Multiple skeletal fibroxanthomas: radiologic-pathologic correlation of 72 cases

Jaffe-Campanacci syndrome; a case series and review of the literature

BACKGROUND

Jaffe-Campanacci syndrome is a rare syndrome, characterized by multiple non-ossifying fibromas (NOF) and cafe-au-lait patches. The name was coined in 1982 by Mirra after Jaffe who first described the case in 1958. Although it's suggested there is a relation with Neurofibromatosis type 1, there is still no consensus on whether Jaffe-Campanacci syndrome is a subtype or variant of neurofibromatosis-1(NF-1).

CASE PRESENTATION

In this article, we present a case series of 2 patients. The first case is a 13-year-old male with Jaffe-Campanacci syndrome who presented with a distal femur fracture. His father had positive features of both Jaffe-Campanacci syndrome and NF-1, while his sister only had features of NF-1, so we presented both.

CONCLUSION

Jaffe-Campanacci has a clear relationship with type 1 neurofibromatosis, which still has to be genetically established. Due to the presence of several large non-ossifying fibromas of the long bones, it is linked to a significant risk of pathological fractures. We concur with previous authors, that an osseous screening program should be performed for all patients with newly diagnosed type 1 neurofibromatosis, to identify non-ossifying fibromas and assess the potential for pathological fracture. Moreover, siblings of patients with NF-1 should be screened for multiple NOFs that may carry a high risk of pathological fractures.

Benign fibrohistiocytic jaw lesions: a 48-year clinicopathologic analysis and review of the literature

OBJECTIVE

Intra-osseous fibrohistiocytic lesions have long been reported in the literature; evidence suggests they represent a heterogeneous group of reactive and neoplastic processes. This study evaluated a series of gnathic fibrohistiocytic lesions to identify and categorize their clinical, radiographic and morphologic spectrum.

STUDY DESIGN

A retrospective case search over 48 years was conducted for maxillary and mandibular intra-bony fibrohistiocytic lesions. Diagnoses were confirmed and demographic, radiographic, clinical and follow-up data was analyzed.

RESULTS

Fifty cases met the inclusion criteria. Most cases (80%) were found in the second through fourth decades (mean, 29 years). The most common location (86%) was the posterior mandible. Radiographic presentations varied, but a few patterns emerged, including a distinctive mottled, honeycomb type with punctate lucencies. All cases demonstrated fibrous components admixed with variable histiocytes. Eight cases (16%) were histiocyte-rich with dominant sheets of xanthoma cells. Immunohistochemical staining revealed strong CD68 and CD163 expression, along with variable smooth muscle actin staining. The vast majority (92%) of cases were treated conservatively. Available follow-up showed lesional stability in 17 cases (average, 85 months) with 2 recurrences (24 months each) and no evidence of malignant transformation.

CONCLUSIONS

This study is the largest to date of fibrohistiocytic gnathic lesions, revealing distinctive radiographic and histologic findings and characteristic clinical and immunophenotypic features. Available evidence suggests that most of these are indolent, slow-growing lesions amenable to conservative therapy.

Update of pediatric bone tumors: osteogenic tumors and osteoclastic giant cell-rich tumors

There are numerous bone tumors in the pediatric population, with imaging playing an essential role in diagnosis and management. Our understanding of certain bone tumors has rapidly evolved over the past decade with advancements in next-generation genetic sequencing techniques. This increased level of understanding has altered the nomenclature, management approach, and prognosis of certain lesions. We provide a detailed update of bone tumors that occur in the pediatric population with emphasis on the recently released nomenclature provided in the 5^th edition of the World Health Organization Classification of Soft Tissue and Bone Tumours.

Comparison of characteristic features and local recurrence in syndromic versus non-syndromic multifocal non-ossifying fibroma

BACKGROUND

Multiple non-ossifying fibromas (MNOF) could be presented with other extraskeletal anomalies (syndromic) or not (non-syndromic). In this study, we aimed to compare characteristic features and local recurrence between symptomatic syndromic and non-syndromic MNOFs.

METHODS

Thirty-five patients with symptomatic MNOF were included in this study, comprised of 30 patients without the café-au-lait spot (non-syndromic) and five with café-au-lait spots plus other signs of neurofibromatosis type 1 (syndromic). Characteristic features of the patients and lesions were compared between syndromic and non-syndromic MNOFs. The lesions were treated with curettage and bone graft. The rate of local recurrences was also compared between the two groups of syndromic and non-syndromic MNOF.

RESULTS

Study population included 19 (54.3%) males and 16 (45.7%) females with the mean age of 7.63 ± 3.1 years (range 4-11). The mean follow-up of the patients was 65.6 ± 38.2 months (range 24-96). The lesion was bilateral in 13.3% of non-syndromic MNOFs and 80% of syndromic MNOFs. This difference was statistically significant (p = 0.01). After curettage and bone grafting, the lesion recurred in 6.7%of non-syndromic MNOFs and 60% of the syndromic MNOF. This difference was statistically significant, as well (p = 0.01). No other significant difference was found between syndromic and non-syndromic MNOFs.

CONCLUSIONS

The syndromic form of MNOF is much less prevalent and is associated with a higher rate of recurrence after surgical removal. Therefore, a more rigorous removal of the MNOF lesions might be necessary when presented in a syndromic context.

Jaffe-Campanacci syndrome or neurofibromatosis type 1: a case report of phenotypic overlap with detection of NF1 gene mutation in non-ossifying fibroma

Background

Jaffe-Campanacci syndrome is characterized by multiple non-ossifying fibromas, café-au-lait macules and giant cell granulomas of the jaw. Even if the association between all these peculiar features and neurofibromatosis type 1 have been described, it has not yet been clarified whether Jaffe-Campanacci syndrome represents a distinct entity or it can be regarded as a neurofibromatosis type 1 subtype.

Case presentation

The patient here described is a young boy, who fulfilled the clinical diagnostic criteria for both syndromes. He had a complex clinical history with café-au-lait macules, axillary and inguinal freckling, multiple non-ossifying fibromas, giant-cell granuloma of the jaw, neurofibromas, plexiform fibroma, ocular Lisch nodules, optic chiasmatic- hypothalamic glioma, pseudarthrosis, scoliosis, short stature, vascular anomalies, seizures. Molecular analysis of the NF1 gene both on blood cells and non-ossifying fibroma’s biopsy tissue allowed the detection of a novel variant within the coding region, NM_000267.3:c.2789_2791delATC(p.Tyr930_Pro931delinsSer), with loss of heterozygosity (second hit mutation) in the non-ossifying fibroma.

Conclusion

This result indicates that every patient with clinical features of Jaffe-Campanacci syndrome should be further evaluated to detect features related to neurofibromatosis type 1 and genetically investigated for mutations in the NF1 gene, since this could lead to a definite diagnosis, but also could clarify and quantify the real genotype-phenotype overlap between neurofibromatosis type 1 and Jaffe-Campanacci syndrome.

A unique case of multiple non-ossifying fibromas with polyostotic monomelic distribution and aggressive clinical course

Multiple non-ossifying fibromas (MNOFs) occur either isolated or in association with other anomalies, are usually localized in the long bones of the lower limbs, may be radiographically confused with other skeletal lesions, and tend to heal spontaneously with the completion of the skeletal growth. Segmental distribution, either monomelic or polymelic and ipsilateral, is rare and commonly observed in the context of developmental diseases known as "RASopathies", which are caused by mutations in genes that encode components or regulators within the Ras/mitogen-activated protein kinase signaling pathway. We describe here the radiographic and pathologic features of an 18-year-old Caucasian boy, whose clinical history started at the age of 3 when the diagnosis of aneurysmal bone cyst was made on a lytic lesion of his left clavicle. Over the following 2 years, the patient developed polyostotic and monomelic lesions within the left humerus, radius, and ulna. No other skeletal and extra-skeletal anomalies were clinically detected. The lesions were interpreted as consistent with polyostotic fibrous dysplasia and MNOFs and showed an unusually aggressive clinical course with progressive increase in size and coalescence. The definitive diagnosis of MNOFs was made after the exclusion of fibrous dysplasia by molecular analysis. The polyostotic and monomelic distribution of the lesions and the unusually aggressive clinical course contribute to make this case of MNOFs unique.

Multiple non-ossifying fibromas as a cause of pathological femoral fracture in Jaffe-Campanacci syndrome

Background

Jaffe-Campanacci is a rare syndrome characterised by the association of café-au-lait spots, axillary freckles, multiple non-ossifying fibromas of the long bones and jaw, as well as some features of type 1 neurofibromatosis. There are less than 30 reported cases, and a genetic profile has not yet been determined. Furthermore, it has not been clarified whether it is a subtype of type 1 neurofibromatosis or a separate syndrome. The risk of pathological fracture is over 50%, due to substantial cortical thinning of the weight-bearing bones.

Case presentation

A 17-year-old female patient, known for type 1 neurofibromatosis, presented with a low-energy distal femoral fracture due to disseminated large non-ossifying fibromas. Investigations revealed all of the distinctive signs of Jaffe-Campanacci syndrome. Both her distal femurs and proximal tibias exhibited multiple non-ossifying fibromas. The fracture was treated by open reduction and internal plate fixation. Some of the bony lesions were biopsied to confirm the diagnosis. The fracture healed eventless, as did the lesions biopsied or involved in the fracture. The other ones healed after curettage and bone grafting performed at the time of plate removal.

Conclusion

Jaffe-Campanacci is a rare syndrome having unclear interactions with type 1 neurofibromatosis, which still needs to be characterised genetically. It is associated with a high risk of pathological fracture, due to the presence of multiple large non-ossifying fibromas of the long bones, with an expected normal healing time. Curettage and bone grafting promote healing of the lesions and should be considered to prevent pathological fracture. We agree with other authors that all patients with newly-diagnosed type 1 neurofibromatosis should undergo an osseous screening to detect disseminated non-ossifying fibromas, and evaluate the inherent risk of pathological fracture.

Jaffe-Campanacci syndrome, revisited: detailed clinical and molecular analyses determine whether patients have neurofibromatosis type 1, coincidental manifestations, or a distinct disorder

PURPOSE

"Jaffe-Campanacci syndrome" describes the complex of multiple nonossifying fibromas of the long bones, mandibular giant cell lesions, and café-au-lait macules in individuals without neurofibromas. We sought to determine whether Jaffe-Campanacci syndrome is a distinct genetic entity or a variant of neurofibromatosis type 1.

METHODS

We performed germline NF1, SPRED1, and GNAS1 (exon 8) mutation testing on patients with Jaffe-Campanacci syndrome or Jaffe-Campanacci syndrome-related features. We also performed somatic NF1 mutation testing on nonossifying fibromas and giant cell lesions.

RESULTS

Pathogenic germline NF1 mutations were identified in 13 of 14 patients with multiple café-au-lait macules and multiple nonossifying fibromas or giant cell lesions ("classical" Jaffe-Campanacci syndrome); all 13 also fulfilled the National Institutes of Health diagnostic criteria for neurofibromatosis type 1. Somatic NF1 mutations were detected in two giant cell lesions but not in two nonossifying fibromas. No SPRED1 or GNAS1 (exon 8) mutations were detected in the seven NF1-negative patients with Jaffe-Campanacci syndrome, nonossifying fibromas, or giant cell lesions.

CONCLUSION

In this study, the majority of patients with café-au-lait macules and nonossifying fibromas or giant cell lesions harbored a pathogenic germline NF1 mutation, suggesting that many Jaffe-Campanacci syndrome cases may actually have neurofibromatosis type 1. We provide the first proof of specific somatic second-hit mutations affecting NF1 in two giant cell lesions from two unrelated patients, establishing these as neurofibromatosis type 1-associated tumors.

Pathological fractures on both lower limbs with Jaffe-Campanacci's syndrome

Jaffe-Campanacci's syndrome is a very rare condition and was first described by Jaffe in 1958. It is presented by non-ossifying fibromas, café-au-lait spots and axillar freckling. Non-ossifying fibromas are usually found after minor traumas or stress fractures. Differential diagnosis to neurofibromatosis include the absence of Lisch granules, neurofibromatous skin lesions and schwannomatous soft tissue masses. In this case, we report a 13-year-old white boy with Jaffe-Campanacci's syndrome, and bilateral pathological lower limbs fracture.

Non-ossifying fibroma, fibrous cortical defect and Jaffe-Campanacci syndrome: a biologic and clinical review

Non-ossifying fibroma of bone (NOF) is a common entity, more frequently found in male children and consisting of a solitary eccentric, lytic expanded lesion in the metaphysis of a long bone. The disorder is benign and most often asymptomatic but may result in a fracture requiring therapy. Of some importance is to distinguish NOF from another very similar but smaller lesion, fibrous cortical defect, which is almost always asymptomatic and eccentrically located. Even more striking is a very rarely encountered lesion known as Jaffe-Campanacci syndrome, which also occurs in children who present with typical non-ossifying fibromatous tumors but in multiple sites. In addition, these patients have some systemic and dermal findings resembling those seen in patients with Type 1 neurofibromatosis.

Metaphyseal fibrous defects

Nonossifying fibromas and fibrous cortical defects are the most common benign lesions of the skeletal system. They are frequently detected incidentally on radiographs taken for an unrelated reason. The diagnosis is routinely made solely on the basis of the history, physical examination, and radiographic appearance. The incidence of multifocal nonossifying fibroma is typically underestimated in patients initially found to have a solitary lesion; the use of a limited skeletal survey rather than bone scan may help detect multifocal lesions in this population. Small, asymptomatic lesions may be followed over time using serial radiographs. Incisional biopsy, curettage, and bone grafting are indicated for large lesions that raise concern for impending pathologic fracture, for lesions that have become painful, and for lesions whose characteristics prevent a definitive radiographic diagnosis. Pathologic fractures involving these lesions should be treated with cast immobilization until the fracture has healed, followed by biopsy, curettage, and bone grafting.

Is Jaffe-Campanacci syndrome just a manifestation of neurofibromatosis type 1?

This article describes four patients with non-ossifying fibromas (NOFs) and multiple café-au-lait spots. Two of the patients were diagnosed with NOFs when they presented with a femur fracture. The other two patients were diagnosed with NOFs because of complaints of leg problems. In addition, axillary freckles and Lisch nodules were present in all four patients and multiple cutaneous neurofibromas in two patients. These four patients fulfilled the diagnostic criteria for neurofibromatosis type 1 (NF1) and also have been diagnosed with Jaffe-Campanacci syndrome. We propose that Jaffe-Campanacci syndrome is a manifestation of NF1 and suggest that patients with NF1 should have more rigorous radiographic screening of the long bones during early adolescence or adulthood to determine the presence or absence of NOFs. Appropriate intervention (exercise restriction, bracing, and/or surgery) might decrease the long-term disability associated with Jaffe-Campanacci syndrome.

Multiple lower limb non-ossifying fibromas in siblings with neurofibromatosis

Non-ossifying fibromas are common benign lesions of tubular long bones. There is recognized association of these bony lesions with neurofibromatosis type 1 although the presence of non-ossifying fibromas in familial members with the condition has not previously been reported. We report two siblings with neurofibromatosis and radiological evidence of multiple lower limb non-ossifying fibromas. Both patients presented with pain in the knees and a pathological fracture was observed in one case. Patients with multiple non-ossifying fibromas should be examined carefully for other evidence of neurofibromatosis.

Multiple, symmetrical non-ossifying fibromata without extraskeletal anomalies: report of two related cases

Two patients, mother and daughter, with multiple, symmetrical, non-ossifying fibromata without extraosseous anomalies are reported. We believe that this is a separate syndrome different from multiple non-ossifying fibromata with extraskeletal anomalies (Jaffe-Campanacci syndrome).