Paget's disease of the skull with osteosarcoma and neurological symptoms associated

Imaging of the calvarium

The skull vault consists of a multitude of flat bones held together by the cranial sutures. Radiologists encounter a vast array of calvarial pathologies that tend to cause abnormalities in thickness, abnormalities in density, focal defects, or an excess of soft tissue or bone tissue. Further anomalies related to the cranial sutures and fontanelles occur in the dynamic pediatric skull. The imaging features of the host of conditions resulting in these commonly detected calvarial abnormalities are reviewed and illustrated.

Neurologic complications of Paget disease of bone

OBJECTIVE

To review the epidemiology, evaluation, and management of the neurologic complications associated with Paget disease of bone (PDB).

METHODS

We reviewed the English-language medical literature using MEDLINE data sources from 1950 to August 2008 and manually searched cross-references from original articles and reviews. Search terms included "Paget* disease of bone" and "neurologic* complications," "cranial nerve," "spinal cord," or "peripheral nerve."

RESULTS

Several neurologic problems in the central and peripheral nervous systems may complicate PDB. Up to 76% of patients may have some form of neurologic involvement. Neurologic complications can occur in patients with a long history of PDB as well as in patients with previously unrecognized disease. The primary mechanisms of nerve damage in PDB involving the spine are ischemic myelitis and compression due to bone hypertrophy. Evaluation includes determining the serum alkaline phosphatase level and imaging by radiography, bone scintigraphy, computed tomographic scanning, and, for lesions of the central nervous system, magnetic resonance imaging. If a soft-tissue mass is found, biopsy should be considered to exclude the presence of sarcoma. Treatment strategies include calcium, vitamin D, bisphosphonates, and possibly surgical intervention for refractory cases.

CONCLUSION

Neurologic sequelae of PDB may be underappreciated. Despite the paucity of data guiding treatment, zoledronic acid is a reasonable first-line therapy. Lack of response to treatment or relapse should prompt diagnostic reevaluation with a heightened suspicion for tumor.

Benign fibro-osseous lesions of the craniofacial complex. A review

Benign fibro-osseous lesions of the craniofacial complex are represented by a variety of disease processes that are characterized by pathologic ossifications and calcifications in association with a hypercellular fibroblastic marrow element. The current classification includes neoplasms, developmental dysplastic lesions and inflammatory/reactive processes. The definitive diagnosis can rarely be rendered on the basis of histopathologic features alone; rather, procurement of a final diagnosis is usually dependent upon assessment of microscopic, clinical and imaging features together. Fibrous dysplasia and osteitis deformans constitute two dysplastic lesions in which mutations have been uncovered. Other dysplastic bone diseases of the craniofacial complex include florid osseous dysplasia, focal cemento-osseous dysplasia and periapical cemental dysplasia, all showing a predilection for African descent individuals; although no specific genetic alterations in DNA coding have yet to be uncovered and most studies have been derived from predominant high African descent populations. Ossifying fibromas are neoplastic lesions with four subtypes varying with regard to behavior and propensity for recurrence after surgical excision. The clinicopathologic and molecular features of this unique yet heterogeneous group of diseases are reviewed.

Polyostotic Paget's Disease with Sarcomatous Change in a Skull Lesion. A Case Report of Imaging Findings

The most serious complication of Paget's disease is sarcomatous degeneration of pagetic bone. Multifocal sarcomatous degeneration occurs mainly in polyostotic Paget's disease. Paget sarcomas are the most threatening sarcomas of bone irrespective of the histopathology, their prognosis being far more negative than primary sarcomas. Paget's disease is a common entity but osteosarcoma arising in Paget's disease is an infrequent complication. The skull involvement is even rarer. We report a case of malignant transformation of a skull lesion in a patient of polyostotic Paget's disease. Skull radiographs, computed tomography and magnetic resonance imaging scans of the tumour area show interesting results.

Osteogenic Sarcomatous Degeneration of the Temporal Bone Squama in Paget's Disease

Paget's bone disease is a common disorder affecting approximately 3–4% of the population over 40 and up to 10–11% of the population older than 80 years. It is characterized by excessive and abnormal bone remodelling. The disease predominates in bones containing red marrow, with a clinical course characterized by active and quiescent periods; pelvis, sacrum, spine and skull are the most affected parts. We report the case of a 79-year-old woman with polyostotic Paget's disease who had a focal sarcomatous degeneration diagnosed by CT and MR.

From the archives of the AFIP. Radiologic spectrum of Paget disease of bone and its complications with pathologic correlation

Paget disease of bone is a common disorder affecting approximately 3%-4% of the population over 40 years of age. The pathologic abnormality in Paget disease is excessive and abnormal remodeling of bone. Three pathologic phases have been described: the lytic phase (incipient-active), in which osteoclasts predominate; the mixed phase (active), in which osteoblasts cause repair superimposed on the resorption; and the blastic phase (late-inactive) in which osteoblasts predominate. Radiographic appearance of Paget disease reflects these pathologic changes and is often characteristic. Initially, there is osteolysis, particularly affecting the skull (osteoporosis circumscripta) and subchondral long bones, with subsequent development of trabecular and cortical thickening and enlargement of bone in the mixed phase of the disease. Finally, areas of sclerosis may develop in the blastic phase. Frequent sites of involvement include the skull (25%-65% of cases), spine (30%-75%), pelvis (30%-75%), and proximal long bones (25%-30%). Bone scintigraphy typically demonstrates marked increased uptake of radionuclide in all phases of Paget disease. Computed tomography and magnetic resonance imaging often show changes similar to those seen radiographically in noncomplicated Paget disease with maintenance of yellow marrow. Complications of Paget disease include the effects of osseous weakening (deformity and fracture), arthritis, neurologic symptoms, and neoplastic involvement. Sarcomatous transformation is the most feared complication, occurring in approximately 1% of cases, and is seen on images as focal bone destruction extending through the cortex with an associated soft-tissue mass. Recognition of the radiologic spectrum of the appearances of Paget disease usually allows prospective diagnosis and differentiation of its associated complications, which helps guide therapy and improve patient management.