Jeng and others and Frederic

Jeng and others and Frederic and coleagues suggested double free flaps (fibula osteocutaneous flap plus a composite anterolateral thigh-tensor fascia lata flap) for large lip defects with mandibulectomy. Such a procedure achieves excellent results if the tumor has been excised completely. Double flap reconstruction will be destroyed or should be sacrificed if tumors recur or osteonecrosis developed after radiotherapy. We planned in all cases to reconstruct the bone defect in the second stage after completing radiotherapy. In our case, oral competence could be resumed by adequate fascia lata sling without bone grafts or osteal flaps. Consequently, we prefer to employ a single free flap in one stage reconstruction for a large lower lip defect in advanced oral cancer patients. Our first choice is the composite anterolateral thigh-tensor fasciae latae free flap. However, relatively few patients reported in the literature have undergone reconstructive surgery using this approach. Further studies with more cases are needed in order to support our findings.
Introduction If an elderly person has a bulging mass on the head, a primary bone tumor or metastatic tumor is first considered. A review of the literature shows that a meningioma originating in an extradural location presenting as an intraosseous mass is very rare. In most cases such a tumor is characterized by osteoblastic or mixed osteoblastic-osteolytic changes without invading soft tissue. We report a rare case of an atypical osteolytic intraosseous meningioma with scalp and retinoic acid receptor invasion in a 68- year-old woman.
Case report A 68-year-old woman was brought to the emergency room with the chief complaint of headache and dizziness, which she had been experiencing for several weeks. Noncontrast computed tomography (CT) of the head showed an osteolytic mass (5×5cm) in the left frontal area of the head (Fig. 1). Under the impression of a metastatic tumor, a series of studies was performed. Tumor marker values, including those for cancer antigen 125 (CA-125; 14.7 U/mL), CA 15-3 (5.8 U/mL), CA 19-9 (13.4 U/mL), squamous cell carcinoma antigen (SCC Ag; 0.3ng/mL), alpha-fetoprotein (AFP; 5.9ng/mL), and carcinoembryonic antigen (CEA; 2.4ng/mL), were within normal ranges. A complete systemic evaluation revealed no evidence of other disease. The patient underwent Simpson grade I resection via the left frontotemporal approach followed by cranioplasty with bone cement. Craniotomy exposed a soft, mildly vascular tumor invading the subcutaneous layers of the scalp, skull bone, and cerebral parenchyma (Fig. 2). No new neurologic deficits developed after the surgery. Pathologic examination revealed atypical meningioma (World Health Organization [WHO] grade II) (Fig. 3). The patient was discharged from the hospital on postoperative day 15. Three weeks after surgery, adjuvant fractionated conformal radiotherapy was initiated (dose, 5400cGy in 30 fractions), covering the entire tumor bed. The patient is currently undergoing regular follow-up at the outpatient department, and no recurrence has so far been observed.
Discussion In adults, the differential diagnosis of osteolytic skull lesions depends on the patient\'s age, clinical presentation, and imaging study. Metastasis is usually the first impression if the patient is older than 40 years. However, primary bone tumors should also be considered. Most meningiomas are thought to be primary intradural lesions and located in the subdural space. Extradural meningiomas arising in locations other than the dura mater, such as the skin, nasopharynx, or neck, also have been reported. A meningioma originating at an extradural location was first reported in 1904 by Winkler. The incidence of primary extradural meningiomas is approximately 1–2% of all meningiomas. Primary intraosseous meningioma is a term used to describe a subset of extradural meningiomas that arise in bone. This type of meningioma approximately accounts for two-thirds of all extradural meningiomas. Even when intraosseous meningiomas invade the dura mater and/or brain parenchyma, some authors insist on using the term ”intraosseous meningioma” or “primary extradural meningioma”. Other authors, however, would say that dural invasion precludes a diagnosis of intraosseous meningioma. In our case, the main part of the tumor was located in the skull, so we considered that this tumor was primarily an intraosseous meningioma.