Research paper
Skeletal stigmata as keys to access to the composite and ancient
Gorlin
–Goltz syndrome history: The Egypt, Pompeii and
Herculaneum lessons
Giovanni Ponti
a,⁎
, Giovanni Pellacani
a, Aldo Tomasi
b, Giuliano Sammaria
a, Marco Manfredini
aaDepartment of Surgical, Medical, Dental and Morphological Sciences with Interest transplant, Oncological and Regenerative Medicine, Dermatology Unit, University of Modena and Reggio Emilia, Italy b
Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia, Italy
a b s t r a c t
a r t i c l e i n f o
Article history: Received 30 July 2015
Received in revised form 5 January 2016 Accepted 9 January 2016
Available online 12 January 2016
There are several genetic diseases with a wide spectrum of congenital bone stigmata in association to cutaneous and visceral benign and malignant neoplasms. Gorlin–Goltz syndrome, also named nevoid basal cell carcinoma syndrome, is an autosomal dominant systemic disease with almost complete penetrance and high intra-familial phenotypic variability, caused by germline mutations of the gene PTCH1. The syndrome is characterized by unusual skeletal changes and high predisposition to the development of multiple basal cell carcinomas, odontogenic keratocysts tumors and other visceral tumors. The Gorlin syndrome, clinically defined as distinct syndrome in 1963, existed during Dynastic Egyptian times, as revealed by a costellation of skeletalfindings com-patible with the syndrome in mummies dating back to 3000 years ago and, most likely, in the ancient population of Pompeii. These paleogenetic and historical evidences, together with the clinical and biomolecular modern ev-idences, confirm the quite benign behavior of the syndrome and the critical value of the multiple and synchro-nous skeletal anomalies in the recognition of these rare and complex genetic disease.
© 2016 Elsevier B.V. All rights reserved.
Keywords: Gorlin–Goltz syndrome NBCCS Skeletal anomalies PTCH1 NBCCS history Ancient Egypt Pompeii Herculaneum 1. Introduction
There are several genetic diseases with a wide spectrum of congen-ital bone stigmata in association to cutaneous and visceral signs and symptoms. The recognition of the inherited skeletal abnormalities, par-ticularly when uncommon, constitute a critical tool to obtain an early recognition of these syndrome both in the archeological remains and in the current population (Ponti et al., 2013a, 2013b). Among the hered-itary tumor syndromes associated to unique skeletalfindings, Nevoid Basal Cell Carcinoma Syndrome (NBCCS; also known as Gorlin syn-drome; OMIM #109400) is an autosomal dominant skin disease with an almost complete penetrance and a high intra-familial phenotypic variability, caused by germline mutations of the gene PTCH1 (Lo Muzio, 2008; Lo Muzio et al., 2013). The syndrome is characterized by an increased predisposition to the development of multiple basal cell carcinomas (BCC) in association with odontogenic keratocystic tumors (OKT), ameloblastoma (AML), visceral tumors (medulloblastomas,
ovarian and cardiacfibromas, rhabdomyosarcomas) and unusual skele-tal changes (Kiwilsza and Sporniak-Tutak, 2012). The NBCCS classic phenotype is characterized by the presence of specific bone abnormali-ties of the skull (frontal and parietal bossing, macrocephaly, calci fica-tions of the falx cerebri, brain tumors and maxillary or mandibular keratocystic ameloblastomas) and of other skeletal segments (bifid ribs, syndactyly, polydactyly) that sometimes facilitate identification and clinical diagnosis (Kiwilsza and Sporniak-Tutak, 2012). The aforementioned abnormalities of the neurocranium and of the splanchnocranium are the main cause of the NBCCS typical facies, char-acterized by asymmetry, hypertelorism and fronto-parietal bossing, that sometimes is the only aid to an early clinical diagnosis (Fig.1).
The NBCCS estimated prevalence is 1 per 40–57,000 (Farndon et al., 1992; Pratt and Jackson, 1987). In Italy, the incidence of the disease (1:256,000) (Lo Muzio et al., 2013) seems to be lower than in Australia (1:164,000) (Shanley et al., 1994) and the United Kingdom (1:55,600) (Evans et al., 1993).
2. From thefirst description of NBCCS to PTCH1 gene identification Thefirst description of a patient affected by the NBCCS was probably published in 1894 when Jarisch described a 22-year old patient affected by short stature, milia, low mentality, marked scoliosis and multiple basal cell carcinoma since the age of 14, one of these skin lesions having
Gene 589 (2016) 104–111
Abbreviations: NBCCS, nevoid basal cell carcinoma syndrome; BCC, basal cell carcinoma; AML, ameloblastoma; OKC, odontogenic keratocystic tumor; CT, computerized tomography; ICOB, Index Cranico of Broca.
⁎ Corresponding author at: Via del Pozzo n. 71, Department of Surgical, Medical, Dental and Morphological Sciences with Interest transplant, Oncological and Regenerative Medicine; University of Modena and Reggio Emilia, Modena 41124, Italy.
E-mail address:giovanni.ponti@unimore.it(G. Ponti).
http://dx.doi.org/10.1016/j.gene.2016.01.012
0378-1119/© 2016 Elsevier B.V. All rights reserved.
Contents lists available atScienceDirect
Gene
the characteristics of ulcus rodens (Jarisch, 1894; White, 1894). The au-thor, in its original manuscript, described a series of patients affected by multiple skin lesions, most likely basal cell carcinomas, in association to systemic anomalies, and probably the aforementioned 22-years old pa-tient, was clearly affected by NBCCS, showing the main clinical and his-tological features of the syndrome.
A relationship between developmental defects and multiple basal cell carcinoma was reported byBinkley and Johnson in 1951(Binkley and Johnson, 1951), andHowell and Caro, 1959(Howell and Caro, 1959). Only in 1960, Gorlin and Goltz described that the association of multiple nevoid basal cell carcinoma, cysts of the jaw and skeletal anomalies, most commonly bifid rib, was consistent enough to consider their occurrence as a distinct syndrome (Gorlin and Chaudhary, 1960; Gorlin et al., 1963). The clinical criteria for the diagnosis of NBCCS
proposed by Gorlin in the 1965 were summarized inTable 1(Fig.1). The developmental defects, described by Gorlin, that are distinctive of the syndrome include: intracranial calcification, fused, bifid and splayed ribs, calcifications of the falx cerebri and frontal bossing (Table 1).
Gorlin's triad of original criteria was later enlarged with other addi-tional features such as other skeletal anomalies and the presence of palmo-plantar pits. The description of palmo-plantar pits was done by Calnan, that defined this feature as a peculiar dyskeratosis of the palms and soles (Calnan, 1953). More precisely, these alterations are caused by the partial or complete absence of the stratum corneum in areas with diameter from 1 to 3 mm.
Diagnostic NBCCS clinical criteria were defined by Evans DG (Evans et al., 1993) and revised by Kimonis in 1997 (Kimonis et al., 1997). Ac-cording to Kimonis et al., two major or one major and two minor criteria should be present for the diagnosis of NBCCS (Table 2). Among thefive major criteria the bone stigmata comprise the lamellar calcification of the falx cerebri under age 20 and the histologically confirmed odontogenic (jaw) keratocyst; among the seven minor criteria the skel-etal abnormalities include the macrocephaly, the cleft lip/palate and
Fig. 1. Pictures of patients (A–H) affected by NBCCS, reproduced from the original manuscript byGorlin et al. (1965).
Table 1
NBCCS signs and symptoms with their relative frequency proposed by Gorlin R in 1963. From the original tabulation we here report only the skin, oral and skeletal manifestations.
Signs and symptoms Relative
frequency Skin
A1 Multiple nevoid basal-cell carcinoma +++ A2 Palmar dyskeratosis (porokeratosis of Mantoux) ++ A3 Milia; cysts, especially extremities ++ A4 Fibromas and/or neurofibromas, especially extremities + Oral manifestations
B1 Multiple jaw cysts +++
B2 Mild mandibular prognathism ++
B3 Fibrosarcoma jaws (?) +
B4 Ameloblastoma +
Skeletal system
C1 Rib: bifid, synostosis, partial agenesis, or cervical rudimentary +++ C2 Vertebrae: scoliosis, cervical or thoracic fusion ++ C3 Frontal and biparietal bossing ++
C4 Shortened metacarpals ++
C5 Deformed chest +
Central nervous system
D3 Calcification dura (falx, tentorium) choroid ++ Eye
Dystopia canthorum, hypertelorism ++
Table 2
Diagnostic criteria for NBCCS proposed by Kimonis in 2004 (2 major or 1 major and 2 minor criteria, or afirst degree relative with NBCCS and 1 major or 2 mi-nor features).
Major criteria
More than 2 BCCs or one BCC under the age of 20 years Odontogenic keratocysts of the jaw proven by histology Three or more palmar or plantar pits
Lamellar calcification of the falx cerebri Rib anomalies (bifid, synostosed, hypoplastic) Ovarianfibroma
Medulloblastoma
Flame shaped lucencies of the phalanges Brachymetacarpaly in all 4 limbs First degree relative with NBCCS Minor features
Any one of the following features:
Spina bifida occulta or other vertebral anomalies Brachymetacarpaly in at least one limb Hypertelorism or telcanthus Frontal bossing
vertebral/rib anomalies including bifid vertebrae/ribs, extra ribs, and/or splayed ribs.
However, clinical and radiologic analyses led to many revisions of the diagnostic criteria over time. Regarding the skeletal anomalies, Kimonis in his NBCCS families reported odontogenic keratocysts in 74% of patients, calcification of the diaphragm of sella turcica in 68% of patients, calcification of the falx cerebri in 65% of patients, coarse face in 54% of patients, macrocephaly in 50% of patients, hypertelorism in 42% of patients, frontal bossing in 27% of patients, calcification of the tentorium cerebelli in 20% of patients, sternal abnormalities in 13% of patients, bifid ribs in 26% of patients, hemivertebrae in 15% of patients and vertebral fusion in 10% of patients (Kimonis et al., 1997).
In 2004 the same authors (Kimonis et al., 2004) enlarged the popu-lation studying additional skeletal features in NBCCS syndrome patients, with the following results: bifid ribs were confirmed in 26% of patients, nuchal ligament calcification was present in 18%, other ribs anomalies (fusion, hypoplasia or aplasia) were present in 16%, hemivertebrae were confirmed in 15%, deformations were present in 14%, clavear ab-normalities were present in 12%, vertebral fusion were confirmed in 10% of patients, phalangeal foot polydactyly was present in 4%. In 2011, Bree AF and Shah MR (Bree and Shah, 2011) proposed less strin-gent criteria for NBCCS diagnosis suggesting that medulloblastoma should be considered a major and not a minor criteria, increasing early detection of the underlying syndrome, since it typically manifest in children aged 2 years and younger (Table 2).
In our report published in 2012, we proposed a restoration of a neglected criterion for NBCCS recognition: the ameloblastoma (AML) (Ponti et al., 2012a, 2012c). In fact, although manuscripts in the literature reported the association between AML and NBCCS (Jensen and Roser, 1978; Schultz et al., 1987; Eslami et al., 2008; Ackermann et al., 1988), in-cluding thefirst cases reported by Gorlin R et al. which suggested that AML as associated Gorlin–Goltz sign (Gorlin et al., 1963), the most recent wider criteria do not include this odontogenic tumor among the NBCCS criteria yet (Kimonis et al., 2004). In 2014, we performed a clinical and ra-diologic characterization of the NBCCS related cranio-facial and other skeletal anomalies using 3D and helical CT scan reporting skeletal stigma-ta as macrocephaly, positional plagiocephaly, skull base and sphenoid asymmetry, bifidity of multiple ribs and giant multilocular odontogenic jaw cysts and extensive multilamellar calcifications of falx cerebri, tentorium, falx cerebelli and of the atlanto-occipital ligament (Fig. 2). In the same study, in addition to the sphenoid asymmetry, we focused our attention on the value of bifid ribs, which are very uncommon in the gen-eral populations (estimated prevalence of 0.15–3.4% in the general
population vs. estimated prevalence of 26% in the NBCCS patients) (Kimonis et al., 2004, Lo Muzio, 2008), and suggested their inclusion as a novel major criteria which may be useful for the recognition and char-acterization of misdiagnosed cases (Ponti et al., 2014) (Fig 2).
Further clinical and radiologic evaluations of a wider population of PTCH1 mutated gene-carriers would be helpful to establish the clinical impact of the different skeletal stigmata among the NBCCS major and minor diagnostic criteria which should be considered dynamic entities that can be improved and better characterized.
The molecular pathogenesis of NBCCS has been known since the dis-covery in 1996 of the germline mutations on the PTCH1 gene. Since then, about 280 germline mutations have been described worldwide so far (Pastorino et al., 2012). The PTCH1, or the human homolog 1 of the Dro-sophila Patched gene, which is mapped on chromosome 9q22.3, consists of 23 exons and encodes an integral membrane protein of 1447 amino acids, Patched 1 (PTCH1) with 12 transmembrane regions, 2 extracellu-lar loops, and a putative sterol-sensing domain (Ponti et al., 2012b).
The SHH signaling pathway plays an important role in the mamma-lian embryonic development of many structures such as the neural tube, axial skeleton, limbs, lungs, skin, hair follicles, and teeth. SHH signaling also regulates growth and determines the shape of teeth (Dassule et al., 2000). PTCH1 mutation spectrum includes point mutations, small and large deletions, insertions and splicing mutations (Jones et al., 2011). Heterozygosity for PTCH1 due to inherited germline muta-tion is likely to give rise to the developmental anomalies seen in NBCCS. Subsequent postnatal loss of the other allele by mutation or silencing can lead to unregulated downstream proliferative activity, which in-duces the cutaneous phenotype and other neoplasm (Levanat et al., 1996).
The PTCH1 mutations are responsible for the clinical expression of the disease and can be found in a large amount of patients exhibiting a classic phenotype. Differently from other cancer predisposing syn-dromes, NBCCS doesn't show the correlations between genotype –phe-notype (Ponti et al., 2012b, 2013b) and its wide phenotypic variation does not appear to be related to the type of PTCH1 mutation, nor to any founder effect. Normally the founder effect is defined as an ancestral mutation, that was introduced in the same population by a common an-cient progenitor, and that can be found in different affected families ap-parently unrelated by any kinship, and living in the same geographic area. This is partly due to the relatively recent identification of the gene responsible of the syndrome and partly to the difficulty of extracting“pure” DNA from the ancient bones that are suggestive of pa-tients affected by NBCCS or other genetic skeletal disease.
Fig. 2. Radiologic CT images of NBCCS patients showing fronto-parietal bossing (A,B), odontogenic abnormalities and cysts (C), calcifications of the falx cerebri (D,E), sphenoid asymmetry (F,G), bifid ribs (H–L).
3. Gorlin–Goltz skeletal stigmata in the ancient Egypt
Although the spectrum of signs and symptoms associated with Gorlin Syndrome was described in detail by Gorlin in 1960, some archeologicfindings document the presence of this syndrome in the an-cient Egypt, more than 3000 years before Gorlin's manuscript.
Three Egyptian skeletons of the Dynastic period (between the V and XI dynasty, 2450–1955 BC) present bone aberrations compatible with the diagnosis of Gorlin Syndrome. They came from the graves of Assyut and Gebelein and were collected among the skeletons that belong to the “G. Marro” Egyptian anthropological collection (Museum of Anthropol-ogy and Etnography of Turin). The specimens were collected during the excavation of the Italian Archeological Mission in Egypt (1903–1937), under the direction of the Turin Egyptian Museum. The collection con-sists of mummified specimens (20 complete mummies and 80 heads) and bones (650 complete skeletons and 1300 isolated skulls) (Leigh, 1934; Boano et al., 2006; Ponti et al., 2014).
The two skeletons excavated at Assyut (case 1, E225 and case 2, E235) were characterized by frontal bossing, multiple bony cavities (probably cysts) of mandible and maxilla; multiple bifid ribs (in the case 2 six bifid ribs are present); sacrum with incomplete fusion of the dorsal laminae; occipital asymmetry; relative shortening of 4th meta-carpals; scoliosis and enlargement of the sella turcica (Satinoff and Wells, 1969) (Figs. 3, 4): thesefindings support the diagnosis of NBCCS with different major criteria met (odontogenic keratocysts, bifid ribs, affected family members, etc.).
The other skeleton with bifid rib compatible with the diagnosis of Gorlin Syndrome (GED 44, E22) come from a single grave at Gebelein (upper Egypt) and are referable to a child of around 4 years (Boano et al., 2006). Although in this skeleton the bifid rib is not associated with any other skeletal alteration in the axial or appendicular skeleton, the suspicion of the Gorlin syndrome is clear due to the crucial role of these coast anomalies in establishing a diagnosis of the genetic disease, particularly in young children (Veenstra-Knol et al., 2005).
4. Gorlin–Goltz bone stigmata in the Pompeian and Herculaneum archeological bones collection
The archeological excavations in Pompeii officially started in 1748 due to the will of the Emperor Charles III of Spain, king of the Two Sicilies.
Over the centuries, in addition to the architectonical structures, the archeological remains comprised many items of the common life, such as furnitures and pottery, mingled with human and animal bones. Some-times it was possible to isolate the whole skeleton, or to create identical molds, other times only separate skeletal segments were isolated and found.
To date there are few paleogenetic studies that analyzed the animal remains (especially horse's) (Di Bernardo et al., 2004). Only a minority of them focus on the anthropometric values of human bones, and even less studies explore the molecular-genetic aspects (Di Bernardo et al., 2009; Cipollaro, 2011).
One of our recent studies at the University of Modena and Reggio Emilia, in collaboration with the Superintendence of Pompei, was conducted in order to characterize the clinical and genetic features of the skeletal remains collected in the Forum Baths from Pompeii archeological site. The anthropometric analysis of the skeletal remains was aimed to the identification of the likely presence of hereditary syndromes (especially the Gorlin syndrome) affecting the roman population in A.D. 79. The specific aim of the study was the identification of the skeletal alteration characteristic of the NBCCS. The analysis of 100 skulls stored in the Forum Baths was con-ducted in order to measure the main anthropometric values of the horizontal cranial index and the vertical cranial index, also called index of Broca (ICOB), that are useful in order to quantify some mor-phologic features of the head. The anthropometric data were collected from 100 skulls and 20 mandibular bones of adults stored in the Forum Baths in archeological site from Pompeii. The measure-ment comprised the determination of the horizontal cranial index and the vertical cranial index, also named horizontal and vertical cranial indices of Broca. In particular, the vertical cranial index (ICOB) was measured on 60 intact skulls and the respective values were analyzed in accordance with the seven categories defined by Garson (inMartin and Saller, 1956-1959).
At the archeological bone collection of Pompeii, our preliminary study, allowed to define a significative heterogeneity of the anthropo-metric cranial parameters: even though the majority of the population had a mesocranic skull (39%) with an average ICOB of 79.89, a vast per-centage of dolicocranic skulls was identified (about 35%) with some indi-viduals having hyperdolicocranic skulls. It was among the dolicocranic and hyperdolicocranic portion of the population that some skulls
Fig. 3. Pictures of skeletal anomalies reproduced from the manuscript by Satinoff et al. from 1969. In detail, the presence of asymmetric skull base (A), odontogenic keratocysts (B, C), relative shortening of 4th metacarpals (D), bifid ribs (E–G), incomplete fusion of the sacral laminae (H).
presenting also different non-metric traits characteristics of the NBCCS (Fig. 5).
This observation, that led us to hypothesize that some individuals of the Pompeii population were affected by NBCCS, was probably the focus of the hypothesis of the anthropologist Stefano Delle Chiaie, that in 1853, analyzed the Pompeian skulls collections and asserted that the ancient population of Pompeii was composed by many ethnic groups (Delle Chiaie, 1854). In fact, it was well known that the population in Pompeii consisted of multiethnic society because of the high number of slaves of the African or Eastern descent.
Thefirst official publication of the human skeletal remains from Pompei was published in 1882 by Giustiniano Nicolucci (Nicolucci, 1882), that was the founder of the Institute of Anthropology of the Uni-versity of Naples. Nicolucci didn't agree with Delle Chiaie when he de-scribed that“some skull were globular, other ovoid and that a few were oblong in form; thefinal type of skull observed in this work was interpreted as African, probably representing slaves who were in the service of the wealthy citizen of Pompei”. Nicolucci though that the population of Pompei in AD 79 was heterogeneous, but autochthonous reporting
that dolichocephalic skulls were found in the 14% cases, mesocephalic skulls were found in the 43% population and brachycephalic skulls were found in the remaining 43% cases.
The same ideas were presented in a recent study published by E. Laser, that in addition to the metric evidences, also assessed the non-metric parameters, concluding that the observed statistical deviations in the measurement of the cranial indices, derived from intra-population variability (of the same ethnic group) rather than inter-population variability (of different ethnic group) (Lazer, 2011).
It's important to underline that our anthropometric results were ob-tained from a different skeletal collection respect to the ones evaluated by the aforementioned authors, in fact, the collection that we analyzed were lacking some of the more unusual skeletal skulls that Nicolucci took to Naples (D'Amore, 1979), but comprised the new skeletal re-mains that were found and added to the collection in the last decades. Even though a high frequency of macrocephaly and frontal bossing was observed in the population of Pompeii, the disarticulated nature of the Pompeian samples constituted an important limit to the analysis of the systemic skeletal anomalies that is necessary to diagnose NBCCS
Fig. 4. Pictures acquired at the Egyptian anthropological collection (Museum of Anthropology and Etnography of Turin). The skeleton excavated at Assyut (E235) was characterized by frontal bossing (A, B), multiple bony cavities (probably cysts) of mandible (C), occipital asymmetry (D) and bifid ribs (E).
Fig. 5. Pictures of selected skulls, acquired at the Forum Baths archeological skeletal collection of Pompeii, showing the typical NBCCS-associated alterations consisting of fronto-parietal bossing, maxillary odontogenic cysts and asymmetry of the skull base (A–L). Reproduced with the permission of the Special Superintendence for the Archeological Remains of Pompeii, Herculaneum and Stabia.
with high confidence. Even though the finding of isolated skull anoma-lies don't lead unequivocally to the NBCCS diagnosis, because it is not sufficient to define the patient as being affected by NBCCS, the high fre-quency of those abnormalities in the dolicocranic population represent an important clue to hypothesize that at least some individuals were af-fected by NBCCS. In detail, some skulls were characterized by marked frontal bossing and parieto-occipital bossing (signs already described by Gorlin in 1963), asymmetry of the cranial base, and presence of mul-tiple odontogenic cysts in the mascellary bone (Fig. 6). The analysis of the mandible and of the ribs of those subjects would have been of great scientific value, but unfortunately it was not possible. Regarding the mandibular cysts, it is worth mentioning that Capasso observed many skeletons with multiple mandibular cysts and among these four individuals with four–five odontogenic abscesses while an individual had a total of 8 oral abscesses (Lazer, 2011).
The observed tendency to macrocephaly and the presence of multi-ple cases with clear asymmetry of the cranial base, with fronto– temporo-parietal bossing in the ancient population of Pompeii is unusual if compared to the anthropometric data found in the near city of Herculaneum, where it was reported a presence of 47% of mesocranic skulls, more than 25% of brachicranic skulls and a relatively low inci-dence of hyperdolicocranic skulls (13.7%) (Capasso, 2001). The analysis conducted by Capasso of the 162 skeletons, extracted from 1982 to 1985, took 7 years of accurate examinations and studies. In his manu-script, entitled“I fuggiaschi di Ercolano”, Capasso focused on the paleo-biology of the remains and tried to reconstruct the most frequent diseases, the alimentary habits, and the life and work activities also in children (Capasso, 2001). Among the 162 Herculaneum skeletal re-mains it is possible tofind a skeleton in relatively good conditions, where it can be described one of the skeletal abnormalities that is more specific for the NBCCS: the presence of bifid ribs in association with cranial base asymmetry (Fig. 7).
The subsequent steps of our paleo-pathologic research, will be pos-sible thanks to the friendly attitude of the, Prof. Massimo Osanna, and of the Head of the Applied Biology Laboratory, dr. Ernesto De Carolis, and his patient technicians, will lead to the documentation through 3D TAC of the most relevant skeletal remains and the determination of
the mutational status of PTCH1, after the laboratory procedures of an-cient DNA extraction.
5. Conclusions
The combination of concomitant skeletal abnormalities in multiple anatomic sites of involvement is an important aid to the diagnosis of NBCCS. Some important semiology signs affecting the facies, as the presence of facial asymmetry, hypertelorism, frontal and parietal bossing, are the result of the corresponding alterations of the neuro-and splanchnocranium (Fig. 8). Those signs are important clues both for the clinician and the archeologist to suspect the diagnosis of NBCCS, which should be confirmed through biomolecular investiga-tions, DNA extraction and PTCH1 sequence analysis. In particular, bone findings are essentials to establish a diagnosis in children, in fact in the pediatric population it is very common that the other clinical diag-nostic criteria are lacking because they have not manifested yet. The longevity of the syndrome can be demonstrated through the analysis of ancient bones, which are fundamental to make paleopathological studies and to diagnose the syndrome. Many congenital skeletal alter-ations recovered from the remains of ancient populalter-ations that lived in Egypt about 3000 years ago, and in Pompeii and Herculaneum about 2000 years ago, shed some light on the history of the syndrome, that was identified as a clinically defined entity only in 1963 AD. The finding of NBCCS phenotype in many old populations demonstrates the rela-tively benignity of NBCCS that allows the survival of the affected indi-viduals to the fertile age, so that the germline mutations has been preserved throughout millenniums.
The sequencing of the gene PTCH1 from ancient DNA, extracted form skeletal remains and mummified bodies, is a necessary step for the con-clusive diagnosis of NBCCS, and will probably allow the analysis of the phylogenesis and of the founder effects of the mutations.
6. Summary
There are several genetic diseases with a wide spectrum of congen-ital bone stigmata in association to cutaneous and visceral benign and
Fig. 6. Pictures of selected mandibles and maxillary bones acquired at the Forum Baths archeological skeletal collection of Pompeii, showing the typical odontogenic NBCCS features of odontogenic cysts (A–I). Reproduced with the permission of the Special Superintendence for the Archeological Remains of Pompeii, Herculaneum and Stabia.
malignant neoplasms. Gorlin–Goltz syndrome, also named nevoid basal cell carcinoma syndrome, is an autosomal dominant systemic disease with an almost complete penetrance and high intra-familial phenotypic variability, caused by germline mutations of the gene PTCH1. The syndrome is characterized by unusual skeletal changes and high predis-position to the development of multiple basal cell carcinomas, odontogenic keratocysts tumors and other visceral tumors. The Gorlin syndrome, clinically defined as distinct syndrome in 1963, existed
during Dynastic Egyptian times, as revealed by a constellation of skeletal findings compatible with the syndrome in mummies dating back to 3000 years ago and, most likely, in the ancient population of Pompeii. These paleogenetic and historical evidences, together with the clinical and biomolecular modern evidences, confirm the quite benign behavior of the syndrome and the critical value of the multiple and synchronous skeletal anomalies in the recognition of these rare and complex genetic disease.
Fig. 7. Pictures of skeletal anomalies reproduced from the manuscript byCapasso (2001). In detail, the presence of bifid ribs (A,B), asymmetric skull base (C,F) and fronto-parietal bossing (D,E).
Fig. 8. Pictures of clinical features of PTCH1 mutated gene-carriers patients (A–H) affected by NBCCS, retrieved from our archive at University of Modena and Reggio Emilia.
Conflict of interest statement Author report no conflict of interest. Acknowledgments
We thank Dr. Cristel Ruini, for her collaboration. We thank Dr. Ernesto De Carolis and Prof. Massimo Osanna of the Superintendence of Pompeii, Dr. Nicolò Masturzo and Prof. Rosa Boano (University of Turin).
References
Ackermann, G.L., Altini, M., Shear, M., 1988.The unicystic ameloblastoma: a clinicopatho-logical study of 57 cases. J. Oral Pathol. 17, 541–546.
Binkley, G.W., Johnson, H.H., 1951.Epithelioma adenoides cysticum: basal cell nevi, agen-esis of the corpus callosum and dental cysts. Arch. Dermatol. Syph. 63, 73–84.
Boano, R., Fulcheri, E., Rabino Massa, E., 2006.A case of bidid rib from the G. Marro Egyptian osteologic collection. J. Biol. Res. 109–111 (Vol. LXXXI, N. 1).
Bree, A.F., Shah, M.R., 2011.BCNS Colloquium Group. Consensus statement from thefirst international colloquium on basal cell nevus syndrome (BCNS). Am. J. Med. Genet. A (Sep;155 A(9):2091–7).
Calnan, G.D., 1953.Two cases of multiple nevoid basal cell epithelioma? Porokeratosis of Mantoux. Br. J. Dermatol. 65, 219–221.
Capasso, L., 2001.I fuggiaschi di Ercolano. Paleobiologia delle vittime dell'eruzione vesuviana del 73 d. C.; Rome, L'Erma di Bretschneider.
Cipollaro, M., 2011.Strengthening ancient mtDNA equid sequences from Pompeii. J. Cell. Biochem. 112 (2), 363–364 (Feb).
D'Amore, C., 1979.Primi risultati degli studi sull'antropologia Pompeiana del 79d.C. La regione sotterrata del vesuvio: studi e prospettive. Atti del convegno 11–15 Nov. Università degli Studi di Napoli, pp. 927–943 (1982).
Dassule, H.R., Lewis, P., Bei, M., et al., 2000.Sonic hedgehog regulates growth and mor-phogenesis of the tooth. Development 127, 4775–4785.
Delle Chiaie, S., 1854.Cenno Notomico-Patologico Sulle Ossa Umane Scavate in Pompei. Napoli, Filiatre Sebezio.
Di Bernardo, G., Del Gaudio, S., Galderisi, U., Cipollaro, M., 2004.2000 year-old ancient equids: an ancient-DNA lesson from Pompeii remains. J. Exp. Zool. B Mol. Dev. Evol. 302 (6), 550–556 (15).
Di Bernardo, G., Del Gaudio, S., Galderisi, U., Cascino, A., Cipollaro, M., 2009.Ancient DNA and family relationships in a Pompeian house. Ann. Hum. Genet. 73, 429–437 (Pt 4).
Eslami, B., Lorente, C., Kieff, D., et al., 2008.Ameloblastoma associated with the nevoid basal cell carcinoma (Gorlin) syndrome. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 105, e10–e13.
Evans, D.G., Ladusans, E.J., Rimmer, S., Burnell, L.D., Thakker, N., Farndon, P.A., 1993. Com-plications of the naevoid basal cell carcinoma syndrome: results of a population based study. J. Med. Genet. 30 (6), 460–464.
Farndon, P.A., Del Mastro, R.G., Evans, D.G., Kilpatrick, M.W., 1992.Location of gene for Gorlin syndrome. Lancet 7 339 (8793), 581–582.
Gorlin, R.J., Chaudhary, A.P., 1960.Multiple osteomatosis,fibromas, lipomas and fibrosar-comas of the skin and mesentery, epidermoid inclusion cysts of the skin, leiomyomas and multiple intestinal polyposis: a heritable disorder of connective tissue. N. Engl. J. Med. 8 (263), 1151–1158.
Gorlin, R.J., Yunis, J.J., Tuna, N., 1963.Multiple nevoid basal cell carcinoma, odontogenic keratocysts and skeletal anomalies. A syndrome. Acta Derm. Venereol. 43, 39–55.
Gorlin, R.J., Vickers, R.A., Kellen, E., Williamson, J.J., 1965 Jan.Multiple Basal-Cell Nevi Syn-drome. An analysis of a syndrome consisting of multiple nevoid basal-cell carcinoma, jaw cysts, skeletal anomalies, medulloblastoma, and hyporesponsiveness to para-thormone. Cancer 18, 89–104.
Howell, J.B., Caro, M.R., 1959.Basal-cell nevus: its relationship to multiple cutaneous can-cers and associated anomalies of development. Arch. Dermatol. 79, 67–80.
Jarisch, W., 1894.Zur lehre von den hautgeschwulsten. Arch. Dermatol. Syphilol. 18, 162–222.
Jensen, M.F., Roser, S.M., 1978.Gorlin's syndrome with ameloblastoma. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 45, 325–326.
Jones, E.A., Sajid, M.I., Shenton, A., Evans, D.G., 2011. Basal cell carcinomas in gorlin syn-drome: a review of 202 patients. J. Skin Cancer 2011, 217378.http://dx.doi.org/10. 1155/2011/217378.
Kimonis, V.E., Goldstein, A.M., Pastakia, B., Yang, M.L., Kase, R., DiGiovanna, J.J., Bale, A.E., Bale, S.J., 1997.Clinical manifestations in 105 persons with nevoid basal cell carcino-ma syndrome. Am. J. Med. Genet. 69 (3), 299–308 (31).
Kimonis, V.E., Mehta, S.G., Digiovanna, J.J., Bale, S.J., Pastakia, B., 2004.Radiological features in 82 patients with nevoid basal cell carcinoma (NBCC or Gorlin) syndrome. Genet. Med. 6 (6), 495–502.
Kiwilsza, M., Sporniak-Tutak, K., 2012.Gorlin–Goltz syndrome — a medical condition re-quiring a multidisciplinary approach. Med. Sci. Monit. 18 (9), RA145–RA153.
Lazer, E., 2011.Resurrecting Pompeii. Routledge, New York.
Leigh, R.W., 1934.Notes on the somatology and pathology of Ancient Egypt. Univ. Calif. Publ. Am. Archaeol. (1934/36,34,1,S,1–53).
Levanat, S., Gorlin, R.J., Fallet, S., Johnson, D.R., Fantasia, J.E., Bale, A.E., 1996.A two-hit model for developmental defects in Gorlin syndrome. Nat. Genet. 12 (1), 85–87.
Lo Muzio, L., 2008.Nevoid basal cell carcinoma syndrome (Gorlin syndrome). Orphanet J. Rare Dis. 25, 3–32.
Lo Muzio, L., Pastorino, L., Levanat, S., Musani, V., Situm, M., Ponti, G., Bianchi Scarra, G., 2013.Clinical utility gene card for: Gorlin syndrome— update 2013. Eur. J. Hum. Genet. 21 (10).
Martin, R., Saller, K., 1956-1959.Lehrbuch der Anthropologie in systematischer Darstellung (Stuttgart).
Nicolucci, G., 1882.Crania pompeiana ovvero descrizione de' crani umani rinvenuti fra le ruine dell'antica Pompei. Tipografia Dell'Accademia Reale Delle Scienze, Napoli.
Pastorino, L., Pollio, A., Pellacani, G., Guarneri, C., Ghiorzo, P., Longo, C., Bruno, W., Giusti, F., Bassoli, S., Bianchi-Scarrà, G., Ruini, C., Seidenari, S., Tomasi, A., Ponti, G., 2012.
Novel PTCH1 mutations in patients with keratocystic odontogenic tumors screened for nevoid basal cell carcinoma (NBCC) syndrome. PLoS One 7 (8), e43827.
Ponti, G., Pollio, A., Mignogna, M.D., Pellacani, G., Pastorino, L., Bianchi-Scarrà, G., Di Gregorio, C., Magnoni, C., Azzoni, P., Greco, M., Seidenari, S., 2012a.Unicystic ameloblastoma associated with the novel K729M PTCH1 mutation in a patient with nevoid basal cell carcinoma (Gorlin) syndrome. Cancer Genet. 205 (4), 177–181.
Ponti, G., Pollio, A., Pastorino, L., Pellacani, G., Magnoni, C., Nasti, S., Fortuna, G., Tomasi, A., Scarrà, G.B., Seidenari, S., 2012b.Patched homolog 1 gene mutation (p.G1093R) in-duces nevoid basal cell carcinoma syndrome and non-syndromic keratocystic odontogenic tumors: a case report. Oncol. Lett. 4 (2), 241–244.
Ponti, G., Pastorino, L., Pollio, A., Nasti, S., Pellacani, G., Mignogna, M.D., Tomasi, A., Del Forno, C., Longo, C., Bianchi-Scarrà, G., Ficarra, G., Seidenari, S., 2012c.Ameloblastoma: a neglected criterion for nevoid basal cell carcinoma (Gorlin) syndrome. Familial Can-cer 11 (3), 411–418.
Ponti, G., Pellacani, G., Seidenari, S., Pollio, A., Muscatello, U., Tomasi, A., 2013a.Cancer- as-sociated genodermatoses: skin neoplasms as clues to hereditary tumor syndromes. Crit. Rev. Oncol. Hematol. 85 (3), 239–256.
Ponti, G., Bertazzoni, G., Pastorino, L., Monari, E., Cuoghi, A., Bergamini, S., Bellei, E., Benassi, L., Azzoni, P., Petrachi, T., Magnoni, C., Pellacani, G., Loschi, P., Pollio, A., Witkowski, A.M., Tomasi, A., 2013b.Proteomic analysis of PTCH1+/− fibroblast ly-sate and conditioned culture media isolated from the skin of healthy subjects and nevoid basal cell carcinoma syndrome patients. Biomed. Res. Int. 2013, 794028.
Ponti, G., Ruini, C., Pastorino, L., Loschi, P., Pecchi, A., Malagoli, M., Mandel, V.D., Boano, R., Conti, A., Pellacani, G., Tomasi, A., 2014.Skeletal and cranio-facial signs in Gorlin syn-drome from ancient Egypt to the modern age: sphenoid asymmetry in a patient with a novel PTCH1 mutation. Oncologia 10 (6), 917–925.
Pratt, M.D., Jackson, R., 1987.Nevoid basal cell carcinoma syndrome. A 15-year follow-up of cases in Ottawa and the Ottawa Valley. J. Am. Acad. Dermatol. 16, 964–970 (5 Pt 1).
Satinoff, M.J., Wells, C., 1969.The basal cell nevus syndrome in ancient Egypt. Med. Hist. 13, 294–297.
Schultz, S.M., Twickler, D.M., Wheeler, D.E., Hogan, T.D., 1987.Ameloblastoma associated with basal cell nevus (Gorlin) syndrome: CTfindings. J. Comput. Assist. Tomogr. 11, 901–904.
Shanley, S., Ratcliffe, J., Hockey, A., Haan, E., Oley, C., Ravine, D., Martin, N., Wicking, C., Chenevix-Trench, G., 1994.Nevoid basal cell carcinoma syndrome: review of 118 af-fected individuals. Am. J. Med. Genet. 50 (3), 282–290 (15).
Veenstra-Knol, H.E., Scheewe, J.H., van der Vlist, G.J., van Doorn, M.E., Ausems, M.G., 2005.
Early recognition of basal cell naevus syndrome. Eur. J. Pediatr. 164 (3), 126–130.
White, J.C., 1894.Multiple benign cystic epitheliomas. J. Cutan. Genitourin Dis. 12, 477–484.
