Xanthoma disseminatum of the central nervous system and cranium

Xanthoma disseminatum is a rare normolipemic histiocytic disorder of non-Langerhans cell origin. It is a chronic systemic disease with a benign course, characterized by disseminated, yellow-orange-colored papules on the face, flexures, and mucosal membranes. We report 3 patients with xanthoma disseminatum, who presented primarily with central nervous system disease and a multitude of imaging findings throughout the craniospinal axis.

Osteosarcoma presenting as a solitary focus of osteolysis in the calvarium

Osteolysis of the skull is fairly common. The clinical presentation and results of laboratory or imaging tests may suggest a benign or a malignant disease. However, histology is the only means of obtaining a definitive diagnosis and should therefore be performed at the slightest doubt. We report the case of a 58-year-old man who presented with a recent painless lump in the right temporoparietal region. Laboratory tests were normal. Brain imaging studies and total body radionuclide scanning showed no other lesions. However, the heterogeneous and aggressive appearance of the skull lesion prompted a surgical biopsy, which showed osteoblastic osteosarcoma. Chemotherapy and radiation therapy were given after complete excision of the tumor.

Temporoparietal fascia plication in rhytidectomy

BACKGROUND

The temporal region has a complex subcutaneous fascial structure known as the temporoparietal fascia, which is part of the subcutaneous musculoaponeurotic system. The temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) of the face in the inferior border, the frontalis muscle, and the orbicularis oculi muscle in the anterior border. Therefore, a properly planned temporoparietal fascia plication can increase the tightness of the SMAS. In addition, plication of the temporoparietal fascia can provide lifting to decrease lateral canthal wrinkles with elevation of the lateral brows in rhytidectomy. Furthermore, plication of the temporoparietal fascia can yield deep tissue support, which prevents alopecia and visible scar formation in the temporal region by decreasing the tension along the skin incision.

METHODS

Plication of the temporoparietal fascia was performed for 16 patients who had undergone face-lifts over the previous 10 years. Careful subcutaneous dissection, performed immediately under the hair follicles to avoid frontal nerve injury, provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy and protects the auriculotemporal nerve and the superficial temporal vessels.

RESULTS

There were no complications such as hematoma, facial nerve injury, alopecia, or visible scar formation attributable to the temporoparietal fascia plication.

CONCLUSION

Temporoparietal fascia plication can be performed simply during rhytidectomy as an additional procedure. It not only augments the effects of the rhytidectomy, especially in the lateral brows, the lateral canthal, and the temporal regions, but also decreases the risk of possible complications.

Radiation-Induced Osteosarcoma 16 Years After Surgery and Radiation for Glioma-Case Report-

A 35-year-old man developed osteosarcoma of the left parietal and occipital bones 16 years after radiotherapy for glioma in the right occipital lobe. Radiotherapy of the primary neoplasm used 50 Gy administered to a localized field through two lateral ports. The secondary neoplasm arose contralateral to the primary lesion but within the irradiated field. The tumor had a multilocular cyst with considerable intracranial extension, and symptoms of elevated intracranial pressure were prominent early in the course. After a short-lived initial remission following surgical intervention and chemotherapy, the patient deteriorated because of tumor recurrence and died 18 months after the diagnosis. Radiation-induced osteosarcoma is a well-known but rare complication of radiotherapy for brain neoplasms with a poor prognosis.

Giant ossifying chondroma of skull

We report a rare case of giant ossifying chondroma of skull arising from temporoparietal region in a 14-year-old female, which was successfully excised. While reviewing world literature few cases of extracranial chondromas arising from the skull base were found.

Osteopontin and bone metabolism: a histology and scintigraphy study in rats

Osteopontin (OPN) is one of the major non-collagen proteins in extracellular bone matrix. To elucidate the function of OPN in bone metabolism, a cellular defect was created in parietal bone and tibia of 12 rats. In Group 1, the left defects were filled with OPN-coated hydroxyapatite (OPN-H). In Group 2, the right defects were filled with non-coated hydroxyapatite (N-H). In both groups, the contra lateral defects were used as control defects. In Group 3, OPN-H was inserted in the left defects and N-H in the right defects. Bone metabolism was measured by (45)Ca and technetium-99m methylene diphosphonate scintigraphy for 4 weeks. Scintigraphy did not show any significant differences in bone metabolism between the defects filled with OPN-H and N-H. A higher bone metabolism was measured between the parietal defects filled with OPN-H or N-H in comparison with the parietal control defects. This difference, however, was not significant and was less for tibia defects. Histological observation (7th week) shows less inflammatory cells at the tibia defects filled with OPN-H compared to the tibia defects filled with N-H. This study did not show any acceleration or inhibition of bone metabolism in parietal or tibia bone in rats, but there is some evidence that OPN might influence inflammatory cells in bone matrix.

Thyroid cancer with skull enlargement: a lesson learned?

A case of endemic goitre associated with thyroid cancer and huge enlargement of the scalp is reported in a Brazilian mulatto from an iodine deficient Central west region of the country. On admission, osteolytic metastases of follicular thyroid carcinoma were found scattered in the parietal bones. Impressive images from old files could illustrate and emphasize the hurdle-like role of poverty and inadequate social and cultural attitudes before the fight against cancer in regions with limited resources. Even in developed countries, goitres still occur in areas with iodine prophylaxis. Another concern is insufficiency of reliable data on the incidence and pattern of head and neck tumours in developing countries.

[A rare case of chondromyxoid fibroma of the parietal bone]

The authors present a very rare case of the chondromyxoid fibroma (CMF) of the parietal bone. This is an uncommon chondroid tumour which constitutes less than 1% of primary bone tumours and which is usually localised in the metaphysis of the long bones, often in the knee region. There are 23 cases of cranial localisation of the chondromyxoid fibroma reported in several papers, 14 cases involved the cranial base and 9 the calvaria. A different ossification process of the skull-base and calvaria is probably responsible for this distribution. In our case we found the focal, lytic lesion in the parietal bone and fibro-greasy tumour mass. The dura was spared. The tumour was removed totally. Curettage of these kind of lesions should be avoided because it may lead to tumour recurrence. Histologically this tumour may cause problems in a differential diagnosis with other chondroid tumours like chondrosarcoma or chondroblastoma.

Infected cephalohematoma of newborns: experience in a medical center in Taiwan

BACKGROUND

The objective of the present retrospective study was to clarify the clinical course, major pathogens, and other infections associated with infected cephalohematoma.

METHODS

From January 1978 to December 2003, records of all newborns were reviewed for evidence of an infected cephalohematoma, based either on local signs of infection or a diagnostic tap that yielded pus. Patients were divided into two groups: those seen in the early period (1978-1990) and in the late period (1991-2003).

RESULTS

Twenty-eight newborns with infected cephalohematoma were identified, 14 each in the early and late periods. The mean age at onset was 17.8 +/- 13.9 days. The most common local findings were erythema (79%), increasing size of the hematoma (68%), and a fluctuant mass (46%), while fever (64%), poor appetite (39%) and irritability (18%) were the common systemic signs. Common laboratory findings included leukocytosis (82%) and an elevated C-reactive protein (61%). Escherichia coli was the most common pathogen (16 patients, 57%) and was isolated significantly more frequently in the late period (early period: 36%, late period: 79%, P < 0.05). Staphylococcus aureus was the second common pathogen (five patients, 18%). Ten patients (36%) had other associated infection: eight had sepsis, three had meningitis, and one had osteomyelitis. In the early period three patients (11%) died.

CONCLUSIONS

Clinicians should be aware that cephalohematoma is a potential site of infection. The incidence of associated system infection is high and may result in mortality. Appropriate diagnostic and therapeutic measures should be undertaken promptly if there are infectious signs.

P253R fibroblast growth factor receptor-2 mutation induces RUNX2 transcript variants and calvarial osteoblast differentiation

Unregulated fibroblast growth factor 2 (FGF2) signaling caused by mutations in the fibroblast growth factor receptor (FGFR2) leads to human craniosynostosis such as the Apert syndrome. In an in vitro control model of calvarial osteoblasts from Apert patients carrying the FGFR2 P253R mutation, we studied the changes in cellular phenotype and evaluated the effects of FGF2. Compared with wild-type controls, osteocalcin mRNA was down-regulated in Apert osteoblasts, Runt-related transcription factor-2 (RUNX2) mRNA was differentially spliced, and FGF2 secretion was greater. Total protein synthesis, fibronectin and type I collagen secretion were up-regulated, while protease and glycosidase activities and matrix metalloproteinase-13 (MMP-13) transcription were decreased, suggesting an altered ECM turnover. Adding FGF2 increased protease and glycosidase activities and down-regulated fibronectin and type I collagen secretion in Apert osteoblasts. High affinity FGF2 receptors were up-regulated in Apert osteoblasts and analysis of signal transduction showed elevated levels of Grb2 tyrosine phosphorylation and the Grb2-p85 beta association, which FGF2 stimulation strongly reduced. All together these findings suggest increased constitutive receptor activity in Apert mutant osteoblasts and an autocrine loop involving the FGF2 pathway in modulation of Apert osteoblast behavior.

Cranioplastie par lambeau libre ostéomusculaire temporo-pariétal

PURPOSE

Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation.

CASE REPORT

A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed.

DISCUSSION

In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

Ossifying Fibroma of the Skull: Interactive Image-Guided Minimally Invasive Localization and Resection

Ossifying fibroma is a benign fibro-osseous tumor commonly affecting the craniofacial bones. It is considered to be a locally aggressive and quickly expansible bone lesion. Because of its aggressive nature and high recurrence rate, early detection and complete surgical removal are essential. Usually, these lesions are excised extensively by craniectomy, and bone loss is reconstructed by cranioplasty using acrylic resin or titanium implants. Alternatively, in the management of skull-ossifying fibroma, an image-guided technique using surgical navigation may provide precise information about localization, enabling complete removal, thereby operating with minimal exposure and within narrow resection borders and avoiding significant bone deformity. A 39-year-old male patient with a history of renal cell carcinoma was admitted to our hospital because a radionuclide scintigraphic bone scan revealed increased uptake in a small area located at the left lateral skull bone. The high-resolution computed tomography scan showed that the lesion was located inside the diploe, destroying the inner table of the calvarium. The patient underwent minimally invasive bone lesion removal using an interactive image-guided approach. Complete resection of the neoplastic lesion was achieved. The histopathological examination revealed an ossifying fibroma. The postoperative course was uneventful, and the patient was discharged 3 days after intervention. To date, there has been no evidence of local recurrence. Interactive multimodal planning and intraoperative image guidance offer an interesting approach for biopsy and minimally invasive removal of small ossifying fibroma lesions of the skull, especially in less accessible locations.

Bone augmentation osteogenesis using hydroxyapatite and beta-tricalcium phosphate blocks

PURPOSE

In this study, we investigated the differences in osteogenesis and resorption between hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP) implanted on the parietal bone of rats.

MATERIALS AND METHODS

HA and beta-TCP were used in blocks with macropores and micropores. They were implanted between the parietal bone and the cranial periosteum in rats. Osteogenesis around the implanted materials was investigated histopathologically and histomorphometrically at 1, 2, 4, 8, and 24 weeks after surgery.

RESULTS

At 2 weeks, osteogenesis from the parietal bone was observed around both materials, and new bone had attached directly to the surfaces of both materials. New bone grew into the pores of the upper regions of both materials with time. The beta-TCP block had a characteristic basophilic reticular structure in which the dissolution of the materials was observed close to the new bone. The HA blocks were stable for 24 weeks, whereas parts of the beta-TCP blocks were fractured and resorbed at 24 weeks. Histomorphometrically, the volume of new bone around HA was larger than that around beta-TCP. There was no remarkable change in the amount of remaining HA, but that of beta-TCP was decreased.

CONCLUSION

HA blocks in this model are suitable for onlay grafts because of its stability and osteogenesis, beta-TCP is not stable. Therefore, when beta-TCP blocks are used for onlay grafts, the mechanical stress on the recipient site should be taken into consideration because of resorption and fracture.

[Diploic epidermoid cyst: case report]

We report the case of a diploic epidermoid cyst in the left front-parietal bone of a 70-year-old woman. A skull x-ray showed an osteolytic lesion with a sclerotic border, and CT scan revealed a low/iso-density mass and the destruction of both inner and outer tables. MRI showed hypo-intensity on T1-weighted image, hyper-intensity on T2-weighted imaging and remarkably-strong intensity on the diffusion-weighted imaging. Gadolinium enhancement was seen in the tumor capsule and dura of the peripheral tumor. In the operative view, most of the bone edge was regular with a sclerotic border, but an irregular section was present. The tumor adhered strongly to the dura mater and periosteum. The tumor was totally extirpated with the peripheral skull, dura mater and periost. On the postoperative MRI, gadolinium enhancement of the nearby dura mater and disappeared. We have added a discussion of the radiological features of diploic epidermoid cysts.

Transcriptional and post-transcriptional regulation of transforming growth factor beta type II receptor expression in osteoblasts

Variations in transforming growth factor beta (TGF-beta) activity depend on the expression of specific receptors in normal as well as transformed cells. For example, in addition to mutations in TGF-beta type II receptor (TbetaRII) that abrogate normal TGF-beta function, its expression decreases during the transition from replication to extracellular matrix production, or in response to other growth regulators in bone. Therefore, to understand how TbetaRII expression is controlled, we cloned the rat TbetaRII gene promoter and defined basic aspects of its structure and activity. Among several cis-acting elements, mutations within an upstream E-box that specifically binds USF nuclear factors or a downstream Sp1 binding site significantly reduced TbetaRII promoter activity in primary cultures of fetal rat osteoblasts. Treatment with bone morphogenetic protein 2 (BMP-2), which induces further osteoblast differentiation, significantly reduced cell surface TbetaRII. However, BMP-2 did not alter TbetaRII promoter activity, steady state TbetaRII mRNA, or total TbetaRII protein, but caused an intracellular relocation of TbetaRII. Select transcriptional elements thus regulate TbetaRII gene expression, whereas post-translational events controlled by BMP-2 rapidly modify the amount of TbetaRII protein on the bone cell surface. Consequently, several processes can alter functional TbetaRII levels in order to regulate the biological effects of this important growth factor.

Numular headache: a coin-shaped cephalgia

Numular headache is a chronic, mild to moderate, pressurelike pain in a circumscribed cranial area of approximately 2 to 6 cm in diameter. Pain usually is limited to the parietal region, although it may appear in any cranial site. It is a benign process of usually unknown origin.

Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein

Anatomy of the superficial temporal artery and vein was analyzed with arteriograms, venograms, and arteriovenograms of fresh cadavers that had been injected with contrast medium. The superficial temporal artery always divided into two major branches: the frontal and parietal branches. However, the superficial temporal vein divided into one, two, or three major branches. The distribution area of the major branches of the superficial temporal vein was larger than that of major branches of the superficial temporal artery, and arteriovenograms clearly demonstrated that, except for its proximal portion, the superficial temporal vein was independent of the superficial temporal artery. The frontal and parietal branches of the superficial temporal artery had thin venae comitantes that originated from the proximal portion of the superficial temporal vein, and the venae comitantes gave off branches toward the skin and the underlying soft tissue. Branches to the skin anastomosed with a superficial venous network in the skin layer, which was formed by ramifications of the superficial temporal vein. The venous architecture of the temporal and parietal regions consisted of cutaneous veins and venae comitantes and was basically similar to that of the forearm and scapular region.

Solitary plasmacytoma of the skull bone

Solitary plasmacytoma of the bone is an uncommon variety of plasma cell tumour. Here an interesting case of solitary plasmacytoma of the skull bone, which is extremely rare, is being reported.

Adamantinoma and meningioma occurring synchronously in a patient with breast cancer: a case report

Screening mammography of a woman with no symptoms led to the diagnosis of carcinoma of the breast, an intracranial meningioma, and adamantinoma of the right tibia. This is the first reported case of three synchronous primary tumors of different tissue origins. Biopsy is essential for diagnosing or excluding primary tumor(s) in cases of suspected metastases occurring at a limited number of sites.

Fibrous dysplasia involving the skull base and temporal bone

OBJECTIVE

To gain a broader appreciation of the clinical presentation, operative treatment, and outcome of patients with fibrous dysplasia involving the skull base.

DESIGN

Retrospective review of a clinical case series.

SETTING

A single tertiary academic medical center.

PATIENTS

Twenty-one patients with histopathologically confirmed fibrous dysplasia involving the skull base cared for over a 15-year-period (1983-1998).

MAIN OUTCOME MEASURES

Clinical and radiographic location of the fibrous dysplasia lesions within the skull base, clinical presentation, surgical intervention, and clinical outcome were tabulated for each patient.

RESULTS

The ethmoids were most commonly involved (71%), followed by the sphenoid (43%), frontal (33%), maxilla (29%), temporal (24%), parietal (14%), and occipital (5%) bones. The most common presenting features included atypical facial pain and headache, complaints referable to the sinuses, proptosis and diplopia, hearing loss, and facial numbness. Surgical treatment, guided by clinical presentation, ranged from simple biopsy with conservative follow-up to craniofacial resection.

CONCLUSIONS

Fibrous dysplasia can present in myriad ways within the skull base. Modern imaging modalities and histopathologic analysis have made diagnosis relatively straightforward. Surgery, particularly in such a challenging region as the skull base, should be reserved for patients with functional impairment or a cosmetic deformity. Because of the benign nature of the condition, the surgery itself should be relatively conservative, with the primary goal being preservation of existing function.

Free temporoparietal fascial flap for coverage of a large palmar forearm wound after hand replantation

A free temporoparietal fascial flap with a split-thickness skin graft was used to cover a large palmar forearm wound in a patient whose hand had been replanted 21 days earlier after traumatic amputation at the distal forearm level. At a 39-month follow-up, the patient had achieved an excellent cosmetic and functional result, with no alopecia or facial nerve injury. The flap is advantageous for coverage of wounds that require a large amount of thin, pliable tissue, and it leaves a concealed donor-site scar.

Malignant giant-cell tumor of the parietal bone: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Giant-cell tumors (GCTs) are primary bone tumors that involve long bones in 75 to 90% of patients. They seldom develop in the cranium and are very rare in patients older than 60 years of age. A GCT rarely occurs with Paget's disease; when it does, however, it is most commonly associated with the polyostotic form and tends to involve the craniofacial bones. Pagetic GCTs are less aggressive than GCTs that are not associated with Paget's disease.

CLINICAL PRESENTATION

We report the case of an 81-year-old woman with a painless left parietal mass and asymptomatic monostotic parietal Paget's disease.

INTERVENTION

Surgical resection was performed, and histological examination of the lesion demonstrated Paget's disease with a malignant GCT. An incidental, low-grade, small-cell lymphocytic lymphoma also was noted. The patient experienced local recurrence of the malignant GCT and eventually died after developing pulmonary metastases of the malignant GCT.

CONCLUSION

This case is the first reported example of a patient with a malignant GCT of the cranium associated with monostotic Paget's disease. It provides evidence that not all pagetic GCTs in the cranium are benign, as has been reported.