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10. Pathology and Oncology MCQs

Practice Set 77 of 351

This practice set contains high-yield board review questions covering key concepts in 10. Pathology and Oncology. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1521

Topic: 10. Pathology and Oncology

A 63-year-old woman has a femoral neck fracture. A biopsy specimen obtained from the fracture site at the time of her hemiarthroplasty reveals metastatic carcinoma. Seven days after surgery, she becomes confused and lethargic. Which of the following laboratory values is most likely implicated in the patient’s symptoms at this time?

. Hemoglobin level of 9.0 g/dL (normal value 11-15 g/dL)
. Sodium level of 132 mEq/L (normal value 135-145 mEq/L)
. Potassium level of 5.0 mEq/L (normal value 4.0-5.2 mEq/L)
. Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)
. Serum uric acid level of 10 mg/dL (normal value 2.7-7.3 mg/dL)

Correct Answer & Explanation

. Hemoglobin level of 9.0 g/dL (normal value 11-15 g/dL)

Explanation

DISCUSSION: Although many hematologic and electrolyte abnormalities may be present in a patient with advanced metastatic cancer, an elevated serum calcium level is most commonly associated with confusion.  Treatment with hydration, diuretics, and bisphosphonates is recommended.REFERENCES: Clohishy D: Management of skeletal metastasis in clinical orthopaedics, in Craig E (ed): Operative Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 994-997.Mundy GR: Hypercalcemia of malignancy revisited.  J Clin Invest 1988;82:1-6.

Question 1522

Topic: 10. Pathology and Oncology

A 32-year-old woman has had pain and a visibly growing mass in the shoulder for 3 years but denies any history of trauma. Examination reveals a swollen, boggy shoulder mass. The AP radiograph and MRI scan are shown in Figures 20a and 20b. Figures 20c through 20e show a portion of the excised mass and the photomicrographs of the biopsy specimen. What is the most likely diagnosis?

. Synovial chondromatosis
. Pigmented villonodular synovitis
. Synovial cell sarcoma
. Tuberculosis
. Chondrosarcoma

Correct Answer & Explanation

. Synovial chondromatosis

Explanation

DISCUSSION: The radiographic findings are classic for synovial chondromatosis because of the small calcified opacities within the joint surrounding the synovium.  The histologic findings show cartilaginous foci of metaplasia, which may be markedly cellular.  However, unlike low-grade chondrosarcoma, it lacks cellular and nuclear pleomorphism.REFERENCES: Murphy FP, Dahlin DC, Sullivan CR: Articular synovial chondromatosis.  J Bone Joint Surg Am 1982;44:77-86.Milgram JW: Synovial osteochondromatosis: A histopathological study of thirty cases.  J Bone Joint Surg Am 1977;59:792-801.

Question 1523

Topic: 10. Pathology and Oncology

Radiographs of a pediatric patient reveal a suspected osteosarcoma of the distal femur. Additional staging studies should consist of

. a radiograph and CT of the chest and a bone scan.
. a radiograph and MRI of the primary tumor.
. CT of the abdomen and pelvis.
. CT of the abdomen, chest, and pelvis, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.
. CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.

Correct Answer & Explanation

. a radiograph and CT of the chest and a bone scan.

Explanation

DISCUSSION: CT of the abdomen and pelvis is not part of the staging of osteosarcoma.  Staging studies should consist of CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.  The MRI should be obtained prior to the biopsy.REFERENCE: O’Reilly R, Link M, Fletcher B, et al: NCCN pediatric osteosarcoma practice guidelines:  The National Comprehensive Cancer Network.  Oncology (Huntingt) 1996;10:1799-1806, 1812.

Question 1524

Topic: 10. Pathology and Oncology

A 6-year-old boy has leg pain. A radiograph, MRI, CT, and bone scans, and a biopsy specimen are shown in Figures 14a through 14e. What is the most likely diagnosis?

. Ewing’s sarcoma
. Osteomyelitis
. Osteosarcoma
. Eosinophilic granuloma
. Fibrous dysplasia

Correct Answer & Explanation

. Ewing’s sarcoma

Explanation

DISCUSSION: From an imaging point of view, all of the diagnoses are possible.  Biopsy results and cultures are necessary to make the diagnosis.  The biopsy specimen shows inflammatory cells and necrotic bone, consistent with osteomyelitis.REFERENCES: Fletcher BD, Hanna SL: Pediatric musculoskeletal lesions simulating neoplasms.  Magn Reson Imaging Clin N Am 1996;4:721-747.Hanna SL, Fletcher BD, Kaste SC, Fairclough DL, Parham DM: Increased confidence of diagnosis of Ewing sarcoma using T2-weighted MR images.  Magn Reson Imaging 1994;12:559-568.

Question 1525

Topic: 10. Pathology and Oncology

An otherwise healthy 16-year-old dancer reports a 1-month history of leg pain. AP and lateral radiographs of the distal femur are shown in Figures 67a and 67b. What is the next most appropriate step in management?

. Immobilization/casting
. Rest, limited weight bearing, and repeat radiographs in 4 weeks
. MRI of the femur
. Biopsy
. Chemotherapy

Correct Answer & Explanation

. Immobilization/casting

Explanation

DISCUSSION: The radiographs show a very ill-defined, aggressive, moth-eaten bony destruction involving the distal left femoral diaphysis just above the metaphyseal junction.  The differential diagnosis includes Ewing’s sarcoma, osteosarcoma, lymphoma of bone, eosinophilic granuloma, osteomyelitis, and others.  MRI would further define the lesion, and soft-tissue and intramedullary extension.  There is aggressive periosteal reaction in the posteromedial aspect of the adjacent lesion with some multilayered components in the distal interface of the periosteum.  The lateral radiograph shows cortical penetration and irregular periosteal reaction of the posterior margin, suggesting some posterior soft-tissue extension at this site as well.REFERENCES: Gebhardt MC, Ready JE, Mankin HJ: Tumors about the knee in children.  Clin Orthop Relat Res 1990;255:86-110.Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Question 1526

Topic: 10. Pathology and Oncology

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain?

. Bisphosphonates
. Calcitonin
. Parathyroid hormone
. Vitamin D and calcium
. Methotrexate

Correct Answer & Explanation

. Bisphosphonates

Explanation

DISCUSSION: McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction.  The most common endocrine presentation is precocious development of secondary sexual characteristics.  Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications.  Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia.REFERENCES: DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation and treatment.  J Bone Joint Surg Am 2005;87:1848-1864.Zacharin M, O’Sullivan M: Intravenous pamidronate treatment of polyostotic fibrous dysplasia associated with McCune Albright syndrome.  J Pediatr 2000;137:403-409.

Question 1527

Topic: 10. Pathology and Oncology

A 13-year-old girl has had a firm mass and pain in her right shoulder for the past several weeks. She denies any history of trauma. A radiograph and MRI scan are shown in Figures 31a and 31b. Biopsy specimens are shown in Figures 31c and 31d. What is the most likely diagnosis?

. Osteosarcoma
. Ewing’s sarcoma
. Osteochondroma
. Chondrosarcoma
. Periosteal chondroma

Correct Answer & Explanation

. Osteosarcoma

Explanation

DISCUSSION: The patient has osteosarcoma.  The radiograph suggests an aggressive primary tumor of bone, and the histology shows malignant cells surrounded by osteoid, classic for osteosarcoma.  Ewing’s sarcoma histologically consists of small round blue cells.  Osteochondroma and periosteal chondroma occur in the shoulder but have a different histologic pattern and a less aggressive radiographic appearance.  Chondrosarcomas rarely occur in children.REFERENCES: Simon MA, Springfield DS, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue Tumors.  Philadelphia, PA, Lippincott Raven, 1998, p 266.Wold LA, et al:  Osteogenic Sarcoma: Atlas of Orthopaedic Pathology.  Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 1528

Topic: 10. Pathology and Oncology

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

. MRI and a radiograph of the thigh and CT of the chest.
. MRI of the thigh, a chest radiograph, and a CT of the pelvis.
. MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the pelvis.
. MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the abdomen and pelvis.
. a CT of the chest and thigh, a total body bone scan, and a chest radiograph.

Correct Answer & Explanation

. MRI and a radiograph of the thigh and CT of the chest.

Explanation

DISCUSSION: The appropriate staging studies should consist of MRI and a radiograph of the primary lesion and CT of the chest.  MRI is superior to CT for soft-tissue imaging.  CT may be useful for evaluating the cortex of bone for invasion by tumor.  Bone scans are not commonly used because soft-tissue sarcomas rarely metastasize to bone.  CT of the abdomen and pelvis is not typically ordered except for possible liposarcoma.  With liposarcoma, there may be a synchronous or metastatic retroperitoneal liposarcoma.REFERENCES: Demetri GD, Pollock R, Baker L, et al: NCCN sarcoma practice guidelines: National Comprehensive Cancer Network.  Oncology (Huntingt) 1998;12:183-218.Pollock R, Brennan M, Lawrence W Jr: Society of Surgical Oncology practice guidelines:  Soft-tissue sarcoma surgical practice guidelines.  Oncology (Huntingt) 1997;11:1327-1332.

Question 1529

Topic: 10. Pathology and Oncology

A 24-year-old man has had pain in the left knee for the past several months. He reports that initially the pain was associated with weight-bearing activities, but it has now become more constant. He denies any swelling but reports a lateral fullness at the tibial plateau. Figures 23a through 23e show radiographs, a bone scan, and T1- and T2-weighted MRI scans. What is the most likely diagnosis?

. Stress fracture
. Simple bone cyst
. Fibrous dysplasia
. Infection
. Giant cell tumor

Correct Answer & Explanation

. Stress fracture

Explanation

DISCUSSION: The radiographs reveal a lytic subchondral lesion that has a poorly defined margin and lacks mineralization.  The bone scan confirms an active lesion that has central photopenia, producing the characteristic doughnut configuration.  The MRI scans confirm the presence of a subchondral lesion that is modestly expansile at the lateral plateau and has low signal intensity on the T1-weighted image and a mixed high signal on the T2-weighted image.  These features strongly suggest giant cell tumor of bone, more than 50% of which appear around the knee.  Simple cyst is excluded by the MRI characteristics.  Fibrous dysplasia is unlikely to be in a subchondral location and typically does not show this intensity of uptake on bone scan.REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H,Malkani AL (eds): Orthopaedics.  St Louis, MO, Mosby, 2002, pp 1027-1035.Resnick D, Kyriakos M, Greenway GD: Tumors and tumor-like lesions of bone: Imaging and pathology of specific lesions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 4.  Philadelphia, PA, WB Saunders, 2002, vol 4, pp 3939-3962.

Question 1530

Topic: 10. Pathology and Oncology

Acetabular reconstruction followed by external beam irradiation The plain radiographs show a purely lytic destructive lesion that is poorly marginated. The technetium bone scan does not show any major uptake. The computerized tomography scan shows purely lytic bone destruction with breakthrough of the cortical bone. Complete destruction of the cortical bone is suggestive of a malignancy. The magnetic resonance image shows a lesion that is homogenously low on T1-weighted images and high on T2-weighted images. Surgeons cannot make a definitive diagnosis based upon the radiographic features. The most common malignancies in this age group are:

. Metastatic bone disease
. Multiple myeloma
. Lymphoma
. Chondrosarcoma
. Malignant fibrous histiocytomaThe biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease.The treatment of metatastic bone disease is either internal fixation with postoperative external beam irradiation or external beam irradiation alone. In this case, there is extensive destruction and fracture is imminent. The treatment of choice is acetabular reconstruction followed by external beam irradiation.

Correct Answer & Explanation

. Metastatic bone disease

Explanation

Slide 1 Slide 2 Slide 3 Slide 4A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. The most likely diagnosis based upon the radiographs would be:

Question 1531

Topic: 10. Pathology and Oncology

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

. Enchondroma
. Nonossifying fibroma
. Chondromyxoid fibroma
. Osteosarcoma
. Chondrosarcoma

Correct Answer & Explanation

. Enchondroma

Explanation

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone.  The photomicrograph shows spindle cells with a myxoid cartilaginous matrix.  These findings are diagnostic of chondromyxoid fibroma.  This is a rare, benign tumor that usually causes pain and can be locally aggressive.REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor.  Clin Orthop Relat Res 2005;439:171-175.Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 1532

Topic: 10. Pathology and Oncology

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

. Fungal infection
. Ingrowth of the medial nail
. Benign exostosis
. Malignant neoplasm
. Reactive pyogenic granuloma

Correct Answer & Explanation

. Fungal infection

Explanation

DISCUSSION: The lesion is typical of a subungual exostosis, which is most often found on the medial aspect of the great toe in children and young adults.  The diagnosis is confirmed on radiographs and usually requires excision for relief.REFERENCES: Lokiec F, Ezra E, Krasin E, Keret D, Wientraub S: A simple and efficient surgical technique for subungual exostosis.  J Pediatr Orthop 2001;21:76-79.Letts M, Davidson D, Nizalik E: Subungual exostosis: Diagnosis and treatment in children.  J Trauma 1998;44:346-349.Davis DA, Cohen PR: Subungual exostosis: Case report and review of the literature. Pediatr Dermatol 1996;13:212-218.

Question 1533

Topic: 10. Pathology and Oncology

A 35-year-old man has had progressive right knee pain for the past 2 months. An AP radiograph, bone scan, MRI scan, and photomicrograph are shown in Figures 34a through 34d. What is the most appropriate treatment of this lesion?

. Observation
. Extended curettage with adjuvant treatment
. Wide resection
. Radiation therapy
. Multimodal treatment including chemotherapy and surgery

Correct Answer & Explanation

. Observation

Explanation

DISCUSSION: This is a classic case of giant cell tumor of bone.  The radiograph and the MRI scan reveal a purely lytic lesion in the medial femoral condyle.  The lesion is well-demarcated without a rim of sclerotic bone.  It is eccentrically located and abuts the subchondral bone.  The lesion demonstrates increased uptake on a technetium TC 99m bone scan.  These imaging studies are highly suggestive of giant cell tumor arising in its most common location.  The photomicrograph confirms the diagnosis of giant cell tumor.  Based on these findings, the most widely accepted treatment is extended curettage plus a local adjuvant such as polymethylmethacrylate bone cement, argon beam coagulation, liquid nitrogen, and/or phenol.REFERENCES: Lackman RD, Hosalkar HS, Ogilvie CM, et al: Intralesional curettage for grades II and III giant cell tumors of bone.  Clin Orthop Relat Res 2005;438:123-127.Ward WG Sr, Li G III: Customized treatment algorithm for giant cell tumor of bone: Report of a series.  Clin Orthop Relat Res 2002;397:259-270.

Question 1534

Topic: 10. Pathology and Oncology

A 21-year-old man has had posterior neck discomfort for the past 6 months. A whole-body bone scan and a cervical single-photon emission CT reveal increased activity at the C7 spinous process. MRI reveals multifocal involvement of the spinous process lamina and facet of C7. A CT-directed needle biopsy reveals osteoblastoma. What is the best course of action?

. Observation
. Radiation therapy
. Curettage
. En bloc excision with stabilization
. En bloc excision followed by radiation therapy

Correct Answer & Explanation

. Observation

Explanation

DISCUSSION: En bloc excision is the recommended treatment of osteoblastoma. Treatment should consist of en bloc removal of the lamina, facet, and spinous process.  Facet removal would necessitate fusion. Radiation therapy is not recommended. Intralesional curettage has a high rate of recurrence.REFERENCES: Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery.  Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1143-1174.Ozaki T, Liljenquist U, Hillmann A, et al: Osteoid osteoma and osteoblastoma of the spine: Experience with 22 patients.  Clin Orthop 2002;397:394-402.

Question 1535

Topic: 10. Pathology and Oncology

What is the most common benign bone tumor in childhood?

. Unicameral bone cyst
. Fibrous dysplasia
. Nonossifying fibroma
. Aneurysmal bone cyst
. Chondromyxoid fibroma

Correct Answer & Explanation

. Unicameral bone cyst

Explanation

DISCUSSION: The most common benign bone tumor in childhood is a nonossifying fibroma.  It is estimated that 30% of children have a nonossifying fibroma.  In most patients, the lesion is not identified until a radiograph is obtained for unrelated reasons.  Similarly, most identified cases of fibrous cortical defect are not biopsied because the radiographic and clinical presentations are diagnostic.REFERENCES: Aboulafia AJ, Kennon RE, Jelinek JS: Benign bone tumors of childhood.  J Am Acad Orthop Surg 1999;7:377-388.Biermann JS: Common benign lesions of bone in children and adolescents.  J Pediatr Orthop 2002;22:268-273.

Question 1536

Topic: 10. Pathology and Oncology

What is the most common clinical presentation of a patient with a malignant bone tumor?

. Incidental finding
. Pain
. Pathologic fracture
. Deformity
. Presence of a mass

Correct Answer & Explanation

. Incidental finding

Explanation

DISCUSSION: The most common clinical presentation of a patient with a malignant bone tumor is pain.  Malignant bone tumors rarely are diagnosed as an incidental finding or pathologic fracture.  In patients who have a pathologic fracture on initial presentation, a history of increasing pain prior to the fracture is typical.  While 90% of malignant bone tumors are associated with a soft-tissue mass, in many patients the soft-tissue component of the tumor is not clinically apparent.REFERENCES: Buckwalter JA: Musculoskeletal neoplasms and disorders that resemble neoplasms, in Weinstein SL, Buckwalter JA (eds): Turek’s Orthopaedics: Principles and Their Application, ed 5.  Philadelphia, PA, JB Lippincott, 1994, pp 290-295.Mehlman CT, Crawford AH, McMath JA: Pediatric vertebral and spinal cord tumors: A retrospective study of musculoskeletal aspects of presentation, treatment, and complications. Orthopedics 1999;22:49-55.

Question 1537

Topic: 10. Pathology and Oncology

Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best next treatment step?

. Biopsy
. Resection
. A CT scan
. An MRI scan
. Observation

Correct Answer & Explanation

. Biopsy

Explanation

Question 1538

Topic: 10. Pathology and Oncology

A 16-year-old girl has had hip pain for 1 year. Approximately 2 months ago she noted the development of a hard mass in the right buttock that has steadily increased in size. She now reports severe pain in the right buttock, with radiation down the leg and numbness involving the right foot and toes. A radiograph is shown in Figure 70a and an axial postcontrast T 1 -weighted MRI scan is shown in Figure 70b. A biopsy specimen is shown in Figure 70c. The chest CT shows multiple lung metastases. Treatment of this lesion should consist of

. surgery alone.
. neoadjuvant chemotherapy and surgical resection.
. radiation therapy.
. chemotherapy and radiation therapy.
. chemotherapy only.

Correct Answer & Explanation

. surgery alone.

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common primary tumor of bone in children.  Depending on the site and extent of disease, chemotherapy, radiation therapy, and surgery are all treatment options.  In this patient with extensive pelvic and metastatic disease, chemotherapy and radiation therapy offer the best oncologic control while preserving functional outcome.REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors.  Instr Course Lect 2002;51:413-428.Thacker MM, Temple HT, Scully SP: Current treatment for Ewing’s sarcoma.  Expert Rev Anticancer Ther 2005;5:319-331.Weber KL: Current concepts in the treatment of Ewing’s sarcoma.  Expert Rev Anticancer Ther 2002;2:687-694.

Question 1539

Topic: Bone Tumors

Which of the following best describes the function of the notochord?

. The notochord becomes the medulla oblongata in adults.
. The notochord induces tissues that eventually become the vertebral column.
. The notochord disappears with ossification of vertebral bodies.
. The notochord develops into the ring apophysis.
. Remnants of the notochord are often found in the coccyx.

Correct Answer & Explanation

. The notochord becomes the medulla oblongata in adults.

Explanation

DISCUSSION: The notochord is the anatomic structure that defines the phylum Chordata.  The notochord plays a fundamental role in the development of the skeleton, and it exists only for a short period of time.  During its temporary existence, the notochord serves as a transient axis of support, provides for the initial axis of orientation of the developing embryo, and most importantly, plays a vital role in the induction of the tissues that eventually form the vertebral column.REFERENCE: Rosenberg A: Embryology of the skull base and vertebral column, in Harsh G (ed): Chordomas and Chondrosarcomas of the Skull Base and Spine.  New York, NY, Thieme, 2003, pp 3-8.

Question 1540

Topic: 10. Pathology and Oncology

What is the most common malignant bone tumor seen in patients with multiple hereditary exostosis?

. Dedifferentiated chondrosarcoma
. Mesenchymal chondrosarcoma
. Secondary chondrosarcoma
. Clear cell chondrosarcoma
. Periosteal osteosarcoma

Correct Answer & Explanation

. Dedifferentiated chondrosarcoma

Explanation

DISCUSSION: Secondary chondrosarcomas are most common in patients with multiple hereditary exostosis.  Dedifferentiated chondrosarcoma is less common and refers to bone lesions in which a high-grade spindle cell sarcoma component is located immediately adjacent to a low-grade cartilage neoplasm.  Mesenchymal chondrosarcoma, clear cell chondrosarcoma, and periosteal osteosarcoma are no more common in patients with multiple hereditary exostosis than in the general population.REFERENCES: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations.  Philadelphia, PA, Lea and Febiger, 1989, pp 1660-1669.Simon MA, Springfield DS, et al: Common Malignant Bone Tumors: Chondrosarcoma. Surgery for Bone and Soft Tissue Tumors.  Philadelphia, PA, Lippincott Raven, 1998, pp 275-286.

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