Hereditary intraosseous vascular malformation of the craniofacial region: an apparently novel disorder

Intraosseous hemangioma with aneurysmal bone cyst-like changes of the hyoid bone: Case report and literature review

RATIONALE

Intraosseous hemangioma is a rare benign vascular tumor of the bone that can affect any body part; however, the most common site is the vertebra, followed by calvarial bones.

PATIENT CONCERNS

We present a case of intraosseous hemangioma in a 23-year-old male who presented a feeling of fullness in the throat for 3 months. The hyoid bone level had a hard mass of about 5 cm. Fine needle aspiration showed 5 mL dark bloody aspirates. Magnetic resonance image showed a 5.3 cm mixed signal intensity lesion in the hyoid body.

DIAGNOSIS

Histopathologic examination showed intraosseous hemangioma with aneurysmal bone cyst (ABC)-like changes in the hyoid bone.

INTERVENTIONS

The mass was completely removed without significant problems.

OUTCOMES

Complete mass excision and symptomatic improvements were achieved, and no subsequent relapses were observed.

LESSONS

The authors experienced a case of intraosseous hemangioma with ABC-like changes. There has been no case report of intraosseous hemangioma in the hyoid bone. This case showed a spectral pattern of the ABC-like changes developing from the underlying bone tumor as a secondary change. ABC-like changes in bone tumors can mislead the diagnosis. Careful examination of the tumor is essential for the correct diagnosis of ABC or ABC-like changes.

Venous Malformations in Childhood: Clinical, Histopathological and Genetics Update

Our knowledge in vascular anomalies has grown tremendously in the past decade with the identification of key molecular pathways and genetic mutations that drive the development of vascular tumors and vascular malformations. This has led us to better understand the pathogenesis of vascular lesions, refine their diagnosis and update their classification while also exploring the opportunity for a targeted molecular treatment. This paper aims to provide an overview of venous malformations (VM) in childhood. Specific entities include common VMs, cutaneo-mucosal VM, blue rubber bleb nevus syndrome or Bean syndrome, glomuvenous malformation, cerebral cavernous malformation, familial intraosseous vascular malformation and verrucous venous malformation. The clinicopathological features and the molecular basis of each entity are reviewed.

Clinical and Molecular Study of ELMO-2-Related Massive Intraosseous Vascular Malformations: Lessons Learned From 25 Years of Follow-up

Massive intraosseous vascular malformations, a relatively rare entity in the vascular malformation spectrum, deserves attention as involving the membranous bones of the craniofacial skeleton and may lead to severe life-threatening hemorrhages and even death. The main aim of this study was to summarize the 25 years of clinical experience with these vascular malformation osseous patients, focus on the molecular and genetic aspect of the clinical entity, and to emphasize the certain challenging conditions in the treatment of these patients. All the patients appeared to be unaffected at birth, whereas initial symptoms occasionally began with painless swelling in the mandible in early childhood. The disease was progressive in behavior especially in the pubertal ages and was specifically involving the maxilla and mandible of the craniofacial skeleton in all the patients. Calvarium and cranial base were the second most common involved regions among these patients (62.5%). Clavicular (50%), costal (25%), and vertebral (25%) involvements were also a significant manifestation of the disease. Tissue samples obtained from the affected individuals and the blood samples from their families were matched, revealing a loss of function mutation in the ELMO-2 gene of chromosome 20 leading to developmental abnormality of the vascular structures via RAC1 signaling and leading to abnormally enlarged vessels in the intraosseus portion of the membranous bone. Immunohistochemical staining revealed positive CD31 and smooth muscle actin staining but negative proliferation and maturity markers such as Ki-67, desmin, h-caldesmon, and myofibroblast-like desmin. The follow-up of 3 of 5 patients ended up with mortality (60%). vascular malformation osseous is intraosseous vascular malformation with aggressive biological behavior associated with ELMO-2 gene mutation. Further studies for obtaining prenatal diagnosis and achievement of gene therapy should take place. As the disease rapidly progresses as the affected individual grows, surgical interventions should be taken into consideration before the initiation of complications.

Homozygous mutation in ELMO2 may cause Ramon syndrome

We report on a girl, born to first cousin Lebanese parents, with intellectual disability, seizures, repeated gingivorrhagia, enlarged lower and upper jaws, overgrowth of the gums, high arched and narrow palate, crowded teeth, hirsutism of the back, large abdomen and a small umbilical hernia. Cysts of the mandible, fibrous dysplasia of bones, and enlarged adenoids causing around 60% narrowing of the nasopharyngeal airways were noted at radiographic examination. Her brother presented with the same features in addition to a short stature, an ostium secundum, and more pronounced intellectual disability. He died at the age of 8 years from a severe pulmonary infection and repeated bleeding episodes. A clinical diagnosis of Ramon syndrome was made. Whole exome sequencing studies performed on the family revealed the presence of a novel homozygous missense mutation in ELMO2 gene, p.I606S in the affected individuals. Loss of function mutations in ELMO2 have been recently described in another clinically distinct condition: primary intraosseous vascular malformation or intraosseous hemangioma, called VMOS. Review of the literature and differential diagnoses are discussed.

Loss-of-Function Mutations in ELMO2 Cause Intraosseous Vascular Malformation by Impeding RAC1 Signaling

Vascular malformations are non-neoplastic expansions of blood vessels that arise due to errors during angiogenesis. They are a heterogeneous group of sporadic or inherited vascular disorders characterized by localized lesions of arteriovenous, capillary, or lymphatic origin. Vascular malformations that occur inside bone tissue are rare. Herein, we report loss-of-function mutations in ELMO2 (which translates extracellular signals into cellular movements) that are causative for autosomal-recessive intraosseous vascular malformation (VMOS) in five different families. Individuals with VMOS suffer from life-threatening progressive expansion of the jaw, craniofacial, and other intramembranous bones caused by malformed blood vessels that lack a mature vascular smooth muscle layer. Analysis of primary fibroblasts from an affected individual showed that absence of ELMO2 correlated with a significant downregulation of binding partner DOCK1, resulting in deficient RAC1-dependent cell migration. Unexpectedly, elmo2-knockout zebrafish appeared phenotypically normal, suggesting that there might be human-specific ELMO2 requirements in bone vasculature homeostasis or genetic compensation by related genes. Comparative phylogenetic analysis indicated that elmo2 originated upon the appearance of intramembranous bones and the jaw in ancestral vertebrates, implying that elmo2 might have been involved in the evolution of these novel traits. The present findings highlight the necessity of ELMO2 for maintaining vascular integrity, specifically in intramembranous bones.

Large Intraosseous Hemangioma of the Temporal Bone in a Child

Hemangiomas of the temporal bone are extremely uncommon tumors, predominantly arising in the area of the geniculate ganglion and the internal auditory canal and affecting mainly middle-aged adults. We present a 6-year-old boy who had suffered from recurrent infections of the left ear associated with a slight conductive hearing loss, but without facial nerve dysfunction. Using high-resolution computed tomography and gadolinium-enhanced magnetic resonance imaging, we detected an unusually large 32 × 32 × 24-mm mass of the left temporal bone occupying the entire mastoid. Histopathologically, a capillary hemangioma was diagnosed. The tumor was removed surgically by a transmastoid approach. We present a thorough review of the literature, focusing on the clinical and radiologic features, as well as the pathogenesis of intratemporal vascular lesions.

Management of Intraosseous Vascular Malformations of the Jaws in Children and Adolescents: Report of 6 Cases and Literature Review

Background

Intraosseous vascular malformations represent a rare clinical entity of the facial skeleton. The purpose of the current study was to present our experience in a Greek paediatric population and propose guidelines for the treatment of these jaws anomalies in children and adolescents.

Methods

A retrospective study (from 2009 to 2014) was performed to investigate the features and management of the intraosseous vascular anomalies in a Greek paediatric population.

Results

Six patients aged between 6 and 14 years were treated for intraosseous vascular malformations (4 venous and 2 arteriovenous) of the jaws. Five lesions were located in the mandible and one in the maxilla. In four lesions with pronounced vascularity superselective angiography, followed by embolization was performed. Individualized surgical treatment, depending on the size and vascularity of the lesions was applied in 4 patients.

Conclusions

The intraosseous vascular malformations of the jaws may escape diagnosis in paediatric patients. A multidisciplinary approach is important for their safe and efficient treatment. Embolization is recommended for extended high-flow lesions, either preoperatively or as a first-line treatment, when surgery is not feasible without significant morbidity.

Radiofrequency-induced thermotherapy of nasopharyngeal angiofibroma and immunohistochemical analysis of vessel proliferation: a case report

Introduction

Nasopharyngeal angiofibroma presents with symptoms of nasal obstruction and epistaxis. The treatment of choice is embolization followed by surgery.

Case presentation

A 52-year-old man underwent surgery for nasopharyngeal angiofibroma after adjuvant radiofrequency-induced thermotherapy. To the best of the authors' knowledge, this is the first case of angiofibroma with clinical follow-up after thermocoagulation therapy supported by quantitative, double immunohistochemistry. We found this case of angiofibroma to be of interest owing to the presentation of symptoms leading to biopsy, the pathohistological observations obtained with synchronous Ki67/cluster of differentiation 34 and Ki67/smooth muscle actin immunohistochemistry and high pericyte proliferation.

Conclusion

Coagulation of angiofibroma vessels followed by acquisition of a thick mantle of pericytes in a patient with a nasopharyngeal growth suggests that radiofrequency-induced thermotherapy could be a useful, palliative therapy for bleeding nasopharyngeal angiofibroma, supporting vessel maturation prior to surgical tumor removal.

Primary Skull Lesions in the Pediatric Population: A 25-Year Experience

Context.—Primary skull lesions are rare in the pediatric population. The differential diagnosis of these lesions is broad and includes both congenital and acquired lesions. Previous studies of skull lesions in the pediatric population suggest that dermoid/epidermoid tumors are the most common childhood skull tumors.

Objective.—To review the clinicopathologic features of primary skull lesions identified within the pediatric population of an academic tertiary medical center.

Design.—A retrospective review of surgical pathology reports during a 25-year period identified 19 primary skull lesions occurring in the pediatric population. Lesions were excluded if they were of known soft tissue or intracranial origin with secondary calvarial involvement, or if they represented a metastasis from a known primary malignancy.

Results.—Nineteen primary skull lesions were identified in 11 male (58%) and 8 female (42%) patients, with a median age at diagnosis of 9.5 years. These lesions were usually benign and most commonly presented as a painless mass (n = 8). The lesions were located in the occipital bone (n = 7), frontal bone (n = 5), parietal bone (n = 2), and temporal bone (n = 1). Diagnoses included epidermoid/ dermoid cyst (n = 8), Langerhans cell histiocytosis (n = 6), intraosseous hemangioma (n = 2), osteoblastoma (n = 1), infantile myofibroma (n = 1), and fibroma (n = 1). Intracranial extension was identified in 1 case, and recurrence was found in only 2 cases.

Conclusions.—Epidermoid/dermoid cysts and Langerhans cell histiocytosis are the most commonly encountered skull lesions in the pediatric population at our institution. Intracranial extension of these lesions is rare, and recurrence is uncommon following complete surgical resection.

Embolisation of arteriovenous malformation of the maxilla

We describe a 20-year-old male patient who presented with gingival bleeding. Physical examination showed gingival swelling of the right maxilla and loosening of the molar teeth. The initial diagnosis of gingivitis was made, but further examination revealed a lytic lesion of the maxilla. On suspicion of fibrous dysplasia, biopsy was attempted but was unsuccessful due to severe haemorrhage. Further evaluation showed palpable and audible bruit on the gingiva, which caused the suspicion of vascular malformation. Angiography was performed and demonstrated arteriovenous malformation (AVM). Embolisation therapy with polyvinyl alcohol was performed. Post-embolisation angiogram demonstrated complete obliteration of the lesion.

Vascular update: Morphogenesis, tumors, malformations, and molecular dimensions

This vascular review is organized under the following headings: vasculogenesis and angiogenesis; vascular endothelial growth factors, their receptors, TIE receptors, and angiopoietins; other factors in blood vessel formation; parallel patterning in blood vessels and nerves; physiological and pathological neovascularization; the role of VEGF receptors in metastasis; anti-angiogenic therapy for tumors; association of blood vessels with fat; vascular malformations and vascular tumors; infantile hemangiomas; congenital hemangiomas; lymphatic malformations; molecular characteristics of some disorders with vascular malformations; Kasabach-Merritt phenomenon; Sturge-Weber syndrome, Klippel-Trenaunay syndrome, and Parkes Weber syndrome; diagnostic and laboratory studies; and future perspectives.

Multiple congenital cranial hemangiomas

Though cranial hemangiomas are second only to vertebral hemangiomas in frequency, such lesions are rarely congenital and multiple. It is probable that the true incidence of congenital calvarial hemangiomas is higher than that reported in the literature, as they are unlikely to undergo imaging, most being asymptomatic and without a significant soft tissue component. We present a case of multiple congenital calvarial and skull base cavernous-type hemangiomas, diagnosed in a 4-day-old female, involving the right zygoma, maxilla, frontal and petrous temporal bones and contralateral squamous temporal bone. Surgical biopsy confirmed the radiological diagnosis as well as the concomitant multiple subcutaneous capillary-type hemangiomas which were identified clinically. No specific clinical syndrome or chromosomal abnormality was identified and the underlying cerebral parenchyma was normal with no intra-axial involvement. With conservative treatment, two lesions completely resolved and a further two lesions subsequently decreased in both size and degree of enhancement. To the best of our knowledge, this is the first case of multiple congenital hemangiomas involving the calvarium and skull base. Despite this, the radiological features, combined with the clinical findings of multiple capillary hemangiomas, were characteristic enough to permit an accurate preoperative diagnosis. Osseous hemangiomas should feature prominently in any differential diagnosis of multiple hypervascular lesions, as they are common, more so when limited to an anatomical region, irrespective of site or age.

Hereditary intraosseous vascular malformation of the craniofacial region: imaging findings

Benign vascular lesions can be classified into two categories depending on clinical behaviour and endothelial cell characteristics: neoplasms (haemangiomas) and vascular malformations. However, intraosseous vascular anomaly, previously called intraosseous haemangioma, is a very rare malformation. In our previous study, we described the first hereditary form of intraosseous vascular malformation of the craniofacial region, vascular malformation osseous (VMOS). Characteristic findings are autosomal recessive inheritance, severe and diffuse intraosseous vascular malformation in all craniofacial bones without soft tissue involvement and associated mid-line abnormalities such as umbilical hernia and supra-umbilical raphe. In this paper, we discuss the imaging findings of this new disorder in detail.

Primary Intraosseous Skull Base Cavernous Hemangioma: Case Report

Primary intraosseous cavernous hemangiomas (PICHs) of the skull base are extremely rare tumors. These lesions are most common in the frontal and parietal bones of the calvarium. The authors describe a 40-year-old female who presented with progressive headaches. Serial imaging revealed a contrast-enhancing intraosseous lesion of the lateral body of the sphenoid bone and the greater wing associated with encroachment of the inferior cavernous sinus and mild posterior displacement of the cavernous carotid artery. Follow-up imaging 9 years later revealed slow growth of the lesion. The patient underwent complete excision of the PICH through an extradural frontopolar approach. Pathological examination revealed an intraosseous cavernous hemangioma. PICHs of the skull base can mimic other more common skull base lesions and thus can be difficult to diagnose preoperatively. Diagnosis is usually made at surgery. The authors review the literature regarding the clinical presentation, radiological characteristics, pathological features, and surgical management of PICHs.