Bone abnormalities in Gardner's syndrome

Benign Bone-Forming Tumors

Benign bone-forming tumors comprise osteomas, osteoid osteomas, and osteoblastomas. Osteomas affect a wide age range and are usually discovered incidentally. They occur predominantly in the craniofacial skeleton and are classically composed of compact bone. Osteoid osteomas and osteoblastomas are painful lesions occurring in young patients. They are morphologically similar and characterized by FOS gene rearrangement and c-FOS expression at a protein level. Osteoid osteomas are usually smaller than 2 cm in maximum dimension with limited growth potential; osteoblastomas are larger than 2 cm and may be locally aggressive. Histologically both are composed of anastomosing trabeculae of woven bone.

Osteomas involving the facial skeleton: a report of 2 cases and review of the literature

Osteomas are benign slow-growing tumors. These lesions are essentially restricted to the craniofacial skeleton and rarely diagnosed in other bones. The etiology is often multifactorial. It could be genetic or congenital, (Gardner syndrome) or related to endocrine disorders, chronic inflammatory processes, or traumas. In this work, the authors wanted to illustrate the correlation between the presence of multiple osteomas in the craniofacial skeleton and Gardner syndrome to underscore the importance of the role of the oral surgeon in the early identification of this pathology. Malignant evolution of intestinal lesions arising from Gardner syndrome can be avoided if diagnosed in an early stage. Two significant clinical cases are described and discussed. In the first one, a diagnosis of Gardner syndrome was made after colonoscopy.

Bone Lesions of the Head and Neck

This article describes the clinical, radiographic, and pathologic features of tumors and tumorlike lesions affecting the bones of the head and neck region. Emphasis is placed on common bone lesions affecting the craniofacial skeleton, particularly those that occur with more frequency or those that are unique to this part of the skeleton. Several of these lesions pose a diagnostic challenge to the pathologist. To ensure that a correct diagnosis is rendered, it is of utmost importance that accurate and detailed clinical and radiographic information is available.

Extra-abdominal desmoid tumors: a report of 234 cases

BACKGROUND/OBJECTIVES

To report on the clinical presentation and outcome for 234 patients with extra-abdominal desmoids tumors.

METHODS

Since 1977, the authors have treated 234 patients with extra-abdominal desmoid tumors. The patients had an average age of 36.7 and 61% were female. The tumors arose adjacent to muscles or bones and the largest number were in the foot, shoulder thigh and calf. All of the patients were treated by primary surgery. Thirty-seven had additional radiation and eight had chemotherapy.

RESULTS

Local recurrence occurred in 39 patients and 23% of the patients required additional surgery. Of great concern were 24 patients who developed multiple sites metachronously, which required further surgery and in many cases caused disability. None of the patients died of disease but 5 required amputations.

CONCLUSIONS

The authors concluded that despite the benign nature of the disease, these patients are difficult to treat and the results are sometimes considerably less than optimal.

Imaging of the calvarium

The skull vault consists of a multitude of flat bones held together by the cranial sutures. Radiologists encounter a vast array of calvarial pathologies that tend to cause abnormalities in thickness, abnormalities in density, focal defects, or an excess of soft tissue or bone tissue. Further anomalies related to the cranial sutures and fontanelles occur in the dynamic pediatric skull. The imaging features of the host of conditions resulting in these commonly detected calvarial abnormalities are reviewed and illustrated.

Gardner's syndrome: Genetic testing and colonoscopy are indicated in adolescents and young adults with cranial osteomas: A case report

We present a case of a 25-year-old female with diagnosed familial adenomatous polyposis and elevated carcinoembryonic antigen with negative family history. The suspicion of Gardner's syndrome was raised because extirpation of an osteoma of the left temporo-occipital region was made 10 years ago. Restorative procto-colectomy and ileal pouch anal anastomosis was made but histology delineated adenocarcinoma of the rectum (Dukes C stage). We conclude that cranial osteomas often precede gastrointestinal manifestations of familial adenomatous polyposis or Gardner's syndrome and such patients should be evaluated with genetic testing followed by colonoscopy if results are positive to prevent the development of colorectal carcinoma. If the diagnosis is positive all family members should be evaluated for familial adenomatous polyposis.

The concomitant occurrence of multiple epidermal cysts, osteomas and thyroid gland nodules is not diagnostic for Gardner syndrome in the absence of intestinal polyposis: a clinical and genetic report

Gardner syndrome, a phenotypic variant of familial adenomatous polyposis, is characterized by the classical clinical triad of skin and soft tissue tumours, osteomas and intestinal polyposis, but disease patterns with pairs of these findings have also been reported. Different mutations in the adenomatous polyposis coli (APC) gene have been shown to be associated with Gardner syndrome disease phenotypes. A 36-year-old patient presented with multiple epidermal cysts on the face, left ear lobe and neck, and the possible diagnosis of Gardner syndrome was based on the additional findings of two classical osteomas in the left radius and ulna and a cold non-malignant nodule of the thyroid gland. Intestinal polyposis was lacking at the time of examination. Major deletions but not microdeletions were excluded by a cytogenetic analysis with 650 chromosomal bands per haploid set. Systematic sequencing of the entire coding region of the APC gene (> 8500 bp) of the patient and five healthy controls was also performed. As a results, new APC gene polymorphisms were identified in exons 13 [A545A (A/G)] and 15 [G1678G (A/G), S1756S (G/T), P1960P (A/G)]. We also detected D1822V (A/T) which has recently been reported to be potentially related to colorectal carcinoma, and genotyped 194 randomly chosen healthy individuals from the Glasgow area for this as well as for the above variants in exons 13 and 15. Interestingly, of the 194 controls, 112 carried the DD (57.7%), 71 the DV (36.6%), and the remaining 11 (5.7%), including our patient, the VV genotype. It is therefore unlikely that APC D1822V serves as an important marker for colorectal carcinoma. In conclusion, we failed to identify obvious germline candidate mutations in > 8500 bp of the coding region of the APC gene in a patient with multiple epidermal cysts, osteomas and a thyroid gland nodule; major chromosomal deletions were excluded. Therefore, we assume that only the presence of intestinal polyposis is a marker for Gardner syndrome.

Gastrointestinal polyposis in childhood: clinicopathologic and genetic features

Gastrointestinal polyps and certain extraintestinal lesions in children may herald a hereditary polyposis syndrome, with an increased risk of neoplasia and other health problems for both children and their relatives. The availability of molecular/genetic screening tests has increased early diagnosis of younger members of known polyposis families. This article reviews the gross and microscopic features of polyposis syndromes of childhood and summarizes the molecular/genetic advances in this field. Clinical management is also briefly discussed.

Osteoma of the innominate bone with intraosseous and parosteal involvement

A case has been presented of a 47-year-old woman with a dense bony mass both within and on the surface of her right public ramus. This was discovered incidentally on plain radiographs of the pelvis. Besides osteoma, a differential diagnosis of parosteal osteosarcoma, ossifying parosteal lipoma, periostitis ossificans, osteochondroma with attenuated cartilage cap, and melorheostosis was considered. Histological evaluation of open biopsy samples showed typical findings of an osteoma. This is an unusual case of an osteoma with both parosteal and intraosseous involvement.

Exophytic variant of fibrous dysplasia (fibrous dysplasia protuberans)

Two cases of an exophytic variant of fibrous dysplasia (fibrous dysplasia protuberans) are reported in which the lesions protruded far beyond the normal bone contour mimicking surface lesions of bone. The first case was an 18-year-old man who had a pedunculated calcified mass of the sixth rib in association with radiologically diagnosed fibrous dysplasia of the skull. The second case was a 33-year-old man who had an exophytic lesion of the proximal tibia. Both of these patients were shown to have benign fibro-osseous lesions consistent with fibrous dysplasia. The intramedullary portions of the host bone adjacent to the exophytic masses also were involved by the fibro-osseous lesions and this fact suggests that the lesions may arise eccentrically in the medullary spaces and mainly grow outwards. It is important to be aware that fibrous dysplasia occasionally presents as an excrescence on the surface of bone. Careful radiographic and histological correlation is required to make a correct diagnosis of this rare variant of fibrous dysplasia.

Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations

The benign bone lesions--osteoma, osteoid osteoma, and osteoblastoma--are characterized as bone-forming because tumor cells produce osteoid or mature bone. Osteoma is a slow-growing lesion most commonly seen in the paranasal sinuses and in the calvaria. When it occurs in the long bones, it is invariably juxtacortical and may need to be differentiated from, among others, parosteal osteosarcoma, sessile osteochondroma, and a matured juxtacortical focus of myositis ossificans. Osteoid osteoma and osteoblastoma appear histologically very similar. Their clinical presentations and distribution in the skeleton, however, are distinct: osteoid osteoma is usually accompanied by nocturnal pain promptly relieved by salicylates; osteoblastoma arises predominantly in the axial skeleton, spinal lesions constituting one-third of reported cases. This review focuses on the application of the various imaging modalities in the diagnosis, differential diagnosis, and evaluation of these lesions. Their histopathology also is discussed, and their treatment briefly outlined.

Computed tomography of the jaws in familial adenomatosis coli

Familial adenomatosis coli is known to be associated with tooth impactions, odontomas, and osteomas. Three cases were examined by panoramic radiography and computed tomography. Computed tomography was especially useful for detecting osteomas in the maxilla and also revealed a wavy cortical thickening in the mandible in one instance. The latter finding has been reported for other bones in the body but not previously for the mandible.

Natural course of jaw lesions in patients with familial adenomatosis coli (Gardner's syndrome)

Twenty-three patients suffering from familial adenomatosis coli (FAC) were followed for an average of 7 years (0.11-16.11 years). In 22 patients, jaw lesions including osteomas and/or odontomas were present at the first examination. In 12 patients, some changes occurred; that is, the number and size of the lesions increased. These findings indicate that changes of jaw lesions in FAC patients occur gradually even in adulthood.

Clinical and radiological findings in Gardner's syndrome: a case report and follow-up study

Gardner's syndrome is characterized by colorectal adenomas, multiple osteomas, especially of the skull, and various soft-tissue tumours. The disease is inherited as an autosomal dominant disorder and all untreated patients will develop colorectal adenocarcinomas. Since the clinical and radiological stigmas in the maxillofacial area, such as exosteal and endosteal osteomas, skin cysts, atypical skin pigmentation and abnormal dental findings or radiopaque lesions can precede the often symptomless adenomas for many years, dentists, maxillofacial surgeons and radiologists should be familiar with the manifestations of this disease. A case is reported to illustrate the dentist's role in the diagnosis of Gardner's syndrome. In a follow-up study of 11 patients with colorectal adenomas, the typical triad of features of Gardner's syndrome was found in eight. In six patients, bony changes were demonstrated by panoramic radiography. It is proposed that radiography of the jaws may serve as a valuable tool for the early detection of carriers of Gardner's syndrome.

Skin and bones. I

Skin disorders in which a radiograph may detect associated bony changes or abnormalities of calcification are discussed. They are grouped into eight categories: (1) inherited diseases (e.g., alkaptonuria, neurofibromatosis); (2) congenital disorders (e.g., Sturge-Weber and Proteus syndromes); (3) inflammatory conditions (e.g., dermatomyositis, sarcoidosis); (4) infections (e.g., dental sinus, syphilis); (5) neoplasias (e.g., histiocytosis, mastocytosis); (6) drug- and environment-induced (e.g., acroosteolysis, retinoid toxicity); (7) calcinosis cutis; and (8) osteoma cutis. Part I of our review discusses the first two categories.

A review of the considerations in the diagnosis of limited mandibular opening

The purpose of this paper is to review the considerations of the dentist for the diagnosis of the patient who presents in his office saying, "I can't open my mouth, Doc." This condition is commonly referred to as trismus, or acute onset of limited mandibular opening. The causes of limited opening are reviewed by the authors. Various methods used in determining the limitation are explained. The general appearance features of each, along with etiologies, are listed.

Mandibular lesions in patients with adenomatosis coli

Adenomatosis coli is a very interesting disease accompanied by a number of associated stigmata in the mandible. If left ignored, colonic lesions in patients with this disease proceed almost entirely to malignancy. Hence, detection of the stigmata is very important. The panoramic radiographs of 26 patients diagnosed as adenomatosis coli at the 2nd Department of Surgery, Hamamatsu University School of Medicine from 1978 to 1988 were compared with those of 264 controls. Osteomatous lesions were present in 62% of the patients with adenomatosis coli and 14% of the controls. Pantomographic comparison of the numbers and areas of the osteomatous lesions between the adenomatosis coli and control groups indicated that specific pathognomonic symptoms were demonstrated in panoramic radiographs of approximately 42% of the patients with adenomatosis coli.

Widespread radiopacity of jaw bones in familial adenomatosis coli

Abnormalities of jaw bones and teeth were evaluated in 37 patients with familial adenomatosis coli (FAC) by means of orthopantomography. Osteomatous radiopaque lesions were evident in 75.7 percent of FAC patients (focal type: 62.2% and wide spread type: 13.5%), odontomes in 29.7% peripheral osteomas in 13.5%, unerupted teeth in 16.2% and supernumerary unerupted teeth in 16.2%. Five of the 37 FAC patients had an unusual widespread type of radiopacity with other abnormalities. Combined abnormalities were most frequent in patients with this type in comparison with patients with the focal type. Osteomas and peripheral osteomas were revealed in this type with statistical significance. Biopsy performed in one patient revealed an osteoma. These results suggest that the multiple abnormalities seen in oral X-ray examination may predict the occult existence of familial adenomatosis coli and these widespread radiopaque lesions probably represent the most extensive manifestation of FAC.

Multiple radiopaque masses in the jaws

In this report, the less common oral findings occurring in Gardner's syndrome are described, which occurred concurrently with colorectal polyposis. In addition, what clinically appeared as small intestinal polyps, microscopically represented nodular lymphoid hyperplasia, as reported in the literature. Review of the literature showed the oral findings reported here are not common and that enzyme assays can help detect polyps at an early stage of this complex syndrome.

Multiple cemental lesions in the jaw bones of a patient with Gardner's syndrome

Unusual multiple lesions of jaws in a middle-aged woman with all classic manifestations of Gardner's syndrome are reported. Clinical examination revealed a diffuse swelling of the mandible and maxilla with bone-like hardness and numerous radiopaque lesions scattered throughout both mandible and maxilla. Impaction of the molar teeth was revealed by roentgenographic examination. Histopathologically, the multiple jaw lesions consisted of trabecular proliferation of hard-tissue which more closely resembled cementum than immature bone or osteoid. It was found to be united with the cementum of tooth-roots through obliteration of the periodontal ligament. The present lesions do not fit into any of the distinct entities of cemental lesions described.

Orbital osteoma in Gardner's syndrome

A 30-year-old woman developed proptosis secondary to a left ethmoidal compact osteoma. At age 29 years, a mandibular eburnated (ivory) osteoma was excised. At age 25 years, multiple adenomatous polyps of the colon were resected. Her father, age 61 years, had multiple intestinal polyps and bilateral mandibular osteoma. A 24-year-old sister had an osteoma of the forehead. Gardner's syndrome is an autosomal dominantly inherited disorder characterized by intestinal polyposis, various skin and soft tissue tumors, and osteomas of the bony skeleton. Orbital osteomas occur rarely.

The Gardner syndrome. Significance of ocular features

Gardner syndrome is a dominantly inherited familial cancer syndrome characterized by intestinal polyposis, bony hamartomata, and various soft tissue tumors. The risk of malignancy during adult life is essentially 100%, but as yet no phenotypic marker nor biochemical or serological linkage have been useful to identify the presence of the gene in early life. We studied three families in which multiple and bilateral patches of congenital hypertrophy of the retinal pigment epithelium are related uniquely to other phenotypic features of the Gardner gene. This readily identifiable characteristic may be useful to identify early in life individuals at risk for malignancy. We also suggest that the Gardner syndrome may be genetically heterogeneous.

Gardner syndrome and periampullary malignancy

In a family with colonic polyposis and the typical associated findings of Gardner syndrome (osteomas and soft-tissue tumors), two and possibly four of the affected members developed periampullary malignancy. A review indicates that individuals with Gardner syndrome may have a 100- to 200-fold increased risk of developing periampullary carcinoma when compared to the general population. While certain families and certain individuals (those with other duodenal involvement, males and those with all of the characteristics of Gardner syndrome expressed) may be most susceptible, all patients with Gardner syndrome should be periodically endoscopically evaluated for the presence of upper gastrointestinal tract disease.

Gardner's syndrome and chondrosarcoma of the hyoid bone

There appears to be a total of five cases of chondrosarcoma of the hyoid bone (not all associated with Gardner's syndrome). The case reported herein is one that was first reported in the literature on Gardner's syndrome and the second reported instance of a patient with Gardner's syndrome who had a malignant bone tumor.

Clinical and roentgen features of the intestinal polyposis syndromes

The intestinal polyposis syndromes represent a challenging diagnostic problem for the radiologist. These syndromes include: familial multiple polyposis, Gardner's, Peutz-Jeghers, Turcot's, Cronkhite-Canada and juvenile polyposis. The polyposis syndromes can usually be differentiated from one another on the basis of the clinical history, examination of the mucocutaneous tissues and roentgen findings. Numerous other conditions, however, may mimmic a polyposis syndrome, and must be considered in the differential diagnosis.

The occult osteomatous changes in the mandible in patients with familial polyposis coli

Characteristic radio-opaque lesions were detected in the manibular bone, most clearly on the panoramic X-ray, in 27 or 93-2 per cent out of 29 cases in 15 families with familial polyposis coli, including 21 cases without Gardner's stigmata, 7 cases with the incomplete syndrome and 1 with the complete syndrome. Only 3 out of 19 members of these families who were free from polposis had radio-opaque jaw lesions. The cases with polyposis of other types also showed a negative result. The radiological diagnosis suggested that the lesions were of the character of endosteoma. Our observation is considered to be significant evidence in the understanding of the pathogenesis of Gardner's syndrome as well as a useful method of the early detection of carriers in the polyposis family.