Journal of Surgical Oncology 11: 135-139 (1979)
Pseudo-Chondrosarcoma: Solitary Osseous Metastases From Atypical Bronchogenic Carcinoma JACOB J. LOKICH,MD, HARRY BAILEY, MD, D. BUD DIXON,MD,and GEORGE STARKEY,MD A patient with bronchogenic carcinoma with a solitary metastases t o the femur in whom the clinical, radiologic, and pathologic setting suggested that the primary tumor was the bone lesion (chondrosarcoma) and the pulmonary lesion was a solitary metastasis is presented. This case is added t o the limited literature indicating that mucin-secreting tumors metastatic to bone may simulate primary bone tumors radiographically. Key words: bone metastases,lung cancer, chondrosarcorna
INTRODUCTION The radiologic characteristics of primary bone cartilage tumors are well established and are rarely confused with primary tumors of extra-osseous origin metastatic to bone [ 11 . An unusual case of primary bronchogenic carcinoma of a mucinous adenocarcinoma type developed a solitary metastases to the femur and upon initial presentation was radiologically, pathologically, and clinically diagnosed and managed as primary chondrosarcoma of the femur with a solitary pulmonary metastasis. This case is reported to document the phenomenon of metastatic lesions to bone mimicking primary bone tumors and to emphasize the importance of histopathologic confirmation of primary and metastatic lesions in atypical clinical circumstances.
CASE REPORT The patient is a 69-year-old man with known Marie-Strumpell disease since the age of 30,who was otherwise well throughout his life. In June 1976 the patient developed some nonspecific complaints which prompted him to see his doctor for an annual physi-
From the Departments of Medicine, Surgery, and Radiology, New England Deaconess Hospital, Boston, Massachusetts. Address reprint requests t o Dr. Jacob J. Lokich, Sidney Farber Cancer Institute, Charles A. Dana Center, 44 Binney Street, Boston, MA 02115.
0022-4790/79/1102-0135%01.400 1979 Alan R. Liss, Inc.
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Fig I . Subtrochanteric lesion demonstrating extraosseous extension into the soft tissue with flocculant calcifications and moderate osteoiysis.
cal examination. On routine chest x-ray he was found to have a large, 10 cm mass in the right mid-lung field. The lesion, because of its size and solitary nature, was presumed to represent a large metastasis, and a search for a primary, as well as other sites of metastases were unremarkable, with the exception that on routine radiographs of the bones a lesion of the left subtrochanteric area was discovered (Fig 1). The lesion was characterized by extra-osseous extension with calcification and osteolysis. Open biopsy of the left femur lesion revealed a pathologic diagnosis of low-grade, aytpical, myxoid chondrosarcoma. Additional history revealed that the patient had, in fact, had a pulmonary lesion noted in June of 1975, one year previously. Therefore, the total clinical radiologic, and pathologic picture appeared t o be one in which primary chondrosarcoma of the femur was fortuitously detected in the presence of a solitary pulmonary metastases of slow-growing potential. On this basis, chemotherapy employing cyclophosphamide, Adriamycin, and dimethyl-triazeno-imidazolecarboxamidein combination was employed because of the disseminated nature of the disease and because the use of this combination in metastatic sarcomas has been successful [2]. Treatment was continued over a five-month period through November 1976. and dramatic and major reduction in the pulmonary lesion was achieved (Fig 2), while the lesions of the femur remained unchanged radiologically. During this period of therapy no additional metastatic lesions developed. The patient underwent thoracotomy, and total removal of the right lung lesion was accomplished.
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Fig 2. Sequential chest radiographs demonstrating regression of the solitary lesion in the right mid-lung field.
Pathologic analysis revealed a primary adenocarcinoma of the lung with mucin secretion, and histologic comparison of lung and osseous lesions suggested that the two lesions were, in fact, identical (Fig 3). Three months later, in February 1977, there were no additional lesions by full lung tomograms and bone scan, and a primary surgical approach t o the solitary metastasis in the left femur was considered. The procedure carried out was curettage of the tumor and implantation of a femoral rod with methyl merthacrylate. Postoperatively radiation therapy was employed t o the local area (to treat minimal residual disease), although pathologic review of the osseous lesion failed t o reveal residual carcinoma.
DISCUSSION The clinical, radiologic, and pathologic features of this case of bronchogenic carcinoma are unusual and resulted in confusion with regard t o clinical management. Primary lung cancer does not generally have a protracted clinical course; does not generally manifest responsiveness to chemotherapy ; and does not generally metastasize as a solitary lesion to bone. Alternatively, from the clinical standpoint, chondrosarcoma would fit the clinical picture perfectly well [3]. The radiologic features of the pseudo-chondrosarcoma were typical for a primary bone tumor, including extra-osseous calcifications characteristic of chondrosarcoma. Previous reports by Siefe have indicated that mucin-secreting tumors of the gastrointes-
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Fig. 3. Histopathologic section cf the pulmonary lesion (top) and the femur lesion (bottom) demonstrating features of carcinoma with mucin secretion.
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tinal tract may mimick primary bone tumors when metastatic t o the skeleton [4]. Calcification and actual ossification have been described in much-producing intestinal neoplasms [5]. The final solution to the clinical dilemma was provided by a critical analysis of the histopathology. The presence of myxoid features is an atypical feature for both primary bronchogenic and chondrosarcoma, but the pulmonary lesion, when examined in toto, revealed the characteristic features of primary bronchogenic carcinoma.
REFERENCES 1. Pendergrass EP, Lafferty JO, Howe RC: Osteogenic and chondrosarcoma. Am J Roentgenol 54: 234,1946. 2. Gottlieb J , et al: Adriamycin (NSC 123127) used alone and in combination for soft tissue and bony sarcomas. Cancer Chemother Rep 6:27 1,1975. 3. Henderson ED, Dahlin DC: Chondrosarcoma of bone - A study of two hundred and eighty-eight cases. J Bone Joint Surg 45-A:1450-1458, 1963. 4. Seife B: Osseous metastases from carcinoma of the large bowel. Am J Roentgenol Rad Ther Nucl Med 119:414-418,1973. 5. Govoni AF, Alcantara AN: Ossifying metastatic carcinoma of the colon. A m J Roentgenol Rad Ther Nucl Med 104561-565.1968.
Pseudo-Chondrosarcoma: Solitary Osseous Metastases From Atypical Bronchogenic Carcinoma JACOB J. LOKICH,MD, HARRY BAILEY, MD, D. BUD DIXON,MD,and GEORGE STARKEY,MD A patient with bronchogenic carcinoma with a solitary metastases t o the femur in whom the clinical, radiologic, and pathologic setting suggested that the primary tumor was the bone lesion (chondrosarcoma) and the pulmonary lesion was a solitary metastasis is presented. This case is added t o the limited literature indicating that mucin-secreting tumors metastatic to bone may simulate primary bone tumors radiographically. Key words: bone metastases,lung cancer, chondrosarcorna
INTRODUCTION The radiologic characteristics of primary bone cartilage tumors are well established and are rarely confused with primary tumors of extra-osseous origin metastatic to bone [ 11 . An unusual case of primary bronchogenic carcinoma of a mucinous adenocarcinoma type developed a solitary metastases to the femur and upon initial presentation was radiologically, pathologically, and clinically diagnosed and managed as primary chondrosarcoma of the femur with a solitary pulmonary metastasis. This case is reported to document the phenomenon of metastatic lesions to bone mimicking primary bone tumors and to emphasize the importance of histopathologic confirmation of primary and metastatic lesions in atypical clinical circumstances.
CASE REPORT The patient is a 69-year-old man with known Marie-Strumpell disease since the age of 30,who was otherwise well throughout his life. In June 1976 the patient developed some nonspecific complaints which prompted him to see his doctor for an annual physi-
From the Departments of Medicine, Surgery, and Radiology, New England Deaconess Hospital, Boston, Massachusetts. Address reprint requests t o Dr. Jacob J. Lokich, Sidney Farber Cancer Institute, Charles A. Dana Center, 44 Binney Street, Boston, MA 02115.
0022-4790/79/1102-0135%01.400 1979 Alan R. Liss, Inc.
136
Lokich e t a1
Fig I . Subtrochanteric lesion demonstrating extraosseous extension into the soft tissue with flocculant calcifications and moderate osteoiysis.
cal examination. On routine chest x-ray he was found to have a large, 10 cm mass in the right mid-lung field. The lesion, because of its size and solitary nature, was presumed to represent a large metastasis, and a search for a primary, as well as other sites of metastases were unremarkable, with the exception that on routine radiographs of the bones a lesion of the left subtrochanteric area was discovered (Fig 1). The lesion was characterized by extra-osseous extension with calcification and osteolysis. Open biopsy of the left femur lesion revealed a pathologic diagnosis of low-grade, aytpical, myxoid chondrosarcoma. Additional history revealed that the patient had, in fact, had a pulmonary lesion noted in June of 1975, one year previously. Therefore, the total clinical radiologic, and pathologic picture appeared t o be one in which primary chondrosarcoma of the femur was fortuitously detected in the presence of a solitary pulmonary metastases of slow-growing potential. On this basis, chemotherapy employing cyclophosphamide, Adriamycin, and dimethyl-triazeno-imidazolecarboxamidein combination was employed because of the disseminated nature of the disease and because the use of this combination in metastatic sarcomas has been successful [2]. Treatment was continued over a five-month period through November 1976. and dramatic and major reduction in the pulmonary lesion was achieved (Fig 2), while the lesions of the femur remained unchanged radiologically. During this period of therapy no additional metastatic lesions developed. The patient underwent thoracotomy, and total removal of the right lung lesion was accomplished.
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Fig 2. Sequential chest radiographs demonstrating regression of the solitary lesion in the right mid-lung field.
Pathologic analysis revealed a primary adenocarcinoma of the lung with mucin secretion, and histologic comparison of lung and osseous lesions suggested that the two lesions were, in fact, identical (Fig 3). Three months later, in February 1977, there were no additional lesions by full lung tomograms and bone scan, and a primary surgical approach t o the solitary metastasis in the left femur was considered. The procedure carried out was curettage of the tumor and implantation of a femoral rod with methyl merthacrylate. Postoperatively radiation therapy was employed t o the local area (to treat minimal residual disease), although pathologic review of the osseous lesion failed t o reveal residual carcinoma.
DISCUSSION The clinical, radiologic, and pathologic features of this case of bronchogenic carcinoma are unusual and resulted in confusion with regard t o clinical management. Primary lung cancer does not generally have a protracted clinical course; does not generally manifest responsiveness to chemotherapy ; and does not generally metastasize as a solitary lesion to bone. Alternatively, from the clinical standpoint, chondrosarcoma would fit the clinical picture perfectly well [3]. The radiologic features of the pseudo-chondrosarcoma were typical for a primary bone tumor, including extra-osseous calcifications characteristic of chondrosarcoma. Previous reports by Siefe have indicated that mucin-secreting tumors of the gastrointes-
138
Lokich et a1
Fig. 3. Histopathologic section cf the pulmonary lesion (top) and the femur lesion (bottom) demonstrating features of carcinoma with mucin secretion.
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tinal tract may mimick primary bone tumors when metastatic t o the skeleton [4]. Calcification and actual ossification have been described in much-producing intestinal neoplasms [5]. The final solution to the clinical dilemma was provided by a critical analysis of the histopathology. The presence of myxoid features is an atypical feature for both primary bronchogenic and chondrosarcoma, but the pulmonary lesion, when examined in toto, revealed the characteristic features of primary bronchogenic carcinoma.
REFERENCES 1. Pendergrass EP, Lafferty JO, Howe RC: Osteogenic and chondrosarcoma. Am J Roentgenol 54: 234,1946. 2. Gottlieb J , et al: Adriamycin (NSC 123127) used alone and in combination for soft tissue and bony sarcomas. Cancer Chemother Rep 6:27 1,1975. 3. Henderson ED, Dahlin DC: Chondrosarcoma of bone - A study of two hundred and eighty-eight cases. J Bone Joint Surg 45-A:1450-1458, 1963. 4. Seife B: Osseous metastases from carcinoma of the large bowel. Am J Roentgenol Rad Ther Nucl Med 119:414-418,1973. 5. Govoni AF, Alcantara AN: Ossifying metastatic carcinoma of the colon. A m J Roentgenol Rad Ther Nucl Med 104561-565.1968.
