Rare Presentation of a Giant Paraspinal Chondrosarcoma: Case Report and Review of Literature

Abstract

Chondrosarcomas are malignant chondrogenic neoplasms that primarily affect the bones of the pelvis and appendicular skeleton. Approximately 15% of these tumors occur in the chest wall. They most commonly originate anteriorly from the costochondral junction or sternum. Posterior thoracic chondrosarcomas frequently arise from the costal angle and vertebral arch of the thoracic spine, and only rarely do they originate at the costovertebral junction. A total of 30 patients with chondrosarcoma arising from the costovertebral junction have been previously reported in the English literature. We report a case of giant costovertebral chondrosarcoma presenting as a large paraspinal mass and review the current literature on the topic. A 42-year-old female with no comorbidities presented with a 3-month history of chest pain and dry cough. Radiologic imaging revealed a massive irregularly calcified paraspinal mass extending from the T5 to T7 vertebral levels. A microsurgical excision of the lesion was performed using a posterolateral thoracic approach, and intraoperatively, the mass was seen arising from the right T5 costovertebral junction with extension into the T4-T5 neural foramen. Histological examination confirmed a diagnosis of grade 2 chondrosarcoma. The uniqueness of our case report lies in the size and location of the chondrosarcoma, with only one other case being as large as ours. Chondrosarcoma must be considered in the differential diagnosis of partly calcified paraspinal masses arising from the costovertebral junction.

 

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Keywords

chondrosarcoma - costovertebral - thoracic spine - paraspinal mass - posterolateral approach

Introduction

Thoracic chondrosarcomas are malignant chondroid neoplasms that account for around one-third of chest wall tumors, making them the most common primary malignancy in this location.[1] [2] They typically arise anteriorly from the costochondral junction or the sternum.[1] [2] [3] Chondrosarcomas originating from the posterior chest wall arise from the costal angle or the posterior elements of the thoracic spine.[4] [5] It is extremely uncommon for them to present as a giant paraspinal mass arising from the posterior costovertebral junction.[2] [6] [7]

In 1985, the Mayo Clinic group initially reported 20 patients with chondrosarcoma originating from the costovertebral junction.[8] Since then, only 10 additional cases have been reported in the English literature ([Table 1]). We describe a 42-year-old female who presented to our institute with a giant paraspinal chondrosarcoma originating posteriorly from the right T5 costovertebral junction and provide a review of the current literature on this rare entity.

Table 1 Clinical presentation of reported cases of chondrosarcoma arising from the costovertebral junction

Author/year	No of cases	Age/Sex	Presentation	Side	Origin	Level of involvement	Maximal diameter
McAfee et al/1985[8]	20	NA	NA	NA	NA	NA	NA
Vertzyas et al/2000[16]	1	8.5/F	Lump involving the left infrascapular region	Left	T8 junction	T8-T9	NA
Briccoli et al/2002[19]	3	NA	NA	NA	NA	NA	NA
Bartalena et al/2007[17]	1	22/F	Right-sided thoracic back pain	Right	T5 junction	T4-T5	NA
Bouali et al/2016[20]	1	61/M	Lower limb weakness with urinary hesitancy/neck pain	Right	T1 junction	C7-T2	NA
Le et al/2016[7]	1	45/M	Left-sided thoracic back pain with numbness/pruritis	Left	T7 junction	T7-T9	48 mm
Bodin et al/2016[3]	1	40/M	Giant subcutaneous mass	Left	T11 junction	NA	300 mm
Upadhyaya et al/2021[18]	1	35/M	Lower limb weakness with urinary retention	Left	NA	T6-T10	NA
Abdullah et al/2023[6]	1	47/M	Right-sided posterior chest pain with dyspnea and dry cough	Right	T5 and T6 junctions	T5-T6	53 mm
Our case	1	42/F	Right-sided chest pain and dry cough	Right	T5 junction	T5-T7	110mm

Abbreviations: F, female; M, male; NA, not available.

 

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Case Presentation

A 42-year-old female with no comorbidities presented to our institute with a 3-month history of dry cough and right-sided chest pain. The onset of pain had been gradual and intermittent, radiating to the back in the interscapular region. The patient denied experiencing any other symptoms of radiculomyelopathy. Examination revealed no neurological deficits. Laboratory tests, including the determination of complete blood count, clotting profiles, electrolytes, and blood chemistry values, were all within the normal range.

A chest X-ray was done initially, which revealed a well-defined radio-opaque lesion with irregular calcifications in the right lung field at the upper-thoracic level ([Fig. 1]). A computed tomography (CT) of the chest showed a solid mass extending from the T5 to T7 vertebral levels in the right paravertebral region with involvement of the apicoposterior segment of the right lung ([Fig. 2]). There was evidence of bone destruction as well as intralesional matrix mineralization. Magnetic resonance imaging (MRI) of the thoracic spine revealed a 11 cm (anteroposterior) × 10 cm (craniocaudal) × 9 cm (transverse) heterogeneously enhancing, partially calcified, T2 hyperintense lesion, which appeared to arise from the right T5 costovertebral junction. The paravertebral lesion extended from the T5 to T7 vertebrae levels, involving the intervertebral foramen of T5 but with no cord compression ([Fig. 3]). A whole-body positron emission tomography CT scan revealed no additional findings.

Fig. 1 Chest X-ray showing a well-defined radio-opaque shadow in the right lung field at the upper thoracic level (block arrow).

Fig. 2 Axial computed tomography (CT) scan of the chest showing a rounded mass with a calcified matrix (star), extending craniocaudally from the T5 to T7 vertebral levels and anteroposteriorly from the posterior costovertebral junction to the aorta (A).

Fig. 3 Preoperative T1-weighted (A and D) and T2-weighted (B and C) thoracic magnetic resonance imaging (MRI) sequences showing a large well-defined lobulated mass lesion (star) in the posterior mediastinum occupying the right paravertebral region. The lesion is heterogeneously hyperintense on T2 imaging (suggestive of intralesional mineralization). The intrathoracic component is seen compressing the right lung parenchyma with displacement of the right main bronchus (Br). The aorta (block arrow) is seen medially on the left side.

A right posterolateral approach was used to reach the lesion, removing the posterior and medial ends of the 5th and 6th ribs ([Fig. 4]). A pearlescent, white, encapsulated lesion was seen. The primary strategy involved extrapleural microsurgical excision of the lesion. Intraoperatively, the lesion was observed to be centered at the right T5 costovertebral junction, with a small intraspinal extension. The thoracic component was initially excised, followed by careful resection of the intraspinal-extradural component by tracing the tumor mass. Notably, the inferior vena cava was displaced anteriorly and medially. By maintaining a strict dissection plane just outside the capsule of the lesion, the major vessel was safely mobilized, thereby allowing for a safe excision of the lesion. The pleura was breached during the dissection of the tumor capsule, which was adherent to it ([Fig. 5]).

Fig. 4 Patient was positioned prone and an infrascapular incision was marked, extending laterally from the midline.

Fig. 5 Intraoperative image showing dissection of the lesion (*) from the parietal pleura.

Histopathological examination revealed vacuolated tumor cells embedded within a chondroid matrix, arranged in irregular lobules and infiltrating the normal bony trabeculae. The histologic findings were consistent with a diagnosis of grade 2 chondrosarcoma ([Fig. 6]).

Fig. 6 (A and B). Hematoxylin and eosin (H&E) staining of the excised specimen shows vacuolated tumor cells surrounded by a chondroid matrix. The tumor cells are seen infiltrating the bony trabeculae.

Postoperatively, the patient did well and was free of her preoperative symptoms. However, she needed prolonged placement of an intercostal drainage tube. A routine postoperative CT scan confirmed radical excision of the tumor. Chest and limb physiotherapy were continued until the patient was discharged on the eighth postoperative day. Following the surgery, she did not receive adjuvant chemotherapy or radiotherapy. The patient was last seen for a follow-up by the senior author 3 months after the procedure. Her CT scan showed no signs of recurrence ([Fig. 7]). She is currently doing well, has no complaints, and is on regular follow-up.

Fig. 7 Axial computed tomography (CT) scan at the 3-month follow-up period showing radical excision of the lesion with a suspect small residual calcification at the neural foramen (arrow).

 

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Discussion

The paraspinal region is a loosely defined anatomic zone extending between the parietal fascia ventrally and the paraspinal muscle aponeurosis laterally.[9] Benign neurogenic tumors, such as schwannoma, followed by neurofibroma, ganglioneuroma, and paraganglioma, are the most common neoplasms in this region.[10] The occurrence of a malignant chondrogenic neoplasm in this location is exceedingly rare.[2]

Chondrosarcoma is a malignant cartilage-forming neoplasm that primarily affects the bones of the pelvis and appendicular skeleton.[6] [7] They may arise spontaneously or through malignant transformation of a benign lesion, such as an osteochondroma or enchondroma.[11] Thoracic chondrosarcomas usually occur in males around the sixth decade of life.[1] The majority of patients present with localized pain and palpable mass in the anterior chest wall.[6] [7] [8] Our patient was a female in the fourth decade of life presenting with a giant nonpalpable paraspinal lesion arising from the posterior costovertebral junction of the fifth thoracic vertebra.

Paraspinal sarcomatous tumors tend to grow to extremely large sizes and present late with nonspecific symptoms.[12] Unlike the hypaxial muscles of the cervical and lumbar regions, the thoracic spine lacks paraspinal muscles anterior to the transverse process.[9] This facilitates the gradual inward growth of these tumors into the thoracic cavity,[5] as was observed in our case. Bodin et al reported a similar but palpable giant-sized costovertebral chondrosarcoma measuring 300 mm.[3]

Popcorn-like “arcs and rings” pattern of calcifications with bony destruction and soft-tissue invasion, as present in our case ([Fig. 2]), are hallmark features of chondrosarcoma on CT imaging.[13] MRI aids in delineating the extraosseous extent of the lesion and assists in preoperative planning. Nuclear imaging helps rule out extrapulmonary metastasis.

McAfee et al recommended early, wide resection with adequate tumor-free margins for achieving optimal surgical outcomes.[8] [Table 2] gives an overview of the nature of the resection performed on patients with costovertebral chondrosarcomas. The senior author (K.S.) used an extrapleural posterolateral approach involving an infrascapular incision ([Fig. 4]) and achieved a radical excision of the lesion, which Lu and Zhang concurred was a good approach for managing large lesions in this region.[14] Rong et al had previously described a modified posterolateral approach involving a semicircular arc incision for resecting paraspinal tumors with a huge extraforaminal component.[10] Tang et al employed a combined anterior and posterior approach to resect a huge chondrosarcoma in this region.[15] The primary challenge in our case was the size of the lesion, second only to that reported by Bodin et al[3](see [Table 1]). This required an extended approach while carefully preserving spinal stability and avoiding lung injury. The presence of vital neurovascular structures, the risk of spinal instability with multilevel joint involvement, and potential respiratory compromise from pulmonary involvement often pose challenges to achieving adequate tumor-free margins[15] (see [Table 2]). In our case, pleural involvement warranted breaching the pleura to achieve a gross total excision of the lesion.

Table 2 Surgical details and outcomes of reported cases of chondrosarcoma arising from the costovertebral junction

Author/ year	Type of resection	Complications	Follow-up	Recurrence
McAfee et al/1985[8]	NA	NA	NA	NA
Vertzyas et al/2000[16]	Radical excision	Progressive scoliosis	12 years	No
Briccoli et al/2002[19]	NA	NA	NA	NA
Bartalena et al/2007[17]	Wide surgical excision	NA	NA	NA
Bouali et al./ 2016[20]	Partial resection	NA	1.2 years	No
Le et al/2016[7]	Wide en bloc resection	NA	NA	NA
Bodin et al/2016[3]	Radical resection	Neurogenic pain	1.5 years	No
Upadhyaya et al/2021[18]	Partial excision	No	NA	NA
Abdullah et al/2023[6]	Wide surgical resection	No	1 year	No
Our case	Radical resection	Persistent pleural effusion	3 months	No

Abbreviation: NA, not available.

Histological grade is an important factor in predicting local recurrence and survival outcomes after surgery.[2] [11] Pathological analysis revealed a diagnosis of grade 2 chondrosarcoma in our patient ([Fig. 6]). However, in clinical practice, grade 1 chondrosarcoma is the most commonly observed subtype.[13] Unlike other sarcomatous tumors, chondrosarcomas, in general, exhibit resistance to chemotherapy and conventional radiation.[1] [6] [7] [11] [16] [17] [18] Consequently, no adjuvant treatment was recommended for our patient.

While the 5-year survival rates for thoracic chondrosarcomas generally range from 85 to 90%, the specific prognostic outcomes for lesions originating from the costovertebral junction are not well-established, given the limited number of reported cases.[1] [6] At the 3-month follow-up, CT imaging showed no signs of recurrence ([Fig. 7]). However, as these patients may experience delayed local recurrence after excision, long-term follow-up is generally recommended.[13]

 

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Conclusion

Surgeons must consider chondrosarcomas as a differential diagnosis for partly calcified masses arising from the costovertebral junction. Early detection and radical surgical excision are imperative for improving the oncologic and functional outcomes of these lesions. When faced with large lesions, as described in the case above, it is necessary to use a combination of surgical techniques to achieve the best outcomes.

 

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Conflict of Interest

None declared.

Authors' Contributions

All authors contributed to the preparation of this manuscript.

Ethical Approval

This case report was written in accordance with the principles of the Declaration of Helsinki.

Patients' Consent

Written informed consent for publication was obtained from the affected individual prior to inclusion in the report. Details that might disclose their identity were omitted.

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Publication History

Article published online:
29 August 2025