirrhosis.
Symptomatic presentation reflects advanced disease: right upper quadrant pain, weight loss, worsening ascites, new or worsening jaundice, and decompensation of previously stable cirrhosis.
A palpable liver mass or bruit may be present. Rupture with intraperitoneal hemorrhage is a rare but recognized acute presentation, causing sudden severe abdominal pain and hypovolemic shock.

In a cirrhotic patient, hepatocellular carcinoma can be diagnosed radiologically without biopsy if a lesion above 1 cm shows the characteristic pattern of arterial phase hyperenhancement with portal venous or delayed phase washout on contrast enhanced CT or MRI (the LI-RADS classification formalizes this).

Biopsy is reserved for atypical imaging or a non-cirrhotic liver.

AFP (alpha-fetoprotein) supports diagnosis and is used for monitoring treatment response, though it lacks sufficient sensitivity to be used alone for surveillance or diagnosis.

Surveillance in at risk patients (cirrhosis of any cause, and high risk hepatitis B carriers as above) uses six monthly ultrasound with or without AFP.

Staging uses the Barcelona Clinic Liver Cancer (BCLC) system, which uniquely incorporates tumor burden, liver function (Child-Pugh class), and performance status together, since treatment options and prognosis in hepatocellular carcinoma depend as much on underlying liver reserve as on tumor stage.

Differentials include other focal liver lesions in a cirrhotic liver (regenerative or dysplastic nodules, hemangioma), intrahepatic cholangiocarcinoma, and metastatic disease to the liver.

Management follows BCLC staged treatment allocation.

Very early and early stage disease (BCLC 0 to A) in patients with preserved liver function is treated with surgical resection, liver transplantation (particularly attractive since it treats both the tumor and the underlying cirrhosis, using Milan criteria to select appropriate candidates), or percutaneous ablation (radiofrequency or microwave ablation) for small tumors unsuitable for resection.

Intermediate stage disease (BCLC B, multinodular, preserved liver function) is treated with transarterial chemoembolization (TACE), delivering chemotherapy directly to the tumor via its arterial supply while embolizing the vessel.

Advanced stage disease (BCLC C, vascular invasion or extrahepatic spread) is treated with systemic therapy, including tyrosine kinase inhibitors (sorafenib, lenvatinib) and, increasingly first-line, combination immunotherapy (atezolizumab with bevacizumab).

Terminal stage disease (BCLC D, poor liver function or performance status) receives best supportive and palliative care, since aggressive treatment offers no benefit and may cause harm in this group.

Referral: hepatobiliary surgery, hepatology, and oncology multidisciplinary team for all confirmed or suspected cases; liver transplant unit assessment where criteria may be met.

Chondrosarcoma

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management