Skip to main content
Download PDF

Complex single step skull reconstruction in Gorham’s disease - a technical report and review of the literature

BMC Surgery volume 15, Article number: 24 (2015) Cite this article

Abstract

Background

Gorham’s disease is a rare osteolytic disorder characterized by progressive resorption of bone and replacement of osseous matrix by a proliferative non-neoplastic vascular or lymphatic tissue. A standardized treatment protocol has not yet been defined due to the unpredictable natural history of the disease and variable clinical presentations. No single treatment has proven to be superior in arresting the course of the disease. Trials have included surgery, radiation and medical therapies using drugs such as calcium salts, vitamin D supplements and hormones. We report on our advantageous experience in the management of this osteolyic disorder in a case when it affected only the skull vault. A brief review of pertinent literature about Gorham’s disease with skull involvement is provided.

Case presentation

A 25-year-old Caucasian male presented with a skull depression over the left fronto-temporal region. He noticed progressive enlargement of the skull defect associated with local pain and mild headache. Physical examination revealed a tender palpable depression of the fronto-temporal convexity. Conventional X-ray of the skull showed widespread loss of bone substance. Subsequent CT scans showed features of patchy erosions indicative of an underlying osteolysis. MRI also revealed marginal enhancement at the site of the defect. The patient was in need of a pathological diagnosis as well as complex reconstruction of the afflicted area. A density graded CT scan was done to determine the variable degrees of osteolysis and a custom made allograft was designed for cranioplasty preoperatively to allow for a single step excisional craniectomy with synchronous skull repair. Gorham’s disease was diagnosed based on histopathological examination. No neurological deficit or wound complications were reported postoperatively. Over a two-year follow up period, the patient had no evidence of local recurrence or other systemic involvement.

Conclusions

A single step excisional craniectomy and cranioplasty can be an effective treatment for patients with Gorham’s disease affecting the skull vault only. Preoperative planning by a density graded CT aids to design a synthetic bone flap and is beneficial in skull reconstruction. Systemic involvement is variable in this patient’s population.

Peer Review reports

Background

Gorham’s disease is a rare and potentially disabling osteolytic disorder. It is characterized by uncontrolled proliferation of non-neoplastic vascular or lymphatic tissues, leading to progressive resorption and replacement of osseous matrix which may extend to the adjacent tissues [1,2]. It was first described by Jackson in 1838 who reported a case of “boneless arm” and much later presented as a distinct clinical syndrome by Gorham and Stout in 1954, who characterized its main pathological features [3,4]. Other terms such as “massive osteolysis”, “disappearing bone disease” and “phantom bone disease” have also been used [5,6]. Gorham’s disease usually occurs in children and young adult patients, most commonly in the 2nd and 3rd decades [7-9] although any age group may be affected (with cases reported spanning from 1.5 to 72 years) [8] and without any race or gender predilection [2,10].

Histologically, Gorham’s disease is characterized by inflammatory osteolysis of bony segments which are then replaced by localized proliferative lymphatic channels [11]. These osteolytic characteristics may be accompanied by several types of non-neoplastic developmental vascular malformations, including capillary, venous and lymphatic malformations without endothelial cell proliferation [10,12]. Here, we present a case of Gorham’s disease affecting only the skull vault which was managed by a single-stage craniectomy and skull reconstruction, using a synthetic bone flap generated preoperatively via distinct computer aided planning technique. To put this into an appropriate context we included a review of the pertinent literature.

Case presentation

A 25-year-old Caucasian man presented with a skull defect over the left frontotemporal region that had progressively enlarged over a 3-year period. He complained of mild dull local aching headaches with short term memory impairment of one year duration, occasional visual symptoms, and subjectively decreased hearing. Symptoms were explained by the polysubstance abuse and the patient’s past medical history of depression. General physical examination was unremarkable with the exception of a clearly visible osseous depression of the left frontoparietotemporal region associated with mild tenderness on palpation and interspersed softness embedded in a thinned but firm skull. The patient was neurologically intact. X-ray of the skull (Figure 1A & B) showed widespread loss of calvarial structure secondary to an osteolytic process. Subsequent head CT scan (Figure 2A, B & F) showed the typical features of a patchy erosive osteolysis of the left frontoparietotemptoral skull region indicative of an active underlying process. Coronal, sagittal and lambdoid sutures were shown to be patent radiographically in skull-scouts (Figure 1A & B) and CT-cuts (Figure 3A & B) in order to exclude craniosynostosis. Post-contrast MRI study revealed marginal enhancement of the calvarial defect with no evidence of brain invasion or soft tissue component. (Figure 2C & D) Bone survey as well as chest x-ray were done to exclude skeletal and pulmonary involvement, respectively. Furthermore, the metabolic and chemical labs’ profile of the patient did not reveal any abnormality indicative of metabolic or endocrinologic disease. This study was approved by the institutional review board (IRB) of our hospital using an IRB protocol number (2013-P-000253/3). An informed patient’s consent was obtained to submit this article to the journal in order to be published.

Figure 1
figure 1

Plain skull films as obtained from CT-scouts: (A) Anteroposterior and (B) lateral projections show the skull preoperatively together with a view C) of the upper cervical spine (lateral view). No other lesions were evident, nor did we observe cervical fractures or misalignment. Sagittal and coronal sutures are visible.

Full size image
Figure 2
figure 2

Preoperative images. A. and B. Preoperative CT of the skull bone window axial and coronal respectively showing frontparietotemporal bone thinning, erosion and defect. C. and D. Preoperative MRI brain T1-WI with contrast showing the marginal enhancement. E. and F. CT skull with 3D reconstruction showing the variable degrees of osteolysis from outside and inside respectively.

Full size image
Figure 3
figure 3

Postoperative CT skull images following excision and reconstruction. A) axial view of bone window, B) coronal view of bone window and C) CT skull with 3D reconstruction.

Full size image

Based on a density graded CT scan, the severity of erosion at the affected skull region was determined. A custom made cranioplasty allograft was designed preoperatively (Figure 4) using a digital computerized software (Stryker®, Kalamazoo, Michigan) to define the size, site and shape of the synthetic bone flap enabling a single-staged surgery of excisional craniectomy, allograft duraplasty and synchronous skull reconstruction. (Figure 3) The pre-fabricated implant was made of Poly Methyl Methacrylate (PMMA). This patient’s pre-manufactured implant configuration was designed using specific software (Mimics, Materialise Company, Belgium) which generated allograft models based on variable degrees of osteolysis seen in the affected part of the skull bone on CT. The extent of calvarial bone to finally be excised and replaced was decided from a density-graded CT scan. To this end, we randomly selected 10 representative points within diseased and healthy skull regions, and obtained the respective Hounsfield units. This yielded a range of bone density values. The mean value for diseased bone was 342 HU (range: 158 to 643 Hounsfield units) whereas the mean value for healthy bone was 1489 HU (range: 1274 to 1630 units), respectively.

Figure 4
figure 4

Preoperative planning. A. Variable densities of the resorbed bone are illustrated in different colors based upon CT. B. The measurements of the expected bone defect after removal of all regions (1, 2 and 3) giving an area of 90 × 110 mm which is the size of the designed implant synthetic bone flap. C. The expected final design of the bone flap replacing the defect and preserving the same skull contour.

Full size image

To generate the final allograft construct, we then color-coded the prospective craniectomy area on the CT scan using the highest obtained density value of diseased skull (643 Hounsfield units). We used this particular value as a cut off since its density was about half that of the mean value obtained from the density measurements of healthy bone. A visual overlay was then used to confirm that the chosen implant shape matched all areas of diseased bone.

Surgery as such was then performed in a standard fashion. The patient underwent general endotracheal anesthesia and was position supine in three point skeletal fixation pins (Mayfield). Preoeprative density graded CT and MRI data were loaded on an intraoperative image guidance system (BrainLab) to map the affected area onto the scalp. The incision was planned accordingly and a conventional myocutaneous flap was raised. The affected area was visually identified. The optimal extent of the resection was taken from the CT and sketched onto the bony surface. For corroboration, the pre-generated bone allograft was put as a stencil onto the marked and affected skull area and it was confirmed that it could be used for the ensuing craniectomy. This way we could excise a bone segment that matched precisely the custom made implant for later repair. After standard craniectomy employing a side cutting saw (Anspach, DePuy; West Chester, PA), we separated the affected bone from the underlying layer of dura and repaired a very small dural defect with a pericranial autograft before we proceeded immediately with vault reconstruction using the prefabricated bony allograft (see Figure 5). The wound was hemostased and closed in layers without the need of subgaleal drains. The patient recovered from anesthesia immediately in the operative room. The postoperative period was uneventful and the patient showed no neurological deficit.

Figure 5
figure 5

Intraoperative images. A. Exposure of the bony lesion following temporalis muscle separation. B. Final view following surgical excision and reconstruction using a synthetic bone flap fixed to the surrounding apparently healthy bone with miniplates and screws.

Full size image

Pathology

Routine hematoxylin and eosin was performed on formalin-fixed, paraffin-embedded sections after decalcification of the submitted bone specimen. The sections revealed distinct areas of bone resorption with replacement by fibrous tissue with variable degrees of vascularity and collagen depositions (Figure 6A). In focal areas adjacent to zones of active bone resorption were numerous thin-walled, predominantly capillary-sized blood vessels (Figure 6B). In other areas, the zones of bone resorption were composed of densely collagenized fibrous tissue with interdispersed small blood vessels (Figure 6C). Beyond these characteristic features there were patchy areas with chronic inflammatory cells, including foamy macrophages (Figure 6D).

Figure 6
figure 6

Histopathology. A) Replacement of bone by fibrous tissue with variable amount of collagen deposition and vascularity. (H&E, 10X objective) B) Presence of marked number of thin-walled vessels next to an area of active bone resorption. The blood vessels are predominantly capillaries, but smaller arterioles and venules are also seen. (H&E, 10X objective) C) Bone replacement by dense fibrous tissue with occasional small blood vessels. (H&E, 10X objective) D) Patchy area of chronic inflammatory infiltration with scattered foamy macrophages. (H&E, 40X objective).

Full size image

The postoperative period was uneventful without local wound complications or any neurological deficit and the patient was discharged four days postoperatively. Over a two-year follow up period, the patient did not show any evidence of resorption of the adjacent skull bone or any other skeletal involvement.

Discussion

Gorham’s disease is a non-hereditary progressive osteolytic disorder that typically affects bones with subsequent lymphatic vascular malformation [13,14]. Gorham’s disease can be monostotic or polyostotic, however multicentric involvement is rare [15,16]. The most commonly involved sites are the mandible (15%), scapula (10%), ribs (12%), humerus (8%), pelvis (10%), femur (11%) [17] and less commonly the skull [18]. Clinical presentations vary based on the site of bone involvement and presence of systemic manifestations. To our knowledge, less than 30 cases of Gorham’s disease with any skull involvement, including this case report, have been reported in the literature.

Table 1 Published case reports of Gorham’s disease involving the skull [15,18-38].

Table 1 Review of reported cases of cranial involvement in Gorham’s syndrome
Full size table

Pathogenesis

The pathogenesis of Gorham’s disease remains poorly understood and a number of possible causes have been reported in literature. While Radhakrishnan and Rockson [6] suggested that Gorham’s disease is a disease of disordered lymphangiogenesis, Aviv and colleagues [39] suggested that it might occur independently from disseminated lymphangiomatosis, therefore representing two varieties of a rare disease etiology. Pathophysiological aspects regarding the presence or absence of osteoclasts in pathological tissue [40] as well as effects of hyperemia and changes in local pH-stimulating hydrolytic enyzmes remain controversial [41].

While Gorham and Stout [42] originally suggested that “osteoclastosis” was not a necessary feature, Foult and colleagues [43] pointed out that osteolysis occurred secondary to angiomatosis, and Spieth and colleagues [44] demonstrated a clear relationship between osteoclast activity and Gorham’s disease. This is further corroborated by the work of Möller and colleague [45], who described a large number of multinucleated osteoclasts with hyperactive resorptive function in his patients.

To determine the presence of blood and lymphatic vessel markers on the endothelial cells of the pathological proliferating vasculature in Gorham’s disease Hagendorn and coworkers [46] stained specimens for specific makers such as panendothelial marker CD 31 (platelet endothelial cell adhesion molecule), lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), and VEGF receptor (VEGFR)-3. Over 90% of endothelial cells expressed CD-31 and were also found staining positive for LYVE-1, suggesting that the proliferating vasculature associated with Gorham’s lymphangiomatosis consists predominantly of lymphatic endothelium [46].

Diagnosis

Clinical diagnosis

The reported clinical manifestations of Gorham’s disease were quite variable and largely depend on the site and extent of involvement. The presentation may be limited to local symptoms, such as pain and swelling of the affected extremity, soft tissue atrophy, and weakness of the involved limb or pathological fractures. However, systemic involvement, such as respiratory or neurological complications, was also frequently reported [7-9,16,44,47,48].

The neurological symptoms of Gorham’s disease vary greatly. Skull involvement may lead to progressive headache, migraines [5], nausea, vomiting, otitis media or recurrent episodes of meningitis secondary to chronic cerebrospinal fluid leakage [5,49]. Furthermore, some patients with temporal bone involvement may have auricular fullness, tinnitus, hearing loss or deafness [15,34,37]. Vertebral column involvement leading to pathological fractures, spine deformities and/or paraplegia has also been reported [7,24,50].

Radiologic diagnosis

Skull X-rays may initially show radiolucent foci which may subsequently extend into progressive dissolution and disappearance of a portion of the calvarial bone [24]. The osteolysis may extend to the contiguous bone and cross the intervening joint [24]. Kotecha and colleagues [51] emphasized the advantage of using quantitative computed tomography in the assessment of bones in patients with Gorham’s disease [52]. Among other benefits, it assesses the stage of the disease and aids in the decision-making processes at the time of initiating a particular treatment regimen also allowing to monitor individual patient response to any given therapy [53].

In addition to CT scans, thin cut fat-suppressed MRI T1-weighted contrast enhanced images help in visualizing a reticular pattern typical for the vascular component of the lesion [38].

Tc-99 scintigraphy is suitable in tracking the course of the disease activity as it may demonstrate increased uptake of radiopharmaceutical agents during initial active stages of the disease and subsequently show areas of decreased uptake corresponding to the diminished bone region in later stages of the disease or in response to treatment [7,16,44]. Torg and coworkers [12,54] classified Gorham’s disease progression by radiographic criteria allowing the differentiation of four sequential stages:

  1. 1.

    An initial stage in which radiolucent foci resembling patchy osteoporosis are present.

  2. 2.

    A second stage defined by an increase of bone deformity along with progressive loss of bone mass.

  3. 3.

    A third stage in which the cortical layer is disrupted by endothelial invasion into adjacent soft tissues or joints

  4. 4.

    Lastly a stage characterized by some shrinkage of the ends of affected bones.

Differential diagnosis and work up

The diagnosis is made via a combination of suspicious clinical and radiologic data as well as distinct histopathological features in conjunction with the exclusion of other hereditary, traumatic, metabolic, neoplastic, endocrinologic, infectious and inflammatory sources of osteolyses [55,56].

Although other osteolytic disorders of the skull (such as multiple myeloma, osteolytic metastases, juvenile Paget’s disease, eosinophilic granuloma and brown tumor) may show similar imaging findings, the CT, MRI and Tc-99 findings in combination with the long asymptomatic clinical course facilitate the differentiation of Gorham’s disease. Identifying areas of distinct vascular or lymphatic proliferation in early disease stages or the transformation to fibrous tissue in late disease stages can be achieved by generous biopsies of the affected bone and is essential for the unequivocal diagnosis of Gorham’s disease [42,57].

To this end, Heffez and colleagues [58] published a case report in which they suggested specific criteria distinguishing Gorham’s disease from other diseases of bony destruction which include:

  • Positive biopsy with the presence of angiomatous tissue

  • Absence of cellular atypia

  • Minimal or no osteoblastic response or dystrophic calcifications

  • Evidence of local bone progressive osseous resorption

  • Non-expansile, non-ulcerative lesions

  • Absence of visceral involvement

  • Osteolytic radiographic pattern

  • Negative hereditary, metabolic, neoplastic, immunologic, or infectious etiology.

The differential diagnosis should further include, but is not limited to: Paget’s disease, metastases, angiosarcoma, essential osteolysis and progressive parietal bone thinning. The latter is an age-related benign process not associated with metabolic or endocrine abnormalities and is usually seen on imaging as an incidental finding [59-61]. In contrast to Gorham’s disease, progressive thinning of the outer aspect of the vault is the main feature of biparietal thinning, occurring in pediatric skulls, although this has also been described in adults [62]. Differential diagnosis in children should include: juvenile fibrosarcoma, juvenile fibromatosis, and chondromyxoid fibroma [63] in Hajdu-Cheney-syndrome [64] which is a rare fibroblastic tumor with a predilection for the scalp of infants.

Management

Current treatments are only experimental as no single treatment has proven to be superiorly effective in arresting the course of the disease owing to its unpredictability [2]. Spontaneous arrest [65] or regeneration [66] of the destroyed bone without treatment has been reported [17,67,68], although the disease process generally requires multiple treatment attempts. [15] This may be particularly relevant in cases in which vital organs such as the spinal cord or lungs are involved, the latter of which can even result in pleural effusions or chylothorax [69]. However, the progressive involvement of vital structures in some cases may be fatal [2,70,71], resulting in an overall mortality of approximately 13.3% [72]. The prognosis of Gorham’s disease is otherwise considered to be good when disease is limited to the limbs or pelvic bones [73-76].

Surgical management

Surgical intervention has been suggested as the method of choice and includes resection of the lesion and possible re-grafting using various constructs [16,77-80]. However in the advanced stages of the disease, surgical procedures may be limited by technical issues such as the lack of bone substance for fixation of autologous or alloplastic material [5] or by the extent of systemic involvement. The pre-fabricated implant we used in our case allows a better cosmetic outcome by providing the exact natural skull contour compared to the conventional use of mesh and bone cement with excellent patient’s satisfaction. Although it may take more time preoperatively to design the compatible shape of the skull graft, it may save a lot of time intraopreratively to do both craniectomy and reconstruction in the same session applying the preformed skull implant precisely to replace the defect following the excision of the pathological bone. As there is no need for cement preparation and allograft molding this minimizes intraoperative time. The implant used in our case was formed of Poly Methyl Methacrylate (PMMA) which is known to have adequate impact resistance similar to native skull bone [81] with less risk of bone resorption compared to autologous bone flaps [82]. Furthermore, the pre-fabricated PMMA allows the surgeon to avoid any cement preparation phase, with its subsequent exothermic reaction which must be alleviated with cooling-irrigation to minimize the risk of thermal injury to the underlying structures such as the dura and/or the brain [83].

A limitation of this technique might be the high cost of such detailed preoperative planning when using density-graded CT scanning with 3D reconstruction as well as designing a patient-specific implant. Beyond this, its use is highly elective as the lag time makes it not suitable for neurosurgical emergencies (e.g. compound depressed skull fractures).

When planning surgery for patients with Gorham’s disease, certain precautions should be considered, as they may influence surgical management and strategies. Anesthesia induction must be done cautiously, as patients with maxillary or mandibular bone involvement may have difficult endotracheal intubation, which can be especially difficult in pediatric age groups. Protection of the spine is also important during induction and positioning [8]. Furthermore, postoperative ventilatory problems have been reported, emphazising that extubation has to be planned carefully and may involve prolonged intensive care management, as chylothorax is a possible life threatening complication that may occur even postoperatively.

Reconstruction techniques using prostheses seems to be effective despite potential obstacles since Woodward and colleagues [80], Kulenkampff and colleagues [73] and Paley and coworkers [84] have reported that the progression of adjacent disease has led to failure of reconstructions.

Conservative management

Based on the experience of Vinee and colleagues [16], medical treatment with hormones in combination with calcium salts and vitamins alone seem to be inefficient. Other treatment options include drug management and have been attempted using bisphosphonates, due to their antiosteoclastic and antiangiogenic activity. Lehmann and coworkers [85] reported a case of Gorham’s disease that was successfully treated with bisphosphonates for a period of 17 years. Hammer and colleagues [86] reported on bisphosphonate monotherapy (30 mg intravenous/3 months) controlling the disorder during a two year follow-up period. A successful conservative management was also reported by Avelar and colleagues [87], whose patient received monthly intravenous bisphosphonate infusions (at a dose of 4 mg) in addition to daily calcium (500mg) and vitamin D (400 UI) over the course of one year, showing maintenance of bone volume and symptomatic improvement of pain.

Interferon may also be useful because of its antiangiogenic effects [41] and its use has been reported by Dupond and colleagues [88] who treated a patient successfully based on a dosage of 7.5 to 15 million IU 3x/week over 5 years. However, this is contrary to results by Deveci and coworkers [89] who reported on a patient who died 4 months after the time of diagnosis, after being treated with interferon alpha-2b and bisphosphonates.

In the case we are presenting here, the patient did not need to receive any adjuvant radiotherapy or complementary medical treatment affecting bone remodeling, since disease was limited to one site only which was treated by excision. Girn and colleagues [15] reported on the management of a two-year-old girl with skull base and cervical spine involvement using radiotherapy and pamidronate therapy but this regimen resulted in failure to arrest the disease process and subsequent failure of surgery providing stabilization. In contrast, Heyd and colleagues [90], demonstrated that radiation therapy with the addition of intravenous zoledronic acid therapy may prevent the progression of the disease in 77% to 80% of cases with applied total doses ranging from 30 to 45 Gy. Similar results were presented in case reports by other authors (Bruch-Gerharz et al. [12], Johnstun et al. [91], Browne et al. [92] and Dunbar et al. [93]), who all came to the conclusion that radiation therapy in moderate doses (40-45 Gy at 1.8 Gy to 2 Gy per fraction) is effective. Due to the increased risk of radiation-induced secondary neoplasms and severe delayed toxicity, judicious use of radiation therapy is advised particularly in young adults and children [94,95].

Conclusion

Gorham’s disease is one of the rare osteolytic disorders which may affect the skull or any other bone with or without systemic involvement. Surgical management by an excisional craniectomy and synchronous skull reconstruction is an effective and safe modality of treatment for Gorham’s disease presented with a solitary skull lesion. Preoperative planning by a density graded CT and special software to design a synthetic bone flap allows for single step reconstruction in this patient’s population for elective settings and complicated diseases such as Gorham’s, this seems to yield superior cosmetic results.

References

  1. Heritier S, Donadieu J. Gorham’s disease and intra-osseous vascular abnormalities. Bull Cancer. 2012;99(5):599–604.

    PubMed  Google Scholar 

  2. Patel DV. Gorham’s disease or massive osteolysis. Clin Med Res. 2005;3(2):65–74.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Gorham LW, Wright AW, Shultz HH, Maxon Jr FC. Disappearing bones: a rare form of massive osteolysis; report of two cases, one with autopsy findings. Am J Med. 1954;17(5):674–82.

    Article  CAS  PubMed  Google Scholar 

  4. Jackson JBS. Absorption of humerus after fracture. Boston Med Surg J. 1872;10:245–7.

    Google Scholar 

  5. Cushing SL, Ishak G, Perkins JA, Rubinstein JT. Gorham-stout syndrome of the petrous apex causing chronic cerebrospinal fluid leak. Otol Neurotol. 2010;31(5):789–92.

    Article  PubMed  Google Scholar 

  6. Radhakrishnan K, Rockson SG. Gorham’s disease: an osseous disease of lymphangiogenesis? Ann N Y Acad Sci. 2008;1131:203–5.

    Article  PubMed  Google Scholar 

  7. Resnick D. Osteolysis and chondrolysis. In: Resnick D, editor. Diagnosis of bone and joint disorders. 4th ed. Philadelphia: WB Saunders; 2002. p. 4928–31.

    Google Scholar 

  8. Sahoo RK, Jagannathan B, Palanichamy G, Natarajan V. Anaesthetic consideration in patients with Gorham’s syndrome: a case report and review of the literature. Indian J Anaesth. 2012;56(4):391–3.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Yoo SY, Hong SH, Chung HW, Choi JA, Kim CJ, Kang HS. MRI of Gorham’s disease: findings in two cases. Skeletal Radiol. 2002;31(5):301–6.

    Article  PubMed  Google Scholar 

  10. Dominguez R, Washowich TL. Gorham’s disease or vanishing bone disease: plain film, CT, and MRI findings of two cases. Pediatr Radiol. 1994;24(5):316–8.

    Article  CAS  PubMed  Google Scholar 

  11. Abrahams J, Ganick D, Gilbert E, Wolfson J. Massive osteolysis in an infant. AJR Am J Roentgenol. 1980;135(5):1084–6.

    Article  CAS  PubMed  Google Scholar 

  12. Bruch-Gerharz D, Gerharz CD, Stege H, Krutmann J, Pohl M, Koester R, et al. Cutaneous lymphatic malformations in disappearing bone (Gorham-Stout) disease: a novel clue to the pathogenesis of a rare syndrome. J Am Acad Dermatol. 2007;56(2 Suppl):S21–5.

    Article  PubMed  Google Scholar 

  13. Chen B, Lv X, Wu J, Zhang X, Jiao X, Zhao J, et al. Bone loss in Gorham’s disease: a case study. Exp and Ther Med. 2013;5(4):1017–8.

    Article  Google Scholar 

  14. Hardegger F, Simpson LA, Segmueller G. The syndrome of idiopathic osteolysis. Classification, review, and case report. J Bone Joint Surg. 1985;67(1):88–93.

    CAS  Google Scholar 

  15. Girn HR, Towns G, Chumas P, Holland P, Chakrabarty A. Gorham’s disease of skull base and cervical spine–confusing picture in a two year old. Acta Neurochir. 2006;148(8):909–13. discussion 913.

    Article  CAS  PubMed  Google Scholar 

  16. Vinee P, Tanyu MO, Hauenstein KH, Sigmund G, Stover B, Adler CP. CT and MRI of Gorham syndrome. J Comput Assist Tomogr. 1994;18(6):985–9.

    Article  CAS  PubMed  Google Scholar 

  17. Choma ND, Biscotti CV, Bauer TW, Mehta AC, Licata AA. Gorham’s syndrome: a case report and review of the literature. Am J Med. 1987;83(6):1151–6.

    Article  CAS  PubMed  Google Scholar 

  18. Mawk JR, Obukhov SK, Nichols WD, Wynne TD, Odell JM, Urman SM. Successful conservative management of Gorham disease of the skull base and cervical spine. Childs Nerv Syst. 1997;13(11–12):622–5.

    Article  CAS  PubMed  Google Scholar 

  19. Chiang CL, Hsu SS, Li SC, Tseng HH, Lai PH. Teaching NeuroImages: vanishing calvarium in Gorham disease. Neurology. 2010;75(15):e65.

    Article  PubMed  Google Scholar 

  20. Zhang J, Li J, Ling L, Zhang YK. Gorham’s disease of the calvarium. Neurol India. 2010;58(1):144–5.

    Article  PubMed  Google Scholar 

  21. Wildforster U. Gorham syndrome. Presentation of a case. Neurochirurgia. 1986;29(5):198–200.

    CAS  PubMed  Google Scholar 

  22. Kawasaki K, Ito T, Tsuchiya T, Takahashi H. Is angiomatosis an intrinsic pathohistological feature of massive osteolysis? Report of an autopsy case and a review of the literature. Virchows Arch. 2003;442(4):400–6.

    PubMed  Google Scholar 

  23. Chai WX, Wu JP, Chen KF. Massive osteolysis of the skull: long-term follow-up observations after cranioplasty. Report of two cases. Acta Neurochir. 1984;73(3–4):201–6.

    Article  CAS  PubMed  Google Scholar 

  24. Lo CP, Chen CY, Chin SC, Juan CJ, Hsueh CJ, Chen A. Disappearing calvarium in Gorham disease: MR imaging characteristics with pathologic correlation. AJNR Am J Neuroradiol. 2004;25(3):415–8.

    PubMed  Google Scholar 

  25. Papeix C, Habert MO, Jarquin S, Cohen L. A dent in the head. Lancet. 2007;370(9602):1854.

    Article  PubMed  Google Scholar 

  26. Rao SV, Reddy DR, Reddy GM, Reddy PK, Mohan UL, Reddy M. Idiopathic massive osteolysis of skull bones: a case report. Neurosurgery. 1987;21(4):564–6.

    Article  CAS  PubMed  Google Scholar 

  27. Frankel DG, Lewin JS, Cohen B. Massive osteolysis of the skull base. Pediatr Radiol. 1997;27(3):265–7.

    Article  CAS  PubMed  Google Scholar 

  28. Hasegawa H, Bitoh S, Tamura K, Obashi J. Idiopathic massive osteolysis of skull bone: a case report. No shinkei geka Neurological surgery. 1989;17(5):481–4.

    CAS  PubMed  Google Scholar 

  29. Parihar V, Yadav YR, Sharma D. Gorham’s disease involving the left parietal bone: a case report. Cases journal. 2008;1(1):258.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Iyer GV. Cerebrospinal fluid rhinorrhoea from massive osteolysis of the skull. J Neurol Neurosurg Psychiatry. 1979;42(8):767–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Girisha KM, Ganesh HK, Rao L, Srilatha PS. Massive cranial osteolysis, skin changes, growth retardation and developmental delay: Gorham syndrome with systemic manifestations? Am J Med Genet A. 2010;152A(3):759–63.

    Article  CAS  PubMed  Google Scholar 

  32. Kurczynski E, Horwitz SJ. Response of lymphangiectasis to radiotherapy. Cancer. 1981;48(2):255–6.

    Article  CAS  PubMed  Google Scholar 

  33. Khosrovi H, Ortiz O, Kaufman HH, Schochet Jr SS, Reddy GN, Simmons D. Massive osteolysis of the skull and upper cervical spine. Case report and review of the literature. J Neurosurg. 1997;87(5):773–80.

    Article  CAS  PubMed  Google Scholar 

  34. Plontke S, Koitschev A, Ernemann U, Pressler H, Zimmermann R, Plasswilm L. Massive Gorham-Stout osteolysis of the temporal bone and the craniocervical transition. HNO. 2002;50(4):354–7.

    Article  CAS  PubMed  Google Scholar 

  35. Schiel H, Prein J. Seven-year follow-up of vanishing bone disease in a 14-year-old girl. Head Neck. 1993;15(4):352–6.

    Article  CAS  PubMed  Google Scholar 

  36. Hernandez-Marques C, Serrano Gonzalez A, Cordobes Ortega F, Alvarez-Coca J, Sirvent Cerda S, Carceller Lechon F, et al. Gorham-Stout disease and cerebrospinal fluid otorrhea. Pediatr Neurosurg. 2011;47(4):299–302.

    PubMed  Google Scholar 

  37. Mowry S, Canalis R. Gorham-Stout disease of the temporal bone. Laryngoscope. 2010;120(3):598–600.

    Article  PubMed  Google Scholar 

  38. Tsutsumi S, Yasumoto Y, Ito M. Idiopathic calvarial thinning. Neurol Med Chir. 2008;48(6):275–8.

    Article  Google Scholar 

  39. Aviv RI, McHugh K, Hunt J. Angiomatosis of bone and soft tissue: a spectrum of disease from diffuse lymphangiomatosis to vanishing bone disease in young patients. Clin Radiol. 2001;56(3):184–90.

    Article  CAS  PubMed  Google Scholar 

  40. Drewry GR, Sutterlin 3rd CE, Martinez CR, Brantley SG. Gorham disease of the spine. Spine. 1994;19(19):2213–22.

    Article  CAS  PubMed  Google Scholar 

  41. Takahashi A, Ogawa C, Kanazawa T, Watanabe H, Suzuki M, Suzuki N, et al. Remission induced by interferon alfa in a patient with massive osteolysis and extension of lymph-hemangiomatosis: a severe case of Gorham-Stout syndrome. J Pediatr Surg. 2005;40(3):E47–50.

    Article  PubMed  Google Scholar 

  42. Gorham LW, Stout AP. Massive osteolysis (acute spontaneous absorption of bone, phantom bone, disappearing bone); its relation to hemangiomatosis. J Bone Joint Surg Am. 1955;37-A(5):985–1004.

    Article  CAS  PubMed  Google Scholar 

  43. Foult H, Goupille P, Aesch B, Valat JP, Burdin P, Jan M. Massive osteolysis of the cervical spine. A case report. Spine. 1995;20(14):1636–9.

    Article  CAS  PubMed  Google Scholar 

  44. Spieth ME, Greenspan A, Forrester DM, Ansari AN, Kimura RL, Gleason-Jordan I. Gorham’s disease of the radius: radiographic, scintigraphic, and MRI findings with pathologic correlation. A case report and review of the literature. Skeletal Radiol. 1997;26(11):659–63.

    Article  CAS  PubMed  Google Scholar 

  45. Moller G, Priemel M, Amling M, Werner M, Kuhlmey AS, Delling G. The Gorham-Stout syndrome (Gorham’s massive osteolysis). A report of six cases with histopathological findings. J Bone Joint Surg. 1999;81(3):501–6.

    Article  CAS  Google Scholar 

  46. Hagendoorn J, Padera TP, Yock TI, Nielsen GP, di Tomaso E, Duda DG, et al. Platelet-derived growth factor receptor-beta in Gorham’s disease. Nat Clin Pract Oncol. 2006;3(12):693–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Sato K, Sugiura H, Yamamura S, Mieno T, Nagasaka T, Nakashima N. Gorham massive osteolysis. Arch Orthop Trauma Surg. 1997;116(8):510–3.

    Article  CAS  PubMed  Google Scholar 

  48. Klein M, Metelmann HR, Gross U. Massive osteolysis (Gorham-Stout syndrome) in the maxillofacial region: an unusual manifestation. Int J Oral Maxillofac Surg. 1996;25(5):376–8.

    Article  CAS  PubMed  Google Scholar 

  49. Kose M, Pekcan S, Dogru D, Akyuz C, Ozcelik U, Ozsurekci Y, et al. Gorham-Stout Syndrome with chylothorax: successful remission by interferon alpha-2b. Pediatr Pulmonol. 2009;44(6):613–5.

    Article  PubMed  Google Scholar 

  50. Al Kaissi A, Scholl-Buergi S, Biedermann R, Maurer K, Hofstaetter JG, Klaushofer K, et al. The diagnosis and management of patients with idiopathic osteolysis. Pediatr Rheumatol Online J. 2011;9:31.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Kotecha R, Mascarenhas L, Jackson HA, Venkatramani R. Radiological features of Gorham’s disease. Clin Radiol. 2012;67(8):782–8.

    Article  CAS  PubMed  Google Scholar 

  52. Venkatramani R, Ma NS, Pitukcheewanont P, Malogolowkin MH, Mascarenhas L. Gorham’s disease and diffuse lymphangiomatosis in children and adolescents. Pediatr Blood Cancer. 2011;56(4):667–70.

    Article  PubMed  Google Scholar 

  53. Bachrach LK, Sills IN, Section on E. Clinical report-bone densitometry in children and adolescents. Pediatrics. 2011;127(1):189–94.

    Article  PubMed  Google Scholar 

  54. Torg JS, Steel HH. Sequential roentgenographic changes occurring in massive osteolysis. J Bone Joint Surg Am. 1969;51(8):1649–55.

    Article  CAS  PubMed  Google Scholar 

  55. Bruch-Gerharz D, Gerharz CD, Stege H, Krutmann J, Pohl M, Koester R, et al. Cutaneous vascular malformations in disappearing bone (Gorham-Stout) disease. JAMA. 2003;289(12):1479–80.

    Article  PubMed  Google Scholar 

  56. Florchinger A, Bottger E, Claass-Bottger F, Georgi M, Harms J. Gorham-Stout syndrome of the spine. Case report and review of the literature. RoFo. 1998;168(1):68–76.

    Article  CAS  PubMed  Google Scholar 

  57. Ross JL, Schinella R, Shenkman L. Massive osteolysis. An unusual cause of bone destruction. Am J Med. 1978;65(2):367–72.

    Article  CAS  PubMed  Google Scholar 

  58. Heffez L, Doku HC, Carter BL, Feeney JE. Perspectives on massive osteolysis. Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol. 1983;55(4):331–43.

    Article  CAS  PubMed  Google Scholar 

  59. Bruyn GW. Biparietal osteodystrophy. Clin Neurol Neurosurg. 1978;80(3):125–48.

    Article  CAS  PubMed  Google Scholar 

  60. Takata S, Takao S, Yoshida S, Hayashi F, Yasui N. Therapeutic effects of one-year alendronate treatment in three cases of osteoporosis with parietal thinning of skull. J Med Invest. 2008;55(3–4):297–302.

    Article  PubMed  Google Scholar 

  61. Wilms G, Van Roost W, Van Russelt J, Smits J. Biparietal thinning: correlation with CT findings. Radiologe. 1983;23(8):385–6.

    CAS  PubMed  Google Scholar 

  62. Yiu Luk S, Fai Shum JS, Wai Chan JK, San Khoo JL. Bilateral thining of the parietal bones: a case report and review of radiological features. Pan Afr Med J. 2010;4:7.

    PubMed  PubMed Central  Google Scholar 

  63. Patterson JW, Moran SL, Konerding H. Cranial fasciitis. Arch Dermatol. 1989;125(5):674–8.

    Article  CAS  PubMed  Google Scholar 

  64. Siklar Z, Tanyer G, Dallar Y, Aksoy FG. Hajdu-Cheney syndrome with growth hormone deficiency and neuropathy. J Pediatr Endocrinol Metab. 2000;13(7):951–4.

    Article  CAS  PubMed  Google Scholar 

  65. Chattopadhyay P, Bandyopadhyay A, Das S, Kundu AJ. Gorham’s disease with spontaneous recovery. Singapore Med J. 2009;50(7):e259–63.

    CAS  PubMed  Google Scholar 

  66. Feigl D, Marmor A. Gorham’s disease of the clavicle with bilateral pleural effusions. Eight years later. Chest. 1987;92(1):189.

    Article  CAS  PubMed  Google Scholar 

  67. Campbell J, Almond HG, Johnson R. Massive osteolysis of the humerus with spontaneous recovery. J Bone Joint Surg. 1975;57(2):238–40.

    Article  CAS  Google Scholar 

  68. Edwards Jr WH, Thompson Jr RC, Varsa EW. Lymphangiomatosis and massive osteolysis of the cervical spine. A case report and review of the literature. Clin Orthop Relat Res. 1983;177:222–9.

    Google Scholar 

  69. Tie ML, Poland GA, Rosenow 3rd EC. Chylothorax in Gorham’s syndrome. A common complication of a rare disease. Chest. 1994;105(1):208–13.

    Article  CAS  PubMed  Google Scholar 

  70. Chong Ng L, Sell P. Gorham disease of the cervical spine-a case report and review of the literature. Spine. 2003;28(18):E355–8.

    Article  PubMed  Google Scholar 

  71. Hagberg H, Lamberg K, Astrom G. Alpha-2b interferon and oral clodronate for Gorham’s disease. Lancet. 1997;350(9094):1822–3.

    Article  CAS  PubMed  Google Scholar 

  72. Grunewald TG, Damke L, Maschan M, Petrova U, Surianinova O, Esipenko A, et al. First report of effective and feasible treatment of multifocal lymphangiomatosis (Gorham-Stout) with bevacizumab in a child. Ann Oncol. 2010;21(8):1733–4.

    Article  CAS  PubMed  Google Scholar 

  73. Kulenkampff HA, Richter GM, Hasse WE, Adler CP. Massive pelvic osteolysis in the Gorham-Stout syndrome. Int Orthop. 1990;14(4):361–6.

    Article  CAS  PubMed  Google Scholar 

  74. Stove J, Reichelt A. Massive osteolysis of the pelvis, femur and sacral bone with a Gorham-Stout syndrome. Arch Orthop Trauma Surg. 1995;114(4):207–10.

    Article  CAS  PubMed  Google Scholar 

  75. Rauh G, Gross M. Disappearing bone disease (Gorham-stout disease): report of a case with a follow-up of 48 years. Eur J Med Res. 1997;2(10):425–7.

    CAS  PubMed  Google Scholar 

  76. Boyer P, Bourgeois P, Boyer O, Catonne Y, Saillant G. Massive Gorham-Stout syndrome of the pelvis. Clin Rheumatol. 2005;24(5):551–5.

    Article  PubMed  Google Scholar 

  77. Escande C, Schouman T, Francoise G, Haroche J, Menard P, Piette JC, et al. Histological features and management of a mandibular Gorham disease: a case report and review of maxillofacial cases in the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(3):e30–7.

    Article  PubMed  Google Scholar 

  78. Gratz KW, Prein J, Remagen W. A reconstruction attempt in progressive osteolysis (Gorham disease) of the mandible. A case report. Schweiz Monatsschr Zahnmed. 1987;97(8):980–4.

    CAS  PubMed  Google Scholar 

  79. Wang HC, Lin GT. Close-wedge osteotomy for bony locking stiffness of the elbow in Gorham disease patients: a case report. Kaohsiung J Med Sci. 2004;20(5):250–5.

    Article  PubMed  Google Scholar 

  80. Woodward HR, Chan DP, Lee J. Massive osteolysis of the cervical spine. A case report of bone graft failure. Spine. 1981;6(6):545–9.

    Article  CAS  PubMed  Google Scholar 

  81. Eppley BL. Biomechanical testing of alloplastic PMMA cranioplasty materials. J Craniofac Surg. 2005;16(1):140–3.

    Article  PubMed  Google Scholar 

  82. Grant GA, Jolley M, Ellenbogen RG, Roberts TS, Gruss JR, Loeser JD. Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. J Neurosurg. 2004;100(2 Suppl Pediatrics):163–8.

    PubMed  Google Scholar 

  83. Goode RL, Reynolds BN. Tobramycin-impregnated methylmethacrylate for mandible reconstruction. Arch Otolaryngol Head Neck Surg. 1992;118(2):201–4.

    Article  CAS  PubMed  Google Scholar 

  84. Paley MD, Lloyd CJ, Penfold CN. Total mandibular reconstruction for massive osteolysis of the mandible (Gorham-Stout syndrome). Br J Oral Maxillofac Surg. 2005;43(2):166–8.

    Article  CAS  PubMed  Google Scholar 

  85. Lehmann G, Pfeil A, Bottcher J, Kaiser WA, Fuller J, Hein G, et al. Benefit of a 17-year long-term bisphosphonate therapy in a patient with Gorham-Stout syndrome. Arch Orthop Trauma Surg. 2009;129(7):967–72.

    Article  PubMed  Google Scholar 

  86. Hammer F, Kenn W, Wesselmann U, Hofbauer LC, Delling G, Allolio B, et al. Gorham-Stout disease–stabilization during bisphosphonate treatment. J Bone Miner Res. 2005;20(2):350–3.

    Article  PubMed  Google Scholar 

  87. Avelar RL, Martins VB, Antunes AA, de Oliveira Neto PJ, Andrade ES. Use of zoledronic acid in the treatment of Gorham’s disease. Int J Pediatr Otorhinolaryngol. 2010;74(3):319–22.

    Article  PubMed  Google Scholar 

  88. Dupond JL, Bermont L, Runge M, de Billy M. Plasma VEGF determination in disseminated lymphangiomatosis-Gorham-Stout syndrome: a marker of activity? A case report with a 5-year follow-up. Bone. 2010;46(3):873–6.

    Article  CAS  PubMed  Google Scholar 

  89. Deveci M, Inan N, Corapcioglu F, Ekingen G. Gorham-Stout syndrome with chylothorax in a six-year-old boy. Indian J Pediatr. 2011;78(6):737–9.

    Article  PubMed  Google Scholar 

  90. Heyd R, Micke O, Surholt C, Berger B, Martini C, Fuller J, et al. Radiation therapy for Gorham-Stout syndrome: results of a national patterns-of-care study and literature review. Int J Radiat Oncol Biol Phys. 2011;81(3):e179–85.

    Article  PubMed  Google Scholar 

  91. Johnstun J, Brady L, Simstein R, Duker N. Chronic recurrent Gorham-Stout syndrome with cutaneous involvement. Rare tumors. 2010;2(3):e40.

    Article  PubMed  PubMed Central  Google Scholar 

  92. Browne JA, Shives TC, Trousdale RT. Thirty-year follow-up of patient with Gorham disease (massive osteolysis) treated with hip arthroplasty. J Arthroplasty. 2011;26(2):339. e337-310.

    Article  PubMed  Google Scholar 

  93. Dunbar SF, Rosenberg A, Mankin H, Rosenthal D, Suit HD. Gorham’s massive osteolysis: the role of radiation therapy and a review of the literature. Int J Radiat Oncol Biol Phys. 1993;26(3):491–7.

    Article  CAS  PubMed  Google Scholar 

  94. McNeil KD, Fong KM, Walker QJ, Jessup P, Zimmerman PV. Gorham’s syndrome: a usually fatal cause of pleural effusion treated successfully with radiotherapy. Thorax. 1996;51(12):1275–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  95. Ricalde P, Ord RA, Sun CC. Vanishing bone disease in a five year old: report of a case and review of the literature. Int J Oral Maxillofac Surg. 2003;32(2):222–6.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurochirurgie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany

    Victoria Ohla

  2. Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, LMOB Suite 3B, Boston, MA, 02215, USA

    Victoria Ohla, Ahmed B Bayoumi & Ekkehard M Kasper

  3. Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Markus Hefty & Matthew Anderson

Authors
  1. Victoria Ohla
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed B Bayoumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Markus Hefty
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Matthew Anderson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ekkehard M Kasper
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ekkehard M Kasper.

Additional information

Competing interests

All others certify that they have NO affiliations with or involvement in any organization or entity with any financial or non-financial competing interest in the subject matter or materials discussed in this manuscript.

Authors’ contributions

VO has drafted the primary manuscript with collection of most of the online published data. AB drafted the final manuscript adding more to the intellectual content of the article by extensive editing of both the format and content of the discussion adding the technical details of pre-operative planning. AB has also designed the final attached figures and was responsible for proper referencing as well as addressing all the major and minor revisions as requested by the reviewers of different journals to reach the final submitted version. MH and MA carried out the histopathological analysis of the tissue sample and reviewed the paragraphs related to the pathogenesis of this rare disease. EK is the neurosurgeon who performed this surgical procedure and proposed the design of this article. EK has also revised the final draft extensively adding more impact to the clinical assessment of the illustrated case, technical surgical details and the strategy of preoperative planning in order to approve the final manuscript to be submitted. All authors read and approved the final manuscript.

Authors’ information

First authorship was shared by Victoria Ohla and Ahmed B. Bayoumi.

Rights and permissions

Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.

The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/.

The Creative Commons Public Domain Dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ohla, V., Bayoumi, A.B., Hefty, M. et al. Complex single step skull reconstruction in Gorham’s disease - a technical report and review of the literature. BMC Surg 15, 24 (2015). https://doi.org/10.1186/s12893-015-0014-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12893-015-0014-4

Keywords

  • Gorham’s disease
  • Osteolytic disorder
  • Cranioplasty

BMC Surgery

ISSN: 1471-2482

Contact us