| Article Access Statistics|
| Viewed||744 |
| Printed||15 |
| Emailed||0 |
| PDF Downloaded||11 |
| Comments ||[Add] |
Click on image for details.
|LETTERS TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 595-598
Meningioma associated with Gorlin–Goltz syndrome and a short review of literature
Pritinanda Mishra1, Mounabati Mahapatra2, Mamita Nayak1, Bhagabati P Dash2, Susama Patra1
1 Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||13-May-2019|
Dr. Susama Patra
Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mishra P, Mahapatra M, Nayak M, Dash BP, Patra S. Meningioma associated with Gorlin–Goltz syndrome and a short review of literature. Neurol India 2019;67:595-8
Gorlin–Goltz syndrome (GGS) is a rare genetic disorder which can be inherited or occurs due to new mutations mostly involving the gene coding for protein patched homolog 1 (PTCH) protein. The syndrome has varied manifestations involving different systems. The estimated prevalence varies from 1 in 50,000 to 1:1,50,000 in the general population; however, the prevalence varies according to the country where the study has been carried out., Meningiomas are rarely associated with this syndrome, and till date, only 19 cases have been reported world-wide. To our knowledge, no such cases have been reported from India. Herein, we report a case of Gorlin-Gotz syndrome who developed a meningioma, which is a rare association with this syndrome.
A 50-year old female patient presented with headache and head-reeling for 1 year, and pain in the right lower jaw and right side of face for 3 months. Magnetic resonance imaging (MRI) of the brain showed an intense enhancement of the lesion as well as the adjacent enhancing dural tail, which was suggestive of a meningioma [Figure 1]. Extraoral examination revealed frontal bossing and mild facial asymmetry with a depressed nasal bridge [Figure 2]a and [Figure 2]b. Intraoral examination showed multiple carious teeth and their generalized attrition/abrasion. Orthopantomogram revealed multilocular radiolucencies involving the ramus, coronoid process, and body of the right mandible, which was suggestive of cystic lesions [Figure 2]c. Three-dimensional (3D) computed tomography (CT) of the maxilla and mandible showed multilocular radiolucencies in relation to the anterior portion of the right maxilla and ramus of the right side [Figure 2]d. Chest X-ray showed kyphoscoliosis and multiple bifid ribs [Figure 3]a. Contrast-enhanced CT (CECT) scan of the chest also demonstrated multiple bilateral bifid ribs involving the second to fifth rib [Figure 3]b. Complete hemogram revealed eosinophilia.
|Figure 1: Axial T2 weighted image (WI) (a) shows a broad-based, mildly hyperintense extra-axial lesion in the right basifrontal region. The lesion appears hypointense on T1WI; (b) Axial postcontrast T1WI shows an intense enhancement of the lesion as well as adjacent enhancing dural tail, (c) which was suggestive of a meningioma |
Click here to view
|Figure 2: (a and b) Frontal bossing and mild facial asymmetry with depressed nasal bridge; (c) Orthopantomogram shows a multiloculated radiolucent lesion in the right ramus and adjacent posterior aspect of the body of the mandible; (d) Axial CECT shows an expansile lytic lesion in the ramus of right mandible, extending up to the posterior aspect of adjacent part of the body of the mandible|
Click here to view
|Figure 3: (a) Chest X-ray showed kyphoscoliosis and multiple bifid ribs; (b) Volume-rendered image of the thorax shows bifid 2nd, 5th , 6th ribs on the right side and 2nd and 4th ribs on the left side|
Click here to view
The patient was referred to the neurosurgery department for her headache. A basifrontal craniotomy was done and the tumor was removed. The tumor was sent for histopathological examination. Macroscopic examination of the tumor revealed multiple fragments of grayish white tissue. Microscopically, the tumor was composed of neoplastic meningothelial cells arranged in lobules, whorls, and syncytium with numerous psammoma bodies [Figure 4]a,[Figure 4]b,[Figure 4]c, confirming a diagnosis of meningothelial meningioma, World Health Organization (WHO) grade-I. Her postoperative course was uneventful and she was discharged on the 7th postoperative day.
|Figure 4: (a) Neoplastic meningothelial cells in lobules and whorls; (b) Cyst lined by ulcerated, parakeratotic squamous epithelium with well-developed basal layer; (c) Underneath the epithelium, cholesterol clefts and foreign body giant cell reaction can be seen|
Click here to view
After 2 months, she was admitted in the dental department for treatment of her jaw cysts. Total enucleation with chemical cauterization was done under general anesthesia. Histopathological examination showed a cyst lined by ulcerated, parakeratotic squamous epithelium with a well-developed basal layer with hyperchromatic nuclei. The epithelial lining rested on the fibrous capsule, which was thickened and contained daughter cysts. Cholesterol clefts, calcification, lymphoplasmacytic infiltration, and foreign body giant cell reaction [Figure 4]b were present. The histomorphological features favoured a diagnosis of odontogenic keratocyst.
The presence of two major criteria (multiple odontogenic keratocysts and bifid ribs) and two minor criteria (kyphoscoliosis and meningioma) led to a diagnosis of GGS. A complete family history was taken, and a physical examination and further investigations were carried out. The family history was not suggestive of any abnormality in any other member of the family. Cutaneous lesions in the form of palmar or plantar pits or nevus were not seen. The ocular examination was within the normal limits. Ultrasonography of the abdomen and pelvis showed a small uterus with atrophic ovaries without any significant abnormality. Echocardiography was normal. The patient was on close follow-up for 12 months with no recurrence.
GGS was first described by Jarisch and White in 1894., Dr Robert Gorlin and Dr Robert Goltz delineated the different clinical features. The major and minor criteria for diagnosing this syndrome was proposed by Evans et al., in 1993), which was later modified by Kimonis et al., in 2004. The presence of two major and one minor or one major and three minor criteria is necessary to establish its diagnosis.,
The major criteria include multiple (>2) basal cell carcinomas (BCCs) or one occurring under 20 years of age; the presence of histopathologically proven keratocystic odontogenic tumor (KCOT) of the jaws, palmar or plantar pits (three or more), bilamellar calcification of the falx cerebri, bifid, fused, or markedly splayed ribs; and, first-degree relative with a nevoid BCC syndrome
The minor criteria include macrocephaly (following adjustment for height); the presence of congenital malformations like a cleft lip or palate, frontal bossing, coarse face, and moderate or severe hypertelorism; other skeletal abnormalities such as Sprengel deformity, marked pectus deformity, and marked syndactyly of the digits; radiological abnormalities such as bridging of the sella turcica, vertebral anomalies such as hemivertebrae, fusion, or elongation of the vertebral bodies, defects of the hands and feet, or flame-shaped hands or feet; an ovarian fibroma; and/or a medulloblastoma
In addition to these minor features, uncommon neoplasms such as a meningioma, ameloblastoma, squamous cell carcinoma, and odontogenic myxoma are also described. To our knowledge, till date in the Indian literature, 54, cases of GGS have been described and meningioma has not been documented in any patient. In addition, scoliosis of the spine, which is rarely reported in the Indian population, was also seen in our case. After an extensive literature search, only 19 cases of meningioma associated with GGS have been reported around the world [Table 1].,,,,,,,,,,,,,,,,,, The primary brain tumor that is commonly associated with GGS is medulloblastoma with a frequency of approximately 20%. Meningioma is reported less commonly. In a study by Kimonis et al., 5% patients were found to have radiological features of a meningioma. It is interesting to note that in the Indian literature, there is paucity of intracranial neoplasms in GGS compared to other parts of the world. This may be attributed to two reasons. First, this entity is poorly recognized and hence underdiagnosed. Second, there may be a variation in the genetic and environmental factors in the indigenous population of patients.
|Table 1: Reported cases of meningioma in patients with jaw cyst-bifid rib syndrome|
Click here to view
Recognition of GGS is important because it is a multisystem disease. A multidisciplinary approach is required because of the multiorgan involvement. Due to the predisposition of the disease to relapse, a close follow-up is required to reduce its morbidity and mortality. Radiotherapy should be avoided in these patients because of a genetic propensity in the patients to develop radiation-induced neoplasms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Hajalioghli P, Ghadirpour A, Ataie-Oskuie R, Kontzialis M, Nezami N. Imaging findings of Gorlin–Goltz syndrome. Acta Radiol Short Rep 2015;4:2047981614552294.
Jawa DS, Sircar K, Somani R, Grover N, Jaidka S, Singh S. Gorlin–Goltz syndrome. J Oral Maxillofac Pathol 2009;13:89-92
Ortega García de Amezaga A, García Arregui O, Zepeda Nuño S, Acha Sagredo A, Aguire Urizar JM. Gorlin–Goltz syndrome: Clinicopathologic aspects. Med Oral Patol Oral Cir Bucal 2008;13:338-43.
Jarisch W. Zur Lehre von den Hautgeschwulsten. Arch Dermatol Syphilol 1894;28:162.
Gorlin RJ, Goltz RW. Multiple naevoid basal cell epithelioma, jaw cysts and bifid rib syndrome. N Engl J Med 1960;262:908-12.
Evans DG, Ladusans EJ, Rimmer S, Burnell LD, Thakker N, Farndon PA. Complications of nevoid basal cell carcinoma syndrome: Results of a population based study. J Med Genet 1993;30:460-4.
Kimonis VE, Mehta SG, Digiovanna JJ, Bale SJ, Pastakia B. Radiological features in 82 patients with nevoid basal cell carcinoma (NBCC or Gorlin) syndrome. Genet Med 2004;6:495-502.
Lata G, Verma N, Kaur A. Gorlin–Goltz syndrome: A case series of 5 patients in North Indian population with comparative analysis of literature. Contemp Clin Dent 2015;6:192-201.
] [Full text]
Thomas N, Vinod VS, George A, Varghese A. Gorlin–Goltz syndrome: An often missed diagnosis. Ann Maxillofac Surg 2016;6:120-24.
] [Full text]
Tamoney HJ Jr. Basal cell nevoid syndrome. Am Surg 1969;35:279-83.
Stoelinga PJ, Peters JH, van de Staak WJ, Cohen MM Jr. Some new findings in the basal-cell nevus syndrome. Oral Surg Oral Med Oral Pathol 1973;36:686-92.
Southwick GJ, Schwartz RA. The basal cell nevus syndrome: Disasters occurring among a series of 36 patients. Cancer 1979;44:2294-305.
Dawber RPR, Ryan TJ. Basal cell naevus syndrome and malignant meningioma. Br J Dermatol 1980;42:103.
Mortimer PS, Geaney DP, Liddell K, Dawber RP. Basal cell naevus syndrome and intracranial meningioma. J Neurol Neurosurg Psychiatry 1984;47:210-2.
Aumaitre O, Sampoux P, Georget AM, Mondie JM, Thieblot P, Dordain G. Neurologic manifestations of basal cell nevomatosis: A case. Presse Med 1986;15:2105-7.
Jones KL, Wolf PL, Jensen P, Dittrich H, Benirschke K, Bloor C. The Gorlin syndrome: A genetically determined disorder associated with cardiac tumor. Am Heart J 1986;111:1013-5.
Albrecht S, Goodman JC, Rajagopolan S, Levy M, Cech DA, Cooley LD. Malignant meningioma in Gorlin's syndrome: Cytogenetic and p53 gene analysis: Case report. J Neurosurg 1994;81:466-71.
Alegre M, Puig L, de Moragas JM. The Gorlin syndrome. A review of 11 cases. Rev Clin Esp 1995;195:684-7.
O'Malley S, Weitman D, Olding M, Sekhar L. Multiple neoplasms following craniospinal irradiation for medulloblastoma in a patient with nevoid basal cell carcinoma syndrome: Case report. J Neurosurg 1997;86:286-8.
Kimonis VE, Goldstein AM, Pastakia B, Yang ML, Kase R, DiGiovanna JJ, et al
. Clinical manifestations in 105 persons with nevoid basal cell carcinoma syndrome. Am J Med Genet 1997;69:299-308.
Tate G, Li M, Suzuki T, Mitsuya T. A new germline mutation of the PTCH gene in a Japanese patient with nevoid basal cell carcinoma syndrome associated with meningioma. Jpn J Clin Oncol 2003;33:47-50.
Fukushima Y, Oka H, Utsuki S, Iwamoto K, Fujii K. Nevoid basal cell carcinoma syndrome with medulloblastoma and meningioma—case report. Neurol Med Chir 2004;44:665-8.
Campbell RM, Mader RD, Dufresne JR. Meningiomas after medulloblastoma irradiation treatment in a patient with basal cell nevus syndrome. J Am Acad Dermatol 2005;53:256-9.
Pribila JT, Ronan SM, Trobe JD. Multiple intracranial meningiomas causing papilledema and visual loss in a patient with nevoid basal cell carcinoma syndrome. J Neuro Ophthalmol 2008;28:41-6.
Kijima C, Miyashita T, Suzuki M, Oka H, Fujii K. Two cases of nevoid basal cell carcinoma syndrome associated with meningioma caused by a PTCH1 or SUFU germline mutation. Fam Cancer 2012;11:565-70.
Endo M, Fujii K, Sugita K, Saito K, Kohno Y, Miyashita T. Nationwide survey of nevoid basal cell carcinoma syndrome in Japan revealing the low frequency of basal cell carcinoma. Am J Med Genet Part A 2012;158:351-7.
Lee CW, Tan TC. Meningioma associated with Gorlin's syndrome. J Clin Neurosci 2014;21:349-50.
Evans DG, Farndon PA, Burnell LD, Gottamaneni HR, Birch JM. The incidence of Gorlin syndrome in 173 consecutive cases of medulloblastoma. Br J Cancer 1991;64:959-61.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]