Metastatic carcinoma in a skull from Savoca (Sicily)

Luca Ventura, Vincenzo Urbani*, Lorenzo Arrizza**, Antonio Fornaciari***, Luisa Lo Gerfo***, Gino Fornaciari***.

Department of Pathology, San Salvatore City Hospital, L’Aquila, Italy;
*Department of Radiology, Villa Serena Clinic, Città S. Angelo (PE), Italy;
**Centre of Electronic Microscopy, University of L’Aquila, Italy;
***Division of Paleopathology, Department of Oncology, Transplants and Advanced Technologies in Medicine, University of Pisa, Italy.

Keywords: Savoca – mummies – osteolysis – metastasis – carcinoma.
Palabras clave: Savoca – momias – osteolìsis – metàstasis – carcinoma.

Introduction
The Capuchins crypt in Savoca, north-eastern Sicily, is well known for hosting an interesting collection of male mummies, dating back to XVIII-XIX century. During a preliminary survey of these human remains, we examined eleven additional, isolated, partially mummified or skeletonized heads, located in the left side of the crypt (Fig. 1).

Material and methods
One of these heads was a badly preserved calva, lacking the right temporal bone and parts of sphenoid and occipital bones. It showed diffusely closed ectocranial sutures, belonging to an old male (over 60 years). A Wormian bone in the lambdoid suture and a honeycomb-like structure in the left orbit were also observed (Fig. 2).
A radiologic (RX) and computed tomography (CT) study was performed at the Department of Radiology of the Villa Serena Clinic, Città S. Angelo, by using a spiral CT scanner (Philips Brilliance).
Samples from the largest and one of the smaller lesions underwent scanning electron microscopy (SEM), performed with a Philips XL30/CP scanning electron microscope at the Centre of Electronic Microscopy, University of L’Aquila.
Additional histologic and confocal microscopy examination was performed on rehydrated and decalcified samples, priorly submitted to SEM.

Results
Twelve parietal and sphenoidal lytic areas were found at macroscopic or radiologic examination: six of them were evident only on the inner surface and one only on the external aspect of skull vault. The largest diameter of the lesions ranged between 21 and 3 mm.
RX and CT scanning highlighted the true extent of the lesions, more pronounced within the diploic layer (Fig. 3). A sclerotic rim was evident around a single posterior lesion. Endocranial remnants were noted in the right above the right occipital bone.
SEM revealed the clear osteolytic character of the process with no evidence of osteoblastic reaction (Figg. 4-5). Such findings were confirmed with histology and confocal microscopy.

Discussion
The absence of postcranial and maxillary bones caused difficulties in the evaluation of the individual’s sex and age at death (Ubelaker, 1989; Meindl & Lovejoy, 1985), as well as in estimating the true extension of the disease (Waldron, 1987). The limited anthropological characters and the presence of only male individuals in the crypt allowed to determine sex and age at death with acceptable accuracy (Ubelaker, 1989; Meindl & Lovejoy, 1985). The endocranial remnants found above the occipital were more evident in the right side of the bone, indicating a slight right rotation of the head after burial.
The macroscopic and radiologic features of the lesions (asymmetrical distribution, variable size, low density, irregular borders), along with their microscopic details, allowed the diagnosis of osteolytic metastatic carcinoma (Duhig, Strouhal & Nĕmečkova, 1996; Strouhal et al., 1991).
Multiple myeloma shares with secondary carcinoma multifocality, lytic character, marrow origin and anatomical sites, but could be reasonably ruled out just because it usually presents a greater density of the lesions, which appear regularly round, smallest and less variable in size, with sharply delimited radiological borders without sclerotic rimming of the surrounding bone (Strouhal, 1991; Waldron, 1987).
No firm conclusion could be drawn about neoplasm’s primary site, but lung, kidney and gastrointestinal tract can be taken into account as the most probable ones, due to the age and gender of the individual (Bullough, 2004). Prostate carcinoma, the most prevalent primary cancer in the elderly male people, can be easily excluded as it usually displays purely blastic or sclerotic secondary lesions (Waldron, 1987; Bulloguh, 2004).

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