Multiple familial pilomatricomas: a cutaneous marker for Gardner syndrome?

A rare case of Gardner syndrome in an African adult male: A case report

Gardner's syndrome with the complete manifestation of colonic and extracolonic features is uncommon. Therefore, every clinician should view extracolonic features with a high index of suspicion. This may be key to early diagnosis, definitive management in these patients and importantly, helps prevent malignant transformation of existing colonic polyps.

No Evidence of Abnormal Expression of Beta-Catenin and Bcl-2 Proteins in Pilomatricoma as One Clinical Feature of Tetrasomy 9p Syndrome

Background

Little is currently known about the genetics of pilomatricoma. A number of studies have reported some evidence that this disease may have a genetic association with mutations of CTNNB1 gene or expression of the beta-catenin protein. In this study, we reviewed literatures involving 30 patients with various genetic syndromes that have been linked to pilomatricoma and found that somatic mutations of the CTNNB1 gene were reported in 67% of patients. Pilomatricoma has been reported in patients with chromosome 9 rearrangements, including 4 patients with tetrasomy 9p syndrome and one patient with partial trisomy 9. In addition to beta-catenin, the expression of bcl2 was observed in pilomatricoma.

Objectives

To report an additional case of tetrasomy 9p syndrome with concurrent pilomatricoma and to examine whether abnormal protein expressions of the CTNNB1 and/or BCL2 genes were present.

Methods

Cytogenetic analysis was carried out on peripheral blood, biopsied skin, and pilomatricoma tissue obtained from a patient with tetrasomy 9p syndrome. Immunohistochemical staining was performed on the pilomatricoma tissue, using beta-catenin and bcl2 monoclonal antibodies.

Results

SNP microarray revealed nonmosaic gain of the short arm of chromosome 9. A nonmosaic isodicentric chromosome 9 was identified in the peripheral blood but this rearranged chromosome was detected in only 8.3% of the skin fibroblasts. Chromosomal abnormalities were not detected in the pilomatricoma nor expression of beta-catenin or bcl2 proteins in our patient.

Conclusion

Pilomatricoma could be a new clinical feature associated with tetrasomy 9p syndrome; however, we found no evidence of tetrasomy 9p or abnormal beta-catenin or bcl2 proteins of the CTNNB1 and BCL2 genes in our pilomatricoma patient.

A Novel Phenotype Combining Primary Ovarian Insufficiency Growth Retardation and Pilomatricomas With MCM8 Mutation

CONTEXT

Primary Ovarian insufficiency (POI) affects 1% of women aged <40 years and leads most often to definitive infertility with adverse health outcomes. Very recently, genes involved in deoxyribonucleic acid (DNA) repair have been shown to cause POI.

OBJECTIVE

To identify the cause of a familial POI in a consanguineous Turkish family.

DESIGN

Exome sequencing was performed in the proposita and her mother. Chromosomal breaks were studied in lymphoblastoid cell lines treated with mitomycin (MMC).

SETTING AND PATIENTS

The proposita presented intrauterine and postnatal growth retardation, multiple pilomatricomas in childhood, and primary amenorrhea. She was treated with growth hormone (GH) from age 14 to 18 years.

RESULTS

We identified a novel nonsense variant in exon 9 of the minichromosome maintenance complex component 8 gene (MCM8) NM_001281522.1: c0.925C > T/p.R309* yielding either a truncated protein or nonsense-mediated messenger ribonucleic acid decay.The variant was homozygous in the daughter and heterozygous in the mother. MMC induced DNA breaks and aberrant metaphases in the patient's lymphoblastoid cells. The mother's cells had intermediate but significantly higher chromosomal breaks compared with a control.

CONCLUSION

We describe a novel phenotype of syndromic POI related to a novel truncating MCM8 variant. We show for the first time that spontaneous tumors (pilomatricomas) are associated with an MCM8 genetic defect, making the screening of this gene necessary before starting GH therapy in patients with POI with short stature, especially in a familial or consanguineous context. Appropriate familial monitoring in the long term is necessary, and fertility preservation should be considered in heterozygous siblings to avoid rapid follicular atresia.

Syndromes associated with multiple pilomatricomas: When should clinicians be concerned?

BACKGROUND

Multiple pilomatricomas have been linked to various syndromes. However, these associations are poorly defined, leaving practitioners conflicted on management of these patients.

OBJECTIVE

To perform a comprehensive review to clarify the strength of these relationships and identify which patients may benefit from additional screening and/or genetic screening.

METHODS

A literature search was performed using the PubMed, Ovid, and Cochrane databases. Syndromic, familial, and sporadic cases of multiple pilomatricomas were stratified based on number of pilomatricomas. This information was graphed for visual comparison.

RESULTS

Sixty-six syndromic cases from 52 publications were identified, with the majority (54) of cases representing myotonic dystrophy, familial adenomatous polyposis-related syndromes (including Gardner syndrome), Turner syndrome, or Rubinstein-Taybi syndrome. Twenty-five of the 54 cases (46.3%) had six or more pilomatricomas. Of sporadic cases, 128 out of 134 (95.5%) had five or less pilomatricomas.

LIMITATIONS

Most articles were case reports and series, which are vulnerable to publication bias. Specific details were not explicitly noted in some original articles, and incomplete data could not always be included in analysis. Syndromes may have been missed in sporadic cases.

CONCLUSION

The presence of six or more pilomatricomas is highly suggestive of an underlying syndrome (>95% specificity). These patients should undergo additional screening. Patients with less than six pilomatricomas and family history of myotonic dystrophy, first-degree relative with colon cancer or FAP-related syndrome, or family history of pilomatricomas should also undergo further screening.

Multiple Pilomatricomas: A Retrospective Study and Literature Review

Pilomatricoma is usually a single lesion. However, some patients present with more than one, a fact that has been reported in association with several systemic diseases. The aim of this analysis is to determine the prevalence of multiple pilomatricomas (MP) in our institution as well as to describe their clinical features and associated comorbidities. This is a retrospective analysis reviewing patients with a histological diagnosis of pilomatricoma registered in the database of the Pathology Department of our institution, from January 2005 to March 2017. One hundred ninety-five patients with histological criteria for pilomatricoma were registered. Fourteen (0.7%) of those patients suffered from MP. Among them, the most relevant findings were: 9 (64%) patients were women and 5 (36%) were men. The median age at diagnosis was 16 years. Seven (50%) had 2 pilomatricomas and 7 (50%) had more than 2. Two (14%) suffered from Steinert myotonic dystrophy (SMD). Regarding family background, 3 of them had relatives with pilomatricomas, one of them with pancreatic cancer, and another one with SMD. A total of 36 pilomatricomas were excised from those 14 patients with the following characteristics: The mean lesion size was 12 mm. The majority of the lesions (53%) were located on the head and neck. There was no recurrence or malignant transformation in any patient. Articles reporting on MP are scarce. We communicate 2 new familial MP without associated comorbidities. We would like to highlight that 2 of our patients with MP also developed SMD, an association previously reported. Thus, a thorough physical examination and inquiring about family history are of utmost importance for an early diagnosis of possible associated diseases.

Childhood pilomatricomas: Associated anomalies

Pilomatricoma is a common benign tumor in children. We present a review of the literature with the aim of helping clinicians manage these patients. A detailed review of the literature was performed in the PubMed database using an exhaustive list of Medical Subject Heading words. One thousand four hundred fifty-eight children were described in retrospective series and case reports. An associated disease was found in 32 children (2.2%), most of whom had several pilomatricomas (n = 23); 9 had a single lesion. Based on this literature review, we recommend reassuring the family and then conducting a detailed interview regarding past medical and family history and a thorough clinical examination for signs of Turner syndrome, constitutional mismatch repair deficiency, Kabuki syndrome, Steiner's myotonic dystrophy, or Gardner syndrome. Regular long-term clinical follow-up is recommended. Specific paraclinical examinations should be performed only in cases of other clinical anomalies or a positive family history. Pilomatricoma requires management because it may be associated with other potentially serious diseases, especially when multiple lesions are present.

Multiple pilomatrixomas in a survivor of WNT-activated medulloblastoma leading to the discovery of a germline APC mutation and the diagnosis of familial adenomatous polyposis

Because children diagnosed with WNT-activated medulloblastoma have a 10-year overall survival rate of 95%, active long-term follow-up is critically important in reducing mortality from other causes. Here, we describe an 11-year-old adopted female who developed multiple pilomatrixomas 3 years after diagnosis of WNT-activated medulloblastoma, an unusual finding that prompted deeper clinical investigation. A heterozygous germline APC gene mutation was discovered, consistent with familial adenomatous polyposis. Screening endoscopy revealed numerous precancerous polyps that were excised. This case highlights the importance of long-term follow-up of pediatric cancer survivors, including attention to unexpected symptoms, which might unveil an underlying cancer predisposition syndrome.

Folliculosebaceous neoplasms: A review of clinical and histological features

Numerous benign and occasionally malignant tumors arise from the folliculosebaceous apparatus. Confusing terminology, rarity of malignant variants and overlapping histological features can lead to diagnostic uncertainty. This review highlights the clinical and histopathological features that help to classify these entities, as well as the various syndromes associated with certain members of this large family of tumors.

Orthokeratinized Odontogenic Cyst with an Associated Keratocystic Odontogenic Tumor Component and Ghost Cell Keratinization and Calcifications in a Patient with Gardner Syndrome

Gardner syndrome (GS) is caused by mutations in the APC and besides adenomatous colorectal polyps includes such manifestations as osteomas, epidermoid cysts (ECs) and occasionally multiple pilomatricomas. More than 50 % of ECs in patients with GS exhibit pilomatricoma-like ghost cell keratinization. The latter may be explained by the fact that the development of both GS and pilomatricoma is driven by activation of the Wnt/β-catenin signaling pathway. A 62-year-old, Caucasian male with history of GS presented with a unilocular, mixed radiopaque/radiolucent mandibular lesion causing divergence and external root resorption of involved teeth. Histopathologically, the lesion was composed of two cystic components, an orthokeratinized odontogenic cyst (OOC) and a smaller one with characteristics of keratocystic odontogenic tumor (KCOT) featuring, focally, ghost cells and an epithelial morule-like structure. Dystrophic calcifications essentially similar to those seen in pilomatricomas were observed in the fibrous connective tissue wall. The KCOT and OOC epithelia revealed strong and diffuse cytokeratin (AE1/AE3) and β-catenin immunoreactivity. CD10 positive immunostaining was seen in the keratin and superficial spinous cell layers in both OOC and KCOT. The intraepithelial and mural ghost cells showed a cytokeratin (+), β-catenin and CD10 (-) immunophenotype. The diagnosis of OOC with ghost cell calcifications in association with KCOT was rendered. The patient was lost to follow-up. Although a coincidental co-existence cannot be excluded, ghost cell calcifications mimicking pilomatricoma-like changes in an unusual odontogenic cyst combining OOC and KCOT features as seen in this patient with GS may be explained by the common molecular mechanisms underlying the pathogenesis of cutaneous pilomatricomas and GS.

Common Pediatric Skin Lesions: A Comprehensive Review of the Current Literature

The timely diagnosis and treatment of dermatologic disease in the pediatric population can be challenging. A basic, yet comprehensive knowledge of common lesions is essential for a successful practice in plastic surgery. In this article, the authors describe vascular, cystic, and pigmented cutaneous lesions that are commonly encountered in the pediatric population. Epidemiology, pathogenesis, clinical course, and management options are discussed for each.

External manifestations of Gardner's syndrome as the presenting clinical entity

Gardner's syndrome is an autosomal dominant disease characterised by the presence of colonic polyposis, osteomas and a multitude of soft tissue tumours. Pathological features such as osteomas of the mandible, skull and facial skeleton are unaesthetic as well as incapacitating. We present the case of a 22-year-old man with pain and discharge from the left eye and a firm swelling in the left infraorbital region leading to proptosis of the left eye. A detailed examination of the patient led to the presence of a large osteoma in the left orbital region, multiple cystic lesion, corneal opacity and parapapillary atrophy in the left eye. Radiography revealed the presence of multiple unerupted supernumerary teeth and osteomas. Colonoscopic findings showed the presence of multiple polyps. Thus, external manifestations of the patient's facial region led to the establishment of the diagnosis of Gardner's syndrome. The importance of our case highlights the necessity of maintaining a high vigilance with regard to the occurrence of such an entity.

Multiple eruptive pilomatricomas in a 9-year-old boy with glioblastoma

A 9-year-old male presented to our dermatology clinic with a recent history of developing numerous cutaneous pilomatricomas, and was subsequently discovered to have sustained a recurrence of his glioblastoma multiforme. Immunohistochemical staining of a representative pilomatricoma and his original brain tumor revealed upregulation and nuclear localization of beta-catenin, a sign associated with poor prognosis in glioblastoma. We hypothesize that the development of multiple pilomatricomas may have been a hallmark of this patient's tumor recurrence and provide support for a recent report of an association between multiple pilomatricomas and gliomatosis cerebri.

Characterizing pilomatricomas in children: a single institution experience

BACKGROUND/PURPOSE

Pilomatricomas, or calcifying epitheliomas of Malherbe, are among the most common superficial cutaneous soft tissue lesions in children. Familiarity with the presenting signs and symptoms allows for the diagnosis to be made on physical examination alone in most patients, avoiding expensive and unnecessary diagnostic imaging.

METHODS

A retrospective IRB-approved review of surgical pathology archives and medical records of all patients undergoing excision of pilomatricomas between 1982 and 2010 was performed to determine the characteristics of the pilomatricoma tumors. Data regarding gender, age, location, size of tumor, and histopathology were collected.

RESULTS

There were 916 pilomatricomas resected in 802 patients. Fifty-five percent of the patients were girls (441 patients). The median age at the time of resection was 6 years (range 5 months to 18 years). Multiple lesions were found in 43 patients (5%). The most common location was head and neck (n = 529, 58%), followed by upper limbs (n = 214, 23%), trunk (n = 130, 14%), and lower limbs (n = 43, 5%). Information on size was available for 674 lesions; mean lesion diameter was 14.0 ± 7.4 mm. Twenty-eight patients (3%) had either recurrent (n = 11) or metachronous (n = 17) lesions resected at our institution, with a median interval of 12 months after initial resection (range 5 weeks to 5 years). No cases of pilomatrix carcinoma were observed.

CONCLUSION

The majority of pilomatricomas occur in the head and neck, although they can present in any location. Approximately 5% of children have multiple lesions. Pilomatricomas occur slightly more commonly in girls, and 66% of lesions occur in children < 10 years of age. Complete surgical excision is necessary to prevent recurrence. Recurrences and pilomatrix carcinoma are very rare if complete excision is achieved.

Multiple pilomatricomas in Kabuki syndrome

Pilomatricoma is a benign tumor of the hair matrix cell that presents predominantly in childhood. Although pilomatricoma occurs spontaneously, multiple pilomatricomas have been described in association with several inherited syndromes. We report on a 28-year-old man with Kabuki syndrome with three pilomatricomas in his head and thigh. Although several reports describe multiple pilomatricomas associated with Turner syndrome, there are no reports of multiple pilomatricomas combined with Kabuki syndrome. Ectodermal abnormalities such as hair abnormality and hirsutism are symptoms of Kabuki syndrome, and pilomatricomas are frequently associated with the mutations of beta-catenin in hair follicle development. The predisposition of pilomatricomas may be not merely a coincidental finding, but an added association with Kabuki syndrome.

Correlates of tumor development in patients with myotonic dystrophy

Patients with myotonic dystrophy (DM) have recently been reported to be at increased risk of tumor development, but clinical associations related to this observation are unknown. We calculated the odds ratios (ORs) and 95 % confidence intervals (CI) of self-reported tumor development by patients' demographic and clinical characteristics to evaluate factors associated with tumor development in DM patients, using data from the National Registry of Myotonic Dystrophy and Facioscapulohumeral Dystrophy Patients and Family Members. Of the 911 participants, 47.5 % were male and 85.7 % had DM type 1 (DM1). Compared to DM1, patients with DM type 2 (DM2) were older at registry enrollment (median age 55 vs. 44 years, p < 0.0001) and at DM diagnosis (median age 48 vs. 30 years, p < 0.0001); and more likely to be females (p = 0.001). At enrollment, 95 (10.4 %) DM patients reported a history of benign or malignant tumor. Tumors were associated with female gender (OR 1.9, 95 % CI 1.2-3.1, p = 0.007) and DM1 (OR 2.1, 95 % CI 1.1-4.1, p = 0.03). In a subgroup analysis of patients with blood-based DNA testing results (397 DM1, 54 DM2), repeat expansion size was not associated with tumor risk in DM1 (p = 0.26) or DM2 (p = 0.34). In conclusion, female gender and DM1 subtype, but not DNA repeat expansion size, were associated with increased risk of tumors in DM. Follow-up studies are warranted to determine if oncogenes associated with dystrophia myotonica-protein kinase are altered in DM, and to determine if repeat expansion size, as in our study, is not associated with tumor development.

Familial multiple pilomatrixomas as a presentation of attenuated adenomatosis polyposis coli

Pilomatrixomas are benign follicular tumors that occur most commonly in children. Rare multiple or familial pilomatrixomas have been associated with myotonic dystrophy and other disorders. Although sporadic pilomatrixomas and hybrid cutaneous cysts with pilomatrixoma-like features have been observed in some kindreds with Gardner syndrome, an autosomal dominant form of familial adenomatous polyposis, no definitive association has been made with multiple or familial pilomatrixomas. Here we describe two siblings with multiple pilomatrixomas who were also found to have a family history of colonic adenocarcinoma. Genetic testing revealed a mutation in the 5' portion of the adenomatous polyposis coli (APC) gene, in a region associated with an attenuated APC phenotype. These findings show that multiple pilomatrixomas may be the presenting symptom of patients with APC gene mutations.

Prevalence of skin lesions in familial adenomatous polyposis: a marker for presymptomatic diagnosis?

BACKGROUND AND AIMS

Benign skin tumors such as lipomas, fibromas, and epidermal cysts are among the extracolonic manifestations of familial adenomatous polyposis (FAP). Readily detectable by inspection, they could serve as presymptomatic diagnostic markers to identify FAP patients. We therefore prospectively determined the prevalence of cutaneous lesions in genetically confirmed adenomatous polyposis coli (APC) mutation carriers and assessed their potential usefulness in the identification of FAP patients.

METHODS

Whole-skin examination was performed in 56 adult APC mutation carriers, compared with a control group (n = 116). In addition, FAP patients were investigated for the presence of congenital hypertrophy of the retinal pigment epithelium (CHRPE), an established clinical marker for FAP, and a detailed review of medical records was performed.

RESULTS

Nearly half of all FAP patients (48.2%) had at least one FAP-associated skin lesion, compared with one third (34.5%) of controls. Only multiple lipomas and combined skin lesions were significantly more prevalent in APC mutation carriers. CHRPE was observed in 22 (43.1%) of 51 FAP patients, including 14 (37.8%) of 37 individuals with APC mutations outside the CHRPE-associated region between codons 311 and 1465.

CONCLUSIONS

Despite a significantly higher prevalence of multiple lipomas, occurring at younger age, and combined skin lesions in APC mutation carriers, the low diagnostic sensitivity of FAP-associated skin lesions precludes their use as markers for FAP in clinical practice. Based on our findings, the common CHRPE-associated region should be extended to APC codons 148-2043.

Multiple large pilomatricomas in the setting of diffuse epidermal nevi

Epidermal nevi are hamartomas arising from the embryonic ectoderm during early embryonic stages, resulting in cutaneous mosaicism. We describe a patient with diffuse epidermal nevi and multiple large pilomatricomas arising near or within epidermal nevi.

Epithelioma of Malherbe: new ultrasound patterns

Backround

Calcifying epithelioma of Malherbe, or Pilomatricoma, is considered an uncommon cutaneous neoplasia, normally occurring in children as a solitary, firm, asymptomatic, hard, subcutaneous, slowly growing nodule on the face, neck, or proximal upper extremity. In literature, two Pilomatricoma ultrasound patterns are described: the totally calcified nodule and the hypoechoic nodule with internal calcific foci. High frequency ultrasound has not yet been applied for routine diagnosis of Pilomatricoma. The aim of the study was to retrospectively identify specific ultrasound features.

Methods

We retrieved 124 histologically Pilomatricoma cases: 28 patients with 32 lesions were preoperatively evaluated with ultrasound.

Results

22/32 have shown a solid formation, hypoechoic, with a sharp outline. Of these 22, 10 lesions were completely calcifying and 12 partially calcified. In 3/32 lesions with uncertain diagnosis, ultrasounds showed a complex/mixed pattern with pseudo-fluid areas and microspots. 7/32 lesions with US different diagnosis included 3 complex lesions, 2 cystic lesions and 2 solid nodular lesions.

Conclusion

In addition to well-known ultrasound patterns (completely calcified and partially calcified) we identified three new, not yet described, patterns that constitute the 31% of the cases: complex, pseudocistyc and pseudotumoral.

Pilomatricomas: the diagnostic value of ultrasound

OBJECTIVE

The purpose of this study was to analyze statistically significant diagnostic factors for pilomatricoma on the basis of ultrasonographic features.

METHODS

Sonographic images were retrospectively reviewed from 44 pilomatricomas, and from 43 control subjects with other subcutaneous tumors. Two radiologists determined the tumoral shape, margin, echotexture, echogenicity, posterior shadowing, posterior enhancement, hypoechoic rim, internal calcification, and vascularity.

RESULTS

The reliable diagnostic factors for pilomatricoma were hypoechogenicity (P < 0.001), heterogenicity (P < 0.05), internal calcification (P < 0.001), hypoechoic rim (P < 0.001), and posterior shadowing (P < 0.001). Scattered dots were the most common patterns of internal calcification. A combination of hypoechogenicity, heterogenicity, internal calcification of scattered-dot pattern, and a hypoechoic rim was a statistically significant difference between the two groups (P < 0.001; odds ratio, 21).

CONCLUSIONS

The features of heterogeneous echotexture, internal echogenic foci in scattered-dot pattern, and a hypoechoic rim or posterior shadowing itself could be discriminative ultrasonographic criteria for differentiating pilomatricomas from other subcutaneous tumors.

Expanded extracolonic tumor spectrum in MUTYH-associated polyposis

BACKGROUND & AIMS

MUTYH-associated polyposis (MAP) is characterized by a lifetime risk of colorectal cancer of up to 100%. However, no systematic evaluation of extracolonic manifestations has been reported.

METHODS

A large cohort of MAP patients was recruited from a European multicenter study. Data were collected on 276 cases from 181 unrelated families. Information on extracolonic tumor spectrum and incidence were evaluated to determine cumulative lifetime risk, which was compared with that of the general population to obtain standardized incidence ratios (SIRs).

RESULTS

Duodenal polyposis occurred in 17% of cases; the relative risk (SIR) of duodenal cancer was 129 (95% confidence interval [CI]: 16-466), whereas the lifetime risk was 4%. The incidence of extraintestinal malignancies among cases was almost twice that of the general population (SIR: 1.9; 95% CI: 1.4-2.5), with a lifetime risk of 38%. We observed a significant increase in the incidence of ovarian, bladder, and skin cancers (SIR: 5.7, 7.2, and 2.8, respectively) and a trend of increased risk of breast cancer among cases. The median ages of onset of these 4 malignancies ranged from 51 to 61 years. In contrast to familial adenomatous polyposis, no desmoid tumors were observed, but sebaceous gland tumors, characteristic of the Muir-Torre variant of Lynch syndrome, occurred in 5 patients.

CONCLUSIONS

The relative risks for several extraintestinal malignancies increased in patients with MAP, but based on the spectrum of cancers (which overlaps with that of Lynch syndrome) and the relatively advanced age at onset, intensive surveillance measures other than frequent endoscopy are unlikely to be helpful to patients with MAP.

Hypothesis: neoplasms in myotonic dystrophy

Tumorigenesis is a multi-step process due to an accumulation of genetic mutations in multiple genes in diverse pathways which ultimately lead to loss of control over cell growth. It is well known that inheritance of rare germline mutations in genes involved in tumorigenesis pathways confer high lifetime risk of neoplasia in affected individuals. Furthermore, a substantial number of multiple malformation syndromes include cancer susceptibility in their phenotype. Studies of the mechanisms underlying these inherited syndromes have added to the understanding of both normal development and the pathophysiology of carcinogenesis. Myotonic dystrophy (DM) represents a group of autosomal dominant, multisystemic diseases that share the clinical features of myotonia, muscle weakness, and early-onset cataracts. Myotonic dystrophy type 1 (DM1) and myotonic dystrophy type 2 (DM2) result from unstable nucleotide repeat expansions in their respective genes. There have been multiple reports of tumors in individuals with DM, most commonly benign calcifying cutaneous tumors known as pilomatricomas. We provide a summary of the tumors reported in DM and a hypothesis for a possible mechanism of tumorigenesis. We hope to stimulate further study into the potential role of DM genes in tumorigenesis, and help define DM pathogenesis, and facilitate developing novel treatment modalities.

Pilomatricomas in Turner syndrome

Pilomatricomas are benign, cutaneous tumors of the hair matrix cells, which present predominantly in childhood. Although usually an isolated finding, they have been described in association with several inherited conditions. We report a 10-year-old girl with Turner syndrome who has two pilomatricomas, including one giant tumor. In combination with a previous report of pilomatricoma in two patients with Turner syndrome, our observation indicates that it is likely a real, although uncommon, association of pilomatricomas with Turner syndrome exists. This apparent predisposition may be etiologically related to the abnormalities of hair-bearing skin observed in Turner syndrome. Doctors involved in the diagnosis and management of cutaneous masses in children should be aware of this association.

Lessons from the skin--cutaneous features of familial cancer

As the molecular basis of disease continues to be elucidated, familial cancer syndromes, which consist of a range of neoplastic and non-neoplastic features, are emerging. The usual pathway of referral to a genetics clinic or familial cancer centre is via an oncologist, when high-risk features that suggest a possible hereditary basis for the presenting cancer are recognised. Traditionally, these high-risk features include more than two family members with similar cancers over two or more generations, a young age of onset, and more than one synchronous or metachronous tumour. These features are effective in ascertaining a substantial proportion of families with hereditary breast and ovarian cancer due to a BRCA mutation, or the more common bowel-cancer predisposition syndromes, such as hereditary non-polyposis colon cancer and familial adenomatous polyposis. However, there are a range of familial cancer syndromes that are not easily detected and that can remain undiagnosed when history and examination are not extended to include non-malignant features. The identification of cutaneous signs associated with rare familial-cancer syndromes provides individuals and their families with the opportunity to undertake early surveillance for malignant and non-malignant complications that might in time be shown to improve outcomes.

Multiple giant pilomatricoma in familial Sotos syndrome

Cerebral giantism or Sotos syndrome consists of a pre- and postnatal overgrowth whose genetic basis are mutations and deletions of the nuclear receptor-binding SET domain containing protein gene. These patients have an increased risk of developing neoplasms, especially in adulthood. We report a 9-year-old boy, diagnosed with familial Sotos syndrome, who had two pilomatrixoma, symmetrically located on both sides of the neck, measuring 4 cm in diameter. Genetic study of the tumor tissue showed deletion of exon 22 of the NSD1 gene, whereas beta-catenin gene mutations were not detected. To the best of our knowledge, presentation of multiple pilomatricomas with Sotos syndrome has never been reported. Therefore their association probably is incidental. Nevertheless, the unusual size of our patient's pilomatricomas could be due to deletion of the NSD1 gene, which characterizes Sotos syndrome.

Germline mutation prevalence in the base excision repair gene, MYH, in patients with endometrial cancer

Germline mutations in the base excision repair gene, MutY human homolog (MYH), have recently been associated with a recessively inherited multiple adenoma polyposis syndrome and colorectal cancer. The spectrum of extracolonic lesions is still being characterized, although preliminary reports suggest that bi-allelic mutation carriers may share some of the clinical features of other hereditary colon cancer syndromes. Of 225 endometrial cancer patients, we identified one individual as a compound heterozygote, carrying mutations Y165C and G382D of MYH, and five individuals with heterozygous defects (three G382D and two Y165C). The patient with the bi-allelic Y165C/G382D mutation also had a sebaceous carcinoma, a feature of Muir-Torre syndrome. Although several intronic polymorphisms were detected in the heterozygous carriers, no other pathogenic variants were identified. While not conclusive, this novel and interesting finding provides evidence that bi-allelic germline mutations in MYH may increase susceptibility to endometrial cancer.

Diagnosis and management of benign lumps and bumps in childhood

PURPOSE OF REVIEW

In every pediatric practice, skin disorders make up a large percentage of outpatient visits. In this article, we highlight three of the most common 'lumps and bumps' seen in childhood: nevus sebaceus, pilomatricoma and juvenile xanthogranuloma.

RECENT FINDINGS

Historically, many authors have advocated the prompt removal of nevus sebaceus at a young age due to the risk of malignant growths arising in these lesions during childhood. Recent articles have revisited this issue, concluding that the actual incidence of malignant growths in nevus sebaceus is quite rare in young patients. Regarding pilomatricomas, new findings show that the clinical accuracy of primary care physicians in diagnosing a pilomatricoma is low. With the identification of several key features, these lesions can be more easily diagnosed. Finally, the association of juvenile xanthogranuloma with neurofibromatosis and chronic juvenile myeloid leukemia has been described more formally in the recent literature, but the incidence and true association of this triad remain debatable.

SUMMARY

Several updates in the recent literature now afford greater understanding of these three benign pediatric tumors. With greater familiarity, an accurate diagnosis can often be made in the office and informed counseling regarding the risks or associations of these specific skin lesions can be performed.

Intraosseous pilomatricoma: a possible rare skeletal manifestation of Gardner syndrome

Here we report a case of intraosseous pilomatricoma in a patient with Gardner syndrome. A 17-year-old boy with a family history of Gardner syndrome and multiple cutaneous epidermoid cysts presented with pain in the region below the knee of the left leg. Plain radiographs displayed a well-circumscribed eccentric lesion of mixed radiolucent and radiopaque density within the diaphysis of the left proximal tibia. By magnetic resonance (MR) imaging, the lesion appeared as a low intensity lesion in T1-weighted images and a heterogeneous high intensity lesion with a low-signal radiation pattern on T2-weighted images. Gadolinium enhancement was observed partially within the lesion and intensely in the lesion rim. After curettage, histological examination revealed a massive accumulation of keratinous material with epithelial nests that displayed both epidermal and trichilemmal keratinization with basaloid and shadow cells and with metaplastic ossification. These features confirmed a pathological diagnosis of intraosseous counterpart of pilomatricoma. In the context of this patient's skin lesions, intraosseous pilomatricoma may be a rare skeletal manifestation of Gardner syndrome.

Pilomatricoma of the Maxillofacial Area in the Northern Regional Jordanian Population: Report of 31 Cases

PURPOSE

To analyze the clinicopathologic features of pilomatricoma affecting the maxillofacial area in Jordanians.

PATIENTS AND METHODS

Records of the Department of Pathology at Jordan University of Science and Technology were reviewed for patients with biopsied pilomatricoma of the maxillofacial region received during the 11-year period extending between 1991 and 2001. These were retrieved, reviewed, and analyzed for age, gender, location, clinical features, and treatment.

RESULTS

There were 31 cases with an age range from 4 to 48 years (mean, 16.7). The majority (74%) of patients were in their first (45%) and second (29%) decades of life with a male to female ratio of 1 to 1.4. The periorbital (36%), the periauricular (28%), and the upper cervical region (23%) were the affected areas. The majority of cases presented as a painless skin nodule with a duration varying from 2 months to 3 years. The majority (97%) of tumors were between 0.5 cm and 2 cm in diameter. Histologically, almost 50% of tumors showed shadow cells alone. All tumors were removed surgically.

CONCLUSIONS

The clinicopathologic characteristics of pilomatricoma of the maxillofacial area in Jordanians are similar generally to those in other countries. Maxillofacial surgeons need to be more aware of this lesion and should consider it in the differential diagnosis of dermal masses they encounter.

A kindred with MYH-associated polyposis and pilomatricomas

MYH-associated polyposis (MAP) is a recently described autosomal recessive form of familial adenomatous polyposis (FAP) associated with susceptibility to colorectal carcinoma (CRC). MAP is caused by biallelic inactivating mutations of the MYH gene, a component of the base excision repair (BER) machinery, whose dysfunction leads to an increase in the rate of G > T transversions following DNA oxidative damage. MAP patients can present with either classic or attenuated polyposis. However, the MAP colonic and extracolonic phenotype has yet to be defined. We report on two siblings, born from consanguineous parents, who were found to be homozygotes for an MYH frameshift mutation. The propositus presented with a low number of colonic lesions and an early-onset CRC. Both siblings had a history of pilomatricomas, benign tumors derived from hair follicles, in childhood. The findings presented provide further evidence of phenotypic variability in MAP, and suggest that multiple pilomatricomas may be a useful cutaneous marker of MAP.

Pilomatrix carcinomas contain mutations in CTNNB1, the gene encoding beta-catenin

Mutations in beta-catenin are present in benign pilomatrixomas. beta-catenin is a downstream effector in the WNT-signalling pathway, acting as a signal for differentiation and proliferation. Mutations in CTNNB1, the gene encoding beta-catenin, are present in a wide variety of benign and malignant neoplasms. We examined beta-catenin in a series of pilomatrix carcinomas (15 cases) by using immunohistochemistry and DNA sequencing of exon 3 from CTNNB1, and compared these to a series of benign pilomatrixomas (13 cases). All 11 pilomatrix carcinomas available for examination showed nuclear localization of beta-catenin and mutations in exon 3 similar to those demonstrated in benign pilomatrixomas. Two of 11 pilomatrix carcinomas showed significant nuclear accumulation of p53, whereas this was absent in all 13 benign pilomatrixomas. Expression of nuclear cyclin D1 was similar in both benign pilomatrixomas and pilomatrix carcinomas. Clinical follow-up from the 15 malignant cases reported in this study and by others indicates that wide excision offers superior control of local recurrence, compared to simple excision. Immunohistochemical and molecular analysis of beta-catenin reveals that both pilomatrix carcinomas and benign pilomatrixomas harbour mutations in beta-catenin. This implies a common initial pathogenesis and is compatible with the proposition that pilomatrix carcinomas may at least on occasion arise from their benign counterparts.

Hereditary cancer syndromes of the skin

Hereditary cancer syndromes are a group of disorders characterized by a genetic susceptibility to the development of malignant tumors. Multiple cancers in the family or an abnormally early onset for the given cancer may suggest an underlying inherited predisposition. Awareness of their associated dermatologic manifestations can facilitate early detection of risk for neoplasms. This article provides an update on the clinical features, diagnostic criteria, and the use of genetic analysis in the detection of causative mutations of those hereditary cancer syndromes with cutaneous manifestations.