What is the treatment approach for Enchondroma?

Treatment Approach for Enchondroma

For asymptomatic enchondromas, observation with regular radiological follow-up is the recommended approach rather than immediate surgical intervention, as the complication rate of curettage is considerable (23%) while malignant transformation is rare. 1

Diagnostic Considerations

• Enchondromas are benign cartilaginous neoplasms that arise from the medullary cavity of bones
• Most common locations: long bones, short tubular bones of hands and feet
• Imaging workup should include plain radiographs, MRI, and CT scan to assess extent of lesion

Treatment Algorithm Based on Presentation

1. Asymptomatic Enchondromas

• Initial approach: Observation with annual radiological follow-up 2
• No immediate surgical intervention required regardless of tumor size
• Follow-up should continue for at least 2 years to detect any changes

2. Symptomatic Enchondromas

• Indications for surgery:

  • Persistent pain
  • Radiologic growth of tumor
  • Pathologic fracture
  • Risk of impending fracture
  • Functional limitation

• Surgical approach: Curettage with or without bone grafting 3, 4

  • Complete removal of tumor tissue
  • Filling of defect with autologous bone graft, allograft, or bone substitutes
  • For hand enchondromas, curettage is standard of care for symptomatic lesions 4

3. Suspected Malignant Transformation

• Warning signs:

  • Increasing pain without trauma
  • Growth after skeletal maturity
  • Cortical destruction or soft tissue extension
  • Size >5 cm

• Treatment: Wide surgical excision with negative margins 3

  • Higher-grade chondrosarcomas and all chondrosarcomas of the pelvis or axial skeleton should be surgically removed with wide margins 3

Special Considerations

Atypical Cartilaginous Tumors (ACT)/Low-Grade Chondrosarcoma

• For extremity ACTs:
  • Can be managed by observation initially 3
  • If progression occurs, complete curettage with or without surgical adjuvants (high-speed burr, cryotherapy) 3
  • Excision may be preferred due to risk of grade progression after local recurrence

Syndromic Patients

• Patients with multiple enchondromas (Ollier disease or Maffucci syndrome):
  • Higher risk of malignant transformation to chondrosarcoma (approximately 30%) 3
  • Require more vigilant monitoring
  • Should be counseled about increased risk of developing secondary chondrosarcomas 3, 5

Unresectable or Recurrent Disease

• Radiotherapy may be offered for:
  • Unresectable disease
  • Adjuvant treatment after surgery with positive margins
  • Palliation of symptoms 3
• Modern RT techniques including particle therapy should be considered when appropriate 3

Follow-up Protocol

• For asymptomatic lesions: Annual radiological evaluation 2, 6
• For treated lesions: Clinical and radiographic evaluation at 6 weeks, 3 months, 6 months, and then annually 5
• Physical examination, imaging of the lesion, and chest radiograph every 6-12 months for 2 years, then yearly as appropriate 3

By following this treatment algorithm, the risk of complications from unnecessary surgery can be minimized while still ensuring appropriate monitoring for the rare cases of malignant transformation.