BRIEF REPORTS

Chondrosarcoma of Calcanaeumin a 12-Year-Old Male Patient:A Case ReportKirti Gupta, M.D.,1 S. Radhika, M.D., Dip, NBE, Ph.D.,1*and R.K.Vasishta, M.D.2

Chondrosarcoma is distinctly uncommon and tends to be locatedoften in the extremities in young patients more than in its adultcounterpart. Cartilaginous tumors involving the small bones of thehands and feet are benign tumors such as enchondromas, chon-dromyxoid fibroma (CMF), and chondroblastoma. Chondrosarco-mas involving calcanaeum in young adults are largely covered inthe literature as single case reports.

A young 12-yr-male patient presented with complaints of painand mild swelling in the ankle. Radiological examination revealeda dense irregular lesion in the calcanaeum. Fine-needle aspirationwas performed and a possibility of chondrosarcoma was sus-pected, which later was confirmed on histopathologicalexamination.

The cytopathologist should be aware of the occurrence of ma-lignant chondroid tumors in the younger age group at this raresite. Correlation to radiological findings is essential in thesecases. Diagn. Cytopathol. 2004;31:399–401.© 2004 Wiley-Liss, Inc.

Key Words: chondrosarcoma; calcanaeum; cytological features

Cartilaginous tumors involving the small bones of the feetand hands are not uncommon.1 They usually are benigntumors such as enchondromas, chondromyxoid fibroma(CMF), and chondroblastoma.2 Although rare, chondrosar-coma also is known to involve these small bones of the feetand hands as reported in several studies.2–5 In a series ofchondrosarcomas of small bones of the hand and feet re-ported by Ogose et al., the calcaneus was involved com-monly and the age of the patients ranged from 14 to 95 yr.To the best of our knowledge, this is the youngest patient ofmalignant cartilaginous tumors of the calcanaeum. The di-agnosis of these lesions on fine-needle aspiration cytology

(FNAC) presents a diagnostic challenge to the cytopatholo-gists. However, the cytodiagnostic accuracy is improved bycorrelating the cytological findings along with the radiolog-ical and clinical findings.6 Here, we present a case of chon-drosarcoma of calcanaeum in a12-yr-old child.

Case ReportA 12-yr-old child presented with pain and mild swelling inthe ankle for 15 days. There was no history of trauma andclinically there was no pus discharge. An X-ray of the footshowed a dense irregular lesion in the calcanaeum (Fig. 1).Tuberculosis was suspected based on the clinical and radio-logical findings.

Fine-needle aspiration was performed by the direct per-cutaneous route using a 22-gauge fine needle attached to thesyringe in a specially designed holder (Cameco AB, Taby,Sweden). The slides made from the aspirate were air-driedand stained with May-Grunwald-Giemsa (MGG) stain andtwo slides were fixed immediately in 95% alcohol andstained with hematoxylin and eosin (H&E) stain.

Cytological FindingsThe smears were highly cellular; the cells were in abundant,pink-purple, amorphous, or granular chondroid matrix, oc-casionally resembling lacunae (Fig. 2). These cells werefound singly or in small sheets or loose aggregates. Thecells had well-delineated cytoplasmic margins with moder-ate-to-marked nuclear atypia, hyperchromasia, and promi-nent nucleoli (Fig. 3). In addition, binucleation andmultinucleation were seen. The cytological diagnosis of-fered was a chondrosarcoma but considering the young ageof the patient and the unusual site, a biopsy and histopatho-logical examination were advised before contemplating rad-ical surgery.

Histopathological FindingsThe biopsy from the tumor revealed bi- and multinucleatedchondrocytes with hyperchromatic nuclei present within the

1Department of Cytology and Gynaecologic Pathology, PostgraduateInstitute of Medical Education and Research, Chandigarh, India

2Department of Histopathology, Postgraduate Institute of Medical Edu-cation and Research, Chandigarh, India

*Correspondence to: S. Radhika, Department of Cytology and Gynaeco-logic Pathology, PGIMER, Chandigarh, India. E-mail: ashim126@glide.net.in

Received 29 December 2003; Accepted 17 May 2004DOI 10.1002/dc.20130Published online in Wiley InterScience (www.interscience.wiley.com).

© 2004 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 31, No 6 399

lacunae in a typically chondroid matrix (Fig. 4). In addition,many mitotic figures were seen as well. Subsequently, a be-low-the-knee amputation specimen was received, which againshowed a lobulated, malignant cartilaginous tumor of the cal-canaeum, confirming the diagnosis of a chondrosarcoma.

DiscussionThe majority of the patients with chondrosarcoma are be-tween 30 and 60 yr of age. Chondrosarcoma in youngpatients, compared with its adult counterpart, is distinctlyuncommon7 and tends to be located often in the extremi-ties.8 Most malignant bone tumors in this age group exhib-iting cartilaginous formation are actually osteosarcomaswith a predominant cartilaginous component.9 In a study byOgose et al., the calcaneus was the most common site forchondrosarcoma of the foot and the age of the patientsranged from 14 to 95 yr.2 The combination of a young age

and a relatively uncommon site for this tumor has promptedus to report this case.

The rarity of chondrosarcomas, unfamiliarity with thehistopathological features, and the drastic treatment optionsthat ensue lead many pathologists to be reluctant to interpretneedle core and, perhaps even more so, needle aspirationbiopsies of these neoplasms. The characteristic findings arethe presence of oval or polygonal chondrocytes with vacu-olated cytoplasm and hyperchromatic nuclei dispersed ei-ther singly or in loosely cohesive aggregates in a back-ground of chondroid matrix.

The benign lesions considered in the differential diag-noses of the cartilaginous lesions of this site are enchon-dromas and CMFs. Chondrosarcoma commonly occurs inolder patients as compared with enchondromas. The site ofinvolvement of these two lesions differs. In contrast, soli-

Fig. 1. Radiograph shows dense, irregular ill-defined lesion in the calca-naeum.

Fig. 2. Cytology of the same lesion consisting of loosely cohesive clustersof chondrocytes embedded in the abundant chondroid matrix (MGG stain,�160).

Fig. 3. Cluster of cells exhibiting nuclear atypia, hyperchromasia, andprominent nucleoli (MGG stain, �280).

Fig. 4. High-power appearance of chondrosarcoma composed of malig-nant chondrocytes present within lacunae exhibiting nuclear atypia andhyperchromasia (H&E, �280).

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tary enchondromas of the tarsal bones are extremelyrare.1Calcaneus and talus were the most common sites forchondrosarcoma of the foot in the series by Ogose et al.2

Moreover, enchondromas have characteristic radiologicalfindings that always should be correlated with cytologicalfeatures for an accurate diagnosis. Cytological smears inenchondromas show benign-appearing chondrocytespresent singly in lacunae against a chondroid background.The histological and cytological distinctions of enchon-droma from a low-grade chondrosarcoma can be difficult attimes. However, in the present case, the high cellularity andmoderate cellular atypia enabled us to diagnose malignancy.

Another important differential diagnosis is CMF. In theFNAC smears, CMF can be cellular and contain cells withenlarged, irregular nuclei and smudgy chromatin and maybe confused for malignancy. However, they lack the nuclearhyperchromasia and irregularity of the nuclear margins seenin chondrosarcoma.10,11 Moreover, the smears in CMF con-tain an admixture of chondroid, stellate, fibroblastic, andgiant osteoclastic cells, whereas chondrosarcoma typicallyshows only chondrocytes.

Hence, in clinical cytological practice, awareness of thisentity in the young age group and its occurrence in the

calcanaeum is important for the cytopathologist in order tomake the correct preoperative diagnosis.

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4. Roberts PH, Price CH. Chondrosarcoma of the bones of the hand.J Bone Joint Surg Br 1977;59:213–221.

5. Granberry WM, Bryan W. Chondrosarcoma of the trapezium: a casereport. J Hand Surg (Am) 1978;3:277–279.

6. Tune M, Ekinci C. Chondrosarcoma diagnosed by fine needle aspira-tion cytology. Acta Cytol 1996;40:283–288.

7. Young CL, Sim FH, Unni KK, McLeod RA. Chondrosarcoma of bonein children. Cancer 1990;66:1641–1648.

8. Huvos AG, Marcove RC. Chondrosarcoma in the young. A clinico-pathologic analysis of 790 patients younger than 21years of age. Am JSurg Pathol 1987;11:930–942.

9. Bone and joints. In: Rosai J, Editor, Ackerman’s surgical pathology,vol. 2, 8th ed. St. Louis, MO: Mosby Publication; 1999. 1952 p.

10. Layfield LJ, Ferreiro JA. Fine needle aspiration cytology of chondro-myxoid fibroma: a case report. Diagn Cytopathol 1988;4:148–151.

11. Gupta S, Dev G, Marya S. Chondromyxoid fibroma: a fine needleaspiration diagnosis. Diagn Cytopathol 1993;9:63–65.

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