Hyperostosis fronto-parietalis - radiology mimic of metastasis: A case report

Hyperostosis frontalis interna (HFI) is a benign entity manifested by bony overgrowth in the frontal endocranial surface. It is most commonly reported incidentally among postmenopausal elderly women. Tracer uptake appearances of HFI can vary on planar bone scans, enabling it to be easily confounded with bone metastases. We report a case of HFI in a 69-year-old postmenopausal female with treated left breast cancer detected on bone scintigraphy, with subsequent confirmation by computed tomography. Our case highlights the importance of having awareness of HFI and its key pattern findings to avoid mistaking it for pathology, and to recognise the use of computed tomography and hybrid fusion imaging techniques as reliable diagnostic tools for HFI.

Co-occurrence of malignant neoplasm and Hyperostosis Frontalis Interna in an Iron Age individual from Münsingen-Rain (Switzerland): A multi-diagnostic study

OBJECTIVE

To re-analyze one of the oldest cases of malignant bone neoplasm with different analytical techniques.

MATERIAL

The available skeletal remains of grave 138 (G138) from the Iron Age necropolis of Münsingen-Rain (Switzerland, 420-240 BC).

METHODS

The bones are analyzed by means of morphological, radiographic, histological, and biogeochemical methods.

RESULTS

The individual, a male aged between 35-50 years old, presents morphologically and radiographically a previously described coral-like bone neoformation on the proximal left humerus. The new analyses highlight previously undocumented coarse bone proliferation on the left scapula and lobular apposition on the endocranial surface of the frontal bone. The histological analysis of the humerus shows a 'lace-like' pattern of osteoid deposition without lamellation.

CONCLUSIONS

Our data support a diagnosis of osteoblastic malignant neoplasm, probably an osteosarcoma or, more likely, a dedifferentiated chondrosarcoma for the humerus and scapula, and of hyperostosis frontalis interna on the frontal. The co-presence of a malignant neoplasm and hyperostosis frontalis interna may be related to a hormonal imbalance, a possibility also suggested by atypical funerary treatment.

SIGNIFICANCE

This study confirms G138 as one of the oldest cases of malignant bone neoplasm, adds new paleopathological data on this individual, and demonstrates the advantages of a multidisciplinary approach.

LIMITATIONS

The discussion of the pathological changes is limited by the representation and preservation of the skeletal elements.

SUGGESTION FOR FUTURE RESEARCH

Biomolecular and protein biomarkers analyses may help to refine the diagnostic conclusions.

Comparative Analysis of Femoral Macro- and Micromorphology in Males and Females With and Without Hyperostosis Frontalis Interna: A Cross-Sectional Cadaveric Study

We hypothesized that subjects with hyperostosis frontalis interna (HFI), which represents local, endocranial thickening of the frontal bone, would express extra-calvarial manifestations of this condition. Therefore, we compared femoral bone mineral density, geometry, and microarchitecture of males and females with HFI to those without this condition as well as between males and females with HFI. The sample was taken from human donor cadavers, 38 males (19 with and 19 without HFI) and 34 females (17 with and 17 without HFI) that were age-matched within the same sex. The specimens of femoral bones were scanned using microcomputed tomography and dual-energy X-ray absorptiometry (DXA). Parameters of hip structure analysis (HSA) were calculated from data derived from DXA scans. Females with HFI had increased cortical bone volume fraction and their cortical bone was less porous compared to females without HFI. Males with HFI showed microarchitectural differences only with the trabecular bone. They had increased bone volume fraction and decreased trabecular separation compared to males without HFI, although with borderline significance. These microarchitectural changes did not have significant impact on femoral geometry and bone mineral density. The same, still unknown etiological factor behind HFI might be inducing changes at the level of bone microarchitecture at a remote skeletal site (femoral bone), in both sexes. These alterations still do not have the magnitude to induce obvious, straightforward overall increase of bone mineral density measured by DXA. HFI could be a systemic phenomenon that affects both males and females in a similar manner.

Micro-computed Tomography Study of Frontal Bones in Males and Females with Hyperostosis Frontalis Interna

Hyperostosis frontalis interna (HFI) represents irregular thickening of the endocranial surface of the frontal bone, mostly seen in postmenopausal females. The microarchitecture of this condition is poorly studied. The aim of this cross-sectional autopsy study was to investigate and compare microarchitectural structure of the frontal bone affected with HFI in both sexes and to test whether HFI severity could be distinguished at the microarchitectural level. The sample was taken from human donor cadavers, 19 males (61 ± 15 years old) and 17 females (75 ± 15 years old). After classification of HFI severity (type A, B, C or D), samples of the frontal bone were taken and scanned using micro-computed tomography. Bone volume fraction was higher and total porosity lower only in the outer table of males with HFI, compared to females with HFI. Mean total sample thickness differed only between males with HFI type A and D. Bone microarchitecture between males and females with corresponding HFI types (e.g., male with type A versus female with type A) differed only in HFI type C regarding the fractal dimension of diploe. The degree of anisotropy differed between HFI subtypes in males, but the post hoc analysis revealed no significant differences between individual groups. Other microarchitectural parameters did not differ among males with different HFI subtypes, as well in females, in any part of the frontal bone. There is no difference in microarchitectural structure of the frontal bone between males and females with HFI, in general aspect and within corresponding HFI subtypes. HFI severity could not be distinguished at the microarchitectural level, neither in males nor in females.

Hyperostosis frontalis interna in ancient populations from the Carpathian Basin - A possible relationship between lifestyle and risk of development

OBJECTIVE

The prevalence of hyperostosis frontalis interna (HFI) was examined in different periods of the Carpathian Basin from 4900 BCE to 17th century AD. The study seeks to evaluate temporal changes in HFI and the possible impact of lifestyle on it.

MATERIALS

The studied material consisted of 4668 crania from Hungary and Serbia.

METHODS

The crania were analyzed employing macroscopic and endoscopic examination.

RESULTS

In historic periods, sex and age played a pivotal role in HFI development. Among predominantly pastoralist populations of the 5th-8th and 10th centuries, prevalence of HFI was considerably higher than in the medieval populations of the 9th-17th centuries.

CONCLUSIONS

In addition to age and sex, other factors could be implicated in HFI development. The physiological effects of the pastoralist lifestyle and diet on insulin regulation could explain the increased risk of developing HFI in the 5th-8th and 10th-century populations.

SIGNIFICANCE

The study provides the first comprehensive dataset of HFI from different archaeological periods from the Carpathian Basin. It has implications for lifestyle and risk of HFI development in past populations.

LIMITATIONS

The archaeological periods are not equally represented.

SUGGESTIONS FOR FURTHER RESEARCH

In order to better understand the etiology of HFI, lifestyle factors can be used to elucidate the risk of developing HFI in ancient populations.

Hyperostosis frontalis interna as an age-related phenomenon - Differences between males and females and possible use in identification

Hyperostosis frontalis interna (HFI) is a condition manifested by thickening of the inner surface of the frontal bone and it could be useful when dealing with the identification of human remains in various anthropological and forensic investigations. We compared the macroscopic appearance and morphologic (metric) features of the skulls in cases with and without HFI, in both sexes, and wanted to establish whether age determined occurrence of HFI. To achieve this aim, we performed prospective autopsy study, covering ten-year period (2007-2016). Study group consisted of southeast Europe Caucasian subjects, with determined age and sex. The severity of HFI was classified by two forensic pathologists independently, according to the four types (A-D) proposed by Hershkovitz et al. Thicknesses of the frontal and temporal bones, as well as the longitudinal and frontal diameters of the skulls were measured. The sample consisted of 35 males and 112 females with HFI, and 55 males and 202 females without HFI (404 individuals in total). Type B was the most common type of HFI among males (45%) and type C among females (41%). HFI type D was almost four times more common in females than in males (OR = 3.73). Frontal and temporal bones were thicker in all subjects who have HFI. Thickness of the skull was not age-dependent, in the entire sample, or in subjects with HFI, or in the control group (in all the cases Spearman's Rho was <0.3). Age seemed to be a predicting factor for HFI occurrence only in females. Females younger than 55 years have similar risk for HFI occurrence as males. An unidentified skull with the general markers of old age and severe form HFI is most probably from a female decedent.

Hyperostosis frontalis interna in female historic skeletal populations: Age, sex hormones and the impact of industrialization

OBJECTIVES

This analysis aims to investigate the impact of industrialization on the prevalence of Hyperostosis Frontalis Interna (HFI), focusing on the roles of age and parity to examine the claim that longevity and changing reproductive patterns have led to increased rates in modern populations.

MATERIALS AND METHODS

A total of 138 individuals from two documented London skeletal assemblages of the Industrial period were analyzed employing macroscopic observation, digital radiography and MicroCT scanning to establish the prevalence rates of HFI according to modern clinical standards. Statistical analysis was also undertaken on a sub-sample of 51 females of post-menopausal age to identify any relationship between parity and HFI.

RESULTS

The majority of cases of HFI were found in older females, reflecting clinical observations. The prevalence rates of HFI corresponded well to those predicted from the proportion of old age females present within populations. Age was therefore shown to be a predominant factor in HFI presence. A plateau in HFI prevalence was noted from the age of 50-59 years onwards. No statistically significant relationship was found between parity and HFI.

DISCUSSION

When recorded consistently, HFI was positively correlated with age and longevity but had also increased among old age females over time. Our results suggest that nulliparity co-occurs with HFI but is not a primary factor in its pathogenesis. Key factors in HFI presence in females are likely to be increased androgens and the dysregulation of insulin and insulin-like growth factor-1.

Wall paintings facies and their possible genetic correlates in the ancient Pompeii: A bio-anthropologic message from the past?

The figurative arts and precisely the ancient Pompeian wall paintings portraits can provide an additional source of information in supplementing bio-anthropological studies. There are several genetic diseases with a wide spectrum of congenital bone stigmata in association to distinctive facial features. Gorlin-Goltz syndrome, also named nevoid basal cell carcinoma syndrome, is an autosomal dominant syndrome characterized by unusual skeletal changes, such as macrocephaly, facial asymmetry, hypertelorism, frontal and parietal bossing caused by germline mutations of the gene PTCH1. The Gorlin syndrome, clinically defined in 1963, existed during Dynastic Egyptian times, as revealed by a spectrum of skeletal findings compatible with the syndrome in mummies dating back to three thousand years ago and, most likely, in the ancient population of Pompeii. In the present research, we discuss the potential relationship between Pompeian wall paintings portrait and the cranio-metric bone changes revealed among the Pompeian skull collections assuming that the ancient portraits can constitute an important tool that should be strictly integrated with osteologic and biomolecular data in order to argue a syndromic diagnosis in ancient population.

What do cranial bones of LB1 tell us about Homo floresiensis?

Cranial vault thickness (CVT) of Liang Bua 1, the specimen that is proposed to be the holotype of Homo floresiensis, has not yet been described in detail and compared with samples of fossil hominins, anatomically modern humans or microcephalic skulls. In addition, a complete description from a forensic and pathological point of view has not yet been carried out. It is important to evaluate scientifically if features related to CVT bring new information concerning the possible pathological status of LB1, and if it helps to recognize affinities with any hominin species and particularly if the specimen could belong to the species Homo sapiens. Medical examination of the skull based on a micro-CT examination clearly brings to light the presence of a sincipital T (a non-metrical variant of normal anatomy), a scar from an old frontal trauma without any evident functional consequence, and a severe bilateral hyperostosis frontalis interna that may have modified the anterior morphology of the endocranium of LB1. We also show that LB1 displays characteristics, related to the distribution of bone thickness and arrangements of cranial structures, that are plesiomorphic traits for hominins, at least for Homo erectus s.l. relative to Homo neanderthalensis and H. sapiens. All the microcephalic skulls analyzed here share the derived condition of anatomically modern H. sapiens. Cranial vault thickness does not help to clarify the definition of the species H. floresiensis but it also does not support an attribution of LB1 to H. sapiens. We conclude that there is no support for the attribution of LB1 to H. sapiens as there is no evidence of systemic pathology and because it does not have any of the apomorphic traits of our species.

Estimated maximal and current brain volume predict cognitive ability in old age

Brain tissue deterioration is a significant contributor to lower cognitive ability in later life; however, few studies have appropriate data to establish how much influence prior brain volume and prior cognitive performance have on this association. We investigated the associations between structural brain imaging biomarkers, including an estimate of maximal brain volume, and detailed measures of cognitive ability at age 73 years in a large (N = 620), generally healthy, community-dwelling population. Cognitive ability data were available from age 11 years. We found positive associations (r) between general cognitive ability and estimated brain volume in youth (male, 0.28; females, 0.12), and in measured brain volume in later life (males, 0.27; females, 0.26). Our findings show that cognitive ability in youth is a strong predictor of estimated prior and measured current brain volume in old age but that these effects were the same for both white and gray matter. As 1 of the largest studies of associations between brain volume and cognitive ability with normal aging, this work contributes to the wider understanding of how some early-life factors influence cognitive aging.

Influence of thickening of the inner skull table on intracranial volume measurement in older people

Introduction

It is generally assumed that intracranial volume (ICV) remains constant after peaking in early adulthood. Thus ICV is used as a ‘proxy’ for original brain size when trying to estimate brain atrophy in older people in neuroimaging studies. However, physiological changes in the skull, such as thickening of the frontal inner table, are relatively common in older age and will reduce ICV. The potential influence that inner table skull thickening may have on ICV measurement in old age has yet to be investigated.

Methods

We selected 60 (31 males, 29 females) representative older adults aged 71.1–74.3 years from a community-dwelling ageing cohort, the Lothian Birth Cohort 1936. A semi-automatically derived current ICV measurement obtained from high resolution T1-weighted volume scans was compared to the estimated original ICV by excluding inner skull table thickening using expert manual image processing.

Results

Inner table skull thickening reduced ICV from an estimated original 1480.0 ml to a current 1409.1 ml, a median decrease of 7.3% (Z = − 6.334; p < 0.001), and this reduction was more prominent in women than men (median decrease 114.6 vs. 101.9 ml respectively). This led to potential significant underestimations of brain atrophy in this sample by 5.3% (p < 0.001) and obscured potential gender differences.

Conclusions

The effects of skull thickening are important to consider when conducting research in ageing, as they can obscure gender differences and result in underestimation of brain atrophy. Research into reliable methods of determining the estimated original ICV is required for research into brain ageing.

Hyperostosis frontalis interna (HFI) and castration: the case of the famous singer Farinelli (1705-1782)

The famous castrato singer Farinelli (1705-1782) was exhumed by our research group in July 2006 for the purpose of gaining some insight into his biological profile through a study of his skeletal remains. Farinelli was castrated before puberty to preserve the treble pitch of the boy's voice into adult life. His powerful and sweet voice became legendary. In spite of its bad preservation state, the skeleton displayed some interesting characteristics that are probably related to the effects of castration, including long limb-bones, persistence of epiphyseal lines and osteoporosis. In particular, the frontal bone was affected by severe hyperostosis frontalis interna (HFI). This condition consists in a symmetrical thickening of the inner table of the bone. The epidemiology of HFI shows that it is relatively common in postmenopausal women but very rare in men. Men affected by this pathology suffer from diseases, syndromes or treatments causing androgen deficiency. In the case of Farinelli, castration was probably responsible for the onset and development of this lesion.

Identifying and classifying hyperostosis frontalis interna via computerized tomography

The aim of this study was to recognize the radiological characteristics of hyperostosis frontalis interna (HFI) and to establish a valid and reliable method for its identification and classification. A reliability test was carried out on 27 individuals who had undergone a head computerized tomography (CT) scan. Intra-observer reliability was obtained by examining the images three times, by the same researcher, with a 2-week interval between each sample ranking. The inter-observer test was performed by three independent researchers. A validity test was carried out using two methods for identifying and classifying HFI: 46 cadaver skullcaps were ranked twice via computerized tomography scans and then by direct observation. Reliability and validity were calculated using Kappa test (SPSS 15.0). Reliability tests of ranking HFI via CT scans demonstrated good results (K > 0.7). As for validity, a very good consensus was obtained between the CT and direct observation, when moderate and advanced types of HFI were present (K = 0.82). The suggested classification method for HFI, using CT, demonstrated a sensitivity of 84%, specificity of 90.5%, and positive predictive value of 91.3%. In conclusion, volume rendering is a reliable and valid tool for identifying HFI. The suggested three-scale classification is most suitable for radiological diagnosis of the phenomena. Considering the increasing awareness of HFI as an early indicator of a developing malady, this study may assist radiologists in identifying and classifying the phenomena.

Hyperostosis frontalis interna: what does it tell us about our health?

OBJECTIVES

To examine whether the prevalence and severity of hyperostosis frontalis interna (HFI) has significantly changed during the past 100 years.

METHODS

Two female populations, 100 years apart, were studied; 992 historic and 568 present day females. Detection of HFI was carried out via direct observation or CT images (Brilliance 64, Philips Medical Systems, Cleveland, Ohio). HFI was graded according to Hershkovitz et al.’s (1999) 4-scale definition and according May et al.’s (2010c) 3-scale definition.

RESULTS

Following correction for age, present day females manifested a significantly higher HFI prevalence compared with historic females (P < 0.05). The risk of developing HFI was found to be approximately 2.5 times greater in present day females compared with females living 100 years ago (P < 0.05). In the young age cohort, present day females manifested a significantly higher prevalence of HFI type B (P < 0.05), whereas in the old age cohort, a significant difference in the prevalence of HFI types C and D was noted between the two groups (P < 0.05). HFI tended to appear at a younger age in the present population. The last two decades has witnessed an increase in HFI prevalence(from 55.6% to 75%).

CONCLUSIONS

HFI prevalence has increased during the last century, especially among young individuals, possibly indicating a profound change in human fertility patterns, together with the introduction of various hormonal treatments) and new dietary habits.