Surgical resection of osteolytic calvarial lesions: Clinicopathological features

doi:10.1016/j.clineuro.2010.07.010

Clinical Neurology and Neurosurgery

Volume 112, Issue 10, December 2010, Pages 865-869

https://doi.org/10.1016/j.clineuro.2010.07.010 Get rights and content

Abstract

Objective

Osteolytic calvarial lesions are infrequent findings. Some cases are found incidentally during cancer staging or subsequent to unspecific symptoms. There are no standardized algorithms for the treatment of such lesions. Thus, the aim of this study was to describe the clinicopathological features and surgical outcome in various osteolytic calvarial lesions.

Material and methods

The clinical presentation, radiological imaging findings, surgical treatment and histopathological findings of 36 patients who underwent surgery for an osteolytic calvarial lesion at our institution between 1998 and 2008 were reviewed.

Results

Thirty-six osteolytic calvarial lesions were identified in 20 men and 16 women. Mean age at diagnosis was 37 years. Ten patients were children younger than 15 years. Five lesions were detected during cancer staging. Complete removal of the calvarial lesions was achieved in all patients without complications. The most common histopathological diagnosis was metastasis (n = 9), Langerhans-cell histiocytosis (n = 9), and intraosseous hemangioma (n = 5). In two asymptomatic patients, histopathological findings revealed metastases of a previously unknown tumor. In two other patients known to suffer from cancer, histopathological findings indicated intraosseous hemangioma and intraosseous meningioma, respectively. Reconstruction of the calvarial defect was performed in 24 cases with poly-methyl-methacrylate and with titanium mesh in 1 case.

Conclusions

Osteolytic calvarial lesions can be found in any age group. The histopathological examination reveals various entities, and in some instances it was not concurrent with a primary malignancy. Because surgical morbidity is low, we recommend complete resection of osteolytic calvarial lesions with reconstruction when feasible.

Introduction

Focal lesions of the calvarium may originate primarily from bony structures or they may be secondary to invasion from adjacent skin- or brain-based lesions into bony structures. They might be found in any layer of the calvarium. Overall, such lesions are infrequent and they present either as sclerotic or lytic pathologies [1]. Gibson et al. reported 138 cases of primary skull lesions, nineteen of them in children, during a 25-year period [2]. The most common histopathological findings were epidermoid cyst and Langerhans-cell histiocytosis. Stark has found 12 skull metastases among 38 patients who underwent surgery for a skull lesion during a 10-year period [3]. Likewise, Wecht et al. have identified 42 patients with primary calvarial lesions during a 13-year period [4].

In previously reported cases, the extent of treatment of calvarial lesions varied widely, from conservative management to complete resection. Gibson and Prayson [2] suggested complete resection of all primary skull lesions to avoid recurrence. Wecht and Sawaya [4] indicated surgical resection for diagnosis, cosmetics, symptomatic relief or potential cure. Stark et al. [3] suggested surgical treatment only in case of presence of neurological deficits, massive destruction of bone with dura infiltration, painful mass, solitary metastasis and to confirm the diagnosis. Biopsy was considered useful to plan the surgery regarding the extension and possible additional technical support [4] or in case of poor general condition [3]. Furthermore, observational follow-up for a limited period of time are also recommended, if clinical and radiographic work up, seems to harbour a benign lesion [4].

Thus, no standardized treatment algorithm for osteolytic calvarial lesions has been suggested.

Here, we review the clinicopathologic features and outcome after surgery for osteolytic calvarial lesions during a 10-year period in our department.

Section snippets

Material and methods

We retrospectively reviewed the medical records of 36 patients who underwent surgical resection of an osteolytic calvarial lesion at the Department of Neurosurgery, Hannover Medical School, between January 1998 and February 2008. The charts with the clinical data (age, sex, preoperative symptoms and signs, concomitant diseases, recurrence of tumor), pre- and postoperative imaging studies, and operative notes (extent of resection, surgical technique) were analyzed. Complete resection was defined

Results

Thirty-six osteolytic calvarial lesions were identified in 20 men (56%) and 16 women (44%). The mean age at the time of diagnosis was 37 years (range, 10 months to 81 years). Ten patients (28%) were younger than 15 years. The lesions were located in the occipital (n = 9), frontal (n = 9), parietal (n = 14), or temporal (n = 4) calvarium (Table 1). Fifteen patients presented with only minor symptoms, such as a painless skull mass or soft tissue enlargement. In 5 cases, the osteolytic lesions were

Discussion

Osteolytic calvarial lesions are relatively infrequent. They may be either asymptomatic, or they may present with unspecific symptoms or with local pain [2], [3], [4]. Our retrospective review of all surgically treated patients in our department during a 10-year period identified 32 cases with osteolytic calvarial lesions. Over one fourth of the lesions (28.6%) were found in the pediatric population. Possibly the actual incidence of such lesions is higher than reported, since they may be

Conclusions

Osteolytic calvarial lesions are found in any age group. Multi-modal imaging with CT and MR, combining information on bone and soft tissue, offers a good perspective for the surgical planning. Histopathological examination may reveal various diagnoses, and in rare cases it does not correspond to the known primary tumor but may reveal another malignancy. No complication was noted following surgical resection. Regarding the unknown dignity of the lesion at surgery and the low surgical morbidity,

Disclosure of interests

The authors have no potential conflicts of interest to disclose.

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Calvarial haemangiomas are benign, vascular tumours of the skull involving parietal and frontal bones. Mostly these lesions remain asymptomatic, and present with cosmetic deformity, headache, uncommon neurological symptoms and reported as case reports and case series. The radiological appearance can range from sessile growing intradiploically to globular and the lesions may extend outwards or inwards after eroding the outer and inner tables of the skull. “Sunburst appearance” and “Wagon-wheel sign” are classical radiological findings but the lesions may present simply as a lytic expansile or even sclerotic calvarial mass. Because of varied clinical presentation and atypical radiological characteristics, the final diagnosis can be clinched by histology only. In selected cases where these lesions are not cosmetically acceptable, en bloc resection with tumour free margins followed by cranioplasty is the treatment of choice. Most reports of calvarial haemangiomas in literature are in the form of case reports.
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The number of articles retained at each stage of data acquisition is shown in a PRISMA flow chart (Fig. 1). We compiled a total of 69 articles from 19 different countries, and it comprised of 64 case reports [3,4,8,9,11,13,16,20–24,26–29,31–43,45–51] 1 case series [17] and 4 retrospective reviews [14,25,30,44] Articles from the United States made up 26 % of the subject population, followed by Germany, 16 %; Japan, Spain and China at 11 %; and the other countries in smaller percentages of representation were Turkey, United Kingdom, India, Italy, Korea, Australia, Taiwan, Brazil, Switzerland, Poland, Oman, New Zealand, Iran, and France. A total of 111 patients with PIM of calvarial origin were analyzed, 58 % of which were females and 42 % males.
Primary intraosseous meningiomas (PIM) of calvarial origin are a small subset of meningiomas that arise from and occur within the calvarial bone. Its definition is often confused with other forms of non-dural based intracranial meningiomas, which has made previously published retrospective reviews heterogenous, non-specific and sometimes inaccurate. We present a systematic review of calvarial PIM.
Using a systematic search protocol that included databases such as PubMed, Web of Science and Embase, we extracted all human studies on PIM published from inception to December 2017. This systematic review includes case reports and retrospective reviews that specifically described PIM.
On review of 166 articles identified with the systematic search protocol, 69 articles were analyzed. These comprised of 64 case reports, 1 case series and 4 retrospective reviews. 111 patients with PIM of calvarial origin were analyzed, 58 % of which were females and 42 % males. The mean patient age was 51 years and the frontal bone was the most common tumor location, occurring in 26.1 % of the cases. Surgical resection was the predominant modality of treatment in 97.2 % of the cases, and gross total resection was achieved in 84 % of cases that reported extent of resection. There were no recurrences for grade I meningiomas. However, all grade III meningiomas recurred and 33.3 % of grade II meningiomas showed recurrence with a mean postoperative follow-up interval of 20 months. Statistical analysis using Fisher’s exact test showed the recurrence rate to be strongly associated with WHO tumor grade (p-value <0.001).
There is statistically significant increased recurrence rate for calvarial PIM of higher grades, and we recommend close follow-up in those cases. Surgical resection remains the overwhelming treatment of choice for calvarial PIM, and it has a high gross total resection rate and low risk of complications and mortality.
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Indications for surgery were to obtain tissue to make a final histopathologic diagnosis and/or to decompress neural structures caused by mass lesions. Surgical techniques according to the departmental standards have been outlined elsewhere.8-10 Further treatment was installed or adjusted according to the results of the histopathologic examinations.
Different inflammatory diseases can manifest as intracranial lesions. They may be indistinguishable from intracranial neoplasms in the clinical setting, imaging studies, or laboratory studies. The value of surgery in the diagnosis and the treatment of such lesions is still unclear.
A total of 3066 reports of histopathologic examinations over a 10-year period were reviewed. Forty patients with an inflammatory intracranial lesion were identified. Clinical, radiologic, and follow-up data were analyzed and the diagnostic and therapeutic value of surgery was assessed.
We identified 24 women and 16 men (mean age, 47 years). The diameter of the lesion varied between 1 and 5.5 cm (mean, 2.6 cm). The location of the inflammatory lesion was intracerebral supratentorial (n = 18, 45%), intrasellar/suprasellar (n = 5, 12.5%), cerebellar (n = 5, 12.5%), in the brainstem (n = 4, 10%), in the cerebellopontine angle (n = 3, 7.5%), meningeal (n = 3, 7.5%), and at other locations (n = 6, 15%). Seventeen patients underwent surgical removal of the mass lesion, whereas in 23 patients a biopsy was taken. The lesions were classified into 7 groups: specific (infectious) granuloma (n = 10, 25%), unspecific granuloma (n = 7, 17.5%), idiopathic inflammatory pseudotumor (n = 5, 12.5%), demyelinating lesions (n = 5, 12.5%) encapsulated hematoma (n = 4, 10%), organized cerebral infarction (n = 3, 7.5%), and vasculitis (n = 4, 10%). Surgery was judged as valuable in 35 patients (87.5%).
The differential diagnosis of intracranial inflammatory lesions involves a wide spectrum. Surgery has a diagnostic and/or therapeutic value in most entities and clinical circumstances. However, attention must be taken to avoid surgery without a therapeutic or diagnostic value for the patient.
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Variation in large ectocranial lesions from pre-Columbian Kuelap, Peru
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While the drilling and boring method of trepanation is clearly the most common technique, several of these lesions seem consistent with the scraping method. The scraping of the outer table in order to debride infected bone tissue or as part of an incomplete trepanation may explain some examples (Hong et al., 2010). If the scalp were merely lacerated, the margins could be rejoined if sutured.
This paper analyses a diverse collection of previously undescribed cranial lesions observed from 42 individuals from the pre-Columbian site of Kuelap, eastern montane, Peru. I describe the presence of cranial lesions, their location on the vault location, shape, and size of affected area, and evidence of remodeling. Seventeen percent of the total cranial sample demonstrates similar superficial cranial lesions including males (25/117, 21.4%) and females (14/74, 18.9%), and adolescents (3/27, 11%). Most lesions are narrow ovals or long and leaf-shaped, with depression of the external cranial vault. While some are well-healed and smooth-surfaced, others are more irregular with variable degrees of remodeling. The highest frequency is on the superior and posterior aspects of the vault, usually along the sagittal plane. Differential diagnoses are considered but no single pathology is clear for all cases. There are some common features consistent with active and healing osteitis and a few are directly associated with trepanation. General patterning suggests intentional treatment, perhaps even possible cauterization of scalp injuries or healed infections. These large cranial “scars” have not been observed at coastal Peruvian sites and may reflect specific regional conditions related to highland environmental factors, local medical treatments of cranial injuries, or population specific malformations.

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Surgical resection of osteolytic calvarial lesions: Clinicopathological features

Abstract

Objective

Material and methods

Results

Conclusions

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Disclosure of interests

Hum Pathol

Surg Neurol

J Pediatr Surg

Surg Neurol

J Clin Neurosci

CT and MRI findings in calvarial non-infectious lesions

Diagn Interv Radiol

Primary skull lesions in the pediatric population. A 25-year experience

Arch Pathol Lab Med

Skull metastases: clinical features, differential diagnosis and review of the literature

Surg Neurol

Lesions of the calvaria: surgical experience with 42 patients

Ann Surg Oncol

MR imaging for evaluation of lesions of the cranial vault

Arq Neuropsiquiatr

CT and MR imaging of focal calvarial lesions

AJR

Adult onset of multifocal eosinophilic granuloma of bone: a long-term follow-up with evaluation of various treatment options and spontaneous healing

Clin Rheumatol

Tumors of the skull

Surgical resection of calvarial metastases overlying dural sinuses

Neurosurgery

Detection of cranial metastases by F-18 FDG positron emission tomography

Clin Nucl Med