Diagnóstico e manejo das exostoses maxilares: relato de caso / Diagnosis and management of maxillary exostoses: case report

As exostoses maxilares são protuberâncias ósseas de caráter benigno, que se originam da cortical óssea e de etiologia controversa. Sua denominação vai depender da localização anatômica em que se encontra. Podem interferir na mastigação, fonação e adaptação de próteses removíveis parciais ou totais, devendo sua remoção ser considerada. O intuito deste trabalho é relatar o manejo de uma paciente com exostoses vestibulares em maxila e realizar uma breve revisão de literatura.

Maxillary exostoses are benign bony protuberances, which originate from the cortical bone and of controversial etiology. Its denomination will depend on its anatomical location. They can interfere with chewing, phonation and adaptation of partial or total removable prostheses, and their removal should be considered. The aim of this work is to report the management of a patient with vestibular exostosis in the maxilla and perform a brief literature review.

Macrophage M1 polarization mediated via the IL-6/STAT3 pathway contributes to apical periodontitis induced by Porphyromonas gingivalis

Abstract Objective: To investigate the involvement of IL-6/STAT3 signaling pathway activation in macrophage polarization and bone destruction related to apical periodontitis (AP) stimulated by Porphyromonas gingivalis. Methodology: Macrophage polarization, IL-6/STAT3 expression, and the presence of P. gingivalis were detected in human AP tissues via RT-qPCR, western blotting, and immunohistochemistry staining. Murine bone marrow derived macrophages were isolated and cultured with P. gingivalis W83 in vitro, and levels of macrophage IL-6 expression, STAT3 phosphorylation, and macrophage polarization with or without the selective STAT3 phosphorylation inhibitor Stattic (5 μM) were detected via ELISA, western blotting, RT-qPCR, and flow cytometry, respectively. P. gingivalis-induced murine AP models were constructed, and bone destruction and macrophage polarization in the apical region were evaluated. Transwell co-culture systems were used to investigate the effects of macrophages infected with P. gingivalis on osteogenesis and osteoclastogenesis. Results: P. gingivalis was detected in human AP tissues that highly expressed IL-6/STAT3, and the M1 subtype of macrophages was more abundant in these tissues. P. gingivalis infection induced IL-6 expression, STAT3 phosphorylation, and M1 polarization of macrophages, while 5 μM of Stattic partially abolished these activation effects. Systemic STAT3 blockade via oral administration of Stattic at a dose of 25 mg kg-1 alleviated murine periapical bone resorption and apical infiltration of M1 macrophages induced by P. gingivalis infection in vivo. Furthermore, macrophages infected with P. gingivalis promoted bone destruction via secretion of IL-6, TNF-α, and RANKL, which hinder pre-osteoblast expression of Runx2 and accelerate pre-osteoclast expression of NFAT2. Conclusions: The activation of IL-6/STAT3 signaling pathway is involved in mediating macrophages M1 polarization in the P. gingivalis induced apical inflammatory context and may also be intimately involved in the bone loss caused by P. gingivalis infection, directing the M1 macrophage infiltration during the progression of AP.

Erdheim-Chester disease with multisystemic involvement: a diagnostic challenge

Erdheim–Chester disease (ECD) is a rare, non-inherited, non- Langerhans form of histiocytosis of unknown origin, first described in 1930. This entity is defined by a mononuclear infiltrate consisting of lipid laden, foamy histiocytes that stain positively for CD68. Individuals affected by this disease are typically adults between their 4th and 6th decades of life. The multi systemic form of ECD is associated with significant morbidity, which may arise due to histiocytic infiltration of critical organ systems. Among the more common sites of involvement are the skeleton, central nervous system, cardiovascular system, lungs, kidneys (retroperitoneum) and skin. The most common presenting symptom of ECD is bone pain. Bilateral symmetric increased tracer uptake on 99mTc bone scintigraphy affecting the periarticular regions of the long bones is highly suggestive of ECD. However, definite diagnosis of ECD is established only once CD68(+), CD1a(−) histiocytes are identified within a biopsy specimen with aid of clinical and radiological data. Here we present a rare case of Erdheim-Chester disease in a 46 year male patient based on clinical data, radiological data, histopathological and immunohistochemistry findings.

Periostina: su expresión en los procesos de reparación ósea / Periostin expression in bone repair processes: sua expressão nos processos de reparação Óssea / Periostina

La periostina es una proteína no colágena expresada preferentemente en el periostio, que tiene un papel importante en la formación ósea durante la embriogénesis pero también durante la reparación de lesiones óseas o enfermedades metabólicas óseas. En el primer caso, en los procesos de consolidación de fractura, en modelos de animales de experimentación, se observó un incremento de la expresión de periostina inmediatamente posterior a la fractura, lo que sugirió que ésta tendría un papel relevante en la formación del callo óseo periostial durante los estadíos tempranos del proceso de consolidación de fractura. En enfermedades óseas benignas, como la displasia fibrosa, se observó un incremento de la expresión de periostina en el componente fibroso de la lesión, y se la propone como un marcador inmunohistoquímico en los estudios anatomopatológicos. La periostina es un factor soluble que puede ser detectado en sangre periférica. En los últimos años se desarrollaron numerosos inmunoensayos para su medición pero con la limitante que estos miden todas las isoformas circulantes de periostina con lo que se resta especificidad ósea. El desarrollo de nuevos inmunoensayos con mayor especificidad y sensibilidad a los actuales es de crucial importancia para investigar el potencial que tiene la periostina como biomarcador del metabolismo del periostio, calidad y resistencia ósea.

Periostin is a non-collagenous protein expressed mainly in the periosteum, which has an important role during embryonic bone formation but also when repairing bone lesions or metabolic bone diseases. In the first case, when healing fractures and during experimental animal models, a periostin increased expression has been observed immediately after fractures. These findings suggest that periostin may play an important role in periosteal callus formation during the early stage of fracture healing. In benign bone diseases, like fibrous dysplasia, the periostin over-expression was observed in the fibrous component lesion. So, this protein could be detected by immune histochemical technique in histopathology studies. Periostin is a soluble factor, which can be detected in peripheral blood. In recent years, several immunoassays have been developed, though the main limiting factor is the detection of all molecule circulating isoforms, without providing bone specificity. Development of new immunoassays with greater specificity and sensibility than the current ones is crucial to the research concerning the potential of periostin as a biomarker of periosteal metabolism, bone quality and resistance.

Periostina é uma proteína não-colágena que se expressa principalmente no periósteo, o que tem um papel importante na formação óssea durante a embriogênese, mas também durante a reparação de lesões ósseas ou doenças metabólicas ósseas. No primeiro caso, nos processos de consolidação de fratura, em modelos de animais de experimentação, observou-se um aumento na expressão de periostina imediatamente após a fratura, sugerindo que ela teria um papel relevante na formação do calo ósseo periosteal durante as fases precoces do processo de consolidação de fratura. Em doenças ósseas benignas, tais como displasia fibrosa, foi observado um aumento da expressão de periostina no componente fibroso da lesão, propondo-se como um marcador imuno-histoquímico nos estudos anatomo-patológicos. Periostina é um fator solúvel, ele pode ser detectado em sangue periférico tendo sido desenvolvido nos últimos anos inúmeros imunoensaios para sua medição, porém com a limitação de eles medirem todas as isoformas circulantes de periostina tirando-lhe especificidade óssea. Desenvolver novos imunoensaios com maior especificidade e sensibilidade que os atuais é de extrema importância para investigar o potencial que tem a periostina como biomarcador do metabolismo do periósteo, qualidade e ressistência óssea.

The Role of SPECT-Guided CT for Evaluating Foci of Increased Bone Metabolism Classified as Indeterminate on SPECT in Cancer Patients.

Planar and SPECT bone scintigraphy has played a major role in the staging of many cancers such as breast and prostate cancer, as well as in orthopedics. Integrated diagnostic CT combined with SPECT has helped improve localization and characterization of skeletal lesions, improving diagnostic confidence and helping management decisions, over traditional SPECT. A major advantage has been improved characterization of indeterminate bone lesions and differentiation of benign from malignant lesions due to additional CT information. In this treatise the role of SPECT-guided CT for evaluating foci of increased bone metabolism classified as indeterminate of SPECT in cancer patients is reviewed. Using this approach, the diagnostic confidence in differentiating malignant from benign bone lesions should better with the fused SPECT/CT image than with separate sets of bone scintigraphic and CT images.

Imaging Findings of Solitary Spinal Bony Lesions and the Differential Diagnosis of Benign and Malignant Lesions

OBJECTIVE: The purpose of this study was to present the MRI and CT findings of solitary spinal bone lesions (SSBLs) with the aims of aiding the differential diagnoses of malignant tumors and benign lesions, and proposing a diagnostic strategy for obscure SSBLs. METHODS: The authors retrospectively reviewed the imaging findings of 19 patients with an obscure SSBL on MRI at our hospital from January 1994 to April 2011. The 19 patients were divided to benign groups and malignant groups according to final diagnosis. MRI and CT findings were evaluated and the results of additional work-up studies were conducted to achieve a differential diagnosis. RESULTS: At final diagnoses, 10 (52.6%) of the 19 SSBLs were malignant tumors and 9 (47.4%) were benign lesions. The malignant tumors included 6 metastatic cancers, 3 multiple myelomas, and 1 chordoma, and the benign lesions included 4 osteomyelitis, 2 hemangiomas, 2 nonspecific chronic inflammations, and 1 giant cell tumor. No MRI characteristics examined was found to be significantly different in the benign and malignant groups. Reactive sclerotic change was observed by CT in 1 (10.0%) of the 10 malignant lesions and in 7 (77.8%) of the 9 benign lesions (p=0.005). CONCLUSION: Approximately half of the obscure SSBLs were malignant tumors. CT and MRI findings in combination may aid the differential diagnosis of obscure SSBLs. In particular, sclerotic change on CT images was an important finding implying benign lesion. Finally, we suggest a possible diagnostic strategy for obscure SSBLs on MRI.

Granuloma reparativo de células gigantes agresivo en región mandibular / Aggressive giant cells reparative granulomas in mandibular region

El granuloma reparativo de células gigantes (GRCG) es un proceso reactivo agresivo, que aparece con mayor frecuencia en los sectores anteriores de la mandíbula y el maxilar, en niños y adolecentes jóvenes. Constituye el 1 por ciento de las lesiones óseas tumorales. Existe una considerable controversia acerca de si son lesiones benignas o reactivas; también desde el punto de vista de su origen, de sus características clínicas e histológicas, así como su terapéutica. En octubre de 2007 acudió un caso a consulta externa de Cirugía Maxilofacial del Hospital Pediátrico Universitario Juan M Márquez, con una lesión diagnosticada como GRCG agresivo, la cual provocó gran deformidad facial y osteólisis del cuerpo mandibular. Se realizaron exámenes físicos, complementarios e iconopatográfico. Se ejecutó tratamiento quirúrgico y análisis de la pieza. La paciente no tuvo alteraciones estéticas ni funcionales. Hubo ausencia de recidiva, luego de 30 meses de seguimiento. Se revisó la literatura más reciente en los sitios Med Line, Lilac, Google, con las palabras clave granuloma reparativo de células gigantes, en inglés y español, para comparar nuestros procederes y resultados con otros reportes(AU)

The giant cells reparative granulomas (GCRG) is a reactive and aggressive process appearing more frequently in anterior sector of mandible and maxilla in children and young adolescents accounting for the 1 percent of tumor bone lesions. There is a considerable controversy if they are benign or reactive lesions from the point of view of its origin, from its clinical and histological features as well as therapeutical. This is the case of a patient seen in external consultation of Maxillofacial Surgery of the Juán Manuel Márquez Children and University Hospital at October, 2007 in whom an extent lesion diagnosed as an aggressive GCRG provoked a facial deformity and osteolysis of mandibular body. Complementary, physical and iconopathographic examinations were made as well as surgical treatment and analysis of this sample. Patient has neither aesthetic alterations nor functional. There was no relapse after 30 months of follow-up. We made a review of more update literature in Med Line, Lilac and Google websites with the giant cells reparative granulomas as key words in English and Spanish languages, to compare our procedures and results with other reports(AU)

Pathologic Fracture of Proximal Femur with Benign Bone Tumor / 대한정형외과학회잡지

PURPOSE: The treatment results for a proximal femur fracture caused by a benign bone lesion were evaluated. MATERIALS AND METHODS: Nineteen patients (23 cases) who had been treated for proximal femur pathologic fracture from 1987 to 2002 were enrolled in this study. The mean follow-up duration was 40 months. The causes and treatments of the pathologic fractures and complications such as nonunion, deformity and recurrence were evaluated. RESULTS: The benign bone lesions treated were fibrous dysplasia (15), simple bone cyst (3), aneurysmal bone cyst (2), giant cell tumor (2) and eosinophilic granuloma (1). An autograft (3), allograft (2), and both autograft and allograft (3) was performed after adjuvant curettage with a high-speed burr. There was no recurrence in these 8 cases. At the final course, internal fixation was performed in 18 cases (intramedullary nail (10), compressive hip screw (6), plate (1), screw (1)), a hip spica cast 3 cases and a THR 2 cases. Three cases where a hip spica cast had been performed showed a varus deformity. A refracture and deformity were prevented in 10 cases who underwent intramedullary nailing. CONCLUSION: The IM nail is very effective in preventing complications such as a deformity, refracture after a treatment for polyostotic fibrous dysplasia. However, in a solitary benign bone lesion, bone graft and internal fixation is effective after thorough curettage.

Lymphangiomatosis of Bone and Visceral Parenchyma : Report of Two Cases / 대한정형외과학회잡지

Lymphangiomatosis is a rare disorder that occurs mainly in children or during the first two decades of life. It is characterized by a diffuse proliferation of lymphatic channels involving the bones, visceral parenchyma, and soft tissue. Most cases of lymphangiomatosis have bone and visceral involvement and usually present with chylothorax, chylous ascites, chylous pericardial effusion, or acute symptoms that are related to the affected organs. The authors experienced two cases that presented with chylothorax and multiple lytic bone lesions. Chest drainage and chemical pleurodesis were performed for treatment of the chylothorax. In one case, lytic bone lesions were found only in the right scapula and bone lengthening with an Ilizarov frame was performed for growth arrest in the right humerus. In the other case, lytic bone lesions were found in both femurs and both humeri, the right tibia, and the right scapula; and were particularly severe in the right tibia and femur. The lytic bone lesion, osteosclerosis, pathologic fracture, and pseudoarthrosis were so severe that weight-bearing was impossible. Internal fixation was performed with an intramedullary nail in the left femur.

A Case of Waldenstrom's Macroglobulinemia Presented as a Compression Fracture of Spine / 대한혈액학회지

Waldenstrom's macroglobulinemia is a rare disease of plasmacytoid lymphocyte proliferation usually presented without bone lesion which is the common presenting symptom in multiple myeloma. We report a 50-year-old female with Waldenstrom's macroglobulinemia presented as a bony lesion without many other features common in this diesease. She was admitted with the chief complaint of low back pain and low extremity paresthesia for two months. Bone marrow biopsy and aspiration, protein and immune electrophoresis showed findings consistent with Waldenstr m's macroglobulinemia. Magnetic resonance imaging of thoracic spine showed pathologic compression fracture in T6 and T7 with posterior epidural mass at T6 to T7 level. We report this unusual case of Waldenstrom's macroglobulinemia presented as compression fracture of thoracic spine with a review of literatures.

Primarily establishment and application of STIR shaking sequence in the early diagnosis of bone lesion

MR imaging may help detect the bone marrow edema, which is seen as increased signal intensity with poorly defined margins on STIR images. Unfortunately, STIR sequence is not available in our Magnetom 1.0 Tesla menu. Based on old IR sequence in this MR unit, we have tried to make a new STIR sequence. This sequence is proved on image quality in bone contusion and early inflammation diagnosis.

X-ray image of bone lesion in the multiple myleoma

We detected skeletal lesions on standard radiographies of 44 patients with multiple myeloma treated in B¹ch Mai Hospital during the period from multiple osteolytic lesions were very frequent abnormalities at all sites. Osteopenia was most common, especially in spine (85.1%). Demineralization with compressed cerebral fractures was found in 74.1% of patients. Other common bone lesions were radiographically observed in ribs (75%), skull (72.7%) and pelvis (60%).