A 32-year-old woman presented to our hospital with three months history of bilateral lower extremity weakness and inability to walk. She was referred for Magnetic Resonance Imaging of the thoracic spine to our department.
MRI of the thoracic spine was performed in a 3 Tesla MRI (Siemens Healthineers, Skyra, Erlangen, Germany) as per our Institute protocol. MRI revealed a large, lobulated and predominantly T2 hyperintense lesion along the posterior aspect of the left 5th rib. There was extradural extension into the posterior aspect of the adjacent spinal canal, causing compression of the spinal cord (Figures 1 and 2).T1 and STIR images revealed alterations of the bone marrow signal in the 5th thoracic vertebra (Figures 3 and 4).To further characterize the lesion, contrast-enhanced computed tomography imaging of the chest was performed, which showed an aggressive type of periosteal reaction at the left 5th rib and a large, heterogeneous and enhancing soft tissue component (Figures 5 and 6).CT also revealed multiple foci of stippled calcifications within the soft tissue component and adjacent spinal canal (Figure 7).
PET CT revealed high metabolic activity within the lesion and adjacent 5th thoracic vertebra (Figure 8).
Background
Chondrosarcoma is the most common primary bone malignancy of the chest wall, accounting for 30% of all primary bone malignancies and 33% of all primary rib tumours. About 10% of chondrosarcoma occurs in the chest wall, most of which are identified adjacent to the costochondral junction[1]. They are usually found between the ages of 40 and 70 and are more common in men.
Clinical Perspective
Pain is the most common symptom and is reported by 95% of patients. Pain is often insidious and progressive, with an average time to manifest being 1 to 2 years. A palpable soft tissue mass is present in 30% to 80% of patients at the time of presentation. Pathological fractures are the main symptom in 3% to 17% of patients[3]. Our case is unique in its clinical presentation of bilateral lower limb weakness being caused by chondrosarcoma of the chest wall due to concomitant vertebral infiltration and associated posterior epidural soft tissue component causing spinal cord compression. An evaluation of the entire extent of the mass by multimodality imaging and histopathological correlation is crucial for proper patient management.
Imaging Perspective
The typical appearance of a chondrosarcoma on multidetector CT images is a well-defined mass with a combination of soft tissue and chondroid matrix, which includes rings, arcs and stippled patterns of calcification. Invasion and destruction of adjacent bony structures are common. At MR imaging, the cartilage background of chondrosarcoma accounts for the iso to hypointense signal on T1-weighted images and hyperintense signal on T2-weighted images[1]. Following the intravenous administration of contrast agent, the lesion showed heterogenous enhancement, predominantly at the periphery of the tumour [2]. In our case, CT demonstrated aggressive periosteal reaction involving the left 5th rib associated with a lobulated soft tissue component which showed enhancing septations and specks of calcifications within. The chondroid matrix of the lesion accounts for the high signal intensity on T2 weighted images. There was also extradural extension of the lesion with infiltration of the 5th thoracic vertebra. PET CT revealed high metabolic activity reflecting the malignant nature of the lesion.
Histopathology
CT-guided biopsy of the lesion was done, and histopathological examination revealed features of Grade 2 Chondrosarcoma with extensive myxoid areas.
Chest wall chondrosarcoma with vertebral infiltration and extradural extension
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This case involves a 32-year-old female patient who has been experiencing bilateral lower limb weakness for 3 months with progressive worsening, leading to difficulty in walking. Based on the provided chest CT and MR images, the following observations can be noted:
Taking into account the patient’s clinical presentation (impaired bilateral lower limb motor function) and the imaging characteristics described above, the following diagnoses or differential diagnoses should be considered:
In light of the characteristic cartilaginous matrix calcification (“ring-arc” calcification patterns) observed on imaging and the histopathological findings (Grade 2 chondrosarcoma), the final diagnosis is chondrosarcoma of the chest wall (involving the 5th rib and extending into the thoracic vertebra and spinal canal). This tumor forms an epidural soft tissue mass that protrudes into the spinal canal and compresses the spinal cord, causing bilateral lower limb motor dysfunction.
Based on the confirmed diagnosis and the patient’s current symptoms, the main treatment strategies include:
Both before and after treatment, the patient needs to focus on rehabilitation and the recovery of motor function, especially during the perioperative period and postoperative rehabilitation. Following a gradual and individualized approach (based on the FITT-VP principle—Frequency, Intensity, Time, Type, Progression, Individual Variation) is recommended:
The overall goal of rehabilitation is to alleviate pain, maintain or improve range of motion, rebuild muscle strength and coordination, and prevent long-term functional impairment. The entire rehabilitation process should be conducted under the guidance and supervision of qualified physicians and rehabilitation specialists, with ongoing adjustments based on the patient’s progress.
This report is intended to provide medical reference and analysis and does not substitute an in-person consultation or professional medical advice. Specific treatment and rehabilitation plans must be determined by a physician and a specialized medical team, taking into account the patient’s actual condition.
Chest wall chondrosarcoma with vertebral infiltration and extradural extension
