Case report 698: Osteoma of the clavicle

Anatomical study of a human skull with multiple osteomas in a seventeenth-century Dutch still-life painting: bone morphology and artistic intention

Skulls were frequently depicted in seventeenth-century Dutch still-life paintings. Skulls were interpreted as symbols of vanitas-meaning the evanescence of life-but their morphological features have received little attention. This study analyzed a skull with abnormal tumors in a seventeenth-century Dutch still-life painting by a renowned artist, Edwaert Collier (ca. 1642-1708), from anatomical, forensic, and pathological perspectives. The morphology of the cranium and teeth indicated that the skull likely belonged to a middle-aged female. We carefully diagnosed the abnormal masses as multiple osteomas on the skull and left femur, based on clinical studies and paleopathological literature, which reported lesions with a similar appearance to those observed in Collier's work. Furthermore, detailed observations of the cranial sutures and epiphyses of the long bones in his paintings revealed that the artist may have selected bones with a morphology that was suitable for the subject of vanitas. Collier repeatedly depicted the skull with metopism, the rare condition of having a persistent metopic suture in adulthood. A skull with a metopic suture is called Kreuzschädel, meaning the cross skull, because it forms a cruciform by connecting with the sagittal and coronal sutures. The artist might have chosen skulls with metopic sutures, which is reminiscent of the crucifixion of Christ, as an appropriate motif for the vanitas painting. This paper argues that anatomical analysis could explain the hidden meaning of the painting and disclose the fascinating collaborations between anatomy and art in the seventeenth-century Dutch Republic.

Costal Osteoma: Report of a Case in an Unusual Site

BACKGROUND Osteoma is a benign bone tumor that typically arises in facial bones and less frequently in the long bones. It rarely occurs in the appendiceal skeleton. Pathologic findings are similar to those for parosteal osteosarcoma, periostitis ossificans, and osteoid osteoma. Diagnosing osteoma at an unusual site is always problematic. Here, we present a case of costal osteoma that was found incidentally on screening and produced mild symptoms in the patient. CASE REPORT A 53-year-old man was examined because of a rib mass in the eighth rib on his left side, which had been present for 2 years. A computed tomography scan revealed that the intensely dense mass arose from the external surface of the eighth rib. Microscopic examination showed that the lesion consisted of mature lamellar bone with several Haversian systems, typical of an osteoma. No atypical spindle cells or necrosis were identified. The diagnosis was osteoma. CONCLUSIONS Because the anatomy of the ribs poses a challenge when performing needle biopsy, diagnosing bony lesions solely based on that technique is difficult. The diagnosis of costal osteoma should be made carefully, based on clinical, radiological, and pathological findings. To the best of our knowledge, ours is the first case report about a costal osteoma. It is useful for chest surgeons, pathologists, and radiologists as an example of a rare presentation of this tumor.

Osteoma of long bone: an expanding spectrum of imaging findings

Osteoma of long bone is an extremely rare, benign bone-forming surface lesion with the largest published case series consisting of only 14 patients. The most important and often most difficult lesion to differentiate from osteoma of long bone radiographically is parosteal osteosarcoma, which is a rare, low-grade surface osteosarcoma with the potential for dedifferentiation. Reports of imaging studies of osteoma of long bone depict a well-defined ossified mass arising from the surface of the diaphysis or metadiaphysis of a long bone. A characteristic feature is the homogeneity of the mass, with uniform density near or equal to that of cortical bone from the base of the lesion to its periphery. The 45-year-old female in this case presented with left hip fullness and was subsequently found to have a proximal femoral osteoma, which was unique in that it contained large fatty marrow spaces that corresponded to bands of relatively low density on plain radiography and computed tomography, giving it a heterogeneous appearance atypical of osteoma of long bone. Furthermore, the osteoma reported here was associated with a small but separate nodular focus of ossification in the adjacent soft tissue. These findings led to a presumptive diagnosis of parosteal osteosarcoma with a local soft tissue metastasis or satellite nodule resulting in radical resection of the tumor. Definitive diagnosis of osteoma was made on histology of both the parent lesion and ossified nodule as no neoplastic spindle cell proliferation was present to establish a diagnosis of low-grade osteosarcoma. This represents, to the best of our knowledge, the first such presentation of osteoma of long bone.

Parosteal osteoma of the clavicle

Introduction. Osteoma is a benign, slowly growing, asymptomatic, osteogenic neoplasm. Osteoma of a bone other than the skull and facial bones is extremely rare. An extremely rare case of parosteal osteoma is reported. Case Presentation. A 51-year-old woman presented with a large mass in the left supraclavicular fossa. Radiographs and computed tomography revealed a well-defined, 9 × 6 cm, lobed mass in the midportion of the clavicle. Magnetic resonance imaging revealed that it had the same density as cortical bone. An open biopsy was performed to rule out malignant bone tumours, and parosteal osteoma was diagnosed. Four years after the biopsy, the patient was asymptomatic. Conclusion. A rare case of parosteal osteoma of the clavicle was described. Open biopsy is required to rule out a malignant bone tumour, even if parosteal osteoma is suspected based on the clinical course and imaging findings.

Clavicular osteoma associated with bronchial osteomas

Osteoma is a rare benign tumor, composed of bony tissues. It predominantly involves the skull but rarely the long bones. In this report we present a case of clavicular osteoma associated with bronchial osteomas. This association has not previously been reported. There was no evidence of Gardner's syndrome.

Osteoma of the long bones and the spine. A study of eleven patients and a review of the literature

The clinical features, radiographic and histopathological findings, treatment, and results are described for eleven patients who were managed for an extracranial osteoma at our medical center between 1980 and 1993. Ten of the patients were initially seen because of dull, aching bone pain that had been present for two weeks to thirty years. Radiographs demonstrated single or multiple homogeneous, well defined, radiodense foci with smooth round or lobulated margins. The histopathological features consistently included uniformly dense, compact, cortical-like, mature lamellar bone. The preoperative diagnosis was unclear for all patients, and osteoma was rarely considered in the differential diagnosis. For four patients, a tentative diagnosis of osteosarcoma was made, and a wide excision was carried out in two of these patients. Marginal excision with less than three millimeters of normal tissue around the lesion was performed in most patients. None of the osteomas recurred, and ten patients had relief of the pain. Awareness of the clinical, radiographic, and histopathological features of osteoma, as described, is valuable for making a differential diagnosis and for distinguishing osteomas from other lesions.

Osteoma of the innominate bone with intraosseous and parosteal involvement

A case has been presented of a 47-year-old woman with a dense bony mass both within and on the surface of her right public ramus. This was discovered incidentally on plain radiographs of the pelvis. Besides osteoma, a differential diagnosis of parosteal osteosarcoma, ossifying parosteal lipoma, periostitis ossificans, osteochondroma with attenuated cartilage cap, and melorheostosis was considered. Histological evaluation of open biopsy samples showed typical findings of an osteoma. This is an unusual case of an osteoma with both parosteal and intraosseous involvement.

Parosteal osteoma of bones other than of the skull and face

BACKGROUND

Osteoma of the skull and facial bones is not uncommon, is usually asymptomatic, and may be associated with Gardner's syndrome. Osteomas involving other bones are unusual.

METHODS

The authors describe 14 cases (eight men and six women from age 21-66 years) of parosteal osteoma of bones other than of the skull and face.

RESULTS

Thirteen lesions involved long bones, and one involved the clavicle. A long-standing (18 months to 31 years) mass was reported in seven patients. Symptoms of pain, a mass, or both were present in all except three patients who were asymptomatic. Lesions ranged from 2.5 to 20 cm in greatest dimension. Histologically, they blended with the cortex, did not infiltrate the medullary cavity, and consisted of dense sclerotic lamellar bone with haversian systems, similar to the architecture of normal cortical bone. There was no spindle cell proliferation. Nine patients underwent resection, four had biopsy, and one had debulking. With a follow-up of 1-23 years, no recurrence or metastasis was reported.

CONCLUSIONS

Parosteal osteoma must be distinguished from parosteal osteosarcoma, a low grade malignant neoplasm. If radiographs do not identify areas of radiolucency and sections do not contain spindle cells, the diagnosis of parosteal osteoma is justified.