The patient presented with a history of right shoulder pain and swelling for two and a half years. She mentioned worsening of the symptoms during the last year. Physical examination showed hyposensitivity of the right upper extremity.
The patient presented with a history of right shoulder pain and swelling for two and a half years. She mentioned worsening of the symptoms during the last year.
Physical examination showed hyposensitivity of the right upper extremity, but no muscle weakness or deep joint reflex abnormality was indicated.
Radiographs of the right scapula revealed a large soft tissue mass containing ring-like calcification.
CT of the scapula showed a lytic lesion arising from the scapula with disruption of the cortex and an extensive soft tissue mass containing calcification and ossification.
MR showed a large lobulated mass with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images with smaller areas of low signal corresponding to areas of calcification/ossification.
A CT-guided fine needle aspiration (FNA) was performed and confirmed the diagnosis of a grade 1 chondrosarcoma.Finaly,histological diagnosis was also grade 1 chondrosarcoma.
Chondrosarcoma is a malignant bone tumour that usually occurs in patients over the age of 40. Chondrosarcoma affects children rarely, often as a malignant degeneration of an osteochondroma or an enchondroma (more often in diaphyseal aclasia or dyschondrodysplasia respectively).
Chondrosarcomas can be subdivided according to their location into:
(a) central: arising within the medullary space and
(b) cortical-based: arising on the surface of the affected bone.
There are also some rare types of chondrosarcoma such as mesenchymal, dedifferentiated, and clear cell chondrosarcoma.
On plain radiographs chondrosarcomas appear as a lytic central or peripheral lesion usually with peripheral scalloping with or without mineralisation. The differential diagnosis of a mineralised chondrosarcoma includes only enchondroma and bone infarction. On the other hand, the differential diagnosis of a non-mineralised chondrosarcoma is wide and includes almost any bone malignancy such as fibrosarcoma, malignant fibrous histiocytoma, plasmacytoma, metastasis and osteolytic osteosarcoma.
CT can better assess the soft tissue mass; the distribution, configuration and the extent of calcification and ossification as well as the integrity of the overlying cortex.
Furthermore, MR images define the extent of intraosseous and soft tissue involvement. Recent studies also suggest that contrast–enhanced MR imaging may assist in the differentiation between benign and malignant cartilaginous tumours.
Chondrosarcoma of the scapula
Based on the provided X-ray, CT, and MRI images, a destructive bone lesion is observed in the right shoulder/chest wall region, with the following specific findings:
1. X-ray: Localized lytic changes can be seen, with cortical bone infiltration and outward bulging. In some areas, irregular or patchy calcification/ossification shadows are visible, consistent with a cartilaginous lesion.
2. CT: The lesion involves the bone marrow cavity, accompanied by varying degrees of soft tissue mass. The boundary between the soft tissue component and the bone lesion is not well-demarcated, and localized or scattered calcifications can be observed. Cortical erosion and thinning suggest a destructive lesion.
3. MRI: On T1-weighted images, the lesion appears slightly hypo- or isointense, while on T2-weighted/fat-suppressed sequences, the signal is markedly increased, consistent with a high cartilaginous component. The lesion extends into the surrounding soft tissues, potentially compressing or invading adjacent muscle and soft tissue. In addition, the patient’s decreased sensation in the right upper extremity suggests possible involvement of local nerve pathways due to compression from the enlarging soft tissue mass.
Taking into account the patient’s age, clinical symptoms (gradual onset shoulder pain and swelling), and imaging findings (bone destruction, cartilaginous calcification, soft tissue mass, incomplete cortical destruction), the most likely diagnosis is Chondrosarcoma.
Further confirmation may require pathological biopsy or surgical resection followed by pathological examination to determine the tumor grade and specific pathological subtype.
1. Treatment Strategy
• Surgical Treatment: The primary treatment for chondrosarcoma is complete surgical resection (wide or marginal resection, depending on tumor grade and extent) to reduce local recurrence.
• Radiotherapy and Chemotherapy: In cases of poorly differentiated or highly aggressive chondrosarcoma, or where residual disease remains after surgery, adjuvant radiotherapy or chemotherapy may be considered. However, their efficacy in chondrosarcoma is generally limited and depends on specific pathology and tumor grading.
• Nerve Protection: The patient has reduced sensation in the right upper extremity. Assessment is needed to determine whether nerves are compressed or invaded; collaboration with neurosurgery or relevant specialists may be required.
2. Rehabilitation/Exercise Prescription Recommendations
• Following surgery or other treatments, an individualized rehabilitation program should be developed based on the surgical approach and lesion location. If shoulder joint function is limited, gradual joint mobilization, muscle strengthening, and posture improvement under specialist guidance (orthopedics or rehabilitation) are essential.
• Apply the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Volume):
- Frequency: 3-5 sessions of moderate rehabilitation exercises per week.
- Intensity: Light to moderate intensity, avoiding pain and excessive fatigue. An RPE (Rate of Perceived Exertion) of about 11-13 is recommended.
- Time: Each session can last around 20-30 minutes of exercise/functional training, divided into stages.
- Type: Start with passive range-of-motion exercises and isometric muscle contractions; then gradually progress to active joint movements, light resistance training, and functional exercises, such as grip strength drills, shoulder rotations, and overhead lifting (adjusting weight as needed).
- Progression: Once tolerated, gradually increase exercise difficulty and muscular load (for example, using resistance bands or light dumbbells).
- Volume: Avoid high-intensity or contact sports until bone and soft tissues have adequately healed. Increase total training volume progressively.
• Precautions: If the patient experiences increased shoulder pain, local swelling, or exacerbation of neurological symptoms, stop exercises and seek medical evaluation. When bone quality is compromised or the lesion is still healing, avoid fracture risk and excessive load.
Disclaimer:
This report is a reference-based analysis derived from the provided information and cannot replace in-person consultation or professional medical advice. Treatment decisions should be made based on the patient’s specific condition, pathological results, and expert team evaluations.
Chondrosarcoma of the scapula
