According to the World Health Organization, osteochondroma is an osseous projection covered by a cartilage layer that arises on the external bone surface. Such neoplasms generally arise in the immature skeleton, i.e. in children and young adolescents. Debate still continues as to the benign or potentially malignant (pseudotumoral) nature of osteochondroma. Howbeit, it causes a number of worrying symptoms and can mask more severe or even malignant conditions. Differential diagnosis of osteochondroma is carried out in specialized orthopedic departments that have vast clinical experience in treating rare bone pathologies.
Clinical symptoms and instrumental examination
Osteochondroma causes bone deformity or destruction due to the growth of its superficial cartilaginous part. It can reach size of 5 cm or even more. Thus, it causes pressure on the adjacent muscles, blood vessels and nerves. These lead to the various clinical manifestations, like:
- Different length of arms or legs (in affection of the knee or shoulder joint)
- Lower height compared to the mean age-specific values (in hip affection)
- Presence of the palpable neoplasm (typically it is immobile and painless)
- Tenderness of the nearby soft tissues and muscles
- Pain during the physical activity (when a neoplasm is located under a tendon)
- Disturbances of the sensitivity or cramps (in nerves involvement)
Nevertheless, such complaints and manifestations are not pathognomonic signs of osteochondroma. Only an experienced orthopedic doctor can determine the final diagnosis correctly. In addition to the clinical examination, the following instrumental studies are carried out during the diagnostics:
- X-ray examination provides clear pictures of bones and other dense structures, revealing the bony component of a tumor.
- Imaging scans (CT, MRI) provide the details of soft tissues structure and cross-sectional images. MRI also allows investigating the cartilaginous component of an osteochondroma. Detecting medullary and cortical continuity of the neoplasm with the main bone is a pathognomonic osteochondroma feature.
- Biopsy specifies the histological structure of a neoplasm and helps differentiating osteochondroma from any malignant formations. The procedure includes harvesting a tissue sample and requires local anesthesia.
Based on the results of clinical examination, laboratory tests and visualizing studies, a doctor makes a provisional diagnosis. The final diagnosis is made after excluding all the pathologies that can be similar to an osteochondroma in clinical manifestations and radiological picture. Determining the exact pathology is essential, as an osteochondroma may require no more than active surveillance, while an osteosarcoma requires urgent surgery.
Thus, the differential diagnosis for an osteochondroma includes both malignant and benign pathologies:
- Subperiosteal hematoma. This is a surface lesion connected with a history of prior trauma. Subperiosteal hematoma mainly consists of organized thrombi, but may also have cystic or mineralization areas.
- Subungual exostosis (Dupuytren exostosis). This is a superficial bone growth of unknown etiology. It is typically located near the nail bed and can be accompanied by skin ulceration or pain.
- Turret exostosis is an extracortical bone growth in the middle or proximal finger phalanx. It is not characterized by the medullary continuity, as the exostosis takes start in the superficial cortical layers.
- Dysplasia epiphysealis hemimelica (Trevor disease) is a rare condition characterized by the multiple osteochondromas development. In Trevor disease osteochondromas arise from the epiphysis of the of the lower extremities’ bones. This is a hereditary condition without a malignant degeneration.
- Bizarre parosteal osteochondromatous proliferation (Nora lesion) arise in the hands and feet, as the superficial lesion without medullary continuity. Despite the risk of malignant degeneration, cases that lead to functional disturbances are eligible for surgical treatment.
- Juxtacortical chondroma is a superficial lesion that leads to the saucerization of the nearby cortex and periosteal reaction. This is a benign periosteal neoplasm with internal calcifications that requires surgery and may recur if excised incompletely.
- Parosteal osteosarcoma is a malignant tumor arising on the surface of long bones (e.g. hip or humerus). In advance stages, it can invade the medullary space and, thus, resemble an osteochondroma radiologically.
Individual treatment options
When confirming the diagnosis of a benign tumor (e.g. osteochondroma, juxtacortical chondroma, subungual exostosis, etc.), doctor chooses between the non-surgical and surgical treatment. In malignant tumors (e.g. parosteal osteosarcoma) surgery is the first-line therapy.
Non-surgical treatment is mainly suitable for patients with solitary lesions that do not demonstrate significant growth. It includes watchful waiting with regular visualizing studies (X-ray) and medications to control pain (if necessary). Nevertheless, timely treatment of benign tumors allows preventing the cosmetic deformity, mechanical complications (e.g. blocking the adjacent joint) or malignant transformation. Thus, in case of osteochondroma growth or transformation doctors consider more invasive interventions.
Surgery resection of osteochondroma or another benign tumor includes removing the neoplasm at the level of normal bone. The intervention is quite invasive, thus it is performed under general anesthesia with combination of intravenous medications and inhaled gasses. Additional surgical procedures may be required in case of severe bone deformities (e.g. the bone is crooked), functional lesions (e.g. affection of tendon’s structure) or significant difference between the length of legs.
Treatment all over the globe with Booking Health
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Author: Dr. Nadezhda Ivanisova