What is the management approach for Enchondroma?

Management of Enchondroma

Observation is the Preferred Approach for Asymptomatic Lesions

For asymptomatic enchondromas, radiographic surveillance without surgical intervention is the recommended management strategy, as malignant transformation of solitary enchondromas is exceedingly rare while surgical curettage carries a 23% complication rate. 1

Initial Assessment and Risk Stratification

Distinguish Benign from Malignant Features

• Asymptomatic lesions in the hands and feet can be observed initially without intervention 2
• Pain at the site of a cartilaginous lesion may indicate malignancy and warrants further evaluation 3
• Serial radiographs showing slow increase in size or a cartilage "cap" measuring >2 cm suggests sarcomatous transformation 3
• Growth after skeletal maturity is concerning for malignant transformation 3
• Contrast-enhanced MRI can reveal high-grade areas and guide biopsy site selection 3

Special Populations at Higher Risk

• Patients with multiple enchondromas (Ollier's disease) or multiple osteochondromas are at increased risk for secondary chondrosarcoma development and require appropriate counseling and surveillance 2
• One documented case of secondary chondrosarcoma occurred in a patient with Ollier's disease 1

Surgical Management Indications

When to Operate

Surgical intervention with curettage is indicated for:

• Symptomatic lesions causing pain 4
• Lesions demonstrating progression on serial imaging 2
• Pathologic fractures 4
• Lesions with concerning features for malignant transformation 2

Surgical Technique

• Complete curettage with or without surgical adjuvants (phenol, cement, cryotherapy) is the standard treatment 3, 4
• Cancellous bone grafting is commonly performed after curettage 1, 5
• For peripheral chondrosarcomas arising from enchondromas, complete excision with a covering of normal tissue is required 3
• Prophylactic internal fixation may be considered for lesions in weight-bearing bones 5

Surveillance Strategy

For Asymptomatic Lesions Under Observation

• Regular radiological follow-up is the better option compared to prophylactic surgery given the low malignant transformation rate and considerable surgical complication rate 1
• Serial radiographs to monitor for size increase or morphologic changes 3
• No standardized surveillance interval is established, but monitoring should continue long-term 6

Post-Surgical Follow-Up

• Monitor for recurrence, though recurrence rate is very low (<5%) 5
• Recurrence suggests possible malignancy and requires re-evaluation 5
• Most patients return to full function after surgery 4

Common Pitfalls and Caveats

Diagnostic Challenges

• Microscopically distinguishing enchondroma from low-grade chondrosarcoma is extremely difficult, even for expert pathologists 4
• In the phalanges of hands and feet, malignancy is extremely rare 3
• In other long bones, central cartilaginous lesions should be considered atypical cartilaginous tumors unless proven otherwise 3
• Dynamic contrast-enhanced MRI can aid differentiation between benign enchondroma and atypical cartilaginous tumor/grade I chondrosarcoma 3

Surgical Complications

• Postoperative complications include joint stiffness and soft-tissue deformities 4
• The 23% complication rate from curettage must be weighed against the rare malignant transformation risk 1
• Recurrence after curettage is uncommon but may indicate malignant transformation 1

Location-Specific Considerations

• Enchondromas most commonly occur in small bones of hands and feet 5, 4
• Less common locations include distal femur, proximal humerus, and rarely the femoral neck 5
• For hand enchondromas presenting with pathologic fracture, controversy exists regarding timing of surgery, but curettage remains the standard treatment 4