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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fibrous dysplasia &#40;FD&#41; is a rare bone disorder consisting of the replacement of normal bone by an excessive proliferation of fibrous connective tissue with non-functional bone structures&#46; FD has three clinical patterns&#58; monostotic&#44; polyostotic&#44; and that associated with McCune-Albright syndrome &#40;MAS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">MAS is a rare disease&#44; characterised by skeletal lesions&#44; skin hyperpigmentation and hyperfunctioning endocrinopathies&#46; It accounts for less than 7&#37; of cases of bone dysplasia and its estimated prevalence is between 1&#47;100&#44;000 and 1&#47;1&#44;000&#44;000&#46; MAS tends to progress slowly&#44; but very rarely it can be aggressive or&#44; in 0&#46;9&#8211;4&#37; of cases&#44; it can undergo malignant transformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Aneurysmal bone cysts &#40;ABC&#41; are rare solitary benign bone lesions&#44; usually arising from the metaphysis of long bones&#44; and rarely involving the skull&#46; They consist of vascular spaces separated by septa of connective tissue&#46; They are usually primary lesions&#44; although they have been described as secondary&#44; particularly to giant cell tumours&#46; ABC secondary to FD or MAS are extremely rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Primary orbital ABC associated with FD have only been described on three other occasions in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This case report involves a female patient with MAS and ABC with orbital involvement&#46; We discuss the clinical and imaging findings&#44; as well as the treatment of this rare entity&#44; and provide a brief review of the literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a 21-year-old woman with no relevant previous medical history&#44; who attended the Accident and Emergency Department of our centre due to symptoms of right proptosis and right-sided headache&#46; She had no relevant previous medical history&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Obvious on physical examination was the deformity in the patient&#39;s right orbitofrontal region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#44; which the patient reported having had for several years&#46; She had right exophthalmos with normal ocular motility and normal visual field by confrontation test&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Also noteworthy was the patient&#39;s short stature &#40;147<span class="elsevierStyleHsp" style=""></span>cm&#41; and the presence of hyperpigmented &#8220;caf&#233;-au-lait&#8221; spots on her back&#44; predominantly on the right &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; After directed questioning&#44; the patient stated she had her first vaginal bleeding at around 5 or 6 years of age&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A neuroimaging study was requested with computed tomography &#40;CT&#41; and magnetic resonance imaging &#40;MRI&#41;&#46; CT of the brain &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41; showed a diffuse thickening of the skull bone with a &#8220;ground glass&#8221; appearance&#44; involving the calvaria as well as the facial region and the base of the skull&#46; There were areas of consolidation and other lithic areas&#46; Also striking was a cystic-like lesion overlying the right orbit&#44; with erosion of the orbital roof and the cranial vault &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; In the MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41; images of this same lesion were suggestive of a cystic lesion with a double level of fluid inside&#44; with low signal on T1 and hypersignal on T2&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Bone scintigraphy with metastable technetium 99 3&#44;3-diphosophono-1&#44;2-propanodicarboxylic acid &#40;Tc99m-DPD&#41; revealed multiple foci of uptake in the axial and peripheral skeleton&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Laboratory tests showed normal hormone levels&#44; including serum oestradiol&#44; FSH and LH&#46; The patient had elevated alkaline phosphatase &#40;1223 IU&#47;L&#44; range 40&#8211;150<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#41; with normal calcium&#44; phosphate and vitamin D levels&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In view of the clinical and radiological findings&#44; a right orbitofrontal craniotomy was performed&#46; On raising the scalp&#44; the wall of the ABC could already be seen eroding the frontal bone &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The cyst was completely resected &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#44; with reaming of part of the dysplasia&#44; particularly towards the optic canal&#46; Finally&#44; the skull was reconstructed with the patient&#39;s own bone&#44; titanium mesh and calcium phosphate cement &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The patient&#8217;s postoperative recovery was uneventful&#44; with adequate control of skull pain and improvement in facial morphology&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Histological analysis revealed fibroblast proliferation composed of benign areas of fibrous bone with others of irregular bone formation&#46; Also found was a cystic structure with haemorrhagic spaces lined by multinucleated giant cells similar to osteoclasts&#46; The results were compatible with FD with ABC&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">MAS was first described separately by Donovan McCune and Fuller Albright in children&#46; It is a relatively rare disease with an estimated prevalence of between 1&#47;100&#44;000 and 1&#47;1&#44;000&#44;000&#44; and is more common in women&#46; It was initially defined by the presence of polyostotic FD&#44; &#8220;caf&#233; au lait&#8221; spots and early puberty&#46; However&#44; it was later described that other endocrine disorders could be associated&#44; such as hyperthyroidism&#44; excess growth hormone&#44; renal phosphate wasting and Cushing&#39;s syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The mutation is located on chromosome 20q13 at the <span class="elsevierStyleItalic">guanine nucleotide-binding protein&#44; alpha stimulating</span> &#40;GNAS&#41; locus&#46; Substitution of arginine for cysteine or histidine leads to hyperactivation of GS&#9001;-cyclic adenosine monophosphate &#40;AMP&#41;&#46; Due to a postzygotic mutation of the GNAS1 gene&#44; it is considered a specific form of endocrine and non-endocrine neoplasia&#44; with the affected cells distributed in a mosaic pattern&#46; This contributes to the variability between patients in clinical manifestations and the severity of the disease&#46; The overproduction and high concentration of cyclic AMP &#40;cAMP&#41; in bone activates abnormal proliferation and differentiation&#46; FD classically affects the long bones&#44; particularly the proximal femur&#46; Both monostotic and polyostotic FD lesions involving long bones arise in the diaphysis or metaphysis&#44; but much less often in the epiphysis&#46; Vertebral bone involvement is common and can be associated with scoliosis&#46; Craniofacial FD is also not uncommon&#44; being reported in up to 60&#8211;70&#37; of patients&#46; The most common sign is that derived from the gradual painless enlargement of the involved bone&#44; in this case&#44; facial asymmetry&#44; with its corresponding aesthetic deformity&#46; Other symptoms result from constriction of cranial foramina or obliteration of bony cavities&#58; anosmia&#59; diplopia&#59; proptosis&#59; epiphora&#59; strabismus&#59; facial paralysis&#59; tinnitus&#59; nasal obstruction&#59; malocclusion and interference with chewing and speech&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Early puberty is the most common endocrine manifestation in MAS&#44; being more common in females than in males&#46; However&#44; as previously mentioned&#44; there are other associated endocrine disorders&#44; including hyperthyroidism&#44; pituitary adenomas&#44; primary adrenal hyperplasia&#44; hypophosphataemia and polycystic ovary&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Caf&#233;-au-lait spots are caused by the over-production of melanin due to G&#9001;&#47;cAMP activation&#44; and appear as irregular lesions along the midline of the body with a tendency to affect one side more than the other&#46; They occur mainly in the frontal and posterior cervical areas&#44; buttocks&#44; chest&#44; back&#44; shoulders and pelvis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Similar clinical manifestations can occur in other conditions such as monostotic FD&#44; Mazabraud syndrome&#44; type I neurofibromatosis and Jaffe-Campanacci syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">ABC are benign pseudotumour-like lesions composed of several expansive cystic compartments filled with blood derivatives&#44; with few endothelial elements&#46; They most commonly occur as primary lesions&#44; and are very uncommon secondary to FD and extremely rare secondary to MAS&#46; They tend to involve the vertebrae and long bones and it is unusual for them to affect the skull&#46; In the literature reviewed with simultaneous presentation of MAS and ABC&#44; among those with cranial involvement&#44; presentation has been reported at the orbital level&#44; skull base and also in the occipital region&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although the mechanism of formation is unknown&#44; one suggestion is that the development of this lesion may be due to an interruption in bone circulation in patients with FD&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Cytogenetic data show that in ABC there is a rearrangement of chromosomal bands 16q22 and 17p13&#44; showing a deregulated expression of the USP6 genes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with MAS&#44; treatment usually requires multidisciplinary teams&#44; involving orthopaedic surgeons&#44; neurosurgeons&#44; maxillofacial surgeons&#44; endocrinologists&#44; dermatologists&#44; ophthalmologists&#44; etc&#44; with personalised care required because of the heterogeneity of the syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The treatment of craniofacial FD is also subject to debate&#46; The initial approach is typically conservative&#46; The most common indications are for cosmetic reasons&#44; due to orbital involvement or neurovascular compression&#44; and in some cases for histological confirmation of the lesion type&#46; Treatment has been proposed with calcitonin&#44; bisphosphonates or denosumab&#44; which in some patients improve analytical parameters and pain&#44; but they have not shown long-term evidence for control of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">With regard to ABC&#44; although cases of spontaneous healing have been reported&#44; treatment is usually required&#44; including surgical curettage with or without bone grafting&#44; complete excision&#44; selective arterial embolisation&#44; radiotherapy&#44; or a combination of these procedures&#46; The role of embolisation in the treatment of ABC is to decrease vascularisation and reduce intraoperative blood loss&#46; This treatment has only been successful in long bones and the pelvis&#46; Total en bloc excision&#44; if possible&#44; provides the highest cure rate with a good prognosis and excellent functional results&#46; Excision should include the entire cyst wall because partial resection is associated with a higher risk of recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have presented a case which we consider to be very rare&#46; MAS is a disease with a great variability of clinical manifestations&#44; some of which involve the field of Neurosurgery&#44; as in our patient due to the presence of FD and ABC with cranio-orbital involvement&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">This work received no funding from public&#44; private or non-profit organisations&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Aneurismal bone cyst"
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            3 => "Craniotomy"
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            0 => "Craneotom&#237;a"
            1 => "Displasia fibrosa"
            2 => "Quiste &#243;seo aneurism&#225;tico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">McCune-Albright syndrome &#40;MAS&#41; is a rare heterogeneous genetic disorder that is characterized by a triad of polyostotic fibrous dysplasia &#40;FD&#41;&#44; caf&#233; au lait spots &#40;CAL&#41;&#44; and multiple hyperfunctional endocrinopathies&#46; In general&#44; it is diagnosed clinically&#46; From the triads&#44; 2 of the findings are enough to make the diagnosis&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Craniofacial fibrous dysplasia is a term that is used to describe the fibrous dysplasia&#44; which was localized at the craniofacial skeleton and is common in MAS patients&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Aneurysmal bone cyst &#40;ABC&#41; is a rare non-neoplastic bone lesion that involves mostly the long bones and vertebrae and may occur very rarely in the craniofacial bones&#46; ABCs may occur as secondary bony pathologies in association with various benign and malignant bone tumors and with fibrous dysplasia&#46; Secondary ABC occurring in craniofacial FD is extremely rare&#46; We present the case of a 21-year-old patient treated at our center for a right orbital aneurysmal bone cyst associated with MAS and provide a review of the relevant literature&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de McCune-Albright &#40;SMA&#41; es un trastorno gen&#233;tico heterog&#233;neo que se caracteriza por la tr&#237;ada de displasia fibrosa &#40;DF&#41; poliost&#243;tica&#44; manchas caf&#233; con leche y m&#250;ltiples endocrinopat&#237;as hiperfuncionales&#46; En general&#44; se diagnostica cl&#237;nicamente&#46; De la tr&#237;ada&#44; 2 de los hallazgos son suficientes para hacer el diagn&#243;stico&#46; La DF craneofacial es un t&#233;rmino que se usa para describir la displasia fibrosa&#44; que se localizaba en el esqueleto craneofacial y es com&#250;n en pacientes con SMA&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El quiste &#243;seo aneurism&#225;tico &#40;QOA&#41; es una lesi&#243;n &#243;sea no neopl&#225;sica infrecuente que afecta principalmente a los huesos largos y las v&#233;rtebras&#44; y puede ocurrir muy raramente en los huesos craneofaciales&#46; Los QOA pueden ocurrir como enfermedades &#243;seas secundarias en asociaci&#243;n con varios tumores &#243;seos benignos y malignos y con displasia fibrosa&#46; El QOA secundario que ocurre en la DF craneofacial es excepcional&#46; Presentamos el caso de una paciente de 21 a&#241;os tratada en nuestro centro de un quiste &#243;seo aneurism&#225;tico orbitario derecho asociado a SMA y realizamos una revisi&#243;n de la literatura relevante&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A and B&#41; View of the patient&#39;s face showing right exophthalmos and bulging of the right frontal region&#46; C&#41; Examination of the patient&#39;s back showing the &#8220;caf&#233;-au-lait&#8221; spots predominantly on the right hand side&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; Axial CT section with the &#8220;ground glass&#8221; appearance of the bones of the facial skeleton and the skull base&#46; B&#41; Coronal reconstruction of the CT showing a lesion with cystic content with erosion of the right orbital roof&#46; C&#41; MRI image&#44; coronal section in T2-weighted sequence showing the cystic content of the lesion and the displacement of the orbital contents&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#41; Wall of the ABC eroding the frontal bone&#46; Thin-walled cyst with xanthochromic contents&#46; B&#41; The defect produced by the ABC in the orbital bone and in the base of the skull is shown&#46; C and D&#41; Reconstruction of the orbital walls and the craniotomy&#46;</p>"
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Case Report
Craniofacial fibrous dysplasia and aneurismal bone cyst in a patient with McCune-Albright syndrome. A case report and review of the literature
Displasia fibrosa craneofacial y quiste óseo aneurismático en una paciente con síndrome de McCune-Albright. Presentación de un caso y revisión de la literatura
Julián Castro Castroa,
Corresponding author
juliancastrocastro@yahoo.es

Corresponding author.
, Juan Manuel Villa Fernándezb, Jesús Patricio Agulleiro Díazc
a Servicio de Neurocirugía, Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
b Servicio de Neurocirugía, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
c Servicio de Neurocirugía, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain

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