medicina

Case Report
Nasal Chondrosarcoma of the Lower Lateral Cartilage
Hannah B. Tan * and Joanne Rimmer
Department of Otolaryngology, Head and Neck Surgery, Monash Health, Clayton, VIC 3168, Australia;
rimmer.joanne@gmail.com
* Correspondence: hannahb.tan@gmail.com




Received: 16 April 2019; Accepted: 8 May 2019; Published: 9 May 2019


Abstract: Head and neck chondrosarcomas are incredibly rare with documented cases arising
from skull base, maxilla, larynx, and nasal septum. We present the first reported case of
chondrosarcoma arising from the lower lateral cartilage of the nose treated with surgical resection
and primary reconstruction.

Keywords: sinonasal; chondrosarcoma; head and neck sarcoma; lower lateral cartilage;
open septorhinoplasty

1. Introduction
Sarcomas of the head and neck are rare, comprising less than one per cent of all head and neck
neoplasms [1]. Of these few cases, only 20% arise from bone or cartilage origin, most commonly the
skull base, maxilla and larynx [1]. There are only a few reported cases of chondrosarcoma arising from
nose, most commonly originating from septal cartilage [2–5]. Nasal tip origin is a rare entity with only
two reported cases [6]. We present the first documented case of chondrosarcoma arising from the
lower lateral cartilage (LLC) of the nose.

2. Case
A 68-year-old man presented with a ten-year history of a lump in the right nasal tip, with a
significant increase in size over a six-month period. Medical history included adenocarcinoma of the
rectum treated with surgery and radiotherapy two years previously, polycythaemia, chronic alcohol
abuse and a 50-pack per year smoking history. Clinical examination revealed a large bulbous firm
swelling of the right lower third of the nose causing significant cosmetic asymmetry and distorting
the right ala (Figure 1). Rigid nasal endoscopy was otherwise unremarkable, and oropharyngeal
and neck examination was normal. Computed tomography (CT) scan showed a 2.8 cm soft tissue
lesion arising from the right anterior nares, abutting but not obviously involving the cartilaginous
septum. Magnetic resonance imaging (MRI) confirmed a right-sided 3.4 cm mass arising from the
lower lateral alar cartilage (Figure 2) with no apparent invasion of the nasal septum or adjacent soft
tissues. An incisional biopsy via the vestibular aspect revealed a well-defined avascular mass with a
lobulated surface. The initial histopathological report was suggestive of benign enchondroma, however
further review considered low-grade chondrosarcoma to be more likely. Imaging of the neck and
chest showed no evidence of metastatic disease, but two small lung nodules were identified, with a
subsequent diagnosis of primary adenocarcinoma of the lung.

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Figure 1. Right nasal tip/vestibule mass.

Figure 1. Right nasal tip/vestibule mass.

Figure 2. Axial T1 weighted magnetic resonance imaging (MRI) showing mass arising from right lower
Figure 2. Axial T1 weighted magnetic resonance imaging (MRI) showing mass arising from right
Figure 2. Axial T1 weighted magnetic resonance imaging (MRI) showing mass arising from right
lateral cartilage.
lower lateral cartilage.
lower lateral cartilage.
After discussion at the multidisciplinary head and neck meeting, the patient underwent primary
After discussion at the multidisciplinary head and neck meeting, the patient underwent primary
resection
Aftervia an external
discussion at therhinoplasty approach.
multidisciplinary headThe
andskin
neckand soft tissue
meeting, envelope
the patient (SSTE) primary
underwent was not
resection via an external rhinoplasty approach. The skin and soft tissue envelope (SSTE) was not
adherent to
resection viathe
antumor, which
external was well-circumscribed
rhinoplasty and easily
approach. The skin dissected
and soft tissue from the surrounding
envelope (SSTE) was soft
not
adherent to the tumor, which was well-circumscribed and easily dissected from the surrounding soft
tissue with no evidence of local invasion. Macroscopic resection of a 3 cm × 3 cm × 3 cm
adherent to the tumor, which was well-circumscribed and easily dissected from the surrounding soft mass arising
tissue with no evidence of local invasion. Macroscopic resection of a 3 cm × 3 cm × 3 cm mass arising
from the
tissue lateral
with crus of the
no evidence rightinvasion.
of local LLC wasMacroscopic
performed (Figures
resection3 of
anda 34).cmSoft
× 3 tissue
cm × 3superficial to the
cm mass arising
from the lateral crus of the right LLC was performed (Figures 3,4). Soft tissue superficial to the tumor
from the lateral crus of the right LLC was performed (Figures 3,4). Soft tissue superficial to the tumor
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tumor and the right upper lateral cartilage were excised as margins. Primary reconstruction of the
and
and the right upper
upper lateral cartilage were excised
excised as margins. Primary
Primaryareconstruction of
of the
the LLC was
LLCthewasright
performed lateral
using cartilage werecartilage
native septal as margins.through
harvested reconstruction
separate left Killian’s LLC was
incision.
performed
performed using
using native
native septal
septal cartilage
cartilage harvested
harvested through
through a
a separate
separate left
left Killian’s
Killian’s incision.
incision. A
A lateral
lateral
A lateral crural strut graft was sutured to the preserved dome of the native LLC medially and placed
crural
crural strut graft
struttissue was
was sutured
graftpocket sutured to the
the preserved dome of
of the native LLC medially and placed into aa
into a soft laterallyto(Figure
preserved dome
5). Silastic splints the native
were placed LLC medially
on either sideand placed
of the rightinto
ala to
soft
soft tissue
tissuethepocket
pocket laterally (Figure 5). Silastic splints were placed on either side of the right ala to
minimize deadlaterally
space left(Figure 5). Silastic
after resection splints
of the tumourwere placed
(Figure 6). on
Aneither side
external of theofright
plaster Paris ala to
splint
minimize
minimize the
the dead
dead space
space left
left after
after resection
resection of
of the
the tumour
tumour (Figure
(Figure 6).
6). An
An external
external plaster
plaster of
of Paris
Paris
was also applied.
splint
splint was
was also
also applied.
applied.

Figure
Figure3.
Figure 3.3.Intraoperative
Intraoperativephotograph
Intraoperative photographshowing
photograph showing mass
showing
mass arising
mass
arising from
arising
from the
from right
thethe lower
right
right lateral
lower
lower cartilage
lateral
lateral (LLC).
cartilage
cartilage (LLC).
(LLC).

Figure
Figure 4.
Figure 4. Resected
4. Resectedspecimen
Resected specimen with
specimen with suture
with suture marking
suture marking the
marking the medial
the medial resection
medial resection margin
resection margin of
of the
the LLC.
LLC.
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Figure5.5.(a)
Figure (a)Remaining
Remainingnative
nativemedial
medialcrus
crusand
anddome
domeofofLLC,
LLC,(b)
(b)Reconstructed
ReconstructedLLC
LLCusing
usingseptal
septal
Figure 5. (a) Remaining native medial crus and dome of LLC, (b) Reconstructed LLC using septal
cartilagegraft.
cartilage graft.
cartilage graft.

Figure6.6.(a)
Figure (a)Pre-operative
Pre-operativephotograph
photographshowing
showingexpansion
expansionofofthe
theskin
skinand
andsoft
softtissue
tissueenvelope
envelope(SSTE)
(SSTE)
Figure 6. (a) Pre-operative photograph showing expansion of the skin and soft tissue envelope (SSTE)
due
duetotomass,
mass,(b)
(b)Immediate
Immediatepost-operative
post-operativephotograph
photographdemonstrating
demonstratingresidual
residualexpansion
expansionofof
SSTE.
SSTE.
due to mass, (b) Immediate post-operative photograph demonstrating residual expansion of SSTE.
Histopathological
Histopathologicalreviewreviewof of
thethe
specimen
specimen confirmed
confirmedan intermediate gradegrade
an intermediate chondrosarcoma with
chondrosarcoma
clear Histopathological review of the specimen confirmed an intermediate grade chondrosarcoma
withresection margins. margins.
clear resection As the tumorAs was
the resected
tumor was fromresected
an easily from
observable area, the
an easily multidisciplinary
observable area, the
withand
head clear
neckresection
meeting margins. As the was
recommendation tumorfor was resected
surveillance from
only, withan
no easily observable
postoperative area, the
radiotherapy
multidisciplinary head and neck meeting recommendation was for surveillance only, with no
atmultidisciplinary head and neck meeting recommendation was for surveillance only, with no
this stage. radiotherapy
postoperative at this stage.
postoperative
There radiotherapy at this stage.
Therewere
werenonopost-operative
post-operativecomplications.
complications. Sutures
Sutures andand splints
splints were
wereremoved
removedone oneweek
week
There
following were no
surgery. The post-operative
SSTE was complications.
contracted and Sutures
adhered to and splints
underlying were
tissue removed
without one week
development
following surgery. The SSTE was contracted and adhered to underlying tissue without development
following
of surgery. The SSTE was contracted and adhered to underlying tissue without development
ofseroma
seromaororhaematoma.
haematoma.At Atfive-week
five-weekreview,
review,thetheright
rightnasal
nasalairway
airwaywaswaspatent
patentwith
withnonodynamic
dynamic
of seroma
collapse of or
thehaematoma.
right nasal At
ala.five-week
At four review,
months the right
(Figure nasal
7), there airway
was was
no patent
evidence with
of no dynamic
locoregional
collapse of the right nasal ala. At four months (Figure 7), there was no evidence of locoregional
collapse
disease of thepatient’s
right nasal ala. At four months (Figure 7),(Figure
there was no patient
evidence of locoregional
diseaseand
andthethe patient’sright
rightnasal
nasalairway
airwayremained
remainedpatentpatent (Figure8).8).The
The patientisisdue
duetotoundergo
undergo
disease and
radiotherapy the patient’s right nasal airway remained patent (Figure 8). The patient is due to undergo
radiotherapyfor forthe
thelung
lungcancer
cancerdiagnosed
diagnosedononhis hisstaging
stagingCT CTscan.
scan.
radiotherapy for the lung cancer diagnosed on his staging CT scan.
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Figure 7. Four-months post-operative.

Figure 7.
Figure Four-months post-operative.
7. Four-months post-operative.

Figure 8.
Figure Four-months post-operative
8. Four-months post-operative photograph
photograph showing
showing adequate
adequate support
support of
of right
right ala.
ala.
Figure 8. Four-months post-operative photograph showing adequate support of right ala.
3. Discussion
4. Discussion
4. Discussion
As demonstrated in this case, chondrosarcoma is histopathologically difficult to differentiate
As demonstrated in this case, chondrosarcoma is histopathologically difficult to differentiate
from benign neoplasms ofthis cartilaginous origin, such as enchondroma, osteochondroma, and synovial
fromAs demonstrated
benign neoplasmsin case, chondrosarcoma
of cartilaginous origin, such asisenchondroma,
histopathologically difficult to and
osteochondroma, differentiate
synovial
chondromatosis
from [7].
benign neoplasms Differential diagnoses
of cartilaginous to
origin, be considered
such for high-grade
as enchondroma, chondrosarcoma
osteochondroma, include
and synovial
chondromatosis [7]. Differential diagnoses to be considered for high-grade chondrosarcoma include
chondroblastic osteosarcoma,
chondromatosis [7]. Differentialfibrosarcoma,
diagnoses toand be malignant
considered fibrous histiocytoma
for high-grade [7].
chondrosarcoma include
chondroblastic osteosarcoma, fibrosarcoma, and malignant fibrous histiocytoma [7].
Surgical
chondroblastic resection is the
osteosarcoma, primary modality
fibrosarcoma, and of treatment
malignant for chondrosarcomas
fibrous histiocytoma [1,5]. A systematic
[7].
Surgical resection is the primary modality of treatment for chondrosarcomas [1,5]. A systematic
review of 161 patients is
Surgical with
thesinonasal chondrosarcoma found surgery alone was performed in 72%
review of 161resection
patients with primary modality
sinonasal of treatment
chondrosarcoma found forsurgery
chondrosarcomas
alone was [1,5]. A systematic
performed in 72%
and a combination
review of 161 patientsof surgery and radiotherapy
with sinonasal in 21.7%
chondrosarcoma of cases
found [5]. Open
surgery surgical
alonesurgical approach alone
was performed
and a combination of surgery and radiotherapy in 21.7% of cases [5]. Open approachinalone
72%
was
and used
a in 89
combination patients
of and
surgery endoscopic
and techniques
radiotherapy in alone
21.7% ofin 10
casespatients
[5]. Open [5]. In this
surgical case, the alone
approach mass
was used in 89 patients and endoscopic techniques alone in 10 patients [5]. In this case, the mass was
was used
was easilyinaccessible
89 patientsthrough an external rhinoplasty approach. Radiotherapy may be considered in
easily accessible through and endoscopic
an external techniques
rhinoplasty alone
approach. in 10 patients
Radiotherapy [5]. In
may be this case,
considered the
in mass was
advanced
advanced
easily disease,
accessible surgically
through unresectable
an external cases approach.
or with positive surgical may
margins, however, in there are no
disease, surgically unresectable casesrhinoplasty
or with positive Radiotherapy
surgical margins, however, be there
considered advanced
are no prospective
disease, surgically unresectable cases or with positive surgical margins, however, there are no prospective
Medicina 2019, 55, 128 6 of 7

prospective studies to guide which patients would benefit [1,7]. Pre-operative radiotherapy to decrease
tumor mass has also been described [5]. Chemotherapy is not supported by current evidence [1,5,7].
Primary reconstruction at the time of resection was both ideal and convenient with native septal
cartilage harvested from an adjacent surgical site. The decision was made not to resect the excess SSTE
to minimize the risk of wound breakdown, particularly in view of his ongoing smoking history.
As the condition is rare, the existing literature is retrospective in nature, and therefore, data
regarding treatment, outcome and prognosis are variable. A wide range of five-year survival rates
from 44 to 88% has been reported [5,6,8–11]. Rate of lymph node (5.6%) and distant metastasis (6.7%)
is low [5]. Invasive disease due to local recurrence is reported as the most common cause of death [5].
In a systematic review of 161 patients with sinonasal chondrosarcoma, the recurrence rate in patients
receiving surgery alone was 32.8% compared to 29.4% in those receiving combination surgery and
radiotherapy [5]. As there are no clinical guidelines regarding adjuvant radiotherapy, there is a
significant possibility of selection bias, and therefore, the difference in recurrence rates. Large tumour
size, high pathological grade and subtotal resection are characteristics associated with the decision for
surgery and radiotherapy compared to surgery alone [5]. However, in the systematic review by Khan
et al., tumor size and staging were not adequately reported in the included studies [5]. The average
age of patients in the surgery and radiation group was younger compared to surgery alone, but this
was skewed by the inclusion of a study of paediatric patients.
A recent retrospective study of 47 patients with grades I and II skull base chondrosarcoma reported
local recurrence was 33% in patients receiving surgery alone compared to surgery and adjuvant proton
therapy (11%), however, there was no significant difference in 10-year disease-specific survival between
the groups [12]. There was no significant difference between the groups regarding patient sex, age, and
tumor size. In the surgery and proton therapy group, a greater proportion of cases had petroclival
tumors compared to the surgery only group. In addition, the presence of internal carotid artery
abutment was significantly greater in the surgery and proton therapy group, which suggests tumor
location and proximity to certain anatomical structures affects the decision for adjuvant radiotherapy.

4. Conclusions
Although rare, chondrosarcoma must be considered in cases of a lower nasal mass as there is a
significant risk of histological misdiagnosis of a benign lesion on biopsy. Surgical access through an
external rhinoplasty approach for resection is ideal for both resection and primary reconstruction of
tumors located at this site.

Author Contributions: Both authors were responsible for writing, editing and final review.
Funding: This research received no external funding.
Acknowledgments: The authors would like to thank the Monash Health Medical Photography Department.
Conflicts of Interest: The authors declare no conflict of interest.

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