What are the key points in managing osteochondroma (benign bone tumor)?

From the Guidelines

Management of osteochondroma primarily involves monitoring and surgical intervention when necessary, with a focus on preventing malignant transformation and managing symptoms. The key points in managing osteochondroma include:

• Monitoring for growth or malignant transformation with clinical examinations and imaging studies every 6-12 months 1
• Surgery is indicated when the tumor causes pain, impingement on surrounding structures, growth plate disruption, vascular or nerve compression, cosmetic concerns, or in rare cases of malignant transformation 1
• Complete surgical excision with removal of the cartilage cap is the standard treatment, typically performed through open surgery though arthroscopic techniques may be used for certain locations
• Pain management with NSAIDs like ibuprofen or naproxen can help with symptomatic relief
• Physical therapy may benefit patients with muscle weakness or limited range of motion due to the tumor
• Patients with multiple osteochondromas (hereditary multiple exostoses) require more vigilant monitoring due to their higher risk of malignant transformation (5-10%) 1 Some important considerations include:
• Evidence of rapid growth of an osteochondroma, increasing pain, and/or a bulky cartilage cap that is thicker than 2.0 to 3.0 cm on an MRI or CT scan suggests progression to chondrosarcoma 1
• Annual physical examinations starting in childhood with early investigations in case of increasing pain or rapid growth of lesions are recommended 1
• A baseline skeletal survey at early adolescence (around 12 years) when most osteochondromas have evolved and before the age of transformation risk is suggested 1
• Regular regional MRI (every 2–3 years) of osteochondromas identified in the pelvis or scapula may be valuable, as transformation is more common in these locations, particularly in males or EXT1 PV carriers 1

From the Research

High Yield Points on Osteochondroma

• Osteochondroma is the most common benign bone tumor, representing 20%-50% of all benign bone tumors and 10%-15% of all bone tumors 2.
• It is a developmental lesion rather than a true neoplasm, composed of cortical and medullary bone with an overlying hyaline cartilage cap, and must demonstrate continuity with the underlying parent bone cortex and medullary canal 2.
• Osteochondromas may be solitary or multiple, with the latter being associated with the autosomal dominant syndrome, hereditary multiple exostoses (HME) 2, 3, 4.
• Complications associated with osteochondromas include deformity, fracture, vascular compromise, neurologic sequelae, overlying bursa formation, and malignant transformation, which is seen in 1% of solitary osteochondromas and in 3%-5% of patients with HME 2, 3, 4.
• Malignant transformation is suggested by continued lesion growth and a hyaline cartilage cap greater than 1.5 cm in thickness after skeletal maturity, or cartilage cap thickness >2 cm in adults or >3 cm in children, as well as new onset of pain or growth, or rapid growth of the lesion 2, 3.
• Surgical resection is indicated for symptomatic lesions, complications, cosmetic reasons, or malignant transformation, with excision of the tumor with free margin being the treatment of choice 3, 4, 5, 6.
• Local recurrence is less than 2% if complete resection is achieved 3.
• Osteochondromas can occur in atypical locations, such as the wrist, and pose diagnostic challenges, emphasizing the importance of considering OC in the differential diagnosis of wrist swellings 6.

Clinical Presentation and Radiological Features

• Osteochondromas usually occur in the metaphyseal region of the long bones, and can present as solitary or multiple lesions 2, 3, 4.
• Most lesions appear in children and adolescents as painless, slow-growing masses, but significant symptoms may occur as a result of complications such as fracture, bony deformity, mechanical joint problems, and vascular or neurologic compromise 4.
• Radiologic features of osteochondromas are often pathognomonic and identically reflect its pathologic appearance, with variants including subungual exostosis, dysplasia epiphysealis hemimelica, turret and traction exostoses, bizarre parosteal osteochondromatous proliferation, and florid reactive periostitis 2.

Treatment Options

• Surgical excision is the treatment of choice for osteochondroma, unless the skeleton is still immature 4.
• Indications for operative intervention include painful mechanical dysfunction unresponsive to conservative measures and sarcomatous change 5.
• Scapular osteochondromas usually require surgical excision, with the size of the lesion dictating precise management 5.