Turban Tumor Syndrome: In Search of a Gold Standard - A Case Report

Turban tumor syndrome (TTS) is a rare condition characterized by predisposition to developing multiple adnexal tumors. It is the rare autosomal dominant genodermatosis that is associated with the mutation of the CYLD suppressor gene. We herein report rare TTS in an adult who suffered from numerous episodic ulcerations of the scalp tumors and frequent bleeding following a minor trauma. The plain radiograms of the skull excluded bone marrow infiltration, and no regional lymphadenopathy was noted. The patient underwent total scalp excision and split skin grafting under general anesthesia in a single-stage operation. Recovery was uneventful. No recurrence was observed during the 2-year follow-up. Due to a high recurrence rate and risk of neoplastic transformation, surgery should be considered as the gold standard.

[Cylindromas-rare but striking]

Cylindromas are rare tumors of adnexal structures in adults. They are predominantly found on the scalp and face. More impressive than incidentally diagnosed solitary cylindromas are multiple tumors in patients with familial Brooke-Spiegler syndrome. If many large cylindromas appear on the head, they are termed turban tumor. Sudden growth or ulceration should raise suspicion for malignant transformation.

[Free latissimus dorsi flap lacing and local care in two-stage scalp reconstruction]

Surgical treatment of large and multiple lesions of irradiated scalp may require subtotal scalp exeresis and reconstruction in two-stage free flap surgery: harvesting and placing the flap first, then scalp removing and defect covering in a second step. This strategy raises the question of how to care the flap between the two surgeries. We report an original technique of free latissimus dorsi flap lacing. A 70-year-old male, afflicted with familial cylindromatosis and treated by brachytherapy 18years ago, received a free latissimus dorsi myocutaneous flap in two-stage surgery, allowing 25×25cm pathological scalp exeresis. During first step, suture clips were fixed in two rows around the future scalp defect, in order to be used as anchors for the flap lacing. Braided wire were chosen for a better steerability, and to prevent knots untightening. Thus, the flap were placed in "anatomical" place, next to the scalp, pending secondary procedure. This situation permitted to avoid flap or pedicle compression or plication, and to ease flap care. The wires were tighten as shoelaces, allowing them to be undone and done as desired. The two-stage free latissimus dorsi flap reconstruction of scalp large defect permitted us to assess the flap reliability before final reconstruction. The lacing solution allowed us regular local care and convenient flap handling, while favoriting its optimal placing next to its future location.

Phenotype-genotype correlations for clinical variants caused by CYLD mutations

Brooke-Spiegler syndrome (BSS; OMIM 605041) is an autosomal dominant condition characterized by skin appendageal neoplasms including cylindromas, trichoepitheliomas, and/or spiradenomas. In 1996, the gene locus for BSS was mapped to 16q12-13, and, in 2000, mutations in the cylindromatosis (CYLD) gene were determined to cause BSS, familial cylindromatosis (FC; OMIM 132700) and multiple familial trichoepithelioma type 1 (MFT1; OMIM 601606). The CYLD gene encodes an enzyme with deubiquitinase activity. To date, a total of 95 different diseases-causing mutations have been published for the CYLD gene. A summary of mutations identified in Hungarian patients and a review of previously published mutations are presented in this update. The majority of the sequence changes are frameshift (48%), nonsense (27%), missense (12%) and splice-site (11%) mutations; however, two in-frame deletions have also been reported. Most mutations are located in exons 9-20. Analysis of the identified CYLD gene mutations and the observed BSS, FC and MFT1 clinical phenotypes of the patients revealed significant genotype-phenotype correlations. Elucidation of these genotype-phenotype correlations is critical for the diagnosis of these rare monogenic skin diseases. In addition, characterizing these correlations may promote the understanding of their mechanisms and may hopefully contribute to the development of future therapeutic modalities.

Knowledge explosion for monogenic skin diseases

During the past few decades, the investigative tech-nologies of molecular biology - especially sequencing - underwent huge advances, leading to the sequencing of the entire human genome, as well as the identification of several candidate genes and the causative genetic variations that are responsible for monogenic skin diseases. These advances provided a solid basis for subsequent studies elucidating mechanisms of monogenic skin diseases and improving our understanding of common skin diseases. Furthermore, these discoveries also contributed to the development of novel therapeutic modalities for monogenic skin diseases. In this review, we have used the disease spectrum caused by mutations in the CYLD gene - Brooke-Spiegler syndrome, familial cylindromatosis and multiple familial trichoepithelioma type 1 - as a model for demonstrating the knowledge explosion for this group of diseases.