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Xu GS, Du Z, Yang GX, You YH, Tian ZW, Wang YA. Clinical, imaging, and pathological characteristics of congenital infiltrating lipomatosis of the face. Int J Oral Maxillofac Surg 2024; 53:661-671. [PMID: 38395686 DOI: 10.1016/j.ijom.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
Congenital infiltrating lipomatosis of the face (CILF) is a rare congenital disease of the head and neck region. In this study, the cases of 20 patients diagnosed with CILF were reviewed retrospectively to analyse the characteristics of the disease. The symptoms, signs, and clinical progression were investigated. Radiological changes were analysed according to the distribution of the trigeminal nerve. The pathological features of the fatty facial lesions, jaw hyperplasia, and lingual lesions were further identified. All 20 patients demonstrated hemifacial hypertrophy at birth. None had a family history of the disease. Significant radiological features of CILF (prevalence ≥90%) included thickened buccal subcutaneous fat, palatal submucosal fat, and temporal subcutaneous fat, maxillary tuberosity heteroplasia, and fatty infiltration of the masseteric intermuscular space. With regard to the trigeminal nerve, the frontal branch region (CNV1) was rarely affected, while the maxillary (CNV2) and mandibular (CNV3) branch regions showed considerable changes. Pathologically, CILF was observed to be characterized by the infiltration of mature adipose tissue into the adjacent buccal soft tissue, osteal remodelling surrounded by sheets of mature lipocytes and supporting fibrovascular stroma, and lingual hamartoma. In summary, CILF exhibits distinct characteristics that are related to the regions controlled by the maxillary and mandibular branches of the trigeminal nerve, suggesting that CILF may be associated with early neural development.
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Affiliation(s)
- G S Xu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Z Du
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - G X Yang
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Y H You
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Z W Tian
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Y A Wang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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El Omri M, Mouna B, Safa J, Zeineb N, Monia G, Jihene H, Wassim K. Congenital Facial Infiltrating Lipomatosis: A Rare Cause of Facial Asymmetry in Infants. EAR, NOSE & THROAT JOURNAL 2024:1455613241241869. [PMID: 38561952 DOI: 10.1177/01455613241241869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Congenital facial infiltrating lipomatosis (CFIL) is a rare condition that typically affects the trunk and limbs, but can also occur in the face. Managing CFIL is a significant challenge due to its diffuse involvement in important facial structures. This case report aims to describe a rare form of lipomatosis and discuss the clinical and therapeutic aspects of this entity. The patient was a 5-year-old girl who was admitted to our department due to a right paralateronasal swelling that had been present for 5 months. During the physical examination, a swelling of the right nasolabial was observed. A computed tomography scan of the facial bone revealed an extra bony soft tissue mass near the vestibule of the right nostril in contact with the frontal process of the maxillary bone and the anterior wall of the right maxillary sinus. The patient underwent excision under general anesthesia. The histological report indicated congenital focal lipomatosis. There was no recurrence of swelling a year after initial surgery. Facial infiltrating lipomatosis is a rare congenital disorder in which mature lipocytes invade adjacent tissue. Due to its diffuse infiltration and involvement of important facial structures, complete surgical excision is often impossible. Specific management of this condition requires insight into its pathogenesis as surgical removal of the mass is usually unsuccessful.
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Affiliation(s)
- Malika El Omri
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
| | - Belakhdher Mouna
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
| | - Jemlii Safa
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
| | - Nfikha Zeineb
- Pathology Department, Farhat Hached University Hospital, Sousse, Tunisia
| | - Ghammem Monia
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
| | - Houas Jihene
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
| | - Kermani Wassim
- Department of Ear, Nose, Throat and Head and Neck Surgery, Farhat Hached University Hospital, Sousse, Tunisia
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Chen H, Sun B, Xia W, Qiu Y, Gao W, Hua C, Lin X. Clinical characteristics and surgical management of facial infiltrating lipomatosis: a single center experience. Head Face Med 2024; 20:13. [PMID: 38378686 PMCID: PMC10877823 DOI: 10.1186/s13005-024-00412-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/27/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Facial infiltrating lipomatosis (FIL) is a rare condition characterized by congenital facial enlargement. Beyond its impact on physical appearance, FIL can also impair essential facial functions such as swallowing, chewing, vision, and breathing, imposing a substantial physiological and psychological burden. Currently, fewer than 80 cases of FIL have been reported, and the characteristics and management strategies for FIL remain unclear. METHODS We reviewed the clinical, surgical, and radiological records of 39 FIL patients who were treated at our center. Of these, genetic testing was performed for 21 patients. RESULTS Aberrant overgrowth involves subcutaneous fat, bones, muscles, glands, tongue, lips, and teeth. Epidermal nevi could be observed in the dermatomes innervated by the three branches of the trigeminal nerve, with the highest frequency seen in the dermatome of the mandibular branch. Four patients exhibited concurrent hemimegalencephaly (HMEG), with one case presenting HMEG on the opposite side of the FIL. Nineteen patients were confirmed to harbor the PIK3CA mutation. Thirty-three patients underwent surgical procedures, with a post resection recurrence rate of approximately 25%. CONCLUSIONS A variety of maxillofacial structures may be involved in FIL. PIK3CA mutations are important pathogenic factors. Emerging targeted therapies could present an additional treatment avenue in the future. However, surgery currently remains the predominant treatment choice for FIL. The timing and modality of surgery should be individually customized, taking into account each patient's unique circumstances. Notably, there is a significant possibility of postoperative recurrence during childhood and adolescence, necessitating early strategic planning of disease management.
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Affiliation(s)
- Hongrui Chen
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China
| | - Bin Sun
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China
| | - Wenwen Xia
- Department of Pathology, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yajing Qiu
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China
| | - Wei Gao
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China
| | - Chen Hua
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China.
| | - Xiaoxi Lin
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Ninth People's Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, P.R. China.
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Cicero G, Arico FM, Mazziotti S. Congenital Infiltrating Lipomatosis of the Face: Multimodality Assessment through CT-Scan and Magnetic Resonance Imaging. Diagnostics (Basel) 2024; 14:176. [PMID: 38248053 PMCID: PMC10814968 DOI: 10.3390/diagnostics14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Congenital infiltrating lipomatosis of the face is a rare and benign condition involving a hamartomatous proliferation of mature adipose cells. The final diagnosis derives from a combination of clinical data, histology, and imaging features and affects the treatment decision. This report describes the clinical case of a young patient suffering from facial lipomatosis with particular emphasis on radiological findings detected at CT-scan and magnetic resonance imaging.
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Affiliation(s)
- Giuseppe Cicero
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, 98124 Messina, Italy; (F.M.A.); (S.M.)
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Chen H, Sun B, Gao W, Jia H, Zhou L, Hua C, Lin X. Facial infiltrating lipomatosis with hemimegalencephaly and lymphatic malformations caused by nonhotspot phosphatidylinositol 3-kinase catalytic subunit alpha mutation. Pediatr Dermatol 2023; 40:1115-1119. [PMID: 37190882 DOI: 10.1111/pde.15346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/28/2023] [Indexed: 05/17/2023]
Abstract
We report an unusual case of facial infiltrating lipomatosis with hemimegalencephaly and lymphatic malformations. In addition to the clinical data and imaging findings, detection of a heterozygous PIK3CA nonhotspot known pathogenic variant C420R in a facial epidermal nevus provided novel insight into the pathogenic effect of somatic PIK3CA mutations.
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Affiliation(s)
- Hongrui Chen
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Bin Sun
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Wei Gao
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Hechen Jia
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Lucia Zhou
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Chen Hua
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoxi Lin
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Chen H, Sun B, Gao W, Qiu Y, Hua C, Lin X. Delineation of the phenotypes and genotypes of facial infiltrating lipomatosis associated with PIK3CA mutations. Orphanet J Rare Dis 2023; 18:189. [PMID: 37452404 PMCID: PMC10347770 DOI: 10.1186/s13023-023-02786-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/18/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Facial infiltrating lipomatosis (FIL) is a rare congenital disorder characterized by unilateral facial swelling, for which surgery is the prevailing therapeutic option. Several studies have shown that the development of FIL is closely associated with PIK3CA mutations. This study aimed to further identify rare clinical features and underlying molecular variants in patients with FIL. RESULTS Eighteen patients were included in this study, and all patients presented with infiltrating adipose tissues confirmed by magnetic resonance imaging. Macrodactyly, polydactyly, hemimegalencephaly and hemihyperplasia were also observed in patients with FIL. In total, eight different PIK3CA mutations were detected in tissues obtained from sixteen patients, including the missense mutations p.His1047Arg (n = 4), p.Cys420Arg (n = 2), p.Glu453Lys (n = 2), p.Glu542Lys (n = 2), p.Glu418Lys (n = 1), p.Glu545Lys (n = 1), and p.His1047Tyr (n = 1) and the deletion mutation p.Glu110del (n = 3). Furthermore, the GNAQ mutation p.Arg183Gln was detected in the epidermal nevus tissue of one patient. Imaging revealed that several patients carrying hotspot mutations had more severe adipose infiltration and skeletal deformities. CONCLUSIONS The abundant clinical presentations and genetic profiles of FIL make it difficult to treat. PIK3CA mutations drive the pathogenesis of FIL, and PIK3CA hotspot mutations may lead to more extensive infiltration of lipomatosis. Understanding the molecular variant profile of FIL will facilitate the application of novel PI3K-targeted inhibitors.
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Affiliation(s)
- Hongrui Chen
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Bin Sun
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Wei Gao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Yajing Qiu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Chen Hua
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China.
| | - Xiaoxi Lin
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China.
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Recurrent PIK3CA H1047R-Mutated Congenital Infiltrative Facial Lipomatosis: A Case Report and Review of Literature. Curr Issues Mol Biol 2023; 45:1712-1719. [PMID: 36826055 PMCID: PMC9955733 DOI: 10.3390/cimb45020110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023] Open
Abstract
Congenital infiltrating lipomatosis of the face (CILF) is a rare, congenital, nonhereditary facial overgrowth due to post-zygomatic activating mutations in PIK3CA gene. It is unilateral and involves hypertrophy of both the soft and hard tissue structures on the affected side of the face. This commonly results in early eruption of the teeth, hypertrophy of the facial bones, macroglossia, and proliferation of the parotid gland. Less than 80 cases of CILF have been reported in the literature so far. Treatment modalities include liposuction and surgical excision. However, since the hallmark of CILF is mutation in the PIK3CA gene, PI3K inhibitors may play a therapeutic role in CILF. We report a case of an 8-year-old boy with recurrent CILF of the scalp and nose, with PIK3CA H1047R mutation. We discuss the differential diagnoses, clinical outcomes, and management of this rare entity.
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Balaji SM, Balaji P. Hemifacial hypertrophy - Report of 2 cases. Indian J Dent Res 2022; 33:344-347. [PMID: 36656200 DOI: 10.4103/ijdr.ijdr_688_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Hemifacial hyperplasia (HH) is a rare congenital condition involving enlargement of one or more tissues of the face. The treatment is surgically challenging and requires expertise. This manuscript aims to report two similar appearing HH but warranting different surgical treatment. A 19-year-old female and a 14-year-old boy presented with right facial asymmetry since birth and sought correction of the same. Surgical treatment was planned. Based on clinical history, diagnosis and imaging, HH was diagnosed. The first case was entirely a soft tissue abnormality that was treated with debulking while the second case had involvement of facial bones, necessitating surgical recontouring. The facial asymmetry was addressed. Healing was uneventful. Though the aesthetical concern and appearance of the two cases of HH were same, the treatment vastly differed. This was based on the source of asymmetry. Proper diagnosis and informed decision are a key for successful surgical outcome.
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Affiliation(s)
- S M Balaji
- Department of Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
| | - Preetha Balaji
- Department of Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
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Update of Pediatric Lipomatous Lesions: A Clinicopathological, Immunohistochemical and Molecular Overview. J Clin Med 2022; 11:jcm11071938. [PMID: 35407546 PMCID: PMC8999862 DOI: 10.3390/jcm11071938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/25/2022] [Accepted: 03/30/2022] [Indexed: 01/27/2023] Open
Abstract
Lipomatous neoplasms are a rare entity in the pediatric population, comprising less than 10% of soft tissue tumors in the first two decades of life. Some characteristics of pediatric adipocytic tumors are analogous to their adult counterparts, some pediatric lipomatous lesions however harbor unique features. In recent years, there have been significant advances in the understanding of the pathogenesis and hence in the classification and treatment of pediatric adipocytic tumors. This literature-based article will provide a review of the presently known clinicopathological, immunohistochemical and molecular features of pediatric lipomatous lesions.
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Beyene ET, Minasie GM, Desalegn YT. Multiple congenital infiltrative lipomatosis (bilateral face, trunk) with massive unilateral reactive follicular hyperplasia of the tonsil: A case report. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Maheshwari S, Jaiswal D, Khandelwal V, Rajesh U. Congenital infiltrating lipomatosis of the face. JOURNAL OF MARINE MEDICAL SOCIETY 2021. [DOI: 10.4103/jmms.jmms_128_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mathew L, George R, Sudhakar S, Keshava SN, Fouzia NA. Clinical Profile of Overgrowth Syndromes Consistent with PROS ( PIK3CA-Related Overgrowth Syndromes)-A Case Series. Indian Dermatol Online J 2020; 11:738-746. [PMID: 33235839 PMCID: PMC7678549 DOI: 10.4103/idoj.idoj_520_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/07/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022] Open
Abstract
Context: PIK3CA-related overgrowth syndrome (PROS) is characterized by focal and disproportionate growth of acral body structures in a mosaic pattern with varied phenotypes. Clinical diagnostic criteria are available and testing of the mutation is recommended for diagnosis. Cutaneous features described in these conditions include epidermal nevi and vascular malformations which form part of the diagnostic criteria. Aims: To detail the clinical profile of patients with presumptive PROS. Settings and Design: We conducted a retrospective study of 15 patients with focal overgrowth of the extremities or macrocephaly who presented to the department of dermatology at a tertiary care hospital in South India. Subjects and Methods: Data were collected through electronic medical records from July 2012 to April 2018 over 70 months. The criterion proposed by Keppler-Noreuil et al. was used for classifying them as presumptive PROS in the absence of genetic studies. Statistical Analysis Used: Descriptive analysis. Results: There were nine males and six females; mean age of 12.10 years (range: 8 months to 73 years) with clinical features consistent with PROS. There was a higher frequency of vascular malformations (9/15, 60%) and of epidermal nevi (7/15, 46.6%) than that reported in the literature. Unusual features included focal acrochordons, blaschkoid hypopigmentation and linear papillomatous growths in the oral mucosa. Conclusions: This study provides data on the clinical features of patients with PROS from the Indian subcontinent. In resource-poor settings, clinical criteria may be adequate for diagnosis due to restricted accessibility of technically challenging diagnostic tests.
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Affiliation(s)
- Lydia Mathew
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - Renu George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sniya Sudhakar
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shyamkumar N Keshava
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - N A Fouzia
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
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