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Successfully Treated Lung and Renal Metastases from Primary Chondrosarcoma of the Scapula with Radiofrequency Ablation and Surgical Resection

Successfully Treated Lung and Renal Metastases from Primary Chondrosarcoma of the Scapula with... Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 6475356, 5 pages https://doi.org/10.1155/2019/6475356 Case Report Successfully Treated Lung and Renal Metastases from Primary Chondrosarcoma of the Scapula with Radiofrequency Ablation and Surgical Resection 1 1 1 1 2 Sho Sekito, Manabu Kato, Kouhei Nishikawa, Yuko Yoshio, Masahiro Kanai, 1 1 1 Hideki Kanda, Kiminobu Arima, and Yoshiki Sugimura Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan Department of Urology, Suzuka General Hospital, Suzuka, Mie, Japan Correspondence should be addressed to Yoshiki Sugimura; sugimura@clin.medic.mie-u.ac.jp Received 5 November 2018; Accepted 20 January 2019; Published 9 June 2019 Academic Editor: Constantine Gennatas Copyright © 2019 Sho Sekito et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Since chondrosarcoma is a relatively rare type of malignant bone tumors characterized by its ability to produce a cartilage matrix and aggressive behavior, a consensus clinical management strategy has not been established. We report a 55-year-old woman who presented with renal metastasis arising from chondrosarcoma of the scapula. Chondrosarcoma of the left scapula was diagnosed 15 years earlier. After surgical resection of a local recurrence in the left scapula, she received focal radiofrequency ablation (RFA). She underwent focal RFA and surgical resection for a total of 21 times for lung metastases. Because invasion of the renal pelvis was suspected from urine cytology, she underwent laparoscopic nephroureterectomy. The histopathological findings showed metastatic chondrosarcoma involving the right renal parenchyma. The patient has remained clinically stable without recurrence for 18 months. To the best of our knowledge, this is the first report of metastatic chondrosarcoma of the lung and renal parenchyma with involvement of the renal pelvis in which remission was achieved with multimodal treatment including RFA and surgical resection. has been reached on whether wide resection or adequate 1. Introduction surgical marginal resection, or even interventional radiol- Chondrosarcoma is the second most common primary ogy (IVR), should be performed; therefore, clinical studies malignant bone tumor after osteosarcoma in the United are necessary to determine the best method of achieving States [1, 2]. Chondrosarcoma shows varying histopathology remission in chondrosarcoma patients using a multimodal and clinical behavior consisting of skeletal (central) and approach. Chondrosarcoma metastasis to the kidney is rela- extraskeletal (peripheral) types. Among these, conventional tively rare—some cases have been reported in the literature central chondrosarcoma is the most frequent type [2]. Based [5–8]. Here, we present a case of renal metastasis arising from on histopathological features, including cell atypia, mitotic primary chondrosarcoma of the scapula that was treated figures, and cellularity, chondrosarcoma is divided into four with multiple procedures, including radiofrequency ablation groups: benign enchondroma and malignant Grade 1, 2, (RFA) and surgery. A short review of the literature is pro- and 3 chondrosarcomas. Chondrosarcoma requires treat- vided to evaluate the possibility of multimodal treatment ment, with surgery being the mainstay of treatment since resulting in a clinical benefit in metastatic chondrosarcoma. chemotherapy and radiation therapy have not demonstrated any efficacy in chondrosarcoma patients [1–4]. Surgical pro- 2. Case Report cedures have been developed to treat chondrosarcoma, even though the tumors are prevalent in different locations in A 55-year-old woman who presented with gross hematuria the body and are of different grades. No medical consensus was admitted to our department for a slow-growing right 2 Case Reports in Oncological Medicine (a) (b) (c) Figure 1: Pathological examination. (a) The primary tumor of her left shoulder demonstrated the sheets of differentiated cartilage cells. (b) Immunohistochemical staining showed positive for toluidine blue reflecting cartilage cells containing acidic mucopolysaccharide. (c) Pathological examination in the kidney was similar to that in the primary tumor of her left shoulder. (a) (b) (c) Figure 2: (a) CT scan demonstrated a cyst in the upper half of the right kidney and no septa or calcifications (arrow). (b) T2-weighted MRI showed a cystic tumor with a high signal (arrow). (c) Diffusion-weighted MRI (DW-MRI) showed rim enhancement (arrow). Case Reports in Oncological Medicine 3 Figure 3: On retrograde pyelography, an incomplete double ureter was showed and a solitary filling defect was observed in the upper pole of the right renal pelvis (arrow). Figure 5: Tumor located in the upper pole with invasion into the renal pelvis. radiologist at our institute. Cooled RFA electrodes (Cool- tip, Valleylab) with a 2 or 3 cm exposed tip were connected to a generator (series CC-1-100, Valleylab) and were inserted into the tumor. Power was applied for a period of 10-12 min using an impedance control algorithm [9]. Six years after RFA treatment, following multiple treatments to the same lesion, VATS was again conducted for a left upper lobe lung metastasis refractory tumor. She then underwent six addi- Figure 4: Urine cytology demonstrated low-grade malignant cells tional RFA procedures for metastatic chondrosarcoma to with a mucus-like substance (×400). bilateral lower lung lobes over the next 5 years. In total, she received 19 RFA and 2 VATS procedures for lung metastases. renal mass monitored over time by computed tomography No relapse of the pulmonary metastasis occurred in 4 years (CT). Chondrosarcoma of the left scapula was diagnosed prior to being admitted to our department. 15 years earlier. She presented with left shoulder pain, and At the time of admission to the urology department, a left scapula X-ray revealed a 7 cm mass with calcification. the patient’s laboratory results were within normal ranges, Magnetic resonance imaging (MRI) displayed a low signal except for the presence of red blood cells in the urinalysis. on T1-weighted and a high signal on T2-weighted. She Three years before the latest admission, CT revealed a cystic underwent scapula and humerus wide margin resection of tumor in the upper half of the right kidney. Over a period of 3 the primary tumor with artificial humeral head replacement. years, the cyst developed from 14 mm to 46 mm. No septa or The tumor was composed of cartilage cells growing a lobular calcifications were observed in the tumor (Figure 2(a)). architecture with eosinophilic reticulum and myxoid stro- Hydronephrosis was not present, and the right ureter was mal tissue and was diagnosed as Grade 2 chondrosarcoma normal. The patient did not undergo a contrast-enhanced (Figure 1(a)). Initial surgical treatment showed no evidence CT due to iodine allergy. A 45 mm cystic tumor without of a residual tumor in the disease area and was deemed a suc- septa, calcifications, or solid components was seen in the cessful surgery. Two years after the initial resection, she upper pole of the right kidney on MRI, displaying a low developed a local recurrence in the left scapula and subse- signal on T1-weighted and a high signal on T2-weighted quently underwent extensive resection surgery for both the MRI. Diffusion-weighted (DW) MRI showed rim enhance- tumor and clavicle. No residual tumor was detected following ment. Contrast-enhanced images showed a thick, slightly surgery. In the following year, multiple bilateral lung nodule enhanced cystic wall, and the tumor was classified as a shadows appeared on CT. Video-assisted thoracic surgery Bosniak IIF cystic renal lesion (Figure 2(b)). Retrograde (VATS) was performed after being diagnosed with metastatic pyelography demonstrated a solitary filling defect in the chondrosarcoma to the lung. She proceeded to undergo 13 upper pole of the right renal pelvis (Figure 3). Urine cytol- RFA procedures for lung metastatic chondrosarcoma, with ogy demonstrated low-grade malignant cells with a light the RFA procedure being performed by an experienced green stained large reticulum and a mucus-like substance 4 Case Reports in Oncological Medicine Table 1: Summary of reported renal metastasis of chondrosarcoma. Author Year Age Gender Primary location Lung metastasis Period from primary treatment Treatment Riggins and Wertlake 1965 28 F Femur Yes 8 years Nephrectomy Liguori et al. 2000 66 M Rib Yes 5 years Nephrectomy Fukumoto et al. 2013 49 F Lumber Yes 5 years Partial nephrectomy Our case 2015 55 F Shoulder Yes 15 years Nephroureterectomy (Figure 4). The preoperative differential diagnosis included In addition, among primary malignant bone tumors, chon- drosarcoma is characterized by a high apparent diffusion cystic renal cell carcinoma, carcinoma of the renal pelvis, and metastatic chondrosarcoma. The patient underwent laparo- coefficient (ADC) on MRI [13]. The combination of CT, scopic nephroureterectomy, partial cystectomy, and regional contrast-enhanced MRI, DW-MRI, and ADC may increase lymph node resection. Macroscopically, the resected speci- the diagnostic accuracy of a preoperative imaging workup men contained a well-circumscribed tumor measuring 5× for patients with renal tumors. 4cm. The tumor involved the renal pelvis, and the cut surface Most chondrosarcomas are slow-growing tumors with of the tumor was white and jelly-like (Figure 5). Histopatho- low metastatic potential that are considered to be refractory logical findings showed a myxoid tumor in the tumor wall to both chemotherapy and radiation therapy due to a low that invaded the renal pelvis. A cartilaginous tumor com- percentage of actively dividing cells and vascular components posed of atypical cartilage cells was observed. No tumor cells [2, 10]. Therefore, for most cases, surgery (wide or en bloc were present in the ureter. Considering the primary tumor excision) is the only therapeutic option [2, 14]. According pathological findings, we hypothesized that the tumor was to the National Cancer Database report, the overall 5- composed of cartilage cells with a high cell density and year survival rate is 75.2% [15]. Angelini et al. reported 5- enlarged nuclei (Figure 1(a)). The tumor cells were positive year survival rates of 99%, 92%, and 77% for patients with for toluidine blue staining, confirming a cartilaginous com- Grade 1, 2, and 3 conventional chondrosarcomas, respec- ponent (Figure 1(b)). The kidney tumor was also diagnosed tively [10]. Metastatic disease develops in 24% of patients, as Grade 2 chondrosarcoma (Figure 1(c)). The resected with a 5-year survival rate of 18% [16]. Chondrosarcomas lymph nodes were negative for metastasis. The final patho- primarily metastasize to the lung; however, other metastatic sites include the humerus, femur, sternum, brain, liver, logical diagnosis was chondrosarcoma metastasis to the kid- ney. The patient’s postoperative course is promising, and she pleura, heart, and ureter. Tumors recur in 18% of patients, has remained disease-free for over 18 months of follow-up. with a mean period between primary surgery and relapse of 24 months [16]. Italiano and colleagues reported that patients with metastatic advanced chondrosarcoma treated 3. Discussion with anthracycline-based chemotherapy experienced mean Chondrosarcoma is a tumor that originates from cartilage overall survival of 18 months [17]. Radiotherapy might pro- vide some benefits in patients with conventional chondrosar- [4]. Compared to osteosarcomas, chondrosarcomas tend to be more prevalent in the older population and exhibit a coma, although its role may be palliative for symptom relief higher frequency of central locations [10]. Clinical symptoms [2]. As shown in these previous reports, neither radiotherapy nor chemotherapy appeared to be curative. However, there is are nonspecific, with pain being the most frequent symptom; swelling and a palpable soft tissue mass have also been one report of a child with high-grade chondrosarcoma in the described [1, 11]. Differential diagnoses include juxtacortical base of the skull that was successfully treated with chemora- chondroma, parosteal osteosarcoma, and periosteal osteosar- diation [18]. Thus, in addition to surgery, multimodal coma [2, 11]. Imaging findings of conventional chondrosar- therapy including chemoradiation may control chondrosar- coma for some time. The present case experienced a long coma typically show a mixed lytic and sclerotic appearance. The sclerotic areas reflect cartilage matrix mineralization disease-free period after treatment with RFA, suggesting that [11]. Both intraosseous and extraosseous chondrosarcomas a well-planned procedure for local or distant disease can mit- with nonmineralized components typically show low attenu- igate high-grade chondrosarcoma. ation and mineralization on CT imaging. Contrast-enhanced A review of literature identified nine case reports of pri- mary chondrosarcoma of the kidney and three case reports CT demonstrates a mild peripheral rim and septal enhance- ment. Higher-grade lesions may show higher CT attenuation, of renal metastasis from chondrosarcoma [5–8] (Table 1). similar to that of a muscle, and more contrast enhancement, These previous renal metastasis cases underwent local treat- reflecting increased cellularity and a reduced water content. ment for lung metastasis. The minimum time from primary The nonmineralized components of chondrosarcoma have treatment to detection of renal metastasis was 4 years. We believe that the kidney metastasis in the present case resulted high signal intensity on T2-weighted MRI, reflecting the high water content of hyaline cartilage [11, 12]. Therefore, a renal from hematogenous spread from a lung metastasis. Our metastasis from chondrosarcoma resembles a complicated patient experienced a total of 23 recurrences, including renal cyst on MRI. In the present case, the CT and MRI find- lesions located in the scapula, lungs, and kidney that were ings were similar to those of images of the local recurrence treated locally, over a period of 15 years. This suggests that repeated local treatments such as surgery and RFA for after the first resection of chondrosarcoma in the scapula. Case Reports in Oncological Medicine 5 metastases may dramatically improve the 5-year survival AFIP: imaging of primary chondrosarcoma: radiologic- pathologic correlation,” Radiographics, vol. 23, no. 5, rate of patients with metastatic chondrosarcoma. All cases pp. 1245–1278, 2003. of kidney metastasis were treated by surgery. Nephrectomy [12] M. D. Murphey, D. J. Flemming, S. R. Boyea, J. A. Bojescul, was performed for 2 patients and partial nephrectomy for 1 D. E. Sweet, and H. T. Temple, “Enchondroma versus chon- patient on review of case reports. To the best of our knowl- drosarcoma in the appendicular skeleton: differentiating fea- edge, the present patient in this case report is the first with tures,” RadioGraphics, vol. 18, no. 5, pp. 1213–1237, 1998. invasion to the renal pelvis, requiring nephroureterectomy. [13] T. Yakushiji, K. Oka, H. Sato et al., “Characterization of Experience with additional cases will help establish better chondroblastic osteosarcoma: gadolinium-enhanced versus treatment strategies for the local control of renal metastasis diffusion-weighted MR imaging,” Journal of Magnetic Reso- arising from primary chondrosarcoma. nance Imaging, vol. 29, no. 4, pp. 895–900, 2009. [14] F. Fiorenza, A. Abudu, R. J. Grimer et al., “Risk factors for Conflicts of Interest survival and local control in chondrosarcoma of bone,” The Journal of Bone and Joint Surgery, vol. 84, no. 1, pp. 93–99, The authors have no areas of conflicts to declare. [15] T. A. Damron, W. G. Ward, and A. Stewart, “Osteosarcoma, Acknowledgments chondrosarcoma, and Ewing’s sarcoma: National Cancer Data Base Report,” Clinical Orthopaedics and Related Research, We show special thanks to Frank Duong at AbbVie vol. 459, pp. 40–47, 2007. Stemcentrx LLC in South San Francisco for the editing of [16] J. Bruns, M. Elbracht, and O. Niggemeyer, “Chondrosarcoma this manuscript. of bone: an oncological and functional follow-up study,” Annals of oncology, vol. 12, no. 6, pp. 859–864, 2001. References [17] A. Italiano, O. Mir, A. Cioffi et al., “Advanced chondrosarco- mas: role of chemotherapy and survival,” Annals of Oncology, [1] K. K. Unni and D. C. Dahlin, Dahlin’s Bone Tumors: Gen- vol. 24, no. 11, pp. 2916–2922, 2013. eral Aspects and Data on 11,087 Cases, Lippincott-Raven, Philadelphia, PA, USA, 5th edition, 1996. [18] T. Yoshimoto, Y. Sawamura, J. Ikeda, N. Ishii, and H. Abe, [2] H. Gelderblom, P. C. W. Hogendoorn, S. D. Dijkstra et al., “Successful chemoradiation therapy for high-grade skull base chondrosarcoma in a child,” Child's Nervous System, vol. 11, “The clinical approach towards chondrosarcoma,” Oncologist, vol. 13, no. 3, pp. 320–329, 2008. no. 4, pp. 250–253, 1995. [3] M. Etchebehere, O. P. de Camargo, A. T. Croci, C. R. Oliveira, and A. M. Baptista, “Relationship between surgical procedure and outcome for patients with grade I chondrosarcomas,” Clinics, vol. 60, no. 2, pp. 121–126, 2005. [4] J. H. Healey and J. M. Lane, “Chondrosarcoma,” Clinical Orthopaedics and Related Research, vol. 204, no. 204, pp. 119–129, 1986. [5] R. S. Riggins and P. T. Wertlake, “Metastatic chondrosarcoma to the kidney,” The American Journal of Surgery, vol. 109, no. 2, pp. 209–212, 1965. [6] G. Liguori, S. Bucci, L. Buttazzi, C. Trombetta, M. Cortale, and E. Belgrano, “A renal metastasis from primary peripheral chondrosarcoma presenting as spontaneous retroperito- neal hematoma,” Archivio Italiano di Urologia, Andrologia, vol. 72, pp. 292–294, 2000. [7] T. Fukumoto, Y. Yanagihara, K. Shimamoto et al., “Metastatic chondrosarcoma in bilateral kidneys: a case report,” The Nishi- nihon Journal of Urology, vol. 75, pp. 135–139, 2013. [8] P. Valente, J. A. Macedo-Dias, C. Lobato, M. Reis, and F. Pina, “Primary mesenchymal chondrosarcoma of the kidney: a case report and review of literature,” Journal of Cancer Research and Therapeutics, vol. 14, no. 3, pp. 694–696, 2018. [9] M. Kashima, K. Yamakado, H. Takaki et al., “Complications After 1000 Lung Radiofrequency Ablation Sessions in 420 Patients: A Single Center’s Experiences,” American Journal of Roentgenology, vol. 197, no. 4, pp. W576–W580, 2011. [10] A. Angelini, G. Guerra, A. F. Mavrogenis, E. Pala, P. Picci, and P. Ruggieri, “Clinical outcome of central conventional chondrosarcoma,” Journal of Surgical Oncology, vol. 106, no. 8, pp. 929–937, 2012. [11] M. D. Murphey, E. A. Walker, A. J. Wilson, M. J. Kransdorf, H. T. Temple, and F. H. 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Successfully Treated Lung and Renal Metastases from Primary Chondrosarcoma of the Scapula with Radiofrequency Ablation and Surgical Resection

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Copyright © 2019 Sho Sekito et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 6475356, 5 pages https://doi.org/10.1155/2019/6475356 Case Report Successfully Treated Lung and Renal Metastases from Primary Chondrosarcoma of the Scapula with Radiofrequency Ablation and Surgical Resection 1 1 1 1 2 Sho Sekito, Manabu Kato, Kouhei Nishikawa, Yuko Yoshio, Masahiro Kanai, 1 1 1 Hideki Kanda, Kiminobu Arima, and Yoshiki Sugimura Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan Department of Urology, Suzuka General Hospital, Suzuka, Mie, Japan Correspondence should be addressed to Yoshiki Sugimura; sugimura@clin.medic.mie-u.ac.jp Received 5 November 2018; Accepted 20 January 2019; Published 9 June 2019 Academic Editor: Constantine Gennatas Copyright © 2019 Sho Sekito et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Since chondrosarcoma is a relatively rare type of malignant bone tumors characterized by its ability to produce a cartilage matrix and aggressive behavior, a consensus clinical management strategy has not been established. We report a 55-year-old woman who presented with renal metastasis arising from chondrosarcoma of the scapula. Chondrosarcoma of the left scapula was diagnosed 15 years earlier. After surgical resection of a local recurrence in the left scapula, she received focal radiofrequency ablation (RFA). She underwent focal RFA and surgical resection for a total of 21 times for lung metastases. Because invasion of the renal pelvis was suspected from urine cytology, she underwent laparoscopic nephroureterectomy. The histopathological findings showed metastatic chondrosarcoma involving the right renal parenchyma. The patient has remained clinically stable without recurrence for 18 months. To the best of our knowledge, this is the first report of metastatic chondrosarcoma of the lung and renal parenchyma with involvement of the renal pelvis in which remission was achieved with multimodal treatment including RFA and surgical resection. has been reached on whether wide resection or adequate 1. Introduction surgical marginal resection, or even interventional radiol- Chondrosarcoma is the second most common primary ogy (IVR), should be performed; therefore, clinical studies malignant bone tumor after osteosarcoma in the United are necessary to determine the best method of achieving States [1, 2]. Chondrosarcoma shows varying histopathology remission in chondrosarcoma patients using a multimodal and clinical behavior consisting of skeletal (central) and approach. Chondrosarcoma metastasis to the kidney is rela- extraskeletal (peripheral) types. Among these, conventional tively rare—some cases have been reported in the literature central chondrosarcoma is the most frequent type [2]. Based [5–8]. Here, we present a case of renal metastasis arising from on histopathological features, including cell atypia, mitotic primary chondrosarcoma of the scapula that was treated figures, and cellularity, chondrosarcoma is divided into four with multiple procedures, including radiofrequency ablation groups: benign enchondroma and malignant Grade 1, 2, (RFA) and surgery. A short review of the literature is pro- and 3 chondrosarcomas. Chondrosarcoma requires treat- vided to evaluate the possibility of multimodal treatment ment, with surgery being the mainstay of treatment since resulting in a clinical benefit in metastatic chondrosarcoma. chemotherapy and radiation therapy have not demonstrated any efficacy in chondrosarcoma patients [1–4]. Surgical pro- 2. Case Report cedures have been developed to treat chondrosarcoma, even though the tumors are prevalent in different locations in A 55-year-old woman who presented with gross hematuria the body and are of different grades. No medical consensus was admitted to our department for a slow-growing right 2 Case Reports in Oncological Medicine (a) (b) (c) Figure 1: Pathological examination. (a) The primary tumor of her left shoulder demonstrated the sheets of differentiated cartilage cells. (b) Immunohistochemical staining showed positive for toluidine blue reflecting cartilage cells containing acidic mucopolysaccharide. (c) Pathological examination in the kidney was similar to that in the primary tumor of her left shoulder. (a) (b) (c) Figure 2: (a) CT scan demonstrated a cyst in the upper half of the right kidney and no septa or calcifications (arrow). (b) T2-weighted MRI showed a cystic tumor with a high signal (arrow). (c) Diffusion-weighted MRI (DW-MRI) showed rim enhancement (arrow). Case Reports in Oncological Medicine 3 Figure 3: On retrograde pyelography, an incomplete double ureter was showed and a solitary filling defect was observed in the upper pole of the right renal pelvis (arrow). Figure 5: Tumor located in the upper pole with invasion into the renal pelvis. radiologist at our institute. Cooled RFA electrodes (Cool- tip, Valleylab) with a 2 or 3 cm exposed tip were connected to a generator (series CC-1-100, Valleylab) and were inserted into the tumor. Power was applied for a period of 10-12 min using an impedance control algorithm [9]. Six years after RFA treatment, following multiple treatments to the same lesion, VATS was again conducted for a left upper lobe lung metastasis refractory tumor. She then underwent six addi- Figure 4: Urine cytology demonstrated low-grade malignant cells tional RFA procedures for metastatic chondrosarcoma to with a mucus-like substance (×400). bilateral lower lung lobes over the next 5 years. In total, she received 19 RFA and 2 VATS procedures for lung metastases. renal mass monitored over time by computed tomography No relapse of the pulmonary metastasis occurred in 4 years (CT). Chondrosarcoma of the left scapula was diagnosed prior to being admitted to our department. 15 years earlier. She presented with left shoulder pain, and At the time of admission to the urology department, a left scapula X-ray revealed a 7 cm mass with calcification. the patient’s laboratory results were within normal ranges, Magnetic resonance imaging (MRI) displayed a low signal except for the presence of red blood cells in the urinalysis. on T1-weighted and a high signal on T2-weighted. She Three years before the latest admission, CT revealed a cystic underwent scapula and humerus wide margin resection of tumor in the upper half of the right kidney. Over a period of 3 the primary tumor with artificial humeral head replacement. years, the cyst developed from 14 mm to 46 mm. No septa or The tumor was composed of cartilage cells growing a lobular calcifications were observed in the tumor (Figure 2(a)). architecture with eosinophilic reticulum and myxoid stro- Hydronephrosis was not present, and the right ureter was mal tissue and was diagnosed as Grade 2 chondrosarcoma normal. The patient did not undergo a contrast-enhanced (Figure 1(a)). Initial surgical treatment showed no evidence CT due to iodine allergy. A 45 mm cystic tumor without of a residual tumor in the disease area and was deemed a suc- septa, calcifications, or solid components was seen in the cessful surgery. Two years after the initial resection, she upper pole of the right kidney on MRI, displaying a low developed a local recurrence in the left scapula and subse- signal on T1-weighted and a high signal on T2-weighted quently underwent extensive resection surgery for both the MRI. Diffusion-weighted (DW) MRI showed rim enhance- tumor and clavicle. No residual tumor was detected following ment. Contrast-enhanced images showed a thick, slightly surgery. In the following year, multiple bilateral lung nodule enhanced cystic wall, and the tumor was classified as a shadows appeared on CT. Video-assisted thoracic surgery Bosniak IIF cystic renal lesion (Figure 2(b)). Retrograde (VATS) was performed after being diagnosed with metastatic pyelography demonstrated a solitary filling defect in the chondrosarcoma to the lung. She proceeded to undergo 13 upper pole of the right renal pelvis (Figure 3). Urine cytol- RFA procedures for lung metastatic chondrosarcoma, with ogy demonstrated low-grade malignant cells with a light the RFA procedure being performed by an experienced green stained large reticulum and a mucus-like substance 4 Case Reports in Oncological Medicine Table 1: Summary of reported renal metastasis of chondrosarcoma. Author Year Age Gender Primary location Lung metastasis Period from primary treatment Treatment Riggins and Wertlake 1965 28 F Femur Yes 8 years Nephrectomy Liguori et al. 2000 66 M Rib Yes 5 years Nephrectomy Fukumoto et al. 2013 49 F Lumber Yes 5 years Partial nephrectomy Our case 2015 55 F Shoulder Yes 15 years Nephroureterectomy (Figure 4). The preoperative differential diagnosis included In addition, among primary malignant bone tumors, chon- drosarcoma is characterized by a high apparent diffusion cystic renal cell carcinoma, carcinoma of the renal pelvis, and metastatic chondrosarcoma. The patient underwent laparo- coefficient (ADC) on MRI [13]. The combination of CT, scopic nephroureterectomy, partial cystectomy, and regional contrast-enhanced MRI, DW-MRI, and ADC may increase lymph node resection. Macroscopically, the resected speci- the diagnostic accuracy of a preoperative imaging workup men contained a well-circumscribed tumor measuring 5× for patients with renal tumors. 4cm. The tumor involved the renal pelvis, and the cut surface Most chondrosarcomas are slow-growing tumors with of the tumor was white and jelly-like (Figure 5). Histopatho- low metastatic potential that are considered to be refractory logical findings showed a myxoid tumor in the tumor wall to both chemotherapy and radiation therapy due to a low that invaded the renal pelvis. A cartilaginous tumor com- percentage of actively dividing cells and vascular components posed of atypical cartilage cells was observed. No tumor cells [2, 10]. Therefore, for most cases, surgery (wide or en bloc were present in the ureter. Considering the primary tumor excision) is the only therapeutic option [2, 14]. According pathological findings, we hypothesized that the tumor was to the National Cancer Database report, the overall 5- composed of cartilage cells with a high cell density and year survival rate is 75.2% [15]. Angelini et al. reported 5- enlarged nuclei (Figure 1(a)). The tumor cells were positive year survival rates of 99%, 92%, and 77% for patients with for toluidine blue staining, confirming a cartilaginous com- Grade 1, 2, and 3 conventional chondrosarcomas, respec- ponent (Figure 1(b)). The kidney tumor was also diagnosed tively [10]. Metastatic disease develops in 24% of patients, as Grade 2 chondrosarcoma (Figure 1(c)). The resected with a 5-year survival rate of 18% [16]. Chondrosarcomas lymph nodes were negative for metastasis. The final patho- primarily metastasize to the lung; however, other metastatic sites include the humerus, femur, sternum, brain, liver, logical diagnosis was chondrosarcoma metastasis to the kid- ney. The patient’s postoperative course is promising, and she pleura, heart, and ureter. Tumors recur in 18% of patients, has remained disease-free for over 18 months of follow-up. with a mean period between primary surgery and relapse of 24 months [16]. Italiano and colleagues reported that patients with metastatic advanced chondrosarcoma treated 3. Discussion with anthracycline-based chemotherapy experienced mean Chondrosarcoma is a tumor that originates from cartilage overall survival of 18 months [17]. Radiotherapy might pro- vide some benefits in patients with conventional chondrosar- [4]. Compared to osteosarcomas, chondrosarcomas tend to be more prevalent in the older population and exhibit a coma, although its role may be palliative for symptom relief higher frequency of central locations [10]. Clinical symptoms [2]. As shown in these previous reports, neither radiotherapy nor chemotherapy appeared to be curative. However, there is are nonspecific, with pain being the most frequent symptom; swelling and a palpable soft tissue mass have also been one report of a child with high-grade chondrosarcoma in the described [1, 11]. Differential diagnoses include juxtacortical base of the skull that was successfully treated with chemora- chondroma, parosteal osteosarcoma, and periosteal osteosar- diation [18]. Thus, in addition to surgery, multimodal coma [2, 11]. Imaging findings of conventional chondrosar- therapy including chemoradiation may control chondrosar- coma for some time. The present case experienced a long coma typically show a mixed lytic and sclerotic appearance. The sclerotic areas reflect cartilage matrix mineralization disease-free period after treatment with RFA, suggesting that [11]. Both intraosseous and extraosseous chondrosarcomas a well-planned procedure for local or distant disease can mit- with nonmineralized components typically show low attenu- igate high-grade chondrosarcoma. ation and mineralization on CT imaging. Contrast-enhanced A review of literature identified nine case reports of pri- mary chondrosarcoma of the kidney and three case reports CT demonstrates a mild peripheral rim and septal enhance- ment. Higher-grade lesions may show higher CT attenuation, of renal metastasis from chondrosarcoma [5–8] (Table 1). similar to that of a muscle, and more contrast enhancement, These previous renal metastasis cases underwent local treat- reflecting increased cellularity and a reduced water content. ment for lung metastasis. The minimum time from primary The nonmineralized components of chondrosarcoma have treatment to detection of renal metastasis was 4 years. We believe that the kidney metastasis in the present case resulted high signal intensity on T2-weighted MRI, reflecting the high water content of hyaline cartilage [11, 12]. Therefore, a renal from hematogenous spread from a lung metastasis. Our metastasis from chondrosarcoma resembles a complicated patient experienced a total of 23 recurrences, including renal cyst on MRI. In the present case, the CT and MRI find- lesions located in the scapula, lungs, and kidney that were ings were similar to those of images of the local recurrence treated locally, over a period of 15 years. This suggests that repeated local treatments such as surgery and RFA for after the first resection of chondrosarcoma in the scapula. Case Reports in Oncological Medicine 5 metastases may dramatically improve the 5-year survival AFIP: imaging of primary chondrosarcoma: radiologic- pathologic correlation,” Radiographics, vol. 23, no. 5, rate of patients with metastatic chondrosarcoma. All cases pp. 1245–1278, 2003. of kidney metastasis were treated by surgery. Nephrectomy [12] M. D. Murphey, D. J. Flemming, S. R. Boyea, J. A. Bojescul, was performed for 2 patients and partial nephrectomy for 1 D. E. Sweet, and H. T. Temple, “Enchondroma versus chon- patient on review of case reports. To the best of our knowl- drosarcoma in the appendicular skeleton: differentiating fea- edge, the present patient in this case report is the first with tures,” RadioGraphics, vol. 18, no. 5, pp. 1213–1237, 1998. invasion to the renal pelvis, requiring nephroureterectomy. [13] T. Yakushiji, K. Oka, H. Sato et al., “Characterization of Experience with additional cases will help establish better chondroblastic osteosarcoma: gadolinium-enhanced versus treatment strategies for the local control of renal metastasis diffusion-weighted MR imaging,” Journal of Magnetic Reso- arising from primary chondrosarcoma. nance Imaging, vol. 29, no. 4, pp. 895–900, 2009. [14] F. Fiorenza, A. Abudu, R. J. Grimer et al., “Risk factors for Conflicts of Interest survival and local control in chondrosarcoma of bone,” The Journal of Bone and Joint Surgery, vol. 84, no. 1, pp. 93–99, The authors have no areas of conflicts to declare. [15] T. A. Damron, W. G. Ward, and A. Stewart, “Osteosarcoma, Acknowledgments chondrosarcoma, and Ewing’s sarcoma: National Cancer Data Base Report,” Clinical Orthopaedics and Related Research, We show special thanks to Frank Duong at AbbVie vol. 459, pp. 40–47, 2007. Stemcentrx LLC in South San Francisco for the editing of [16] J. Bruns, M. Elbracht, and O. Niggemeyer, “Chondrosarcoma this manuscript. of bone: an oncological and functional follow-up study,” Annals of oncology, vol. 12, no. 6, pp. 859–864, 2001. References [17] A. Italiano, O. Mir, A. Cioffi et al., “Advanced chondrosarco- mas: role of chemotherapy and survival,” Annals of Oncology, [1] K. K. Unni and D. C. Dahlin, Dahlin’s Bone Tumors: Gen- vol. 24, no. 11, pp. 2916–2922, 2013. eral Aspects and Data on 11,087 Cases, Lippincott-Raven, Philadelphia, PA, USA, 5th edition, 1996. [18] T. Yoshimoto, Y. Sawamura, J. Ikeda, N. Ishii, and H. Abe, [2] H. Gelderblom, P. C. W. Hogendoorn, S. D. Dijkstra et al., “Successful chemoradiation therapy for high-grade skull base chondrosarcoma in a child,” Child's Nervous System, vol. 11, “The clinical approach towards chondrosarcoma,” Oncologist, vol. 13, no. 3, pp. 320–329, 2008. no. 4, pp. 250–253, 1995. [3] M. Etchebehere, O. P. de Camargo, A. T. Croci, C. R. Oliveira, and A. M. Baptista, “Relationship between surgical procedure and outcome for patients with grade I chondrosarcomas,” Clinics, vol. 60, no. 2, pp. 121–126, 2005. [4] J. H. Healey and J. M. Lane, “Chondrosarcoma,” Clinical Orthopaedics and Related Research, vol. 204, no. 204, pp. 119–129, 1986. [5] R. S. Riggins and P. T. Wertlake, “Metastatic chondrosarcoma to the kidney,” The American Journal of Surgery, vol. 109, no. 2, pp. 209–212, 1965. [6] G. Liguori, S. Bucci, L. Buttazzi, C. Trombetta, M. Cortale, and E. Belgrano, “A renal metastasis from primary peripheral chondrosarcoma presenting as spontaneous retroperito- neal hematoma,” Archivio Italiano di Urologia, Andrologia, vol. 72, pp. 292–294, 2000. [7] T. Fukumoto, Y. Yanagihara, K. Shimamoto et al., “Metastatic chondrosarcoma in bilateral kidneys: a case report,” The Nishi- nihon Journal of Urology, vol. 75, pp. 135–139, 2013. [8] P. Valente, J. A. Macedo-Dias, C. Lobato, M. Reis, and F. Pina, “Primary mesenchymal chondrosarcoma of the kidney: a case report and review of literature,” Journal of Cancer Research and Therapeutics, vol. 14, no. 3, pp. 694–696, 2018. [9] M. Kashima, K. Yamakado, H. Takaki et al., “Complications After 1000 Lung Radiofrequency Ablation Sessions in 420 Patients: A Single Center’s Experiences,” American Journal of Roentgenology, vol. 197, no. 4, pp. W576–W580, 2011. [10] A. Angelini, G. Guerra, A. F. Mavrogenis, E. Pala, P. Picci, and P. Ruggieri, “Clinical outcome of central conventional chondrosarcoma,” Journal of Surgical Oncology, vol. 106, no. 8, pp. 929–937, 2012. [11] M. D. Murphey, E. A. Walker, A. J. Wilson, M. J. Kransdorf, H. T. Temple, and F. H. 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