HEREDITARY CUTANEMOMANDIBULAR POLYONCOSIS. A SYNDROME OF MYRIAD BASAL-CELL NEVI OF THE SKIN, MANDIBULAR CYSTS, AND INCONSTANT SKELETAL ANOMALIES

Ameloblastoma: a neglected criterion for nevoid basal cell carcinoma (Gorlin) syndrome

Ameloblastomas are considered to be aggressive and locally invasive neoplasms derived from odontogenic epithelium with a tendency for recurrence and bone destruction. Although the relationship between nevoid basal cell carcinoma syndrome (NBCCS) and ameloblastoma is less frequent, it might constitute a peculiar stigmata of this hereditary disorder. The objective of the current study was to evaluate whether a combined clinical and biomolecular approach could be useful for the identification of NBCCS among patients with a diagnosis of ameloblastoma. The authors collected ameloblastoma tumors recorded in the databases of the Pathology Departments of the University of Modena during the period 1991-2011. Family trees were drawn for all 41 patients affected by these specific odontogenic tumors. Two patients with ameloblastoma were also affected by multiple basal cell carcinomas and odontogenic keratocysts tumors (OKCTs) achieving the requested clinical criteria for the diagnosis of NBCCS. The clinical diagnoses were confirmed by the identification of two different novel PTCH1 germline mutations (c.2186A > T [p.K729 M]; c.931insA) in those unrelated patients. Clinical ameloblastoma findings can be used as screening for the identification of families at risk of NBCCS. Ameloblastomas diagnosis warrants the search for associated cutaneous basal cell carcinomas and other benign and malignant tumors related to NBCCS. Thus, we propose the inclusion of ameloblasoma as criterion for the identification of NBCCS.

[Calcification of the falx cerebri. A pathognomonic symptom of Gorlin-Goltz syndrome]

BACKGROUND

Gorlin-Goltz syndrome is an autosomal dominant disorder with variable penetration characterized primarily by keratocysts of the jaws, multiple basal cell carcinomas, skeletal abnormalities and intracranial calcifications.

METHOD

In this study, 4787 radiographs with occipitomental x-rays from the hospital archives for oral and maxillofacial surgery of the Christian Albrechts University Kiel were examined for calcifications in the area of the falx cerebri.

RESULTS

Four characteristic alterations in the falx cerebri could be assigned to four groups of structures. Those in group 4 could be found only within Gorlin-Goltz syndrome patients, and differed significantly in form and extent from the remaining three groups.

CONCLUSION

The plurilamellar appearance of this group could be rated as a pathognomonic symptom of the Gorlin-Goltz syndrome.

Radiological features in 82 patients with nevoid basal cell carcinoma (NBCC or Gorlin) syndrome

PURPOSE

Nevoid Basal Cell Carcinoma Syndrome (NBCCS) is an autosomal-dominant disorder characterized by multiple basal cell carcinomas, jaw cysts, palmar/plantar pits, calcification of the falx cerebri, and spine and rib anomalies. NBCCS is due to mutations in PTCH1, the human homologue of the Drosophila segment polarity gene patched. Mutations are detected in approximately 60% to 85% of individuals tested by sequencing of PTCH1; therefore, clinical examination and x-rays remain important in diagnosis of NBCCS.

METHODS

We studied 82 NBCCS patients and 38 of their unaffected siblings at the NIH between 1985 and 1994. Chest, rib, spine, skull, hand and foot x-rays, brain MRI or CT, and pelvic ultrasound (in females) were obtained in the affected individuals and compared to their unaffected relatives.

RESULTS

The following features were significantly more frequent in those with NBCCS: calcification of the falx cerebri, the most frequent radiological feature, was present in 79% of patients > 20 years and in 37% <20 years, calcification of the tentorium cerebellum was present in 20%, bridging of the sella in 68%, and abnormal frontal sinus aeration in 18% of affected individuals. Bifid ribs most often involving the third, fourth, and fifth ribs were seen in 26%; splayed, fused, and misshapen ribs in a further 16%, and widened ends of clavicles in 12%. Spine X-rays revealed calcification of the nuchal ligament in 18%, fusion of vertebrae in 10%, and hemivertebrae in 15%. Flame-shaped lucencies of the metacarpals and/or phalanges were present in 30%, modeling deformities of the phalanges in 14%, and polydactyly of the feet in 4%. The frequency of scoliosis, cervical ribs, absent or rudimentary ribs, spina bifida occulta, or short 4th metacarpal was not higher in the affected individuals as compared to their unaffected relatives. Except for falx calcification, the frequency of radiological manifestations was similar in different age groups. Cranial CT or MRI in 42 affected individuals revealed asymmetric or dilated ventricles in 24%, cerebral atrophy in 10%, cavum septum pellucidum in 19%, dysgenesis or agenesis of the corpus callosum in 10%, and meningioma in 5%. Ovarian fibromas were detected in 17% of females.

CONCLUSIONS

This study reports the varied radiological manifestations of NBCCS. In the absence of major features such as basal cell carcinomas, jaw cysts, or falx calcification, which is often not evident until the teen years, other radiological manifestations of the disorder can permit early diagnosis of NBCCS in childhood. This will allow optimum surveillance for medulloblastoma and other neoplasms (cardiac fibromas and basal cell carcinomas) associated with NBCCS.

Examine your orofacial cleft patients for Gorlin-Goltz syndrome

The Gorlin-Goltz syndrome is characterized by four primary symptoms: multiple nevoid basal cell epitheliomas that usually undergo malignant transformation; jaw keratocysts that show constant growth; skeletal anomalies; and intracranial calcifications. A myriad of additional findings may also be noted. Among the most frequent are: palmar and plantar pits, a characteristic flattened facies and broad nasal root, frontal and parietal bossing, mandibular prognathia, hypertelorism, strabismus, dystrophia of the canthi, and clefts of the lip, alveolus, and/or palate. In this study, we review the literature and our 25 cases of Gorlin-Goltz syndrome patients, questioning their incidence of cleft formations (8.5%) as compared to the general population (0.1%). It is our contention that all patients who present with an orofacial cleft warrant deeper investigation as to the presence of additional signs indicative of Gorlin-Goltz syndrome. The nevi turn malignant with time, and thus, early diagnosis, follow-up, and treatment are imperative.

The prevalence of cervical and thoracic congenital skeletal abnormalities in basal cell naevus syndrome; a review of cervical and chest radiographs in 80 patients with BCNS

The major clinical stigmata of basal cell naevus syndrome (BCNS) appear in adolescence and adult life but some occult skeletal abnormalities are congenital. BCNS is dominantly inherited and it would be useful to identify, as early in life as possible, which of the offspring of patients with BCNS are at risk of developing the syndrome. Radiographs of the neck and chest of 80 patients with BCNS diagnosed confidently on clinical criteria have been examined for abnormalities which were considered to be congenital skeletal anomalies. Congenital abnormalities of the cervical and thoracic spine, mainly spina bifida occulta, were found in 45%. Congenital abnormalities of ribs were found in 49% and of the shoulder(s) in 36%. Overall congenital abnormalities were shown on the neck or chest radiograph in 55 (69%) patients. The presence of one or more of these congenital abnormalities on the chest or neck radiograph of a child who is the offspring of a person with BCNS makes it extremely likely that the child also has BCNS. The absence of these features, and of any clinical features of BCNS, would suggest that the risk of the child developing BCNS has been reduced from the prior expectation of 50% to approximately half that (24%).

Nevoid basal cell carcinoma syndrome associated with renal cysts and hypertension

A case of nevoid basal cell carcinoma syndrome with a coincidental finding is presented. In addition to the odontogenic cysts, hypertelorism, scapula deformity, rib fusion, dural calcification, and short fourth metacarpal bones of the syndrome, the patient had cystic disease of both kidneys with a large cyst of the right kidney. This case also illustrates that the presence of painful jaw lesions may lead the patient with this syndrome to seek treatment initially.

Variable expressivity of the multiple nevoid basal cell carcinoma syndrome

Four cases of multiple nevoid basal cell carcinoma syndrome are presented. No one component of the syndrome is present in all patients; instead, the many malformations associated with the syndrome have variable expressivity. The triad of jaw cysts, basal cell epitheliomas, and skeletal anomalies is well known, whereas other aspects, such as intracranial calcifications, hypertelorism, mental retardation, ectopic calcification, cleft lip and palate, cutaneous cysts, and palmar and plantar dyskeratosis, are more subtle and easily overlooked.

Familial basal cell nevus syndrome

The basal cell nevus syndrome is characterized by multiple basal cell nevi and basal cell carcinoma, cysts of the jaw, anomalies of ribs and spine, abnormal calcifications, and additional anomalies of the facial skull. A German family is described with manifestations of the syndrome in the mother and her three daughters. Expressivity was variable, in part due to age effects. The observation conforms to the assumed autosomal dominant mode of inheritance with high penetrance.

What is Gorlin's syndrome? The diagnosis and management of the basal cell naevus syndrome, based on a study of thirty-seven patients

A series of 37 patients with Gorlin's syndrome is described; 23 had the typical naevi, 19 had jaw cysts and only 10 had both. A wide range of associated deformities was noted. The need for early identification of patients at risk is stressed; follow-up is essential for 2 reasons: The naevi although indistinguishable histologically from basal cell carcinomas only rarely require radical removal. The jaw cysts are locally invasive and should be radically removed when small. In 8 patients examined there was a low level of alpha-globulins in the plasma. Spontaneous involution of the naevi may occur in un-irradiated skin.

Gorlin's syndrome

The uncommon familial syndrome of multiple odontogenic keratocysts, basal cell naevi and skeletal anomalies is reviewed, and seven cases are described, including one patient who developed squamous cell carcinoma in a previous odontogenic keratocyst of the maxilla. We wish to thank Consultants from the Royal National Throat, Nose and Ear Hospital, The Middlesex Hospital and the Eastman Dental Hospital, who allowed us access to their patients; Mr. D. Garfield Davies, Dr. M. F. Spittle, Mr. D. Winstock, Mr. H. P. Cook, Professor H. C. Killey and Mr. L. W. Kay. We are grateful to Professor L. Michaels and Mr. D. J. Connolly for preparation of the illustrations and to Mrs. A. Matthews for the typescript.