Phenotyping Pain in Patients With Fibrous Dysplasia/McCune-Albright Syndrome

CONTEXT

Pain is a poorly managed aspect in fibrous dysplasia/McCune-Albright syndrome (FD/MAS) because of uncertainties regarding the clinical, behavioral, and neurobiological underpinnings that contribute to pain in these patients.

OBJECTIVE

Identify neuropsychological and neurobiological factors associated with pain severity in FD/MAS.

DESIGN

Prospective, single-site study.

PATIENTS

Twenty patients with FD/MAS and 16 age-sex matched healthy controls.

INTERVENTION

Assessments of pain severity, neuropathic pain, pain catastrophizing (pain rumination, magnification, and helplessness), emotional health, and pain sensitivity with thermal quantitative sensory testing. Central nervous system (CNS) properties were measured with diffusion tensor imaging, structural magnetic resonance imaging, and functional magnetic resonance imaging.

MAIN OUTCOME MEASURES

Questionnaire responses, detection thresholds and tolerances to thermal stimuli, and structural and functional CNS properties.

RESULTS

Pain severity in patients with FD/MAS was associated with more neuropathic pain quality, higher levels of pain catastrophizing, and depression. Quantitative sensory testing revealed normal detection of nonnoxious stimuli in patients. Individuals with FD/MAS had higher pain tolerances relative to healthy controls. From neuroimaging studies, greater pain severity, neuropathic pain quality, and psychological status of the patient were associated with reduced structural integrity of white matter pathways (superior thalamic radiation and uncinate fasciculus), reduced gray matter thickness (pre-/paracentral gyri), and heightened responses to pain (precentral, temporal, and frontal gyri). Thus, properties of CNS circuits involved in processing sensorimotor and emotional aspects of pain were altered in FD/MAS.

CONCLUSION

These results offer insights into pain mechanisms in FD/MAS, while providing a basis for implementation of comprehensive pain management treatment approaches that addresses neuropsychological aspects of pain.

Clinicopathological and genetic study of a rare occurrence: Malignant transformation of fibrous dysplasia of the jaws

BACKGROUND

Malignant transformation of fibrous dysplasia (FD) is very rare and little is known about this occurrence.

METHODS

We present the detailed clinical course of three cases of osteosarcoma arising from FD of the jaws and explore the genetic aberrations by Sanger sequencing, whole-exome sequencing (WES) and immunohistochemistry (IHC). A literature review of important topics related to this occurrence was also performed.

RESULTS

It was observed that patients with secondary sarcoma from FD showed a wide range of ages, with most during the third decade. Female and males were equally affected. Craniofacial bones and femurs were the most affected sites. High-risk factors for this occurrence included polyostotic FD, McCune-Albright syndrome and excess growth hormone. Notably, a potential relationship between thyroid hormones and sarcoma development was suggested in one patient, who began to show malignant features after hypothyroidism correction. Sanger sequencing revealed GNAS mutations of FD retained in all malignant tissues. Additionally, abnormal TP53 was demonstrated in all three cases by WES and IHC. WES also revealed two other driver mutations, ROS1 and CHD8, and large amounts of somatic copy number alterations (CNAs) where various oncogenes and tumour suppressors are located.

CONCLUSION

This study demonstrated and reviewed the clinical features and risk factors for a rare occurrence, secondary sarcoma from FD, and provided important new knowledge about its genetics.

[Early manifestation and progressive multicomponent current of McCune-Albright-Braitsev syndrome in a girl 9 years old: a clinical case and literature review]

McCune-Albright-Braitsev Syndrome (MAB syndrome) is a very rare multisystem disease manifested by fibrous bone dysplasia, coffee-and-milk colored spots, hyperfunction of various endocrine glands and a number of pathologies of other body systems. We present a description of a clinical case of a severe progressive course of MAB Syndrome in a nine-year-old girl. With this diagnosis, the girl is observation of the girl began when she was 2.5 years old, when spots of coffee-and-milk, polyosseous fibrous dysplasia, peripheral premature sexual development against a backdrop of estrogen--secreting ovarian cysts, multinodular goiter were detected. In the process of dynamic observation, it was noted that the child's active growth stopped against a backdrop of deformities of the skeletal system with multiple repeated fractures of the extremities; progression of skull deformity with stenosis of the optic nerve canals and deterioration of visual acuity; development of STH hypersecretion, hypophosphatemic rickets, tachycardia. Appropriate suppressive / replacement therapy was prescribed for each of the endocrine dysfunctions. The article presents algorithms for examining a girl in dynamics, criteria for choosing a component-wise management tactics and a discussion of the features of the course of all manifestations of the Syndrome.

Pathogenic postzygotic mosaicism in the tyrosine receptor kinase pathway: potential unidentified human disease hidden away in a few cells

Mutations occurring during embryonic development affect only a subset of cells resulting in two or more distinct cell populations that are present at different levels, also known as postzygotic mosaicism (PZM). Although PZM is a common biological phenomenon, it is often overlooked as a source of disease due to the challenges associated with its detection and characterization, especially for very low-frequency variants. Moreover, PZM can cause a different phenotype compared to constitutional mutations. Especially, lethal mutations in receptor tyrosine kinase (RTK) pathway genes, which exist only in a mosaic state, can have completely new clinical manifestations and can look very different from the associated monogenic disorder. However, some key questions are still not addressed, such as the level of mosaicism resulting in a pathogenic phenotype and how the clinical outcome changes with the development and age. Addressing these questions is not trivial as we require methods with the sensitivity to capture some of these variants hidden away in very few cells. Recent ultra-accurate deep-sequencing approaches can now identify these low-level mosaics and will be central to understand systemic and local effects of mosaicism in the RTK pathway. The main focus of this review is to highlight the importance of low-level mosaics and the need to include their detection in studies of genomic variation associated with disease.

Genotype-Phenotype Correlation in Fibrous Dysplasia/McCune-Albright Syndrome

CONTEXT

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare bone and endocrine disorder resulting in fractures, pain, and disability. There are no targeted or effective therapies to alter the disease course. Disease arises from somatic gain-of-function variants at the R201 codon in GNAS, replacing arginine by either cysteine or histidine. The relative pathogenicity of these variants is not fully understood.

OBJECTIVE

This work aimed 1) to determine whether the most common GNAS variants (R201C and R201H) are associated with a specific clinical phenotype, and 2) to determine the prevalence of the most common GNAS variants in a large patient cohort.

METHODS

This retrospective cross-sectional analysis measured the correlation between genotype and phenotype characterized by clinical, biochemical, and radiographic data.

RESULTS

Sixty-one individuals were genotyped using DNA extracted from tissue or circulating cell-free DNA. Twenty-two patients (36.1%) had the R201C variant, and 39 (63.9%) had the R201H variant. FD skeletal disease burden, hypophosphatemia prevalence, fracture incidence, and ambulation status were similar between the 2 groups. There was no difference in the prevalence of endocrinopathies, ultrasonographic gonadal or thyroid abnormalities, or pancreatic involvement. There was a nonsignificant association of cancer with the R201H variant.

CONCLUSION

There is no clear genotype-phenotype correlation in patients with the most common FD/MAS pathogenic variants. The predominance of the R201H variant observed in our cohort and reported in the literature indicates it is likely responsible for a larger burden of disease in the overall population of patients with FD/MAS, which may have important implications for the future development of targeted therapies.

Bilateral Dysplastic Gangliocytoma with Concurrent Polyostotic Fibrous Dysplasia: A Case Report and Literature Review

BACKGROUND

Dysplastic gangliocytoma is a sporadic cerebellar benign tumor with the characteristics of hamartoma and true tumor, also known as Lhermitte-Duclos disease (LDD). Bone fibrous dysplasia (FD) is a slowly progressive self-limited benign bone tissue disease. Cowden syndrome, an autosomal dominant genetic disorder caused by germline mutations in the PTEN gene, is considered to be closely related to dysplastic gangliocytoma. McCune-Albright syndrome is a disease characterized by café-au-lait skin macules, polyostotic FD, and precocious puberty. The etiologic mechanism of both conditions is not yet clear. We report a rare case of bilateral dysplastic gangliocytoma with concurrent polyostotic FD.

CASE DESCRIPTION

We describe a 16-year-old boy with both LDD and FD. He presented for medical examination with headache and poor eyesight. Magnetic resonance imaging revealed proliferation of the skull and abnormal signals in the cerebellum, and supratentorial hydrocephalus. Subtotal resection of the cerebellar tumor was performed, and the diagnosis of LDD and FD was confirmed by histopathology. No other abnormal changes were found in systemic medical examination and no PTEN gene mutation was found in the genetic analysis; therefore, the diagnoses of Cowden syndrome and McCune-Albright syndrome were excluded.

CONCLUSIONS

LDD and FD are 2 rare diseases, and the simultaneous occurrence of the 2 conditions has not been reported before, to our knowledge. Our report challenges the etiology of the 2 diseases and the relationship between them, hoping to provide a reference for the study of the 2 diseases.

Multi-analytic study of a probable case of fibrous dysplasia (FD) from certosa monumental cemetery (Bologna, Italy)

OBJECTIVE

To evaluate, via a multidisciplinary approach, a distinctive paleopathological condition believed to be fibrous dysplasia, found on a 19th/20th century skeleton from Certosa Monumental Cemetery, Bologna, Italy.

MATERIALS

A skeletonized cranium and mandible recovered from an ossuary in 2014.

METHODS

Pathological alterations were analysed by radiological examination, dental macrowear, histopathological and genetic analyses.

RESULT

The skeleton is believed to be an adult male. Differential diagnoses include Paget's disease, McCune-Albright syndrome, osteochondroma and osteosarcoma. The radiographic findings, along with the solitary nature of the lesions, are strong evidence for the diagnosis of fibrous dysplasia (FD). Genetic analysis further revealed a frequency of ˜1% of mutant alleles with the R201C substitution, one of the post-zygotic activating mutation frequently associated with FD.

CONCLUSIONS

The multi-analytical method employed suggests a diagnosis of monostotic form of FD. The diagnostic design incorporates multiple lines of evidence, including macroscopic, histopathological, and genetic analyses.

SIGNIFICANCE

Through the use of a multi-analytic approach, robust diagnoses can be offered. This case serves as one of the oldest examples of FD from an historical context. The genetic mutation detected, associated with FD, has not been previously reported in historical/ancient samples.

Long-term health outcomes of adults with McCune-Albright syndrome

CONTEXT

McCune-Albright syndrome (MAS) is associated with numerous health problems. Comprehensive long-term health problems of adults with MAS are less well defined in the literature.

OBJECTIVE

Our objective is to report comprehensive health outcomes of adults with MAS (>18 years).

DESIGN

Retrospective case note review of 16 adults with MAS managed by one clinician. Results expressed as median (range).

RESULTS

The study included 16 adults (seven males) with MAS. Median current age is 29 years (20, 46). Twelve of 16 had craniofacial fibrous dysplasia with five of 12 (42%) with progressive facial asymmetry. Growth hormone excess was observed in six of 16 (38%) and T3-toxicosis in five of 16 (31.3%). Six of the seven men (86%) had abnormalities on testicular ultrasound with one man exhibiting marked atrophy of germ and sertoli cells with reduction in spermatogenesis. Six of the 16 (38%) had cardiorespiratory complications including high output cardiac failure (n,3), hypertension (n,2) and one man with congestive cardiac failure and restrictive lung disease. Six of eight (66%) who had screening endoscopy for upper gastrointestinal polyps show increasing numbers of polyps, with benign histology to date. One woman with a previous history of early puberty presented with early aggressive breast carcinoma, which was positive for GNAS. Two patients had GNAS-positive muscle myomas. Platelet dysfunction with bleeding tendency responsive to platelet transfusion during surgery was seen in four.

CONCLUSION

A range of complex health problems is encountered in adults with MAS. These have important implications for transition of patients with MAS and adult care. Long-term cancer risk is currently unknown but requires careful follow-up.

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.

Fibrous Dysplasia/McCune-Albright Syndrome: Clinical and Translational Perspectives

Fibrous dysplasia (FD) is an uncommon and debilitating skeletal disorder resulting in fractures, deformity, functional impairment, and pain. It arises from post-zygotic somatic activating mutations in GNAS, in the cAMP-regulating transcript α-subunit, Gsα. Constitutive Gs signaling results in activation of adenylyl cyclase and dysregulated cAMP production. In the skeleton, this leads to the development of FD lesions with abnormal bone matrix, trabeculae, and collagen, produced by undifferentiated mesenchymal cells. FD may occur in isolation or in combination with extraskeletal manifestations, including hyperfunctioning endocrinopathies and café-au-lait macules, termed McCune-Albright syndrome (MAS). This review summarizes current clinical and translational perspectives in FD/MAS, with an emphasis on FD pathogenesis, natural history, pre-clinical and clinical investigation, and future directions.

Osteosarcoma of the Mandible Arising in Fibrous Dysplasia-A Case Report

Fibrous dysplasia (FD) is a benign fibro-osseous lesion that typically behaves as a painless, slowly expanding tumor. On rare occasion, FD will undergo malignant transformation. When sarcomatous change occurs, osteosarcoma is the typical variant, followed by chondrosarcoma and fibrosarcoma. The incidence of malignant change varies from 1 to 4% depending on whether the disease is mono-ostotic or polyostotic and syndromic (McCune-Albright or Jaffe-Lichtenstein syndrome). Despite the low incidence of malignant change, the potential lethality of this disease behooves treating surgeons to be keenly aware of the signs and symptoms indicative of malignancy. This report documents a case of spontaneous transformation of FD into osteosarcoma in the setting of longstanding craniomaxillofacial FD in a 39-year-old woman.

Polyostotic osteolysis and hypophosphatemic rickets with elevated serum fibroblast growth factor 23: A case report

We report on a boy who presented with hypophosphatemic rickets with elevated serum fibroblast growth factor 23 (FGF23) and polyostotic osteolytic lesions at age 2 years. Tumor-induced hypophosphatemic rickets was suspected; however, bone biopsy for osteolytic changes revealed no tumorous change, except for irregularly dilated vessels associated with osteoclasts and fibrous proliferation. Venous sampling failed to point to FGF23-producing foci. After alfacalcidol and phosphate supplementation, the rachitic skeletal changes improved, but FGF23 increased and new osteolytic lesions developed. Serum levels of neopterin and a few cytokines, including plasma transforming growth factor-β and soluble tumor necrosis factor receptor type II, were elevated. At age 4 years, high doses of phosphate resulted in increased serum phosphate levels, decreased neopterin and cytokines, decreased FGF23, and stabilization of osteolysis. We excluded germline mutations in PHEX, FGF23, DMP1, and ENPP1 (genes for hereditary hypophosphatemic rickets) and somatic mutations in the GNAS and HRAS/KRAS (the disease-causing genes for McCune-Albright syndrome and linear nevus sebaceous syndrome, respectively). We could not perform octreotide scintigraphy or fluorodeoxyglucose-positron emission tomography, and thus could not completely exclude occult FGF23-producing tumors. However, considering the course of the disease, it is intriguing to assume that dysregulation of osteoclast-macrophage lineage may have induced increased neopterin levels, increased cytokine levels, osteolytic process, and possibly FGF23 overproduction.

Fibro-osseous lesions of the craniofacial skeleton: an update

Benign fibro-osseous lesions of the craniofacial skeleton (BFOL) are a variant group of intraosseous disease processes that share similar microscopic features characterized by hypercellular fibroblastic stroma containing various combinations of bone or cementum-like tissue and other calcified structures [1-6]. Whereas some are diagnosable histologically, most require a combined assessment of clinical, microscopic and radiologic features. Some BFOL of the craniofacial complex are unique to that location whereas others are encountered in bones from other regions. Reactive, neoplastic, developmental and dysplastic pathologic processes are included under the rubric of BFOL and treatment varies from disease to disease. This review will discuss the clinical, microscopic and radiologic aspects of the more important types of BFOL of the craniofacial complex with updated information on underlying genetic and molecular pathogenic mechanisms of disease. Four main groups of BFOLs will be addressed.

Polyostotic fibrous dysplasia

An 18-year-old man was referred to the authors' institution's thoracic cancer specialists for further consultation after abnormal findings were seen on chest radiograph.

McCune-Albright syndrome: a detailed pathological and genetic analysis of disease effects in an adult patient

CONTEXT

McCune Albright syndrome (MAS) is a clinical association of endocrine and nonendocrine anomalies caused by postzygotic mutation of the GNAS1 gene, leading to somatic activation of the stimulatory α-subunit of G protein (Gsα). Important advances have been made recently in describing pathological characteristics of many MAS-affected tissues, particularly pituitary, testicular, and adrenal disease. Other rarer disease related features are emerging.

OBJECTIVE

The objective of the investigation was to study the pathological and genetic findings of MAS on a tissue-by-tissue basis in classically and nonclassically affected tissues.

DESIGN

This was a comprehensive autopsy and genetic analysis.

SETTING

The study was conducted at a tertiary referral university hospital.

PATIENTS

An adult male patient with MAS and severe disease burden including gigantism was the subject of the study.

INTERVENTION(S)

Interventions included clinical, hormonal, and radiographic studies and gross and microscopic pathology analyses, conventional PCR, and droplet digital PCR analyses of affected and nonaffected tissues.

MAIN OUTCOME MEASURE

Pathological findings and the presence of GNAS1 mutations were measured.

RESULTS

The patient was diagnosed with MAS syndrome at 6 years of age based on the association of café-au-lait spots and radiological signs of polyostotic fibrous dysplasia. Gigantism developed and hyperprolactinemia, hypogonadotropic hypogonadism, and hyperparathyroidism were diagnosed throughout the adult period. The patient died at the age of 39 years from a pulmonary embolism. A detailed study revealed mosaiscism for the p.R201C GNAS1 mutation distributed across many endocrine and nonendocrine tissues. These genetically implicated tissues included rare or previously undescribed disease associations including primary hyperparathyroidism and hyperplasia of the thymus and endocrine pancreas.

CONCLUSIONS

This comprehensive pathological study of a single patient highlights the complex clinical profile of MAS and illustrates important advances in understanding the characteristics of somatic GNAS1-related pathology across a wide range of affected organs.

Multifocal intraosseous ganglioneuroma

We report a case of asymptomatic intraosseous ganglioneuroma of the ilium, which was initially misdiagnosed as polyostotic fibrous dysplasia. Our patient presented with multiple asymptomatic skeletal lesions. Despite extensive work-up of our patient to rule out metastatic disease, we were unable to find a primary source; biopsy showed intraosseous ganglioneuroma of the ilium. To the best of our knowledge, we report an exceedingly rare pathologic entity; only 3 cases have been described of intraosseous ganglioneuroma from spontaneous cytomaturation of metastatic neuroblastoma. Knowledge of the natural history of ganglioneuroma is limited, but patients with primary and multifocal disease appear to have benign histologic tumor appearance and excellent prognoses. Similar to previous studies, the rarity of this tumor and its nonspecific radiographic and clinical presentation resulted in the correct diagnosis only after histopathologic analysis. Because intraosseous ganglioneuroma may mimic fibrous dysplasia it should be considered in the differential diagnosis of benignappearing skeletal lesions, particularly if the patient has a history of neuroblastoma.

Disease severity and functional factors associated with walking performance in polyostotic fibrous dysplasia

The purpose of this study was to determine the association between measures of disease severity, impairment, and ambulation ability in persons with polyostotic fibrous dysplasia (PFD). A cross-sectional sample of 81 patients (ages 5-57) with polyostotic fibrous dysplasia was evaluated as part of an ongoing study. Subjects were scored on the Skeletal Disease Burden Score (SDBS), completed a 9-minute walk test (9MW), manual muscle testing (MMT), and measurements of range of motion (ROM). Correlations between continuous variables were calculated using the Pearson correlation coefficient and ordinal variables by Spearman correlation coefficient. It was found that subjects with more severe disease walked slower than those with less skeletal disease, with the exception of the youngest subjects. Walking velocity was faster in subjects with better hip strength and range of motion and slower in those with bilateral coxa vara. Those subjects with more severe disease had less range of motion, were weaker at the hips, and more likely to have leg length discrepancy. Skeletal disease severity was associated with hip weakness, leg length discrepancy, and loss of range of motion. In most cases, findings did not differ in the presence or absence of associated endocrinopathies. Skeletal disease severity, MMT and ROM each has an impact on walking efficiency in persons with PFD. These findings suggest that treatment focused on strategies to improve or, at least, maintain hip strength and range of motion, correct leg length discrepancies and hip malalignment may help preserve ambulation ability in persons with PFD and that treatment should begin at a young age.

Hepato-pancreato-biliary lesions are present in both Carney complex and McCune Albright syndrome: comments on P. Salpea and C. Stratakis

One of the key messages of recent Salpea and Stratakis work is to underline the clinical similarities shared by these syndromes that could be explained by a defect in the same signaling pathway, i.e. activation of the cAMP pathway. That being said, we would like to emphasize that hepatopancreato-biliary lesions are one additional feature shared both by Carney complex and McCune Albright syndrome.

Virilizing sclerosing-stromal tumor of the ovary in a young woman with McCune Albright syndrome: clinical, pathological, and immunohistochemical studies

CONTEXT

McCune-Albright syndrome (MAS) is characterized by polyostotic fibrous dysplasia, café-au-lait skin pigmentations, and gonadotropin-independent sexual precocious puberty, resulting from a somatic postzygotic activating mutation of the GNAS1 gene.

SETTING

We report a virilizing sclerosing-stromal tumor of the ovary in a young female with MAS.

PATIENT

She presented polyostotic fibrous dysplasia of the left upper and lower limbs and a café-au-lait skin spot in the posterior area of the neck. She had a history of precocious puberty, diagnosed at the age of 6 years and treated with cyproterone acetate until the age of 10 years; then she developed central puberty with severe oligomenorrhea. At the age of 23 years, she was hospitalized for a virilization syndrome including hirsutism, acne, deepening of the voice, amenorrhea, and clitoromegaly. Serum levels of T were dramatically increased (1293 ng/dl; normal range, 10-80). The abdominal computed tomography scan revealed a solid mass located on the left ovary.

INTERVENTION

An ovariectomy was performed, and histological examination revealed a sclerosing-stromal tumor with pseudolobular pattern.

RESULTS

Immunohistochemical studies revealed that the tumor cells expressed all steroidogenic enzymes involved in androgen synthesis. Molecular analysis revealed that ovarian tumor cells harbored the Arg 201 activating mutation in the GNAS1 gene. After surgery, T levels returned to normal, the patient retrieved a normal gonadal function, and she was able to become pregnant.

CONCLUSION

This observation extends the clinical spectrum of ovarian pathology of women with MAS. However, the mechanisms causing this ovarian tumor remain unclear, even if the gsp oncogene has been implicated in the pathogenesis of some gonadal tumors.

Characterization and management of testicular pathology in McCune-Albright syndrome

CONTEXT

The testicular phenotype in McCune-Albright syndrome (MAS) has not been well characterized. Boys present with a relatively low incidence of precocious puberty in comparison with girls. Radiographic and histological studies are limited to small series and case reports, which report testicular microlithiasis and Sertoli cell hyperplasia.

OBJECTIVE

Our objective was to characterize the biochemical, radiological, and histological spectrum and clinical management of testicular pathology in males with MAS.

PATIENTS, DESIGN, AND SETTING

Fifty-four males with MAS participated in this prospective cohort study at a clinical research center.

INTERVENTION

Evaluation included testicular exam, pubertal staging, testicular ultrasound, measurement of LH, FSH, and testosterone. Orchiectomies were performed when considered clinically indicated.

MAIN OUTCOME MEASURE

Prevalence and characterization of ultrasound lesions with correlation to histology were evaluated.

RESULTS

Of 54 males, 44 (81%) presented with ultrasound abnormalities including hyperechoic lesions (49%), hypoechoic lesions (30%), microlithiasis (30%), heterogeneity (47%), and focal calcifications (11%). Eight subjects underwent orchiectomy revealing large foci of Leydig cell hyperplasia, which could not be definitively distinguished from Leydig cell tumor. After no subjects developed clinical malignancy, a conservative approach was instituted, and subsequent subjects were followed with serial imaging. Testosterone and gonadotropins were normal in subjects without precocious puberty or pituitary disease. Eleven (21%) presented with precocious puberty, and a combination of aromatase inhibitors, androgen receptor blockers, and leuprolide resulted in improved predicted adult height. In addition, the first cases of testicular adrenal rest and bilateral germ cell tumors in association with MAS are presented.

CONCLUSIONS

Contrary to prevailing thinking, the incidence of gonadal pathology in MAS is equal in males and females. The predominant histopathological finding was Leydig cell hyperplasia, which carries a low risk of malignant transformation and can be managed conservatively.

Multiple or familial café-au-lait spots is neurofibromatosis type 6: clarification of a diagnosis

A café-au-lait macule (CALM) is an evenly pigmented macule or patch of variable size. Solitary CALMs are common birthmarks in up to 2.5 percent of normal neonates and their incidence rises to up to 25 percent in preschool-aged children. Two or more CALMs occur much less frequently. Multiple lesions may warrant investigation to identify an underlying disease including neurofibromatosis types 1 (NF1), neurofibromatosis type 2, McCune-Albright syndrome, and neurofibromatosis type 1-like syndrome. Considered a hallmark and diagnostic criteria for NF1 is the presence of 6 or more CALMs greater than 0.5 cm in prepubertal individuals. Rare reports describe families which demonstrate the phenomenon of multiple CALMs without other stigmata of NF1 or evidence of other systemic disease. Herein is a description of the condition and justification for this entity to be named Neurofibromatosis type 6.

[Clinical characteristics of McCune-Albright syndrome in Chinese patients]

OBJECTIVE

To present the ophthalmological characteristics of McCune-Albright syndrome (MAS).

METHODS

Case series study. Best corrected visual acuity (BCVA), visual field, color vision, retinal nerve fiber layer (RNFL) thickness, visual evoked potentials (VEP), fundus examination, computed tomography (CT) imaging of the optic canal, follow up results of multidisciplinary comprehensive treatments were analyzed.

RESULTS

Of the 6 patients, three were male and three were female. Their age were between 4 to 43 years old (median, 16 years old). Based on CT imaging of the optic canal, encasement of the optic canal was found in all 6 patients (12 eyes); three patients (6 eyes) had circumferential encasement of the optic canal; the remaining 3 patients (6 eyes) had partial encasement of the optic canal. Two patients (3 eyes) with circumferential encasement of the optic canal had optic neuropathy versus none in the remaining 9 eyes with circumferential or partial optic canal encasement. In addition, lengthening of the optic nerve was found in all 4 patients (8 eyes).

CONCLUSION

Optic canal encasement and lengthening of the optic nerve are common in MAS patients, which is worthy of attention in clinical practice.

Primary bimorphic adrenocortical disease: cause of hypercortisolism in McCune-Albright syndrome

McCune-Albright syndrome (polyostotic fibrous dysplasia, café-au-lait skin spots, and precocious puberty) is a genetically mosaic disorder with populations of mutant and normal cells in affected organs. Cushing syndrome, a rare feature of the condition, usually affects infants and is the result of corticotropin-independent primary bilateral adrenal disease, usually interpreted as nodular adrenocortical hyperplasia. In this study of 9 patients with Cushing syndrome and McCune-Albright syndrome, light microscopy revealed a characteristic bimorphic pattern of diffuse and nodular hyperplasia and a distinctive form of cortical atrophy with apparent zona glomerulosa hyperplasia in 8 patients, all very young. The pattern could be explained by the presence of a mosaic distribution of mutant and normal cells in the adrenal glands. The findings are different from those in inherited or other forms of genetically caused Cushing syndrome. The ninth patient, aged 17 years, had an adrenal adenoma and diffuse cortical hyperplasia in each adrenal gland.

[Recurrent painful ophthalmoplegia secondary to polyostotic fibrous dysplasia of the maxillary sinuses with involvement of the superior orbital fissure]

INTRODUCTION

Fibrous dysplasia is a bone disease that is usually accompanied by asymptomatic lesions but which may sometimes display neurological manifestations due to the involvement of the craniofacial bones.

CASE REPORT

A 25-year-old female, with a history of migraines, who visited at the age of 18 due to pain in the right retro-ocular and maxillary region, although with characteristics that were unlike those of her usual migraines, and which was associated with ipsilateral ophthalmoparesis. The condition had a self-limiting course and responded well to corticoids, although it was recurring. Examination revealed intense pain on palpation of the right-hand maxillary sinus and incomplete paralysis of the ipsilateral oculomotor nerve with palpebral ptosis. Results of complementary studies were normal, except for magnetic resonance imaging of the head and computerised axial tomography of the face, which revealed an expansive lesion with involvement of the right superior maxillary sinus and the greater wing of the sphenoid bone, with probable compromise of the superior orbital fissure, consistent with the diagnosis of fibrous dysplasia, which was confirmed by means of a pathology study.

CONCLUSIONS

Fibrous dysplasia is a benign bone disorder, of unknown causation, in which normal bone tissue is replaced by amorphous conjunctive tissue. There is sometimes craniofacial involvement and a hypertrophic bone mass is formed which can fill the paranasal sinuses and the orbit, resulting in exophthalmus and visual disorders. To date the scientific literature does not include any reports of this disease manifesting as bouts of recurrent painful ophthalmoparesis which responds to corticoids, as happened in the case of our patient.

The pathology of pituitary adenomas from a clinical perspective

Pituitary adenomas present with a variety of clinical endocrine manifestations and arise in a sporadic setting or rarely as part of hereditary genetic syndromes. Molecular analysis of familial pituitary adenomas has provided significant insight into pituitary tumorigenesis. Some specific genes have been identified that predispose to pituitary neoplasia, but these are rarely involved in the pathogenesis of sporadic tumors. The number of identified genes involved in pituitary tumorigenesis is progressively increasing. The possible resulting mechanisms of action involve abnormalities in signal transduction pathways, cell cycle regulators, growth factors, chromosome stability and others. Further studies are needed to evaluate the clinical significance of genetic alterations and their implications for patient prognosis, as well as to identify targets for existing and new therapeutic options. The aim of this review is to focus on the molecular pathology of pituitary adenomas from a practical perspective and discuss the possible clinical implications which may relate to particular molecular alterations. We have summarised familial syndromes related to pituitary adenomas and considered the prognostic value of selected molecular alterations in these tumors.

Genetic factors in the development of pituitary adenomas

Pituitary adenomas are one of the most frequent intracranial tumors. Usually, they are benign but are of great clinical significance because of tumor compression syndrome and hormone overproduction. The interest in this pathology is increasing, particularly after some recent reports on their prevalence that proved to be 3-5 times more than previously estimated. Pituitary tumors arise in a sporadic setting and rarely as part of hereditary genetic syndromes. Such rare hereditary conditions like MEN1, Carney complex and McCune-Albright syndrome give significant insight into pituitary tumorigenesis. Newer genes associated pituitary tumor development include CDKN1B (MEN4) and AIP, the latter of which is involved in the pathophysiology of 15% of FIPA kindreds. The number of genes involved in pituitary tumorigenesis is progressively increasing and the possible mechanisms of action include signal transduction pathways, cell cycle regulators, growth factors, chromosome instability and others. Nevertheless, in the majority of sporadic adenomas, the primary genetic defect remains unknown. Furthermore, there is not a well established relationship between the genotype and its influence on the protein expression, ligand-receptor interaction, tumor growth or hormone hyperproduction. Further studies should evaluate the clinical significance of genetic alterations and their implications for existing and new therapeutic options.

Upper lip bite test in a patient with McCune Albright syndrome with acromegaly

We report a patient with McCune Albright syndrome with acromegaly and features predictive of difficult airway except a class I upper lip bite (ULB) test. Our patient, a 33-year-old woman, had a history of polyostotic fibrous dysplasia. Tracheal intubation was performed under general anaesthesia. Although we did not find any difficulty in visualizing the glottis by direct laryngoscopy; our patient had multiple poor predictive signs of airway assessment including a Mallampati grade III, restricted neck movement and macroglossia. Our report suggests that the ULB test in people with acromegaly may act as an indicator of easy intubation in spite of other poor predictive signs. However, this finding needs further corroboration by a large study to evaluate the role of the ULB test in people with acromegaly.

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.

CT and MRI in the evaluation of craniospinal involvement with polyostotic fibrous dysplasia in McCune-Albright syndrome

In this study, the efficacy of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of craniospinal involvement with polyostotic fibrous dysplasia (PFD) in McCune-Albright syndrome (MAS) and related complications were reviewed. In CT, ground-glass appearance with well-defined borders was seen, with medullary widening and cortical thinning. More rarely, cystic/necrotic areas were observed within involved bone. These lesions were seen as hypointense in T1-weighted sequences and as hyperintense in T2-weighted sequences of MRI. There was no heterogeneous contrast enhancement. Cystic/necrotic areas were seen as hyperintense images on T2-weighted sequences. While bone marrow involvement was shown more clearly with MRI, compression of cranial and spinal nerves was determined most effectively by evaluation of CT and MRI together. CT and MRI should be employed together in order to demonstrate the extent of disease, and complications of craniospinal involvement of PFD in patients with MAS.

[Fibrous dysplasia involving sphenoid and occipital bone: one case report and literature review]

OBJECTIVE

To study the clinical manifestation, radiograph features, pathology, diagnosis and treatment of fibrous dysplasia in cranial bone.

METHOD

A case of fibrous dysplasia involving sphenoid and occipital is reported and literature were reviewed.

RESULT

The most common complaint were headache, proptosis, diplopia, or visual changes. Distinguishing features of fibrous dysplasia on CT include "ground-glass" appearance, bone fiber anisotrophy, aneurysmal bone cyst formation and thickness of the cranial cortices. Fibrous dysplasia could be exactly diagnosed by pathology. Computed tomography was also a choice for diagnosis.

CONCLUSION

Fibrous dysplasia involving the cranial bone can present in myriad ways. Modern imaging modalities and histopathologic analysis is required to make accurate diagnosis. Surgery, particularly in a challenging region such as sphenoid and occipital bone, should preserve the existing function for the patients with functional impairment or a cosmetic deformity.

Craniofacial polyostotic fibrous dysplasia: a case report and review of the literature

Craniofacial fibrous dysplasia is 1 of 3 types of fibrous dysplasia that can affect the bones of the craniofacial complex, including the mandible and maxilla. A 49-year-old white male presented with an extensive previous medical history. Initial radiographic assessment comprised panoramic and PA cephalometric radiographs and provided a working diagnosis of fibrous dysplasia. Advanced imaging included conventional CT, cone beam CT, and MRI. Three areas in the craniofacial complex were diagnosed as FD. The patient also presented with severe degenerative joint disease of the left TMJ. In this case, all FD lesions were radiopaque and presented with ground glass appearance. The relative importance of each imaging modality in the diagnosis and assessment of FD is discussed.

Work-up and management of paediatric Cushing's syndrome

PURPOSE OF REVIEW

Paediatric Cushing's syndrome presents a diagnostic and therapeutic challenge. Most paediatric endocrinologists have limited experience in managing children or adolescents with Cushing's syndrome and thus benefit from close consultation with adult colleagues. A protocol for investigation of the child with suspected Cushing's syndrome is presented followed by principles of management.

RECENT FINDINGS

Cushing's syndrome is rare in childhood, but causes serious morbidity. Investigations have evolved and now include new genetic and imaging techniques as well as classical endocrine studies. In Cushing's disease trans-sphenoidal surgery has transformed management, although only a few surgeons have experience in children. Pituitary radiotherapy is effective second-line therapy.

SUMMARY

Early diagnosis and treatment of Cushing's syndrome is vital for long-term outcome. The overall prognosis for Cushing's syndrome is good but challenges remain to ensure normal postcure growth and body composition.

Regulation of spermatogenesis in McCune-Albright syndrome: lessons from a 15-year follow-up

CONTEXT

McCune-Albright syndrome (MAS) is a disorder caused by a post-zygotic gain-of-function mutation in the gene encoding the Gs-alpha protein. Sexual precocity, common in girls, has been reported in only 15% of boys, and little is known on the long-term evolution of MAS in males.

OBJECTIVE

In a boy with MAS, we studied spermatogenesis, testis histology, and immunohistochemistry with the aim to shed light on seminiferous tubule activity.

DESIGN

A boy who presented at the age of 2.9 years with sexual precocity, monolateral macroorchidism, increased testosterone levels, and suppressed gonadotropins was followed up until the age of 18.

RESULTS

Throughout follow-up testicular asymmetry persisted and gonadotropin and testosterone pattern did not change. At the age of 18, inhibin B was undetectable while alpha-immunoreactive inhibin was within normal range. Anti-Mullerian hormone level was slightly subnormal. Sperm cells were 3,900,000 per ejaculate. Histology of both testes showed spermatogonia, spermatocytes, and, in some tubes, matured spermatozoa. Sertoli cells were markedly stained with anti-inhibin alpha-subunit antibody in both the testes. There was no immunostaining of Sertoli, Leydig, or germ cells with anti-betaA or anti-betaB antibody. MAS R201H mutation was identified in both the testes.

CONCLUSION

The 15-year follow-up in this boy with MAS demonstrated that autonomous testicular activation and gonadotropin suppression persisted over time. This provides an interesting model of active spermatogenesis despite long-term FSH suppression. It also suggests that FSH is needed for the full expression of the inhibin betaB-subunit gene, an expression previously reported in the germ and Leydig cells of normal adult subjects.

[Acute blepharoptosis caused by fibrous dysplasia]

We report a case of fibrous dysplasia revealed by acute ptosis in a 38-year-old patient. Ophthalmologic examination disclosed a moderate right ptosis. The rest of the results were strictly normal except for a known facial asymmetry. Visual acuity was 20/20 in both eyes, there was no extrinsic or intrinsic oculomotor disorder, and funduscopy was normal. Given this acute presentation, emergency cerebral imagery was carried out, providing a diagnosis of fibrous dysplasia with orbital and cavernous repercussions, with no sign of cerebral disorder or obvious vascular lesion. Progression was marked by a regression of the ptosis. Fibrous dysplasia is a rare pathology but presents varied clinical presentations. The authors present the broad characteristics of this pathology and the management of an acquired ptosis. They discuss the possible mechanisms involved in the drop of the right upper eyelid of this patient and the therapeutic solutions.

Relief of severe retro-orbital pain and vision improvement after optic-nerve decompression in polyostotic fibrous dysplasia: case report and review of the literature

INTRODUCTION

We describe a case of a 9-year-old girl who developed progressive severe retro-orbital pain and partial visual loss in association with left optic-nerve compression due to polyostotic fibrous dysplasia of the skull.

MATERIALS AND METHODS

Intradural decompression of the optic nerve resulted in immediate and complete resolution of the pain as well as a vast visual improvement.

CONCLUSION

In cases of fibrous dysplasia of the skull with evidence of optic-nerve compression, relief of retro-orbital pain should be an additional consideration when deciding to proceed with surgical management.

Polyostotic fibrous dysplasia of the cervical spine: case report and review of the literature

BACKGROUND CONTEXT

Multiple lytic lesions of the spine usually represent metastatic or infectious disease processes.

PURPOSE

To describe an extremely rare presentation of an uncommon disease process.

STUDY DESIGN/SETTING

Case report/university hospital.

METHODS

We describe the management of a patient who presented with a pathological fracture of C3 and multiple lytic lesions of the cervical spine.

RESULTS

After reconstructive surgery, the final pathological diagnosis was fibrous dysplasia.

CONCLUSION

Fibrous dysplasia is rarely seen in the cervical spine and may mimic other pathological processes. The surgical and medical management of spinal fibrous dysplasia is described.

Cyst degeneration in craniofacial fibrous dysplasia: clinical presentation and management

Object

Fibrous dysplasia (FD) is a common osseous tumor that may affect the craniofacial skeleton. Cyst degeneration may occur within an existing FD lesion, manifesting as acute clinical deterioration. Because existing reports of this entity are limited, the object of this study was to describe the presentation and management of cyst degeneration in a relatively large series of patients.

Methods

For nine patients who were treated for cyst degeneration of craniofacial FD the following data were reviewed: demographic factors, clinical presentation, tumor type, computed tomography (CT) findings, surgical management, intraoperative findings, and histopathological findings.

Results

The mean age at tumor presentation was 14.9 years. Seven patients had received a diagnosis of FD before the acute changes of cyst degeneration occurred; this change occurred between 1 and 7 years after the initial diagnosis. The most common presenting symptoms were sudden mass enlargement (78% of patients) and pain (67%). No predisposing factor for cystic change was identified. Four patients presented with visual disturbance; blindness developed in two despite optic nerve decompression. Cyst degeneration occurred most commonly in the sphenoid and frontal bones. The cysts' appearance ranged from a simple lesion to aneurysmal bone cyst.

Conclusions

Cyst degeneration may occur spontaneously within the FD lesion years after the initial diagnosis. Evaluation with CT scanning remains effective in the diagnosis and monitoring of disease progression, and in treatment planning. Surgical intervention is indicated for patients with symptoms or functional impairment. Optimal management of this entity has been facilitated through careful collaboration between neurosurgeons and plastic surgeons.

Thyroid disease in patients with McCune-Albright syndrome

Involvement of the thyroid gland in the McCune-Albright Syndrome (MAS) is a common and sometimes overlooked feature of this disorder. The characteristics of the thyroid in MAS include isolated or combinations of generalized inhomogeneity, cystic and/or nodular features coupled with functional abnormalities. While most often the pathology is diffuse, it is rarely associated with compressive symptoms and signs. The functional abnormalities, which are seldom observed in the absence of underlying echographic structural changes, are characterized by autonomous function, frequently with a shifted T3/T4 ratio, suggesting an increase in intra-thyroidal conversion of the pro-hormone T4 into the active metabolite T3. While MAS-associated thyrotoxicosis is not always symptomatic, it is often linked with increased morbidity, especially in the presence of underlying conditions requiring surgical intervention. Although thyroid cancer has been described in two cases of MAS, the prevalence of malignancy does not appear to be high. The therapeutic options in MAS involvement of the thyroid gland include thionamides, 131Iodine and surgery.

Persistent hyperestrogenism after precocious puberty in young females with McCune-Albright syndrome

In this review we report the literature about ovarian function of young women with McCune-Albright Syndrome and describe our personal experience in the follow-up of a small cohort.Collectively, the existing data demonstrate that ovarian hyperfunction with ovarian cysts and hyperestrogenism persists in those women who had precocious puberty. The recording of menstrual cycles and the analysis of gonadotropin and estrogen secretion indicate that, when hypothalamic-pituitary pubertal activation begins, alternating episodes of gonadotropin control and ovarian autonomy can be seen. The persistence of estrogen hypersecretion causes menstrual disturbances and hypofertility. The long term consequences of this condition are hypothesized to be an increased risk of ductal breast cancer, which seems to be higher when growth hormone hypersecretion is also present. Therefore, young MAS women should receive counseling regarding fertility and ongoing surveillance for the development of estrogen related diseases.

The pathology of fibrous dysplasia and the McCune-Albright syndrome

Fibrous dysplasia (FD) is the most serious and least understood clinical expression in patients with activating mutations of the GNAS gene. Since the discovery of the causative mutation, important progress has been made in the understanding of the pathology of FD and the pathogenesis of bone lesions. The histology of FD has been reinterpreted in light of the pathological effect of the genetic lesions on mutated skeletal stem cells. True histological hallmarks of the disease have emerged, along with genetic analysis, as additional tools to establish the correct diagnosis. Furthermore, the recognition of FD as a disease of excess, abnormal and imperfect bone formation has helped to explain relevant mechanisms of its clinical morbidity, based on which potential specific therapeutic approaches may be developed in the near future.

The spectrum of McCune Albright syndrome

Since the original description of McCune Albright syndrome, the clinical spectrum of fibrous dysplasia, café au lait marks and precocious puberty has been enlarged to include multiple features within an individual or forme fruste of the disorder. This review serves as an introduction to a more detailed analysis of individual organ involvement in later papers. Recent insights into molecular pathways and recognition of overlap between clinical syndromes and signaling pathways of embryonic cellular differentiation, growth and function of many tissues, has improved understanding of this complex disorder. The article touches briefly on the underlying stimulatory G protein mutations with their mosaic distribution in tissues. Fibrous dysplasia, associated malignancies and endocrinopathies are discussed, including gonadotrophin independent precocious puberty in females and males, thyroid disease, acromegaly and Cushing syndrome. Café au lait marks are an overlapping feature seen in other signaling disorders. Their management is discussed.

The role of stem cells in fibrous dysplasia of bone and the Mccune-Albright syndrome

Stem cells have become a major area of interest in the treatment of human disease, but more recently, stem cells have come to be appreciated as the cause of disease. Fibrous dysplasia of bone and the McCune-Albright Syndrome evolve from activating missense mutations in Gsalpha in pluripotent embryonic stem cells. The legacy of these mutations remains in a population of mutated multipotent post-natal skeletal stem cells ("mesenchymal" stem cells), which direct the formation of abnormal bone and a fibrotic marrow in fibrous dysplasia. Future therapeutic approaches for the treatment of fibrous dysplasia, the most significant component of the McCune-Albright Syndrome, will depend on a greater understanding of post-natal skeletal stem cell biology and how skeletal stem cells can be manipulated for efficient bone regeneration.

McCune-Albright syndrome in adulthood

The McCune-Albright syndrome is characterized by cafe-au-lait spots, precocious puberty and fibrous dysplasia. It is due to mutations in the gene encoding the Gs protein alpha subunit coupling 7-transmembrane-domain receptors to adenylate cyclase, leading to constitutive adenylate cyclase activation and cAMP overproduction. Endocrinologists, rheumatologists and gynecologists are confronted with new issues when these children reach adulthood. Dysplastic bone lesions seem to stabilize after puberty, but their disabling consequences (pain, fractures, etc.) may continue into adulthood. Gonadal function and fertility are often abnormal in women in whom puberty was precocious, owing to the persistence of a variable degree of ovarian autonomy that hinders adequate follicular development and ovulation. Acromegaly, when present, is often difficult to treat surgically because of skull-base dysplasia. Somatostatin analogs are only partially effective in most cases; fortunately, the GH receptor antagonist, pegvisomant may be more effective in normalizing IGF-I levels. Hyperthyroidism, generally due to multinodular toxic goiter, can be successfully treated by surgery or radioiodine administration. Recent data suggest that cancer incidence in adulthood (bone, breast, thyroid...) is increased in these patients.