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Chondrosarcoma
Biology and Clinical
Management
Francis J. Hornicek
Editor

123
Chondrosarcoma
Francis J. Hornicek
Editor

Chondrosarcoma
Biology and Clinical
Management
Editor
Francis J. Hornicek
Department of Orthopaedic Surgery
David Geffen School of Medicine at UCLA
Los Angeles, CA
USA

ISBN 978-3-030-74571-4    ISBN 978-3-030-74572-1 (eBook)

https://doi.org/10.1007/978-3-030-74572-1

© Springer Nature Switzerland AG 2021

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Foreword

Inspired by the biblical admonition, “If the blind lead the blind,
all will fall into the ditch” (Matthew 15:14), the Flemish Renais-
sance master Pieter Brueghel the Elder portrayed a scene from a
sixteenth-century century village. Depicted is a line of sight
impaired men who, by following their blind leader, appear to be
dragged one by one over an edge. Prophetic then and still true
today, if we do not get the initial diagnosis correct, then everyone,
especially the patient, may experience an adverse outcome.
Critical and central to the proper management of any neoplas-
tic condition is the correct diagnosis. This cannot be left solely to
the surgical pathologist who, of course, is critical, central, and
pivotal in this process. Pathologists knowledgeable with bone and
soft tissue tumors are rare, and the best of the best have a real pas-
sion for the field. The accuracy of their diagnoses often is depen-
dent on the pertinent clinical and diagnostic information being
shared with them. We have found this to be best achieved by col-
laborative consultation, in real time, to include the pathologist, the
radiologists, and the physicians and surgeons. The radiologists
add very important information as to location and extent of dis-
ease, as well as their independent differential diagnosis, which
often correlates with the histologic diagnosis. The physicians and
surgeons who are tasked with carrying out all subsequent treat-
ment add their own differential based on the patient’s presenting
signs and symptoms. It is imperative that this occur not only at
presentation, but throughout the patient’s course.

v
vi Foreword

At the University of California, Los Angeles, we endeavor to

achieve this through participation in a multidisciplinary “tumor
board.” This board convenes weekly. New patients are discussed
at presentation and are followed throughout their course of treat-
ment. The multidisciplinary tumor board reviews all the informa-
tion to determine the location, the pathologic diagnosis including
stage and grade, and the clinical setting, and then discusses all
potential surgical and medical treatment options. At subsequent
meetings there is a review of the surgical margins, the effective-
ness of any medical adjuvant treatment that may have been ren-
dered, as well as recommendations for future medical or surgical
intervention.
The multidisciplinary musculoskeletal tumor board at UCLA
was initiated in 1984. The original four participants consisted of
Fredrick R. Eilber, M.D. (surgical oncology), Jeffrey J. Eckardt,
M.D. (orthopedic oncology), Joseph M. Mirra, M.D. (surgical
pathology), and Richard H. Gold, M.D. (radiology). Today, in
2020, there are 22 members representing 8 disciplines: 5 orthope-
dic oncologists, 3 surgical oncologists, 3 musculoskeletal radiolo-
gists, 4 medical oncologists, 2 surgical (sarcoma) pathologists, 2
pediatric oncologists, 2 thoracic oncologists, and 1 gynecologic
oncologist. The meetings are regularly attended by the majority,
with generally 30–45 new and follow-up cases reviewed each
week. Not only is it rigorous and educational, but it is also fun.
Getting it right is paramount. Difficult or questionable diagnoses
and/or treatments are sent out for second or third opinions without
hesitation. Pride does not have a seat on this board.
Dr. Hornicek has assembled an outstanding and renowned
group of clinicians, clinician- scientists, and researchers to address
and review the presentation, the clinical management, and current
research endeavors of benign and malignant cartilage neoplasms.
This includes chondrosarcoma’s primary and secondary bone
locations, as well as the rare soft tissue presentations. Different
diagnostic modalities, surgical techniques, and the various adju-
vant methods of treatment are thoroughly discussed. Ongoing
protocols are presented along with their rationales.
Differentiating chondrosarcomas from other benign or even
non-neoplastic conditions has proven difficult and can be one of
the most difficult diagnoses to make. Much has been written on
Foreword vii

this topic. Chondrosarcoma’s varying clinical presentations and

pathology were first elucidated in articles by Dr. Dallas Phemister
in 1930, followed by Dr. Louis Lichtenstein and Dr. Henry L. Jaffe
in 1943. Subsequent books and articles are referenced:

• Jaffe, Henry L.: Tumors and Tumorous Conditions of the Bones

and Joints. Lea & Febiger, 1958.
• Unni, K. Krishnan, Dahlin, David Carl: Dahlin’s Bone
Tumors: General Aspects and Data on 11,087 Cases. 5th ed.,
Lippincott-Raven, 1996.
• Mirra, Joseph M., Picci, Piero, Gold, Richard H. “Intramedul-
lary cartilage and chondroid producing tumor.” Bone Tumors:
Clinical, Radiographic and Pathologic Correlations. Vol. 1,
Lea & Febiger, 1989;439–690.
• Mirra JM, Gold R, Downs J, Eckardt JJ. A new histologic
approach to the differentiation of enchondroma from chondro-
sarcoma of the bones. A clinicopathologic analysis of 51 cases.
Clin Orth Rel Res. 1985;201:214–37
• Murphey MD, Flemming DJ, Boyea SR, Bojescul JA, Sweet,
DE, Temple T. From the Archives of the AFIP. Enchondroma
versus Chondrosarcoma in the Appendicular Skeleton: Differ-
entiating Features. RSNA. 1998;18:1213–1237

There are many neoplastic and non-neoplastic conditions that

contain cartilage. These conditions need to be recognized for
what they are. Differentiating chondrosarcoma from the other car-
tilage lesions can be challenging, with the surgical pathologist’s
role pivotal. This publication by Dr. Francis J. Hornicek, M.D.,
Ph.D., and the use of a multidisciplinary review board should
prove helpful in achieving this goal.

Jeffrey J. Eckardt, M.D.

Distinguished Professor
and Chair Emeritus,
Department of Orthopaedic surgery
UCLA David Geffen School
of Medicine at Los Angeles,
Los Angeles, CA, USA
February 1, 2020
Preface

This book focuses on chondrosarcoma biology, pathogenesis, and

emerging treatment strategies. While this rare and malignant
cartilage-­forming tumor tends to occur within the bones, it can
also arise within various soft tissues. Unlike other bone sarcomas
that predominantly affect the young, chondrosarcomas are more
often diagnosed in the adult population. In addition to being
highly resistant to available chemotherapies and radiotherapies,
management guidelines have been difficult to refine as low-grade
and benign tumors are challenging to differentiate. Along with
anatomic location and spread, tumor grade is a primary determi-
nant of adjuvant therapy. Low-grade or grade 1 lesions are either
observed or undergo surgical resection, with grade 2 or 3 tumors
often receiving chemotherapeutic regimens. Clinical trials have
been hindered by limited study participants robust pre-­clinical
evidence.
Although some progress has been made in characterizing
chondrosarcoma pathogenesis, its genetic and epigenetic mecha-
nisms are poorly described, and no known effective systemic
therapy exists. There is, therefore, an urgent need to identify the
underlying molecular mechanisms of chondrosarcoma for tar-
geted therapies in prospective clinical trials. Recent studies have
explored inhibitors that combat aberrant metabolic pathways,
such as isocitrate dehydrogenase (IDH), an enzyme whose gene is
frequently mutated in chondrosarcoma. COL2A1, a gene that
encodes the α-chain of type II collagen fibers and the major con-
tributor of collagen matrix and articular cartilage, is another
­frequently mutated gene chondrosarcoma. Other promising thera-

ix
x Preface

peutic targets include the EXT gene seen in hereditary multiple

osseocartilaginous exostoses, as well as p16 and p53 alterations
that transform enchondroma to chondrosarcoma. Tumorigenic
gene signaling pathways including Hedgehog, CDK4, and TGF-
beta/Sox have also been described in these cancers. Although pre-
clinical studies have shown the targetability of these genetic
pathways in chondrosarcoma therapy, follow-up clinical trials are
needed to establish their utility within the clinic. In addition to
these works, immunotherapies have generated considerable atten-
tion for their success in various human cancers and have led to
emerging results in chondrosarcoma.
This book draws from impactful papers as well as the decades
of experience from the contributing authors in the laboratory and
treating patients in high-volume sarcoma centers. I have previ-
ously worked with several of the named authors in writing a book
on bone pathology.
This book provides practical coverage of chondrosarcoma
biology and therapy for medical students, residents, fellows, prac-
ticing physicians, and researchers. I hope our passion in caring for
these patients comes through while reading this text.

Los Angeles, CA, USA Francis J. Hornicek, M.D., Ph.D.


Acknowledgement

I would like to thank all the contributors to this in-depth book on

chondrosarcoma. Moreover, I would like to thank Dr. Jeffery Eckardt
and the members of the UCLA sarcoma team.

xi
Contents

Part I Biology of Chondrosarcoma

1 Pathology of Chondrosarcoma�������������������������������������  3
Muhammad Omar Hakim and Andrew Eric Rosenberg
2 Advances in the Molecular Biology of
Chondrosarcoma����������������������������������������������������������  27
Zhenfeng Duan, Dylan C. Dean, Susan Bukata,
and Francis J. Hornicek
3 Imaging Features of Chondrosarcoma������������������������ 53
Jonathan Lin, Benjamin D. Levine,
and Leanne L. Seeger

Part II Skeletal and Extraskeletal Chondrosarcoma

4 Chondrosarcomas: Conventional and Secondary������ 77

Christopher M. Hart, Zachary Burke, Alex Nobori, and
Bennett L. Davis
5 Primary Soft Tissue Chondrosarcoma������������������������ 93
Brooke Crawford

Part III Management of Chondrosarcoma

6 Chondrosarcoma of the Axial Skeleton������������������������113

Akash A. Shah, Howard Young Park, Gideon Blumstein,
and Don Young Park

xiii
xiv Contents

7 Chondrosarcoma of the Appendicular Skeleton ��������133

Erik J. Geiger and Nicholas M. Bernthal
8 Chondrosarcoma of the Hand��������������������������������������169
Karren Takamura and Neil Ford Jones
9 Chondrosarcoma of the Clavicle����������������������������������187
Tang Liu, Chao Tu, and Zhihong Li
10 Radiation Therapy for Chondrosarcoma����������������  203
Ting Martin Ma, Thomas DeLaney, and Anusha Kalbasi
11 Systemic Therapy for Chondrosarcoma����������������������255
Arun S. Singh, Jomjit Chantharasamee,
and Francis J. Hornicek
12 Vascular Issues in Complex Surgical Resection of
Chondrosarcoma������������������������������������������������������������269
Rhusheet Patel and Donald T. Baril

Part IV The Future of Chondrosarcoma Research and

Treatment

13 The Future of Chondrosarcoma Research

and Treatment����������������������������������������������������������������283
Pichaya Thanindratarn, Dylan C. Dean,
Francis J. Hornicek, and Zhenfeng Duan
Index����������������������������������������������������������������������������������������299
Contributors

Donald T. Baril, MD Division of Vascular Surgery, Cedars-

Sinai, Los Angeles, CA, USA
Nicholas M. Bernthal, MD Department of Orthopaedic Surgery,
University of California, Los Angeles, Santa Monica, CA, USA
Gideon Blumstein, MD UCLA Department of Orthopaedic Sur-
gery, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA
Susan Bukata, MD Department of Orthopaedic Surgery, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Zachary Burke, MD Department of Orthopaedic Surgery,
UCLA, Los Angeles, CA, USA
Jomjit Chantharasamee, MD Division of Hematology and
Oncology, Department of Medicine, University of California Los
Angeles, Los Angeles, CA, USA
Division of Medical Oncology, Department of Medicine, Faculty
of Medicine Siriraj Hospital, Mahidol University, Bangkok,
Thailand
Brooke Crawford, MD Department of Orthopaedic Surgery,
UCLA, Santa Monica, CA, USA
Bennett L. Davis, MD Department of Radiology, UCLA, Los
Angeles, CA, USA

xv
xvi Contributors

Dylan C. Dean, MD Department of Orthopaedic Surgery, David

Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Thomas DeLaney, MD Department of Radiation Oncology,
Massachusetts General Hospital, Harvard Medical School, Bos-
ton, MA, USA
Zhenfeng Duan, MD, PhD Department of Orthopaedic Surgery,
David Geffen School of Medicine at UCLA, Los Angeles, CA,
USA
Erik J. Geiger, MD Department of Orthopaedic Surgery, Uni-
versity of California, Los Angeles, Santa Monica, CA, USA
Muhammad Omar Hakim, MD Department of Pathology, Uni-
versity of Miami, Miller School of Medicine, Miami, FL, USA
Christopher M. Hart, MD Department of Orthopaedic Surgery,
UCLA, Los Angeles, CA, USA
Francis J. Hornicek, MD, PhD Department of Orthopaedic
Surgery, David Geffen School of Medicine at UCLA, Los Ange-
les, CA, USA
Neil Ford Jones, MD Department of Orthopaedic Surgery, Uni-
versity of California, Los Angeles, Santa Monica, CA, USA
Anusha Kalbasi, MD Department of Radiation Oncology, Jons-
son Comprehensive Cancer Center, David Geffen School of Med-
icine, University of California Los Angeles, Los Angeles, CA,
USA
Benjamin D. Levine, MD Department of Radiology, UCLA
Health System, Los Angeles, CA, USA
Zhihong Li, MD Department of Orthopaedics, The Second
Xiangya Hospital of Central South University, Changsha, Hunan
Province, China
Jonathan Lin, MD Department of Radiology, UCLA Health
System, Los Angeles, CA, USA
Tang Liu, MD Department of Orthopaedics, The Second
Xiangya Hospital of Central South University, Changsha, Hunan
Province, China
Contributors xvii

Ting Martin Ma, MD, PhD Department of Radiation Oncology,

Jonsson Comprehensive Cancer Center, David Geffen School of
Medicine, University of California Los Angeles, Los Angeles,
CA, USA
Alex Nobori, MD Department of Pathology, UCLA, Los Ange-
les, CA, USA
Don Young Park, MD UCLA Department of Orthopaedic Sur-
gery, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA
Howard Young Park, MD UCLA Department of Orthopaedic
Surgery, David Geffen School of Medicine at UCLA, Los Ange-
les, CA, USA
Rhusheet Patel, MD Division of Vascular Surgery, UCLA Med-
ical Center, Los Angeles, CA, USA
Andrew Eric Rosenberg, MD Department of Pathology, Uni-
versity of Miami, Miller School of Medicine, Miami, FL, USA
Leanne L. Seeger, MD, FACR Department of Radiology, UCLA
Health System, Los Angeles, CA, USA
Akash A. Shah, MD UCLA Department of Orthopaedic Sur-
gery, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA
Arun S. Singh, MD Division of Hematology and Oncology,
Department of Medicine, University of California Los Angeles,
Los Angeles, CA, USA
Karren Takamura, MD Department of Orthopaedic Surgery,
University of California, Los Angeles, Santa Monica, CA, USA
Pichaya Thanindratarn, MD Department of Orthopaedic Sur-
gery, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA
Chao Tu, MD Department of Orthopaedics, The Second Xiangya
Hospital of Central South University, Changsha, Hunan Province,
China
 Part I
Biology of Chondrosarcoma
Pathology of
Chondrosarcoma
1
Muhammad Omar Hakim
and Andrew Eric Rosenberg

Introduction

Chondrosarcoma is the second most common primary bone sar-

coma following osteosarcoma and comprises 25% of skeletal sar-
comas [1–5]. In adults, it accounts for 40% of bone sarcomas,
whereas, in children, it is uncommon and represents 6% of tumors.
The SEER data (National Cancer Institute Surveillance
Epidemiology and End results) from 2013 to 2017 shows that the
age adjusted incidence per 100,000 individuals in adults is 0.7 for
males and 0.5 for females in the United States [6].
Chondrosarcoma is classified according to its location, mor-
phology, grade, and whether it is primary or secondary. The dif-
ferent histological types are conventional hyaline and/or myxoid,
dedifferentiated, clear cell, and mesenchymal variants. Except for
mesenchymal chondrosarcoma, they are graded using a three-tier
scheme based on cellularity, atypia, mitotic activity, and necrosis;
mesenchymal chondrosarcoma is not graded and is considered
high grade (grade 3) [2, 3, 7]. The tumors can arise in the m
­ edullary

M. O. Hakim · A. E. Rosenberg (*)

Department of Pathology, University of Miami, Miller School of
Medicine, Miami, FL, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2021 3

F. J. Hornicek (ed.), Chondrosarcoma,
https://doi.org/10.1007/978-3-030-74572-1_1
4 M. O. Hakim and A. E. Rosenberg

cavity (central) or on the surface (peripheral) and may be de novo

(primary) or arise in diseased bone or a preexisting benign tumor
such as enchondroma or osteochondroma (secondary) [8]. Most
chondrosarcomas are primary, central, conventional, and low to
intermediate grade [5]. Grade 1 conventional chondrosarcoma has
a very low risk for developing metastases; therefore, in the appen-
dicular skeleton, the WHO fifth edition recommends that they it
be designated atypical cartilaginous tumor, whereas in the axial
skeleton and flat bones the term conventional chondrosarcoma,
grade 1, is retained because of potential local aggressive growth
and biological transformation [9–11].
The pathological diagnosis of chondrosarcoma should always
include careful correlation of the morphology with the clinical
and radiological findings [12–17]. The morphological heteroge-
neity of chondrosarcoma can be challenging, and pathologists
need to be aware of diagnostic pitfalls and the implications of
their diagnosis [13, 18, 19]. If the diagnosis is expected to be ren-
dered on needle biopsy, the specimen should include a minimum
of three tumor-bearing cores of tissue, as well as the diagnostic
considerations of the clinical team.
There have been significant advances in the discovery of the
mutational landscape of chondrosarcoma, and the aberrations can
be of diagnostic utility. IDH1 or IDH2 mutations are present in
the majority of conventional primary and secondary central chon-
drosarcomas and are also commonplace in dedifferentiated vari-
ants [8, 20–25]. IDH mutation status can help distinguish
conventional and dedifferentiated chondrosarcoma from mimics
such as chondroblastic osteosarcoma and fibrosarcoma, as the lat-
ter lack these mutations, and IDH aberrations are also absent in
peripheral, clear cell, and mesenchymal chondrosarcomas [10,
11, 26, 27]. The HEY1–NCOA2 gene fusion is the driver mutation
in mesenchymal chondrosarcoma and is pathognomonic [28].
Gene copy number changes, mutations in Tp53 [29] and CDKN2a,
epigenetic changes [11], and dysregulation of micro-RNA also
play a role in the biology of these neoplasms.
Currently, most chondrosarcomas are managed with surgery;
atypical cartilaginous tumors are aggressively curetted with the
addition of an adjuvant, and the remainder are resected en bloc
1 Pathology of Chondrosarcoma 5

with widely negative margins, if possible. All of the different

types of chondrosarcoma can locally recur, especially if they are
removed with positive margins [30], and local recurrence of con-
ventional chondrosarcoma and clear cell chondrosarcoma may be
associated with biological transformation into a higher grade neo-
plasm [31, 32]. Systemic therapy is often used to manage patients
with dedifferentiated and mesenchymal chondrosarcoma. The
incidence of metastasis of chondrosarcoma is related to tumor
type and grade, and the overall 5-year survival rate is 75% [33].
Common sites of metastatic spread are the skeleton and lungs.

 rimary Conventional Chondrosarcoma (80–90%

P
of Chondrosarcomas)

Central conventional chondrosarcoma is the most common type

of primary chondrosarcoma (90%) [11] and arises in the axial
skeleton and the proximal portions of the large tubular bones [14].
The pelvis, scapulae, ribs, femur, tibia, and humerus are favored
sites. Unlike enchondroma, chondrosarcoma of the short tubular
bones of hands and feet are uncommon. Approximately 70–80%
of conventional chondrosarcomas are low-­grade sarcomas [4, 5].
Tumors composed of hyaline cartilage manifest as a solid,
multinodular, firm blue-white mass with scattered, gritty, white
flecks (Fig. 1.1). Myxoid tumors are mucinous and slimy and may
undergo cystic change. Histologically, they usually grow with a
permeative pattern with replacement of the marrow, encasement
of preexisting lamellar bone, and growth into the Haversian sys-
tems of the cortex [1–5, 34] (Fig. 1.2).
Hyaline matrix is characterized by round or oval neoplastic
cells of variable size residing in lacunar spaces embedded in a
solid-appearing basophilic or eosinophilic sheet-like matrix. In
myxoid cartilage, the cells are not in lacunar spaces and are bipo-
lar or stellate shaped and enmeshed in a flocculent bubbly matrix
[1–3, 5, 34].
Atypical cartilaginous tumor/grade 1 chondrosarcoma (50–
70% of conventional chondrosarcoma) is hypo- to moderately
cellular, and the chondrocytes exhibit mild cytologic atypia in the
6 M. O. Hakim and A. E. Rosenberg

Fig. 1.1 Conventional chondrosarcoma of humeral head with intramedullary

gray-blue glistening cartilage lobules showing cortical destruction, medially,
with extension into soft tissue forming a sizable mass

form of nuclear enlargement, fine chromatin, and small nucleoli.

Scattered cells may be binucleate, and there are no or rare mito-
ses. The matrix may be focally calcified and undergo enchondral
ossification (Fig. 1.3). The neoplastic features may overlap with
1 Pathology of Chondrosarcoma 7

Fig. 1.2 Conventional chondrosarcoma growth pattern: neoplastic hyaline car-

tilage replaces the marrow and entrapsping the preexisting cancellous bone
trabeculae. The tumor is more cellular than the overlying articular cartilage

enchondroma, and an essential characteristic that distinguishes

between these types of neoplasms is the presence of infiltration [1,
5, 18, 35].
Grade 2 chondrosarcoma (25–40% of conventional chondro-
sarcoma) shows moderate cellularity and moderate cytological
atypia. The nuclei are large, may have irregular contours, and are
hyperchromatic. Some cells may be trinucleate, and mitoses are
uncommon. The amount of matrix calcification and enchondral
ossification is limited (Fig. 1.4). Many myxoid chondrosarcomas
are grade 2 [4, 7, 9, 18, 35–37].
Grade 3 chondrosarcoma (5–15% of conventional chondrosar-
coma) is highly cellular and exhibits severe pleomorphism and
mitotic activity, including atypical forms (Fig. 1.5). This type of
chondrosarcoma should raise the differential diagnosis of chon-
droblastic osteosarcoma, and genetic studies in search of muta-
tions in IDH are helpful as it is not present in osteosarcoma [4, 7,
18, 36–38].
8 M. O. Hakim and A. E. Rosenberg

Fig. 1.3 Grade 1 chondrosarcoma: Minimally hypercellular neoplastic hya-

line cartilage with clustered chondrocytes displaying mild nuclear enlarge-
ment, mostly round nuclei, some with open and others with condensed
chromatin, occasional nucleoli, and minimal nuclear size variability. No
mitoses are present

The prognosis of grade 1 chondrosarcoma is very good with over

90% survival at 5 years and 89–95% survival at 10 years. Grade 2
chondrosarcoma is associated with a 70–80% 5-year survival and
58–86% 10-year survival. Grade 3 chondrosarcoma has 0–77%
5-year survival and 30% 10-year survival rate [7, 9, 30, 36, 37].

Secondary Chondrosarcoma

Secondary chondrosarcoma refers to a chondrosarcoma that devel-

ops in abnormal bone that may be a benign neoplasm, irradiated
bone, or bone affected by Paget’s disease. Morphologically, the vast
majority of secondary chondrosarcomas are conventional chondro-
sarcoma, and most arise in benign neoplasms, especially enchon-
droma and osteochondroma [11, 39] (Figs. 1.6, 1.7, and 1.8).
1 Pathology of Chondrosarcoma 9

Fig. 1.4 Conventional chondrosarcoma, grade 2: Hypercellular malignant

hyaline cartilage that has irregular hyperchromatic nuclei that vary in size

In fact, in our experience, many conventional chondrosarco-

mas have radiological or histological evidence of an underlying
enchondroma; therefore, one can argue that secondary conven-
tional chondrosarcoma is more common than primary variants.
The risk of malignant transformation of solitary enchondroma or
osteochondroma is a small fraction of 1% and is greater in the
setting of syndromes associated with multiple lesions such as
hereditary multiple osteochondromatosis (1–25%) and the Ollier
disease and Maffucci syndrome (5–50%) [4, 9, 16, 40]. The basis
for the great variability in rates of malignant transformation is
related to morphological definition of malignancy.

Dedifferentiated Chondrosarcoma

Dedifferentiated chondrosarcoma is a biphasic tumor and com-

posed of a high-grade, non-cartilage-forming sarcoma arising in
the background of an enchondroma or grade 1 or grade 2 conven-
10 M. O. Hakim and A. E. Rosenberg

Fig. 1.5 Grade 3 conventional chondrosarcoma: Striking nuclear pleomor-

phism with marked variation in nuclear size and scattered mitoses

tional or clear cell chondrosarcoma. Approximately 10% of con-

ventional chondrosarcomas show dedifferentiation [14]. The
skeletal distribution is femur (30%), pelvis (20%), humerus
(16%), ribs (7%), and scapula (7%) [14]. This type of chondrosar-
coma is the most aggressive variant of chondrosarcoma, and it
often exhibits rapid growth with pathological fracture and soft tis-
sue extension in half of cases. Approximately 20% of cases have
metastases at presentation, and 60–90% subsequently develop
systemic spread (Fig. 1.10).
The dedifferentiated tumor is solid and has fleshy, pink-tan
regions admixed with nodules of opalescent blue-gray cartilage
that may have specks of gritty white calcifications (Fig. 1.9). The
­dedifferentiated component usually has the morphology of pleo-
morphic fibrosarcoma and is composed of pleomorphic spindle
cells with eosinophilic cytoplasm that are enmeshed in a collage-
nous stroma and arranged in intersecting fascicles (Fig. 1.10).
However, the dedifferentiated element may have protean appear-
1 Pathology of Chondrosarcoma 11

Fig. 1.6 Secondary chondrosarcoma arising in an osteochondroma, a rem-

nant of which is seen on the left, that is replaced by chondrosarcoma. Fibrous
bands dissect through the neoplastic myxo-hyaline cartilage lobules impart-
ing an irregular configuration

ances and consist of epithelioid cells or exhibit heterologous dif-

ferentiation such as osteosarcoma, rhabdomyosarcoma,
angiosarcoma, and rarely carcinoma [41]. Diagnostic difficulties
and misinterpretation may occur if both components of the tumor
are not recognized or present which most commonly occurs in the
setting of limited small core biopsies or FNA material. Mutational
analysis for IDH1/IDH2 genes is valuable in instances where no
low-grade cartilaginous component is identified as the vast major-
ity (87%) of tumors bear an IDH1/IDH2 mutation.
Immunohistochemistry is helpful in confirming a specific lineage
of the dedifferentiated component, and in the appropriate setting
metastatic spindle cell carcinoma or melanoma may be in the dif-
ferential diagnosis. Overall survival of patients is dismal as the
5-year survival rate is 24% and most fatalities occur within in
1–2 years after diagnosis [3, 4, 9, 38, 42–45].
12 M. O. Hakim and A. E. Rosenberg

Fig. 1.7 Chondrosarcoma secondarily arising in the cartilaginous cap of an

osteochondroma. The malignant component is low grade and composed of
nodules of cellular hyaline cartilage delineated by fibrous bands

Clear Cell Chondrosarcoma

Clear cell chondrosarcoma is very uncommon and accounts for

2% of chondrosarcomas. It typically arises in the epiphysis or
epiphyseal equivalent in the long tubular bones such as the proxi-
mal femur and humerus, and in the axial skeleton it has a propen-
sity to develop in the ribs and vertebrae. Grossly the tumor is
lobulated and gray-tan and may have hemorrhagic and cystic
change (Fig. 1.11).
Histologically, the tumor contains small areas of low-grade
conventional chondrosarcoma, and the majority is composed of
groups and sheets of large polygonal chondrocytes that have
vesicular nuclei and abundant clear to palely eosinophilic cyto-
plasm. Deposited throughout these areas are small trabeculae of
1 Pathology of Chondrosarcoma 13

Fig. 1.8 Secondary chondrosarcoma arising in the Ollier disease: hypercel-

lular homogenously myxoid chondrosarcoma that has flocculent stroma in
contrast with the hypocellular, hyaline cartilage of the adjoining enchon-
droma

woven bone that are focally rimmed by nonneoplastic osteoblasts

and occasional osteoclasts (Figs. 1.12, 1.13, and 1.14)
Immunohistochemistry shows that both clear cell and conven-
tional chondrosarcoma components are positive for SOX-9 and
S-100; a significant number of cases also stain with a variety of
molecular weight keratins. Unlike conventional chondrosarcoma,
IDH1 or IDH2 mutations are not present. Clear cell chondrosar-
coma is more aggressive than conventional low-grade conven-
tional chondrosarcoma, and the tumor is excised en bloc with
negative margins – the local recurrence rate is 16–20%, and
metastases develop in 20–25% of cases, usually over a period of
many years following diagnosis [9, 42]. Very rarely
­dedifferentiation occurs, and this complication is associated with
a more aggressive clinical course.
14 M. O. Hakim and A. E. Rosenberg

Fig. 1.9 Dedifferen­

tiated chondrosarcoma
composed of fish
flesh - like, gray-tan,
soft tissue mass with
necrotic foci and
cavitation
(dedifferentiated
component) arising in
the humeral head. The
conventional component
fills the proximal
diaphysis and consists of
homogenous iridescent
cartilaginous lobules of
hyaline cartilage

Mesenchymal Chondrosarcoma

Mesenchymal chondrosarcoma is a high-grade malignancy that is

responsible for 1–10% of chondrosarcomas. The tumor harbors a
specific HEY-1-NICOA2, in-frame, gene fusion [1]. Most cases
arise in the skeleton (40–78%), where it affects individuals
20–30 years old, whereas in the soft tissues, patients (22–60%) are
often 40 years or older. The North American experience using the
SEER database estimates 60% of mesenchymal chondrosarcomas
1 Pathology of Chondrosarcoma 15

Fig. 1.10 Dedifferentiated chondrosarcoma: Biphasic appearance with rela-

tively hypocellular hyaline cartilage and low-grade chondrocyte atypia in
conventional chondrosarcoma (left half of image) adjacent to markedly
hypercellular pleomorphic spindle cell sarcoma

arise in soft tissues, whereas in a large European series it is esti-

mated 36% arise in soft tissues [46, 47]. In bone the tumor involves
the maxilla, mandible, vertebrae, ribs, pelvis, and humerus. The
appendicular skeleton is less frequently involved [29].
The tumors are usually large and are solitary, solid, gray-tan,
fleshy masses. The neoplasm is composed of primitive small
round and short spindle cells and islands of well-differentiated
fibro-hyaline cartilage. The round cells may grow in a sheet-like
pattern and often contains a staghorn-like supportive vascular
tree. The cartilage is deposited in islands that are moderately cel-
lular, and the chondrocytes exhibit mild cytological atypia
(Figs. 1.15 and 1.16).
Cortical bone destruction with an associated soft tissue mass
occurs in 50% of cases. Immunohistochemistry shows that the
round cells are positive for Sox 9, CD99, and Fli1, and a minority
cells may express desmin and myogenin [48–50].
16 M. O. Hakim and A. E. Rosenberg

Fig. 1.11 Proximal femur involved by clear cell chondrosarcoma that is

pink-tan gray and extends up to the base of the articular surface
1 Pathology of Chondrosarcoma 17

Fig. 1.12 Conventional chondrosarcoma showing relatively hypocellular

hyaline neoplastic cartilage (left half of image) juxtaposed to groups of clear
cell chondrosarcoma (right half of image). The large clear cells surround a
central trabeculum of metaplastic woven bone that shows osteoblastic rim-
ming (nonneoplastic bone)

The differential diagnosis includes Ewing sarcoma and other

translocation-associated round cell sarcomas, rhabdomyosar-
coma, small cell osteosarcoma, and lymphoma [28]. The treat-
ment is systemic therapy and wide resection with negative
margins. The local recurrence rate reported ranges from 13% to
75%, and 10.6% of cases show metastases at initial presentation
[47, 51]. The overall 5- and 10-year survival rates reported in
recent SEER data review are 51% and 43% [46] with older litera-
ture reporting 55% and 26% [52], respectively. There are, how-
ever, significant 5-year survival differences noted in axial,
appendicular, and cranial sites as they are 37%, 50%, and 74%,
respectively [46]. Some metastases occur years after initial diag-
nosis [9, 42, 46, 47, 51].
18 M. O. Hakim and A. E. Rosenberg

Fig. 1.13 Large polyhedral chondrocytes with abundant clear cytoplasm,

well-defined cytoplasmic membranes, and generally vesicular nuclei, some
with distinct nucleoli, surround a centrally located fragment of metaplastic,
reactive woven bone, rimmed by osteoblasts. Scattered multinucleated non-­
tumoral giant cells also present
1 Pathology of Chondrosarcoma 19

Fig. 1.14 Mesenchymal chondrosarcoma composed of pink-blue, well-­

demarcated islands of hyaline cartilage, vaguely archipelagic, within a “busy”
hypercellular small round to focally spindled tumor
20 M. O. Hakim and A. E. Rosenberg

Fig. 1.15 Biphasic tumor composed of a hypercellular small blue round cell
tumor with abrupt interface with a neoplastic nodule of hyaline cartilage –
typical of mesenchymal chondrosarcoma. Note pink hue of the cartilage
matrix. A staghorn-like vascular pattern is present in the round cell compo-
nent
1 Pathology of Chondrosarcoma 21

Fig. 1.16 Membranous CD99 immunostaining in mesenchymal chondrosar-

coma. A diagnostic pitfall for misclassification as other round cell sarcomas
are positive for CD99
22 M. O. Hakim and A. E. Rosenberg

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Advances in the Molecular
Biology of Chondrosarcoma
2
Zhenfeng Duan, Dylan C. Dean,
Susan Bukata, and Francis J. Hornicek

Introduction

Chondrosarcoma (CS) is a heterogeneous cartilage-producing

tumor and the second most common primary bone cancer after
osteosarcoma [1, 2]. It accounts for more than 20% of all pri-
mary bone malignancies. Although CS is proposed to arise from
the chondrocyte lineage of mesenchymal cells, its exact cellular
origin remains unknown [3]. Unlike osteosarcoma, which tends
to affect children and adolescents, CS occurs in all ages with a
predilection for the hip and femur [4]. Given its heterogeneity,
pathologic and radiographic data are often combined in order to
distinguish CS subtypes and inform treatment [5].
CS is classified into low, intermediate, or high grade accord-
ing to histopathological cellularity, nuclear atypia, and pleomor-
phism [6]. Progression from low to high grade is reflected by
increased muco-myxoid matrix and vascularization in addition
to cellularity and nuclear atypia. A classification change was
approved in 2013 by the World Health Organization (WHO),

Z. Duan (*) · D. C. Dean · S. Bukata · F. J. Hornicek

Department of Orthopaedic Surgery, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2021 27

F. J. Hornicek (ed.), Chondrosarcoma,
https://doi.org/10.1007/978-3-030-74572-1_2
28 Z. Duan et al.

whereby grade 1 (low-­grade) CS was renamed “atypical carti-

laginous tumor” [6, 7]. Because grade 1 CS rarely metasta-
sizes, it is considered a locally aggressive neoplasm rather than
malignant sarcoma. Additionally, the 5-year survival rate for
grade 1 is relatively good at 85–95%. Grade 2 (intermediate-
grade) CSs are comparatively more cellular with less chondroid
matrix than grade 1. While mitoses are present, they are widely
scattered. The chondrocyte nuclei are enlarged and either vesic-
ular or hyperchromatic. Between the low- and high-grade sub-
types, the metastatic potential is intermediate at approximately
10–15%. Grade 2 CS has a 5-year survival rate of approximately
70–85%. The vast majority (85%) of conventional (primary and
secondary) CSs are grade 1 or 2. Grade 3 (high-grade) CSs are
hypercellular with nuclear pleomorphism, detected mitoses, and
a sparse to absent chondroid matrix. High-­grade CSs have high
rates of metastasis up to 70% and a dismal prognosis when sur-
gical resection is used alone. Five-year survival rates for grade 3
CS are less than 20%, largely a result of early disseminated
metastases. In most cases, the histological grade of recurrent CS
mimics the primary tumor; however, up to 13% of recurrences
form a higher comparative grade. In addition to grade, CS is
divided into subgroups, where 90% are conventional CS and the
remaining 10% include the dedifferentiated, clear cell, mesen-
chymal, periosteal, or myxoid CS subtypes [6, 7]. As diagnos-
tics and sequencing technologies advance, the pathogenic
biology and sensitivities between subtypes have gained increased
attention with therapeutic selection.
CS is notorious for its resistance to traditional chemotherapy
and radiation treatment [8] and has more recently shown robust
resistance to several lauded targeted and immune therapies [9].
Extensive surgical resection has, therefore, remained the primary
treatment modality, with prognosis a function of histological
grade and negative surgical margins. Given the limitations of
treatment for inoperable or metastatic CS, these patients maintain
the shortest median survival times at less than 12 months. And
while low-grade CS rarely metastasizes and can often be managed
with surgery alone, high-grade CS is often recurrent, metastatic to
the lung, liver, kidney, brain and frequently lethal [3, 8].
2 Advances in the Molecular Biology of Chondrosarcoma 29

Differentiating these two major subtypes and subsequently man-

aging patient expectations are complicated as no validated predic-
tive or prognostic biomarkers for CS exist [10]. Additionally,
as few therapeutics are used within the clinic, outcomes over
the last several decades have plateaud and relied primarily on sur-
gery. There is, therefore, an urgent need to identify novel CS treat-
ments. Clearly, the efficacy of future therapies will necessitate a
deeper understanding of the molecular biology of CS, perhaps
with increased attention to subtype tailored management, so that
newer and more precise targets are investigated in this heteroge-
neous and resistant cancer.
Although great strides have been made in understanding the
pathology and morphology of CSs, many genetic and epigenetic
mechanisms underlying their pathogenesis are poorly character-
ized. The current understanding is that CS develops in multistep
fashion in which precursor mesenchymal stem cells (MSCs)
exponentially accumulate genetic and pathway alterations, which
encourage an increasingly more malignant histological phenotype
[1, 3]. CS has been referred to as a sarcoma with a complex cyto-
genetic signature. Historically, comparative genomic hybridiza-
tion (CGH), fluorescence in situ hybridization (FISH), methylation
assays, single-nucleotide polymorphism (SNP) microarrays, and
coding and noncoding RNA arrays were the major detection tech-
niques of CS genomic and epigenomic alterations [1, 3]. More
recently, an emergence of large-scale next-generation sequencing
(NGS) studies have discovered a vast array of DNA amplification/
deletions, somatic mutations, and epigenetic changes [1, 3].
Simply put, these technologies have significantly improved our
understanding of the molecular landscape that drives CS. The
NGS technology has revolutionized our understanding through its
variants such as whole genome sequencing (WGS), whole exo-
some sequencing (WES), and RNA sequencing (RNA-Seq). WGS
is more comprehensive, as it can reveal an unbiased landscape of
somatic mutations in noncoding and unannotated regions of the
whole genome. WES is the preferred method for uncovering
genetic variants in known protein-coding regions of the exosome
across an entire genome. Finally, RNA-Seq can characterize an
entire transcriptome, including protein-coding messenger RNAs
30 Z. Duan et al.

(mRNAs) and noncoding RNAs (ncRNAs). This article reviews

the most recent and relevant discoveries of the molecular biology
driving CS, with a specific focus on the novel biomarkers and
targets for prognostics and therapeutics.

Frequently Amplified or Deleted Genes in CS

DNA copy-number alterations such as gene amplification or

deletions represent a core mechanism of cancer pathogenesis.
As a heterogeneous cancer, the CS genome displays compara-
tively more DNA amplifications and deletions than other
tumors. Past CGH and more recent NGS investigations have
highlighted these changes and reflect the chromosomal instabil-
ity which drives CS initiation and progression. In a CGH study
of 67 CS cases, a remarkable 59 displayed abnormal DNA copy
numbers. Specific and recurrent amplifications included
8q24.21-q24.22 and11q22.1-q22.3. The amplified region of
8q24.21-q24.22 contains the noteworthy genes MYC, MLZE,
FAM49B, DDEF1, and ADCY8. The MYC oncogene has been
shown to be frequently amplified in grade 2 and 3 CS and cor-
relates with shorter overall survival. In contrast, no MYC
amplification was found in lower grade samples of enchon-
droma or grade 1 CS [11]. Homozygous deletions of 9p21.3,
8q24.11, and 11p11.2, which contain CDKN2A (p16) as well
as exostosin glycosyltransferase genes (EXT1 and EXT2), are
present in some CSs [12]. The EXT genes encode glycosyl-
transferases involved in the biosynthesis of heparan sulfate
(HS) chains at HS proteoglycans (HSPGs). These HSPGs are
important in the diffusion of IHH, PTHLH, and fibroblast
growth factor (FGF), all of which promote chondrocyte prolif-
eration and differentiation. Therefore, EXT deletions are able
to affect hedgehog signaling by defective HS. Similar results
have been reported in skull base CS [13]. Another CGH array
was used to investigate the copy-number changes in CS that
initiate genetic events related to tumor progression. This same
study showed genomic imbalances were rare in grade 1 CS
tumors yet much more frequent in high-grade CS [14]. In total,
2 Advances in the Molecular Biology of Chondrosarcoma 31

22 chromosome regions were imbalanced in ≥25% of the high-

grade CS tumors, with three of those regions located on chro-
mosome 12 containing the PTPRF-interacting protein-binding
protein 1 (PPFIBP1) gene [14]. Loss of chromosome 6 and gain
of 12q12 were associated with higher grade. Importantly, array
CGH with cDNA expression showed gene amplification of
chromosomal region 12q13 correlated with expression of the
cyclin-dependent kinase 4 (CDK4) gene [14]. RNA expression
analysis revealed higher expression of CDK4 in the CSs with
this region being amplified. Loss of p16 occurs in 75% of high-
grade central CSs and no low-­grade CSs [15]. Another study
showed loss of heterozygosity (LOH) at chromosomal band
9p21 is one of the few consistent genetic aberrations found in
CS [16]. This locus harbors two cell-­cycle regulators, p16 and
INK4A-p14ARF (p14), which are inactivated in various human
malignancies [16]. Loss of p16 protein expression was detected
by immunohistochemistry in 12 of 73 central CSs and corre-
lated with increasing histological grade. However, LOH at 9p21
was found in 15 of 39 CSs (38%) but did not correlate with loss
of p16 protein expression [16]. Single-­ strand conformation
polymorphism (SSCP) analysis of p16 did not reveal any muta-
tions in the 47 cases. To investigate whether an epigenetic
mechanism was responsible for loss of p16 protein expression,
methylation-specific PCR was used to detect p16 promotor
methylation, which it found in 5 of the 30 tumors. Of note, p16
promotor methylation did not correlate with p16 protein expres-
sion or LOH at 9p21 [16]. These studies suggest that although
alterations exist in the general DNA sequence and its promoter
regions, the absence of correlation between LOH, promotor
methylation, and protein expression indicates a locus outside
p16 is the likely target of LOH at 9p21 [16, 17]. The correlation
between p16 protein expression and tumor grade indicates that
a loss of p16 protein expression is an important event of CS
progression [16]. This is supported by other studies as well,
where loss of p16 protein expression also correlated with histo-
logical grade. In dedifferentiated, mesenchymal, clear cell, and
periosteal CS, p16 aberrations were common and occurred in
85%, 70%, 95%, and 50% of the cases, respectively [18].
32 Z. Duan et al.

 requently Mutated Genes and Signaling

F
Pathways in CS

Gene mutations are often the nidus for cancer initiation. CS is no

different, as multiple mutations, either germline or somatic, have
been identified [3, 18]. The most commonly mutated genes in CS
include isocitrate dehydrogenase (IDH) 1 and 2, COL2A1, p53,
the tumor suppressor retinoblastoma protein (Rb), and hedgehog-­
associated genes (Table 2.1).

IDH Somatic mutations of IDH1 and IDH2 were first discovered

in gliomas and then in acute myeloid leukemia (AML) [19]. IDH1
and IDH2 mutations were the first common genetic abnormalities
identified in CS and occur in 50–75% of CSs, with frequency
varying by CS subtype and grade [20–23]. Similar to gliomas and
AML, these mutations occur early on in CS tumourigenesis [23].
In a mutational analysis including 25 high-grade CSs, 61% of the
cases (14/23) harbored a somatic mutation in IDH1/2, with the
majority (86%) of mutations occurring in the IDH1 gene. IDH1/2
mutation analysis is a promising distinguishing biomarker
between CS and chondroblastic osteosarcoma [22]. These muta-
tions are quite specific, as the point mutations of IDH1 and
IDH2 in CS are often different from the mutations in other tumor
types including AML and glioma. CS predominantly harbors

Table 2.1 Most frequently mutated genes in CS

DNA mRNA
size size Signaling
Gene Location Class (kb) (kb) pathway
IDH1/2 2q34/15q26 Enzymes 29.8 2.5 Cell
metabolism
COL2A1 12q13 Collagen 52.3 5.0 Cartilage
p53 17p13 Tumor 25.8 2.6 p53
suppressor
Rb1 13q14 Tumor 29.6 4.7 Cell cycle/
suppressor apoptosis
Hedgehog 7q36 Hedgehog 12.4 4.6 Sonic
genes hedgehog
2 Advances in the Molecular Biology of Chondrosarcoma 33

R132C mutations in IDH1, whereas glioma has mainly R132H

mutations in IDH1 and AML has R140Q mutations in IDH2.
Caution is advised diagnostically, however, as these mutations are
not entirely exclusive, suggesting the IDH1 and IDH2 mutations
share tumorigenic pathways in cancers [22]. In another study with
102 tissues from 37 CS patients, which included both primary and
recurrent samples, researchers found that detection of an IDH1
mutation in a primary CS would also present in any locally recur-
rent or metastatic tumors [15].
IDH1 and IDH2 have similar enzymatic functions in the tricar-
boxylic acid cycle (TCA cycle), where they normally convert iso-
citrate to α-ketoglutarate (α-KG). Mutant IDH loses this function
and instead causes accumulation of δ-2-hydroxyglutarate (D2HG)
[24]. Different IDH1 and IDH2 mutations produce variable levels
of this oncogenic metabolite. R132C is a strong D2HG producer,
whereas R132H and R140Q are weak producers. D2HG functions
as an oncometabolite by mimicking the α-KG structure and there-
fore inhibiting α-KG-dependent dioxygenases involved in DNA
and histone demethylation. This ultimately produces a hyper-
methylated state of DNA and histones [24, 25] (Fig. 2.1). IDH
mutations also affect metabolism, cell growth, signaling path-
ways, and DNA damage repair [25]. Studies have shown introduc-
tion or imitation of IDH mutations in mesenchymal stem cells
impairs osteogenic differentiation and promotes chondrogenic
differentiation in vitro. Thus, DNA copy-number alterations and
IDH1/IDH2 mutations likely represent early initiating events in
CS. Subsequent mutations CS may acquire such COL2A1 and
p53 further drive CS tumorigenesis.
In addition to their roles in malignant CS, mutated IDHs are
found in benign cartilaginous enchondromas [26]. A wide range
of mutations have been reported in these neoplasms, including the
IDH1-R132Q mutation. Mice with IDH1-R132Q in a single allele
with concomitant COL2A1 expression form a disordered growth
plate, with persistence of type X-expressing chondrocytes.
Chondrocyte cultures from these animals showed increased pro-
liferation and expression of genes characteristic of hypertrophic
chondrocytes, including IDH1-R132Q. COL2A1-Cre; IDH1-­
R132Q mutant knock-in mice (mutant allele expressed in
34 Z. Duan et al.

Chondrosarcoma cell metabolism and mutation of IDH

Mitochondria Cytoplasm Nucleus

Dioxygenases
D2HG
TCA cycle HIF-1

Citrate Histone demethylation

Collagen hydroxylation

Mutant IDH1/2
Isocitrate NADP+

NADPH + CO2

NADP+
IDH1/2

NADPH + CO2

Microenvironment changes

α-KG α-KG
Oncogene expression

DNA and histone modifications

Fig. 2.1 Chondrosarcoma cell metabolism and mutation of IDH. The IDH
enzyme family includes three proteins: IDH1, IDH2, and IDH3. IDH1 and
IDH2 catalyze the oxidative decarboxylation of isocitrate to α-KG, which is
dependent on reversible NADP+. IDH3 catalyzes isocitrate to α-KG in the
TCA cycle, and dependent on NAD+. Mutant IDH1/2 enzymes catalyze
NADPH and α-KG to NADP+ and D2HG. D2HG is a competitive inhibitor
of α-KG-dependent dioxygenases, which are involved in various cellular pro-
cesses and act as oncometabolites. Superfluous D2HG can lead to increased
histone methylation, oncogene expression, and impaired cell differentiation.
Abbreviations: D2HG δ-2-hydroxyglutarate, IDH isocitrate dehydrogenase,
NAD nicotinamide adenine dinucleotide, NADP nicotinamide adenine dinu-
cleotide phosphate, TCA cycle tricarboxylic acid cycle, αKG alpha ketoglu-
tarate

c­hondrocytes) did not survive after the neonatal stage [26].

COL2A1-Cre/ERT2; IDH1-R132 Q mutant conditional knock-in
mice developed multiple enchondroma-like lesions. Taken
together, these findings suggest mutant IDH causes a persistence
of chondrocytes, giving rise to growth-plate cells that form in the
bone as enchondromas [26].

COL2A1 A comprehensive WES analysis by the Cancer Genome

Project was conducted with 49 CS cases and their paired normal
tissues, including 30 central, 4 peripheral, 14 dedifferentiated, and
1 synovial chondromatosis. In total, 1428 somatic mutations were
identified, with a somatic mutation burden ranging from 1 to 115.
2 Advances in the Molecular Biology of Chondrosarcoma 35

These mutations comprised 944 missense, 61 nonsense, 37 essen-

tial splice, 80 indel, and 301 synonymous changes [27]. The
somatic mutation burden was significantly associated with
increasing grade. In fact, high-grade CS (grade 2, 3, and dedif-
ferentiated) contained more than double the somatic mutations
per sample of grade 1 CS. The most striking finding of this study
was the discovery of COL2A1 mutations via insertions, deletions,
and rearrangements, which were identified in 37% of the CS
cases. The mutation patterns were selective for those variants
more likely to impair normal collagen biosynthesis [27]. As CS is
an extracellular matrix (ECM)-rich sarcoma and collagen is the
major component of the ECM, the aberrant ECM collagen in CS
is likely driven by these COL2A1 mutations [28, 29]. COL2A1
encodes the α-chain of type II collagen fibers and is the major
contributor to this collagen matrix and articular cartilage. Indeed,
if normal collagen production is affected by mutant COL2A1,
there is opportunity for therapeutic strategies which upregulate
the cellular and endoplasmic reticulum stress responses geared
toward managing misfolded proteins as a natural defense mecha-
nism. The entire COL2A1 gene has also been sequenced in osteo-
sarcomas, chordomas, and meningiomas to compare mutation
patterns. The results showed specificity for the COL2A1 in CS
[27]. As an ECM component, type II collagen matrix restores car-
tilaginous features of human primary chondrocytes greater than
type I collagen matrix [30]. COL2A1 mutations likely represent
hallmark alterations of CS matrix deposition and signaling and
are therefore attractive oncogenic targets.

P53 and Rb1 Tumor suppressor genes p53 and Rb1 are the most
commonly mutated genes in human cancer, and their pathways
are pivotal in the control of cell cycle progression and apoptosis.
As expected, mutated p53 is also observed in CS [2, 27, 31]. A
significant correlation exists between p53 overexpression or alter-
ation and tumor histological grade and metastasis in CS [32, 33].
Additionally, p53 protein inactivation may occur by binding with
the protein mouse double minute 2 homolog (MDM2, 18).
Overexpression of MDM2 was evidenced by immunohistochem-
istry (IHC) in 33% of high-grade CSs and correlated with increas-
36 Z. Duan et al.

ing histological grade. These results warrant the development of

strategies which block the p53–MDM2 interaction in order to
restore normal p53 function in CS. The other prominent tumor
suppressor, Rb, prevents progression from the G1 to S phase of
the cell cycle by binding and inhibiting E2 factor (E2F). Cyclin-­
dependent kinase 4 or 6 (CDK4/6) phosphorylates Rb (pRb) and
therefore switches off the tumor-suppressing function of Rb,
hence releasing the E2F complex. In short, the pRb is unable to
restrict cell cycle progression in its phosphorylated form [34].
Over-­activation and expression of CDK4 complexes exist in CS
and similarly disrupt cell cycle breakpoints and enable uncon-
trolled cell proliferation [35]. Complete deletion or low expres-
sion of the Rb gene has been found in a majority of high-grade
CSs. One study reported the Rb pathway is aberrant in a remark-
able 96% of high-grade CSs, either via decreased tumor suppres-
sor p16 (48%) or increased CDK4 (55%) or cyclin D1 (62%) [36].

Hedgehog Three hedgehog-related genes have been reported

and include sonic hedgehog (SHH), desert hedgehog (DHH), and
Indian hedgehog (IHH). They all undergo similar processing, cell
secretion, and share signaling pathways within the cells. Once
produced, HH proteins are first cleaved in order to become func-
tional signal molecules. After this posttranslational processing,
the protein is secreted from the cell before binding to membrane
protein patched (PTH). The signal is received by another mem-
brane protein, Smoothened (SMO), and then transduced into the
nucleus by the transcription factor Gli. The stability and activity
of Gli are modified by scaffold protein suppressor of fused
(SUFU). This complex hedgehog signaling pathway is instrumen-
tal in chondrocyte proliferation and bone development [37]. WES
has revealed 18% of CS tumors contain mutations in hedgehog
signaling genes. High-grade CS is notable for its high expression
of hedgehog pathway factors. Mutations of SHH-associated genes
(hedgehog receptor PTCH1, Gli2/3) constitutively activate hedge-
hog signaling, resulting in benign cartilaginous neoplasms includ-
ing enchondroma, osteochondroma, chondroblastoma, periosteal
chondroma, and chondromyxoid fibroma [27, 38, 39]. These
growths, while benign, can be precursor lesions to malignant
Discovering Diverse Content Through
Random Scribd Documents
 With regard to St. Martin's Church, we have already quoted the
statement made by the Venerable Bede.
The same historian also informs us that Augustine, "when the
Episcopal See was granted to him in the royal city, recovered therein,
supported by the king's assistance, a church which, he was
informed, had been built by the ancient work of Roman believers;
and consecrated it in the name of our Holy Saviour, God and Lord,
Jesus Christ."
He does not mention St. Pancras, but we are indebted for an
account of it (evidently based on older traditions) to Thorn, a
Benedictine monk of St. Augustine's, in the fourteenth century.
"There was not far from the city towards the east, as it were midway
between the Church of St. Martin and the walls of the city, a temple
or idol-house, where King Ethelbert, according to the rites of his
tribe, was wont to pray, and with his nobles to sacrifice to his
demons, and not to God—which temple Augustine purged from the
pollutions and filth of the Gentiles; and having broken the image
which was in it, changed it into a church, and dedicated it in the
name of the martyr St. Pancras; and this was the first church
dedicated by St. Augustine." St. Pancras, a Roman boy of noble
family, was martyred under Diocletian at the age of fourteen, and
was regarded as the patron saint of children. Dean Stanley reminds
us that the monastery of St. Andrew on the Cœlian Hill, from which
St. Augustine came, was built on the very property which had
belonged to the family of St. Pancras, so that the name would have
been quite familiar to the Roman missionary.
Now, these are the written traditions with regard to the early
churches of Canterbury. How far, then, are they confirmed by actual
discoveries? A great deal of light has been thrown upon the point
within the last few years. In the course of explorations conducted in
the Cathedral crypt by Canon Scott Robertson, Dr Sheppard, and
myself, there was found at the base of the western wall some
masonry of Kentish ragstone covered by a smooth facing of hard
plaster, manifestly older than the columns of Prior Ernulf's vaulting
shafts, and than Lanfranc's masonry in the upper portion of the wall.
We may, therefore, consider it as more than probable that a portion
of this wall (which was laid bare to the length of twenty-seven feet)
formed part of the original building granted to St. Augustine by King
Ethelbert.
The ruins of St. Pancras have also been carefully and minutely
investigated, and traces have been found there of both an
undoubtedly Roman, and a somewhat later, building. Though Mr J. T.
Micklethwaite has satisfied himself that the present foundations can
only be assigned to an Early Saxon period, asserting, indeed, that
"we have evidence that it was used by St. Augustine himself," his
arguments can not yet be accepted as conclusive, and much may be
said on the other side.
We may observe an apparent difference in the shapes of these
three churches. Of St. Martin's we shall speak at length hereafter,
but we may note that, besides the different width of the nave and
chancel, there is no sign of an apse at the west end, while
indications of an eastern apse are more or less conjectural. In the
plan of the original Cathedral, conjecturally drawn by Professor Willis
from Edmer's description, and which he supposes was the old
Christian church preserved by St. Augustine, the building was a plain
parallelogram, with apses at both the east and west ends. The choir
was extended into the nave, enclosed by a high breast-wall, and
about the middle of the church (on the north and south) were two
towers, the tower on the south side containing an altar, and also
serving as a porch of entrance. This church was built, according to
Edmer, "Romanorum opere," and in imitation of the Church of St.
Peter, chief of the apostles, meaning the Vatican Basilica.
In St. Pancras there is a tower, or square porch, at the west end,
and two transepts of the same size branching off from the centre of
the nave, while the foundations of the chancel walls start farther in
than those of the nave wall; and, at the distance of twelve or
thirteen feet from the point of junction, can be detected the
commencement of an apse. In this church we have discovered no
doorways, except the one at the west end through the tower, and
the possible indications of one leading into the southern transept,
where we may yet see remains of an interesting altar (size, 4 ft. 4 by
2 ft. 2), which, if not the identical one that St. Augustine erected on
the site occupied by the idol of Ethelbert, is at any rate a very
ancient memorial of it.
It is worthy of remark that these three churches are situated in
almost a direct line from east to west, and were all outside the
Roman walls, and apart from the Roman cemeteries. The orientation
of all of them is nearly perfect.

In treating of the time between the departure of the Romans in

410 and the mission of St. Augustine in 597, we must remember that
history is almost silent; only a meagre outline of facts is given us,
and these often of a very contradictory character. We must
endeavour, however, to give a brief sketch of this intervening period
as far as it concerns the south-eastern portion of our island, and of
necessity, therefore, includes the fortunes of Canterbury. To account
for the comparatively easy conquest of Britain in the middle of the
fifth century, we are bidden to remember that the Roman rule, which
had at first been of a civilising character, and had fostered commerce
and the various arts, had in its latter period degenerated into
corruption. Town and country alike were crushed by heavy taxation,
aggravated by the arbitrary and ruinous oppression of the tax-
gatherers. The population, too, had gradually declined as the estates
of landed proprietors grew larger. Moreover, the Roman government
had disarmed and enervated the people, and, by crushing all local
independence, had crushed all local vigour, so that men forgot how
to fight for their country, and constant foreign invasions found them
without hope or energy for resistance.
Bishop Stubbs (in his "Constitutional History") remarks on the
great contrast between the effects of the Roman occupation in Gaul
and Britain. Gaul had so assimilated the cultivation of its masters,
that it became more Roman than Italy itself, possessing more
flourishing cities and a more active and enlightened church, as well
as a Latin language and literature; while Britain, though equally
under Roman dominion, had never become Roman. When the
legions were removed, any union that may have existed between the
two populations absolutely ceased. The Britons forgot the Latin
tongue; they had become unaccustomed to the arts of war, and had
never learnt the arts of peace, while their clergy lost all sympathy
with the growth of religious thought. They could not utilise the
public works, or defend the cities of their masters, so that the
country became easy to be conquered just in proportion as it was
Romanised.
After a continuance of internal dissensions, described by Gildas in
high-flown and rhetorical language, the native chiefs were once
more troubled by piratical attacks, and by their Irish enemies. It was
impossible to resist this combination by the forces of the province
itself, and so, imitating that fatal policy of matching barbarian
against barbarian, which led to the fall of the Roman Empire, the
Britons summoned to their aid a band of English or Jutish warriors,
to whom they promised food, clothing, pay, and grants of land. And
this application for help was not unnatural, as there was probably in
many of the towns a leaven of Teutonic settlers, especially along the
"Saxon shore," who had maintained a steady intercourse with their
kinsmen that remained behind, and some of whom may have been
German war-veterans, pensioned off by successive Roman emperors.
The statement by Mr Green that the "History of England begins in
449 with the landing of Hengist and Horsa in the Isle of Thanet" is
principally applicable to the Kingdom of Kent, for the Jutes had been
preceded by Angles in the north, who seem to have been for some
time in more or less undisputed possession of the country between
the mouth of the Humber and the wall of Antoninus; and the eastern
shores of the island were to a great extent colonised by kindred
tribes.
 The leaders in this expedition naturally sent for reinforcements
after their first successes, and it is probable that their followers were
at the beginning contented with a settlement in the Isle of Thanet,
where they would be secure against any possible treachery from the
Britons, and would be near the sea, whence their compatriots would
bring them aid if necessary—yet they gradually advanced, and their
subsequent exploits culminated in the victory of Aylesford, six years
after their landing, and the alleged death of the warrior Horsa.
This victory, it is said, was followed in Kent by a dreadful and
unsparing massacre. The Jutes, merciless by habit, were provoked
by the sullen and treacherous attitude of their victims, and destroyed
all the towns which they captured. Some of the wealthier
landowners of Kent fled in panic over the sea, but many of the
poorer folk took refuge in forests, or escaped to Wales and Cornwall.
Famine and pestilence devoured some, others were ruthlessly
slaughtered. There was no means of escape, even by seeking shelter
within the walls of their churches, since the rage of the English burnt
fiercest against the clergy. The priests were slain at the altar, the
churches burnt, and the peasants rushed from the flames, only to be
cut down by the sword.
The above is the generally accepted theory, but probably in many
respects it is an exaggerated account, such as is common in the
traditions of conquered nations, and should be accepted with very
great hesitation.
A few years after the victory of Aylesford, Richborough, Lympne,
and Dover fell permanently into the hands of the invaders.
The Jutes, with whom Kent is more immediately concerned, were
the northernmost of the three tribes of the Germanic family. They
lived in the marshy forests and along the shores of the extreme
peninsula of Denmark, which retains the name of Jutland to the
present day. We know little of their early history, but it is probable
that the Jutes, the Angles, and the Saxons, although speaking the
same language, worshipping the same gods, and using the same
laws, had no national or political unity—and the separate
expeditions, resulting in the final conquest of Britain, were
unconnected with one another, though almost continuous in point of
time. It is certain that the invaders to a large extent declined to
amalgamate with the people whom they had conquered; nor would
they consent to tolerate their existence side by side. A few may have
lingered on in servitude round the homesteads of their conquerors,
but a large portion of the survivors (as we have said) took refuge in
Western Britain.
As to their religion, we know that England for nearly a century and
a half was almost entirely a heathen country, represented on a map
as a black patch between the Christians of Gaul and the Christian
Celts of our island. While the Goths, Vandals, Burgundians, and
Franks in other parts of the Roman empire soon became Christians,
the English went on worshipping their false gods, such as Woden,
Thor, and others, who gave their names to river, homestead, and
boundary alike, and even to the days of the week.
And yet their mythology was not so degraded but that it presented
in fragments the outlines of Christianity. This was recognised
afterwards by Pope Gregory's wise counsel to Augustine not to
interfere needlessly with the religious faith of his pagan converts,
but allow them to worship the old objects under new names; not to
destroy the old temples, but to consecrate them as Christian
churches, the reason being that "for hard and rough minds it is
impossible to cut away abruptly all old customs, because he who
wishes to reach the highest place must ascend by steps and not by
jumps." Kemble (in his "Saxons in England") gives an insight into the
character of their religion, and accounts for the ultimately rapid
spread of Christianity among them by this process of adaptation,
and also because the moral demands of the new faith did not seem
to the Saxons more onerous than those to which they were
previously accustomed. Bede not unnaturally reproaches the Britons
for refusing or failing to convert their enemies to the true faith,
whereas it had been the habit elsewhere for the Christian priesthood
to act as mediators between barbarian invaders and the conquered.
Canterbury seems to have been at once abandoned by the
vanquished, because it would have been utterly untenable owing to
its position on the main road between the sea-fortresses of Kent and
the rest of the kingdom; and it was probably at first unoccupied by
the Jutes, so that it remained for many long years uninhabited and
desolate. We know that the very name of Durovernum had become
forgotten, while the fortresses of the coast still retained their former
names without any radical change. This opinion is confirmed by the
fact that, while numerous Saxon cemeteries have been found in East
Kent—such as at Ash, Kingston, Sarre, etc.—none whatever have
been discovered in the district immediately round Canterbury,
though the soil has been thoroughly and completely turned over for
the purposes of road and drain making, as well as for pits of gravel,
sand, and chalk. Moreover, not a single street of our city is on the
site of a Roman street, with the partial exception of Watling Street
and Beer Cart Lane.
Probably in the early days of the Jutish conquerors Richborough
would have been their headquarters, as being conveniently near the
coast; and it was not till they had pretty well settled themselves in
the country that they fixed on a new capital, to which they gave the
name of Cantwarabyrig, "the city of the men of Kent."
The curtain of Christian history is not again lifted over England till
the year 597, when, according to the "Anglo-Saxon Chronicle,"
"Gregory the Pope sent into Britain very many monks, who gospelled
God's Word to the English folk." And, connected closely as the
mission was with St. Martin's Church, we must enter into it with
some detail, though it is an oft-told story, and is familiar even to
those who have never visited Canterbury, and know little else of
ecclesiastical history.
Gregory had been appointed at an early age "Praetor of the City"
by the Emperor Justin II., and had afterwards been sent by Benedict
I. and Pelagius II. to Constantinople, where he resided for many
years as the representative of the Bishop of Rome. He returned to
Rome in 585, and it was near this date that the event occurred
which we are now about to narrate. He was at that time about forty-
five years old, a monk in the great monastery of St. Andrew on the
Cœlian Hill, which he had himself founded; and we may believe that
he was remarkable, then as afterwards, for his comprehensive
policy, his grasp of great issues, and his minute and careful attention
to details in secular as well as religious matters. The vast slave trade
prevalent in Europe was to him a special cause of sorrow; and for
the purpose of trying to check the evil, to redeem the captives, or to
mitigate their sufferings, he was wont to resort to the market-place
in Rome whenever a new cargo of slaves arrived from distant
countries.
One day, on his visit to the Forum of Trajan, he observed some
(traditionally, three) boys with fair complexions, comely faces, and
bright flowing hair, exposed for sale. When he saw them, he asked
from what region or country they had been brought, and on being
told "from the island of Britain, whose inhabitants were of similar
appearance," inquired whether these islanders were Christians, or
still involved in pagan errors. The answer was, "They are pagans."
Then he heaved deep sighs from the bottom of his heart and said:
"Alas! that men of such bright countenance should be subject to the
author of darkness, and that such grace of outward form should hide
minds void of grace within." Being told further, in answer to his
question, that they were called Angles, "Rightly so called," said he,
"for they have the faces of Angels, and are meet to be fellow-heirs
with the angels in heaven. But what is the name of the province
from which they were brought?" "Deira" (the land between the Tees
and the Humber), said the merchant. "Right again," was the reply,
"from wrath (de ira) shall they be rescued, and called to the mercy
of Christ." Lastly, on hearing that the king of that province was
named Ælla, he exclaimed: "Alleluia! the praise of God the Creator
shall be sung in those parts."
 Gregory went from the Forum to the Pope (probably Pelagius),
and asked him to send to the English nation some minister of the
word, by whom the island might be converted to Christ, saying that
he himself was prepared to undertake this work with the assistance
of the Lord. But though the Pope gave his consent, so great was the
love of the Roman people for him, that he was obliged to start from
the monastery in the strictest secrecy, accompanied by a few of his
comrades. When his departure became known, the people were
much excited, and, dividing themselves into three companies,
assailed the Pope as he went to church, crying with a terrible voice
"What hast thou done? Thou hast offended St. Peter, thou hast
destroyed Rome, since thou hast sent Gregory away." The Pope,
greatly alarmed, despatched messengers with all possible speed to
recall Gregory to Rome. He had already advanced three days along
the great northern road when the messengers arrived, and led him
back to the city.
Gregory afterwards become abbot of the monastery, and, much
against his will, was elected Pope on the death of Pelagius, and
consecrated on September 3, 590.
But he never forgot his project for the conversion of England, and
in 595 wrote to Candidus, a priest in Gaul, directing him to use part
of the Papal patrimony to purchase English youths of the age of
seventeen or eighteen years, to be educated in monasteries, no
doubt with the intention of sending them afterwards as missionaries
to their countrymen.
It was not, however, till the following year that he was able to fulfil
the desire of his heart, when he selected as the head of a mission to
England Augustine, Prior of St. Andrew's Monastery, and charged
him with letters to Vigilius, Bishop of Arles, to the Kings Theodoric
and Theodebert, and to their grandmother, Queen Brunehaut or
Brunichild. In the course of their journey, however, this missionary
band was so terrified by the rumours they heard that they became
faint-hearted on the road, and despatched Augustine to Rome to beg
that they might be recalled. But Gregory would have no withdrawal,
and sent him back again with letters of encouragement to his
colleagues. So they went on, crossed the sea from Boulogne, and,
either in the autumn of 596 or the early spring of 597, landed in
England, somewhere in the Isle of Thanet.
The King of Kent at this time was Ethelbert, who was the most
powerful King in England (reckoned by some as the third Bretwalda),
and had established his supremacy over the Saxons of Middlesex
and Essex, as well as over the English of East Anglia as far north as
the Wash: and had driven back the West Saxons when, after an
interval of civil feuds, they began again their advance along the
Thames, and marched upon London. Ethelbert began to reign in
561. He was believed to be great-grandson of Eric, son of Hengist, a
"son of the ash-tree." He had previously, when quite young, been
engaged in an encounter with Ceawlin, King of Wessex, and been
defeated at Wimbledon. But Ceawlin himself was worsted in 591 by
his nephew Cedric at Woodnesbury, in Wiltshire; and Ethelbert had
now asserted his supremacy.
Unlike most English kings then, and for a long time afterwards, he
had married a foreign wife, Bercta, or Bertha, daughter of Charibert,
one of the kings of the Franks in Gaul, reigning in Paris. Bertha was
a Christian, and, as Ethelbert was a heathen, it had been expressly
stipulated, either by her father, or by her uncle and guardian
Chilperic, King of Soissons, that she should enjoy the free exercise of
her religion, and keep her faith inviolate.
Bertha is one of the most interesting and romantic characters in
English history—our first Christian Queen—possessing apparently
much the same influence over Ethelbert as Clotilda had done over
Bertha's great ancestor, Clovis, and (though not able to convert him
yet) without doubt disposing him favourably towards the new
religion. It is variously conjectured that she was born about 555 or
561. We do not know much of her early life, but St. Gregory of
Tours, in his contemporary pages, informs us that King Charibert
took to wife, Ingoberga, by whom he had a daughter, who
afterwards "married a husband in Kent." Charibert was not a man of
good character, and being annoyed with his wife Ingoberga, he
forsook her, and married Merofledis, the daughter of a certain poor
woolmaker in the queen's service. The unfortunate queen was
thereupon obliged to fly, and, taking up her abode at Tours, devoted
herself to a life of religious seclusion, bringing up her daughter
Bertha under the direction of Bishop Gregory, and preparing her thus
for the part she afterwards filled in the conversion of England. We
may mention here that King Charibert, after the death of Merofledis,
proceeded to marry her sister, for which outrage he was solemnly
excommunicated by St. Germanus; and, refusing to leave her,
"perished, stricken by the just judgment of God." Ingoberga died at
the age of seventy, in the year 589.
Bertha was accompanied to England by her chaplain, Liudhard,
who was sent with her to preserve her faith. Of Liudhard we know
very little that is certain. His name is variously spelt Leotard,
Liudhard, or even Liupard. By some he was supposed to be Bishop
of Senlis, but his name does not occur in the list of bishops of that
see, though it is inserted with a mark of interrogation in Gow's
Series Episcoporum. By others he has been entitled Bishop of
Soissons, though without any documentary authority. We may
probably accept the notion that he was one of the "wandering
bishops" who were very numerous at a later period in Gaul. Gocelin
calls him the "faithful guardian of the queen." It seems strange that
he, who could speak a language akin to that of the English, did not
convert some of them previously to the coming of Augustine, who
only spoke Latin, and was obliged to converse with them at first
through the medium of an interpreter.
However that may be, he was undoubtedly the "harbinger" of
Augustine, and had probably endeavoured to stir up his brother
prelates of Gaul on behalf of the English, since Pope Gregory, writing
at this time to Theodoric and Theodebert, severely condemns the
supineness of the Gallic Church, in neglecting to provide for the
religious wants of their neighbours, whose "earnest longing for the
grace of life had reached his ears."
 We may mention here that a coin was found some years ago in
the churchyard of St. Martin's, with the inscription, "Lyupardus
Eps"—and the Rev. Daniel Haigh (in his notes on the Runic
monuments of Kent) says that he has no doubt that this coin
belongs to Liudhard, who is called Liphardus in Floras' addition to
Bede's Martyro-logia.
Queen Bertha and her chaplain used to worship in the little church
of St. Martin, going there daily from Ethelbert's palace, near the site
of the present cathedral, through the postern gate of the precincts
opposite St. Augustine's gateway. To this circumstance, though by a
somewhat fanciful etymology, is attributed its name of Queningate.
Owing to long disuse, it is probable that the church had fallen into a
state of partial decay, but it was again restored and made suitable
for Christian worship—though the Queen, with her chaplain and
attendant maidens, may only have used a portion of the ancient
building.
But we must now return to Augustine. "On the east of Kent," says
Bede, "is the large Isle of Thanet, containing, according to the
English way of reckoning, six hundred families, divided from the
mainland by the river Wantsum," which at that time was a channel
nearly a mile in width, running from Richborough to Reculver, though
it has since become a narrow ditch. Here was a small place called
Ebbsfleet, still the name of a farmhouse, rising out of Minster Marsh,
but, owing to the retreat of the sea, now situated among green
fields. There is little to catch the eye in Ebbsfleet itself, which is a
mere spit of higher ground, distinguished by its clump of trees, but
must then have been a headland, running out into the sea. "Taken
as a whole," says Mr Green, "the scene has a wild beauty of its own.
To the right, the white curve of Ramsgate Cliffs looks down on the
crescent of Pegwell Bay. Far away to the left, across grey
marshlands, where smoke-wreaths mark the sites of Richborough
and Sandwich, rises the dim cliff-line of Deal." It is unnecessary to
enter into the controversy whether Augustine first set foot on
English ground here or at Stonar, or beneath the walls of the Roman
fortress of Richborough, as apparently stated by Thorn. The whole
question is fully discussed in an appendix to the "Mission of St.
Augustine," carefully compiled by Canon Mason.
The missionaries had no sooner landed than one or two of their
body proceeded to Canterbury, where they duly acquainted King
Ethelbert with the fact and object of their arrival. The king gave the
messengers a favourable hearing, but bade them remain where they
were, saying that he himself would visit them—making, however,
this curious stipulation, that they should not hold their first interview
under a roof, lest they should practise on him spells and incantations
—"though they came," adds Bede, "furnished with Divine and not
with magic power."
After some days, the king came to the island, where the interview
took place, possibly under a large oak tree close to Cottington Farm,
where a Sandbach Cross has been erected by the late Earl Granville
as a memorial of the event—and it was at this place that the
commemoration of the "Coming of St. Augustine" was held in 1897,
by the bishops of both the Anglican and Roman communions. Other
traditions name the centre of the island, or the walls of Richborough
—but, where-ever it was, the missionaries, on hearing of the king's
arrival with his attendant thanes, came to meet him, chanting
litanies, with a tall silver cross before them, and a figure of the
Saviour painted on an upright board. Besides Augustine himself, who
was of great stature, head and shoulders taller than anyone else,
were Laurence, afterwards Archbishop of Canterbury, Peter, who
became first Abbot of St. Augustine, and nearly forty others.
When the procession stopped, and the chant ceased, Ethelbert
courteously bade the missionaries be seated. Then Augustine,
through the medium of a Frankish interpreter, having preached to
the king the Words of Life and the mercies of the Saviour, was
answered by the king in the well known passage:—"Fair indeed are
your words and promises, but as they are new to us and of
uncertain import, I cannot assent to them so far as to forsake that
which I have so long held in common with the whole English nation.
But because you have come as strangers from afar into my kingdom,
and are desirous to impart to us those things which you believe to
be true and most beneficial, we will not do you any harm, but rather
receive you in kindly hospitality, and take care to supply you with
necessary sustenance. Nor do we forbid you to preach, and win over
as many as you can to the faith of your religion."
The king was as good as his word. Before his return to
Canterbury, he gave orders that a suitable abode should be prepared
for the missionaries near the "Stable Gate," which stood not far from
the present church of St. Alphege.
From the Isle of Thanet, Augustine and his companions crossed
the ferry to Richborough. Thence they proceeded for about twelve
miles almost due west to Canterbury, passing by Ash and Wingham,
and then between the villages of Wickham and Ickham, till they
came to St. Martin's Hill. There they would catch sight of the little
church of St. Martin, which (as they well knew) had been
consecrated afresh to the worship of Jesus Christ, and of the city
below with its wooden houses dotted about among the ash-groves.
As soon as they beheld the city, they walked in procession down the
hill, bearing aloft the silver cross and the painted board—and as they
passed St. Martin's Church, the choristers, whom Augustine had
brought from Gregory's school on the Cœlian Hill, chanted one of
Gregory's own litanies, "We beseech Thee, O Lord, in all Thy mercy,
let Thy wrath and anger be turned away from this city and from Thy
holy house, for we have sinned. Alleluia!"
We can well imagine that the heathen inhabitants of Canterbury
must have been struck with astonishment at the unwonted sight, as
well as at the swarthy complexions and strange dress of the Roman
missionaries. And we may believe that Queen Bertha came forth to
meet the band with a feeling of intense joy. Whether Bishop
Liudhard was still alive or not, we have no evidence to determine.
Bede tells us that they began at once to imitate the course of life
practised in the primitive church, with frequent prayer, watching, and
fasting, preaching the word of life to as many as they could,
receiving only necessary food from those whom they taught, living
themselves conformably to their teaching, being always prepared to
suffer, even to die, for the truth which they preached. In St. Martin's
Church they met, sang, prayed, celebrated mass, preached, and
baptised. And soon the first fruits of their mission began to appear in
the conversion and baptism of Ethelbert.
Ethelbert was baptised, according to an early tradition, on the
Feast of Pentecost (June 2nd) in the year 597—but where? Of one
thing there can be little doubt, that we should certainly expect him
to have been baptised in St. Martin's Church. It was here that his
queen had worshipped for so many years. It was here that
Augustine is distinctly stated by Bede to have baptised—and so it
was here (we may conclude with little hesitation) that the baptism of
Ethelbert took place—even though we can find no direct statement
to that effect earlier than that of John Bromton, writing at the end of
the twelfth century, who says that "there (i.e. in St. Martin's) the
king was baptised in the name of the Holy Trinity and the faith of the
Church."
The rumours of the king's conversion had probably brought a vast
multitude of strangers to the city, not only from other parts of Kent,
but also from distant quarters. We cannot doubt that, as in the case
of the baptism of Clovis, the ceremony was performed with much
pomp, to impress the minds of the heathen Saxons. "On that
occasion the Church was hung with embroidered tapestry and white
curtains: odours of incense like airs of paradise were diffused
around, and the building blazed with countless lights."
While Ethelbert remained at the entrance, Queen Bertha, with her
attendants, repaired to her customary place of devotion. A portion of
the service was performed at the altar, and then Augustine
descended to the font, chanting a litany, and preceded by two
acolytes with lighted tapers. Then followed prayers for the
benediction of the font and the consecration of the water, over which
Augustine makes the sign of the Cross three times. Then (according
to one variation of the ancient Gallican rite) the two tapers are
plunged into the font, and Augustine breathes into it (insufflat) three
times, and the Chrism is poured into the font in the form of a Cross,
while the water is parted with his hand. Ethelbert at this point is
interrogated in the following simple form:—"Dost thou believe in God
the Father Almighty? Dost thou too believe in Jesus Christ, His only-
begotten Son, our Lord, who was born and suffered! and Dost thou
believe in the Holy Ghost, the Holy Church, the remission of sins,
and the Resurrection of the flesh?" To each of which questions the
king answers, "I believe."
Here follows the actual baptism, after which Ethelbert is signed on
the forehead with Chrism in the form of a Cross. Augustine returns
to his seat, and another litany is chanted. Had Augustine been at
that time a bishop, he would now have administered to the king the
Sacrament of Confirmation, but he was not consecrated bishop of
the English till a few months afterwards.
It has indeed been objected that the ceremony could not have
taken place in St. Martin's Church, because at that time baptism was
administered by immersion. This was indeed the general rule, and
such expressions as being "let down into the water," "stepping forth
from the bath," "coming up from the font," and so on, occur in the
writings of Tertullian, Jerome, the Gelasian and Leontine
Sacramentaries; and octagonal or circular baptisteries are found in
ancient churches, sometimes as much as twenty feet in diameter
and five feet deep, erected for this purpose.
On the other hand, this practice was by no means universal, and
even as early as the second century affusion was frequently used,
with or without immersion. A picture of our Lord's baptism in the
baptistery of St. John's at Ravenna (about 450) represents Jesus as
standing in the water, and the Baptist pouring water over him from a
shell. There is a similar representation in the church of St. Maria in
Cosmedin (about 550), and one of earlier date in a fresco from the
cemetery of St. Callixtus. On two sarcophagi, mentioned by
Ciampinus, representations of a like character are engraved,
supposed to be the Baptism of Agilulfus and Theodolinda (about
590), and of Arrichius, second Duke of Beneventum (591). In the
latter case a man somewhat advanced in years, kneels to receive
baptism, which is administered by affusion only. Both of these are
assigned to the same decade as that of King Ethelbert. We may
conclude, therefore, that both forms of administering the rite were
practised from early times, and it is by no means impossible that
Ethelbert was baptised by affusion. It was probably not from the
existing font, even though in the seal of N. de Battail, Abbot of St.
Augustine's (1224-1252) and in the common seal of St. Augustine's
Abbey, the king is represented as standing in a font, resembling in
many respects the present one—while the baptism of Rollo, the first
Christian Duke of Normandy, is illustrated in an early MS. of the
twelfth-century Chronicle of Beuvit de St. More, with Rollo standing
(or sitting) naked in a similar tub-like font.
St. Martin's, "a small and mean church," as it is unkindly called by
Stukely, after the death of Augustine, Ethelbert, and Bertha, relapses
into comparative obscurity, and its history is gathered chiefly from
the testimony of architecture. We may, however, mention, as
connected with the immediately succeeding period, that there were
dug up in the churchyard (besides the Roman ornaments already
described) a Saxon or Frankish circular ornament set with garnets,
and other things which were of too costly a description to have
belonged to any but persons of distinction, with whom they had
probably been interred—also three gold looped Merovingian coins,
fully described by Mr Roach Smith.
The first historical post-Augustinian record that we find in
connection with the church is the well-known charter of 867 (from
the Cottonian MSS. Augustus II. 95) granted, when the Kentish
Wittenagemot was held at Canterbury, by King Ethelred, and entitled
"Grant of a sedes in the place which is called St. Martin's Church,
and of a small enclosure pertaining to the same sedes by King
Ethelred to his faithful friend Wighelm, priest," endorsed in a
contemporary hand, "An sett æt sc'e Martine." In this document
Ethelred, King of the West Saxons and Kentishmen, gives and
concedes to Wighelm a sedes and tun or enclosure pertaining
thereto, of which the boundaries are named, but the Latin is very
provincial and obscure. The grant is given to Wighelm for his life,
and after his death to his heirs, and the king in strong language lays
injunction on his successors "by the faith of St. Martin, confessor of
Christ," not to presume to infringe the grant.
Now this charter is one of the most remarkable in the whole series
of Anglo-Saxon documents, and confessedly one of the most difficult
to comprehend, especially as to the word sedes, which is variously
interpreted to refer to the episcopal character of St. Martin's, or to
some official appointment in the church, or to a shop, dwelling, or
stall for market purposes, in the parish. Whatever be the meaning of
many difficult expressions, the charter is important as giving what is
probably a complete list of the Canterbury clergy, all of whom
attested it.

Archbishop Ceolnoth.
Abbot Biarnhelm.
Archdeacons Sigefred, Bearnoth, Herefreth.
Priests Nothheard, Biarnfreth, &c. &c. &c.

It is also attested by King Ethelred, Duke Eastmund, Abbot

Ealhheard, and many others, and is confirmed "in Jesus Christ with
the sign of the Holy Cross" in the year 867.
We can hardly doubt that the church suffered some injury at the
hands of the Danes, by whom Canterbury was wasted in 851 and
again in 1009, though the most serious devastation took place in
1011, when, in the reign of Ethelred the Second, the Danes laid
siege to, and captured, the city. On that occasion Archbishop
Elphege was seized, bound, and dragged to the Cathedral to see it in
flames. He was then carried off, and eventually murdered at
Greenwich.
 Not very long after this period we discover mention of the
suffragan "Bishops of St. Martin's," who were evidently Chorepiscopi,
an ancient order of bishops, dating from the third century, who
overlooked the country district committed to them, ordaining
readers, exorcists and subdeacons, but not (as a rule) deacons and
priests, except by express permission of the diocesan bishop. It has
been wrongly supposed, without any evidence or tradition, that the
bishops of St. Martin's belonged to the great church at Dover, or the
Oratory of St. Martin at Romney.
It is said by Battely that the succession of these bishops lasted for
the space of nearly four hundred years; but of this there is no proof,
and the idea may have sprung from the charter which we have
discussed above, while the actual tradition is first mentioned in the
"Black Book of the Archdeacons of Canterbury" (probably compiled
in the fourteenth or fifteenth century), wherein it is said that "In the
time of St. Augustine, first Archbishop of Canterbury, to the time of
Archbishop Lanfranc of blessed memory, there was no archdeacon in
the city and diocese of Canterbury. But from the time of Archbishop
Theodore, who was sixth from St. Augustine, to the time of the
aforesaid Lanfranc, there was in the church of St. Martin's, a suburb
of Canterbury, a bishop ordained by Theodore, under the authority
of Pope Vitalian, who in all the city and diocese of Canterbury
undertook duties in the place of the archbishop, conferring holy
orders, consecrating churches, and confirming children during his
absence." Archbishop Parker speaks of the Bishop of St. Martin's as
performing in all things the office of a bishop in the absence of the
archbishop, who, for the most part, attended the king's court. "The
bishop, himself being a monk, received under obedience the monks
of Christ Church, and celebrated in the Metropolitical Church the
solemn offices of Divine worship, which being finished he returned to
his own place. He and the Prior of Christ Church sat together in
synods, both habited alike."
The names of only two bishops are preserved to us—that of Eadsi
or Eadsige (1032-38), subsequently Archbishop of Canterbury, who,
soon after he had received the pall from the Pope, was afflicted with
a loathsome disease which incapacitated him for a time; though he
afterwards recovered and administered the see until his death on the
fourth day before the Kalends of November in 1050. The other
Bishop was Godwin, appointed in 1052 by Archbishop Robert of
Jumiéges, who died, according to the Saxon Chronicle, in 1061. The
Bishop of St. Martin's was practically merged into the Archdeacon of
Canterbury in the time of Lanfranc, who refused to ordain another
bishop, saying that "there ought not to be two bishops in one city."
After the Conquest, St. Martin's was partially restored by the
Normans, and the interior of the church underwent considerable
alteration in the thirteenth century.
The list of the rectors is given in an appendix. They were not
persons of any distinction, but from time to time we glean a few
interesting details concerning them.
Thus, for instance, in 1321, a dispute arose between Robert de
Henney, rector of St. Martin's, and Randolph de Waltham, master of
the Free Grammar School of the city of Canterbury, about the rights
and privileges of their respective schools. A Special Commission was
appointed by the Archbishop, including the chaplain of St.
Sepulchre's, the vicar of St. Paul's, the rector of St. Mary de Castro,
rector of St. Peter's, and others. The point of dispute was whether in
the St. Martin's School (within the church fence or boundary) there
should be more than thirteen grammar scholars. The rector was
limited to this number for fear of infringing on the privilege of the
City Grammar School, though he was entitled to take as many
scholars in reading and singing as he pleased. In fact, however, the
rector took as many grammar boys as he could get, it being
necessary only that when his school was visited by the city
schoolmaster or his deputy, the surplus should conceal themselves
for the time being. An injunction, however, was granted in the
Archbishop's Court to restrain the rector from taking more than his
bare thirteen.
 This is an extremely interesting record, because it shows that
there were two flourishing public schools in Canterbury, probably the
most ancient Grammar Schools in England, early in the fourteenth
century; and that the pupils paid for their teaching, and learnt other
subjects besides grammar.
Thorn, the monk of St. Augustine's, tells us also an amusing story
of how John de Bourne, rector of St. Martin's, aided in the escape of
one Peter de Dene from St. Augustine's Monastery by placing
ladders against the monastery walls. They then rode on horseback
together to Bishopsbourne, but Peter was at length recaptured.
In the fourteenth century we find no less than three rectors who
were instituted to St. Martin's by the Prior of Christ Church during a
vacancy in the see of Canterbury.
We have already mentioned the difficulty of obtaining information
concerning the church in the Middle Ages, owing to its being exempt
from the jurisdiction of the Archdeacon of Canterbury, and therefore
not included in the Archidiaconal Registers, while the Archbishop's
Visitations of the diocese were not, as a rule, parochial. By a lucky
chance, however, we find some entries in Archbishop Warham's
Visitation in 1511, one of which is to the effect that the
churchwardens had not furnished accounts for five years, though
they had received various monies for keeping graves in order. They
were ordered to furnish accounts before the Feast of Purification,
under pain of excommunication, &c.
There are many details of interest to be found in the pre-
Reformation wills of parishioners, which are preserved in the
"Consistory Court." In them we find bequests to the Light of the
Holy Cross, the Light of the Blessed Mary, the Light of St. Martin, the
Light of St. Christopher, the Light of St. Erasmus, for daily masses
before the image of St. Nicholas, to the High Altar, for the purchase
of a new Cross, for various ornaments, for paving,—together with
tenements, real estate, legacies for the benefit of the poor, and
sundry curious personal gifts which wonderfully illustrate the habits
and customs of the period. And from an inventory of Parish Church
goods in Kent, made in 1552, we find the following entry relating to
St. Martin's under the head of "19th July vi., Edward vi.":—
Bartylemewe Barham gent. and Stevyn Goodhewe,
churchwardens.
Ffirst, one chalys with the paten of sylver.
Item, one vestment of blewe velvett with a cope to the same.
Item, one vestment of whyte braunchyd damaske with a cope to
the same.
Item, one other olde vestment with a cope to the same.
Item, two table clothes.
Item, one long towell, one short towell.
Item, ij corporas with their clothes.
Item, one velvet cushon and one saten cushon.
Item, ij chysts, iiij surplysys.
Item, iij bells and one waggerell bell in the steple. Whereof left in
the churche for the mynystracion of dyvyne service: The chalys with
the paten of sylver, one cope of blewe velvett, one cope of whyte
braunchyd damaske, ij albes, ij table clothes, one long towell, and
one short towell, iiij surplysys, the bells in the steple.
For any further particulars concerning the Church after the
Reformation we may refer to the meagre account given by William
Somner, and the additions made to his history by Nicholas Battely,
who states that "St. Martin's claims the priority in the catalogue of
Canterbury parish churches upon several titles of antiquity and
dignity." He says that he cannot pretend that the present fabric is
the same building which was erected in or near the days of King
Lucius, or which was repaired and fitted up for Queen Bertha. "But
yet it has at this day the appearance of ancientness, not from the
wrinkles and ruins of old age, but from the materials (i.e. Roman
bricks) used in the repairing or re-edifying of it." He then goes on to
make the erroneous statement that "in the porch of this church were
buried Queen Bertha, and Liudhard, Bishop of Senlis, and (Thorn
saith) King Ethelbert." About ninety years after the time of Battely
we come to a description of the church in the pages of Hasted, who,
without assigning any reason, ventures on the suggestion that "the
Chancel was the whole of the original building of this church or
oratory, and was probably built about the year 200: that is, about
the middle space of time when the Christians, both Britons and
Romans, lived in this island free from all persecutions." Hasted's
history is, as a rule, extremely valuable, not only from the style of
his writing, but from his extraordinary general accuracy, and the
minuteness of his original researches: and we are often at a loss to
imagine from what source he could have derived so much
information, which at that period was not so accessible as at
present.
Gostling, a minor canon of the cathedral, writes also at the end of
the last century ("Walks in and about Canterbury"), but he adds
nothing fresh except that "if the church was larger and more
magnificent (as Mr Battely seems to believe) this might tempt the
Danish invaders to make a ruin of that, but they had no provocation
here!" and he calls it elsewhere "an obscure chapel."
It is probable that the church was much neglected during the last,
and the first forty years of the present, century. Its existence was
almost forgotten by the public at large. From an historical edifice it
sank into the insignificance of a small parish church in a small
village. It was the site of great events, but only a site: and its
condition is faithfully described in some verses beneath an old print
now hanging in the vestry.

"A humble church recalls the scenes of yore

To present memory, yet humbled more
By lapse of years, by lack of reverent care,
And ill-advised expedients for repair.
Oh! would this age its taste and bounty blend,
The faults of bygone ages to amend!
And lib'rally adorn this lowly pile
Where sleeps the first Queen Christian of our isle."

ST. MARTIN'S CHURCH (in 1840).

(From a Water-colour Drawing.)
 CHAPTER III
DESCRIPTION OF THE CHURCH

We come now to a description of the church, which consists of a

rectangular Nave, 38 ft. long by 25 ft. wide; a Chancel (in its present
form) 40 ft. by 14 ft.; a tower built in the fourteenth century, and a
modern organ chamber and vestry.
The chancel originally was not as large as it is now, and probably
extended only 18 or 20 ft. from the present chancel arch. An
external buttress on the south side marks its termination, beyond
which it has been conjectured that there was an Eastern apse, as
sketched in the annexed plan.
The first question that naturally suggests itself is with regard to
the Dedication. Battely, followed by Hasted, was of opinion that the
church was originally dedicated to the Blessed Virgin Mary, and
afterwards re-dedicated to St. Martin by Bishop Liudhard. For this
statement there is apparently no authority, yet we must remember
that the earliest dedications of churches were either to the Saviour,
the Blessed Virgin, or one of the twelve Apostles. That the Italian
Mission followed generally this ancient practice is shown in their
dedication of the cathedrals of Canterbury, Rochester, London, and
York to Christ, St. Andrew, St. Paul, and St. Peter respectively—of St.
Augustine's Abbey church to St. Peter and St. Paul, of another
church in the same abbey to the "Holy Mother of God," and also of
the early Saxon church in Lyminge to St. Mary; but it is unnecessary
to multiply further instances, the very rare exceptions to the rule
(such as St. Pancras) applying principally to churches which
contained the relics of martyrs. This exception would not embrace
St. Martin's—and Battely's statement, therefore, from whatever
source he derived it, is not intrinsically impossible. We can say
nothing more positive in its favour—but assuming it to be true, and
that the original dedication was forgotten, nothing would be more
natural than that the re-dedication of the church should be to the
saintly Bishop of Tours, made either by Germanus in 429, or Bishop
Liudhard, or even Augustine himself. It is marvellous how
widespread was the influence of St. Martin's name. Nearly 4000
churches are dedicated to him in France alone, and the largest
number of these (in a comparison of dioceses) is in the part of
France nearest to English shores.

PLAN OF ST. MARTIN'S, CANTERBURY, by G. M. Livett.

Dimensions: Nave, 38 by 25 ft.; Chancel, 40 by 14 ft.

But, supposing we take literally the words of Bede, that the church
"dedicated to the honour of St. Martin, was built of old, while the
Romans still occupied Britain," we are met by this apparent difficulty.
If (as is maintained) the church was built in the fourth century, how
came it to be dedicated to St. Martin, who died about 397? Some
colourable support to the possibility of this can be derived from the
fact that the first stone church built in Scotland (at Whithern) by St.
Ninian was certainly dedicated to the same saint. There are indeed,
in that case, some special reasons, because St. Ninian, a personal
friend of St. Martin, called on him at Tours, and received from him
workmen accustomed to the Roman method of building, with whom
he returned home. As the church was in course of erection, the
news of St. Martin's death reached him, and the church was in
consequence dedicated in 398 to his memory. There need be no
difficulty on the doubtfulness of such an early Canonization. The first
formal act of canonization by a Pope did not take place till the ninth
or tenth century. Before this, it was done in a somewhat irregular
manner by the bishop of the diocese, who recited the names of the
departed martyrs, or holy men, in the Canon of the mass, not for
invocation, but in memory of those who had finished their course,
and for an example to others. It has been asserted that St. Martin
was the first person to be honoured as a confessor, that is, that he
was the first who was treated as a saint without being a martyr. In
the antiphon to the Magnificat on his festival we have, "sanctissima
anima, quam etsi gladius persecutoris non abstulit, palman tamen
martyrii non amisit." Though there were other St. Martins, such as
the Bishop of Vienne, a Bishop of Tongres at the end of the third
century, and a Bishop of Trêves, yet there can be little doubt that the
one alluded to by Bede was the Bishop of Tours, whose fame had
completely overshadowed the rest.
Now there is one suggestion that deserves a passing notice, and
that is, the possibility of St. Martin himself having been the founder
of the church; even in a closer sense than by merely sending
masons from his monastery, as he did to St. Ninian. In the constant
interchange of communication between Britain and Gaul, not only for
commercial but for military purposes, it may have happened that
Christians had migrated, or been transferred, from Tours to Kent—
and for the benefit of Christian soldiers, St. Martin, once a soldier
himself, may have urged the erection of a church. It is unnatural to
suppose that St. Martin, who travelled over a great part of Gaul, did
not in some way associate himself with Britons, with whom he would
have been brought into contact. We know this, at any rate, that
during the latter year of his episcopate he exercised great influence
over the Emperor Maximus and his Empress—and Maximus had
resided for several years in Britain, was proclaimed emperor there in
383, had thence invaded Gaul with a fleet and army, which were
long afterwards remembered as the "emigration of a considerable
part of the British nation," and finally settled at Trêves, where he
was more than once visited by St. Martin. Some of these British
emigrants or soldiers would very naturally have returned to their
native country and brought Christianity with them. There is no
conclusive reason why St. Martin himself, either prompted thereto by
Maximus, or yielding to the entreaties of Britons whom he met at
Trêves or elsewhere in Gaul, should not have visited Canterbury in
person, and there founded the church. It is remarked by Haddan
and Stubbs that "it was a peculiarity of British Christians that
churches were not dedicated to any saint already dead, after the
fashion then beginning to be common, but were called by the name
of their living founder." Or the original dedication made by St. Martin
(acting either directly or indirectly) may have fallen into popular
disuse, and been supplanted by his own name, as was the case with
the church of St. Gregory on the Cœlian Hill, which St. Gregory had
dedicated to St. Andrew, but which soon after came to be called
after himself, though he was not buried there. And attention may be
directed to instances of a similar kind at Rome, where the names of
founders lingered on in churches like the Basilica Constantiniana,
Basilica Liberiana, and St. Lorenzo in Damaso. We may also note the
fact, that a chapel in Canterbury Cathedral, originally dedicated to
St. Peter and St. Paul, soon acquired the name of its founder, St.
Anselm, and even the great Cathedral itself, the "Church of Christ,"
was popularly known in the Middle Ages as the Church of St.
Thomas. These latter instances are not indeed exactly parallel,
because the relics of the name-saints were actually buried in these
places, but they may be quoted as showing how readily the original
dedication may have been subsequently changed; and it would not
be difficult to give additional examples.
Before proceeding to a minute description of the principal objects
of interest outside the church, we may say a few words about the
walls, which, however, have been so patched and repaired in
successive ages, that they have lost all signs of uniformity. The
thickness of the walls is, on an average, about 2 ft., and this
dimension is noticeable, because we meet with it over and over
again in Roman villas. The materials, too, are similar, and resemble
what have been found in villas—a mass of rather rough walling,
partly of brick, partly of stone, evidently intended to be plastered on
both sides, and, to a great extent, built with hard "sea-shore"
mortar. This mortar is composed of pebbles, small shells, etc., and is
of such remarkable solidity and strength that, although the walls of
the church are thin and lofty, they have sustained without any injury,
and with comparatively low buttresses, the thrust of a high-pitched
Gothic roof. It was not uncommon for churches to be erected on the
site of, and using part of the structure of, Roman secular buildings,
or temples. And we give for what it is worth the opinion of Mr Roach
Smith, an experienced antiquary, who gave special attention to
Roman work, and who states in a letter written on January 6, 1883:
"There are many examples of churches being built upon the remains
of Roman buildings, no doubt often temples, and not unfrequently of
a small size. Some instances are very remarkable, as that of Britford,
near Salisbury, at old Verulam, etc. I have ever had a belief that St.
Martin's Church is founded upon, or built upon, or built into, a
Roman temple."
The walls of the church form an interesting study, not only for
their venerable aspect, but also for their irregularity. The brick
courses in the Nave are pretty general throughout, sometimes at 9
inches apart, sometimes as much as 20 inches, or even more. A
great deal of old plaster is found externally in the middle of the
south wall of the nave, and there are masses of Roman bricks
congregated at the east and west ends of the same wall (the angles
of the walls in public buildings being often composed entirely of
bricks); and we find also, in parts, large blocks of grey stone, as well
as pieces of travertine, tertiary sandstone, Kentish rag, red
sandstone, Purbeck marble, chalk, and many other geological
specimens. Here and there, interspersed with Roman bricks, are
patches of "chequy" masonry, the stones being placed at wide
intervals, notably on the south-east corner, and on the north side.
 The masonry of the early chancel is, however, entirely different,
being composed of Roman bricks laid evenly upon one another with
narrow joints, averaging four bricks to a foot. In many instances the
arrises of these bricks are sharp and true, showing no sign of having
been taken from any other building; in other cases they are more
fragmentary, but we can have no hesitation in saying that the
walling of the early chancel is well-built, satisfactory to a
professional eye.
We have then these two distinct modes of building (1) Roman
bricks laid evenly and closely upon one another, (2) stone-work with
courses of Roman brick at various intervals. And we shall have to
consider hereafter whether these are genuine Roman walls, or are
merely composed of Roman materials used up for the second time,
as at St. Albans and elsewhere.
We learn from competent authorities that there were five or six
kinds of Roman wall-building—(a) The quadrangular, with masses of
square or oblong stones laid alternately lengthwise and cross-wise,
not cemented by mortar, but bound together by leaden clamps, such
as is found in the so-called wall of Romulus on the Palatine; (b)
polygonal masonry, where the stones are irregular, and with small
stone splinters wedged into the joints where necessary; (c) concrete
—rude, without ornamentation, which has at a distance the
appearance of being panelled, since beams of timber are let in to
strengthen it, or sometimes thin layers of brick to prevent settlement
in the concrete from the shrinking of the lime when it cools and
dries; (d) opus reticulatum, which consists of stone net-work of
diamond-shaped blocks, as in the "Muro Torto" at Rome; (e) opus
lateritium, the ordinary construction of bricks laid evenly upon one
another (f) mixture—i.e. stones bonded together with courses of
bricks, sometimes at regular, often at irregular, intervals. Mr Parker,
in his "Archæology of Rome," referring to the mixture (i.e. the style
of the building used in the nave) which is so constant in Roman wall-
work, in England and Northern Europe generally, says that in itself it
is no evidence of date as to the period of Roman work, since other
things must be taken into account: but that it is found in the circus
of Maxentius, and many other places. It is usually attributed to the
beginning of the fourth century, but it occurs also at Pompeii, in
parts of the substructure of the walls of Aurelian, in tombs of the
second century at Ostia, and in some of the foundations of Hadrian's
villa near Tivoli.
With regard to the comparative antiquity of the nave and chancel,
no positive judgment has yet been arrived at. Hasted, indeed,
ventured on the opinion that the latter was the more ancient, but he
also believed that the chancel was built about the year 200 A.D., and
had not the benefit of the recent explorations, so that his opinion is,
in itself, of little value. But it has been adopted on scientific and
architectural grounds by the Rev. G. M. Livett (who has paid careful
attention to the architecture and masonry of the church) and by
other distinguished antiquaries. Their arguments are very forcible,
and there is much reason for believing that the theory will hereafter
find general acceptance, although at present further investigation is
necessary before it can be pronounced as incontrovertible.
We know indeed that some of the earliest Roman buildings were
constructed of Roman bricks or tiles laid evenly upon one another
(the opus lateritium), but the tiles of the first two centuries were
remarkably thin, as contrasted with later specimens. They vary, at
different periods, in length from 15 inches to 2 feet, and in thickness
from ¾ inch to 3 inches. Unfortunately little credence is now given
to the ingenious rough-and-ready rule, formulated by Mr Parker, that
where (including mortar) there are ten bricks to one foot, the wall is
of the first century, as in the arches of Nero; where eight bricks, of
the second century, as in the villa of Hadrian; where six bricks, of
the third century, as in Aurelian's wall; where four bricks, of the
fourth century. We may lament the non-acceptance of this rule, for,
were it true, we might confidently assign the early wall of the
chancel (containing four bricks to a foot) to the fourth century, which
is the exact date that is claimed for it!
 With regard to the foundations, those in the chancel are of flint-
stones and mortar, with a footing of a single course of Roman bricks,
while in the nave we find a mixture of sandy mortar and crushed
flint, topped with courses of Kentish rag-stone, and one or
sometimes two courses of brick.
Closely connected with the walls are the buttresses. Of flat
pilaster buttresses there are at the present moment (a) one on the
south side of the chancel; (b) two at the south-east corner of the
nave, at right angles to each other; (c) one at the north-west corner
of the nave, the corresponding buttress at this place having been cut
away. In addition to these, there is an evidently later one on the
north-east of the nave, and a semi-circular buttress in the middle of
the south wall. They have all been repaired very frequently,
especially at the top, and it is difficult to determine which stones are
original, and which have been inserted afterwards. The sole
remaining buttress in the chancel has been mutilated in a painful
manner. Not so many years ago, before the modern quoins of Caen
stone were added, it was largely composed of Roman bricks similar
to the walling. The other flat buttresses on the south side project 6
inches from the wall, and, as we see them at present, consist of
blocks of rough-hewn Caen stone to the height of 4 ft. 6 in., and,
above that, of Roman brick, considerably patched.
In themselves flat pilaster buttresses furnish no evidence as to
date, since they are found alike in Roman, Saxon, and Norman
buildings. It is contended by Mr Livett that the buttresses in the nave
are Norman, or (at any rate) insertions of a later date than the
adjacent wall—but only those at the south-east angle have been
explored, where the foundations seem to be of a whiter, harder
mortar than those of the wall, containing large stones, but no small
angular flints. It is too early as yet to pronounce any positive opinion
on the point.
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