Skeletal Stigmata As Keys to Access to the Composite and Ancient Gorlin–Goltz Syndrome History: the Egypt, Pompeii and Herculaneum Lessons

Gene 589 (2016) 104–111

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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,AldoTomasib, Giuliano Sammaria a, Marco Manfredini a a Department 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 article info abstract

Article history: There are several genetic diseases with a wide spectrum of congenital bone stigmata in association to cutaneous Received 30 July 2015 and visceral benign and malignant neoplasms. Gorlin–Goltz syndrome, also named nevoid basal cell carcinoma Received in revised form 5 January 2016 syndrome, is an autosomal dominant systemic disease with almost complete penetrance and high intra- Accepted 9 January 2016 familial phenotypic variability, caused by germline mutations of the gene PTCH1. The syndrome is characterized Available online 12 January 2016 by unusual skeletal changes and high predisposition to the development of multiple basal cell carcinomas, fi Keywords: odontogenic keratocysts tumors and other visceral tumors. The Gorlin syndrome, clinically de ned as distinct fi Gorlin–Goltz syndrome syndrome in 1963, existed during Dynastic Egyptian times, as revealed by a costellation of skeletal ndings com- NBCCS patible with the syndrome in mummies dating back to 3000 years ago and, most likely, in the ancient population Skeletal anomalies of Pompeii. These paleogenetic and historical evidences, together with the clinical and biomolecular modern ev- PTCH1 idences, confirm the quite benign behavior of the syndrome and the critical value of the multiple and synchro- NBCCS history nous skeletal anomalies in the recognition of these rare and complex genetic disease. Ancient Egypt © 2016 Elsevier B.V. All rights reserved. Pompeii Herculaneum

1. Introduction ovarian and cardiac fibromas, rhabdomyosarcomas) and unusual skeletal changes (Kiwilsza and Sporniak-Tutak, 2012). The NBCCS classic There are several genetic diseases with a wide spectrum of congen- phenotype is characterized by the presence of specific bone abnormali- ital bone stigmata in association to cutaneous and visceral signs and ties of the skull (frontal and parietal bossing, macrocephaly, calcifica- symptoms. The recognition of the inherited skeletal abnormalities, par- tions of the falx cerebri, brain tumors and maxillary or mandibular ticularly when uncommon, constitute a critical tool to obtain an early keratocystic ameloblastomas) and of other skeletal segments (bifid recognition of these syndrome both in the archeological remains and ribs, syndactyly, polydactyly) that sometimes facilitate identification in the current population (Ponti et al., 2013a, 2013b). Among the hered- and clinical diagnosis (Kiwilsza and Sporniak-Tutak, 2012). The itary tumor syndromes associated to unique skeletal findings, Nevoid aforementioned abnormalities of the neurocranium and of the Basal Cell Carcinoma Syndrome (NBCCS; also known as Gorlin syn- splanchnocranium are the main cause of the NBCCS typical facies, char- drome; OMIM #109400) is an autosomal dominant skin disease with acterized by asymmetry, hypertelorism and fronto-parietal bossing, an almost complete penetrance and a high intra-familial phenotypic that sometimes is the only aid to an early clinical diagnosis (Fig.1). variability, caused by germline mutations of the gene PTCH1 (Lo The NBCCS estimated prevalence is 1 per 40–57,000 (Farndon et al., Muzio, 2008; Lo Muzio et al., 2013). The syndrome is characterized by 1992; Pratt and Jackson, 1987). In Italy, the incidence of the disease an increased predisposition to the development of multiple basal cell (1:256,000) (Lo Muzio et al., 2013) seems to be lower than in carcinomas (BCC) in association with odontogenic keratocystic tumors Australia (1:164,000) (Shanley et al., 1994) and the United Kingdom (OKT), ameloblastoma (AML), visceral tumors (medulloblastomas, (1:55,600) (Evans et al., 1993).

Abbreviations: NBCCS, nevoid basal cell carcinoma syndrome; BCC, basal cell carcinoma; 2. From the first description of NBCCS to PTCH1 gene identification AML, ameloblastoma; OKC, odontogenic keratocystic tumor; CT, computerized tomography; ICOB, Index Cranico of Broca. The first description of a patient affected by the NBCCS was probably ⁎ Corresponding author at: Via del Pozzo n. 71, Department of Surgical, Medical, Dental published in 1894 when Jarisch described a 22-year old patient affected and Morphological Sciences with Interest transplant, Oncological and Regenerative Medicine; University of Modena and Reggio Emilia, Modena 41124, Italy. by short stature, milia, low mentality, marked scoliosis and multiple E-mail address: [email protected] (G. Ponti). basal cell carcinoma since the age of 14, one of these skin lesions having

Fig. 1. Pictures of patients (A–H) affected by NBCCS, reproduced from the original manuscript by Gorlin et al. (1965). the characteristics of ulcus rodens (Jarisch, 1894; White, 1894). The au- proposed by Gorlin in the 1965 were summarized in Table 1 (Fig.1). thor, in its original manuscript, described a series of patients affected by The developmental defects, described by Gorlin, that are distinctive of multiple skin lesions, most likely basal cell carcinomas, in association to the syndrome include: intracranial calcification, fused, bifid and splayed systemic anomalies, and probably the aforementioned 22-years old pa- ribs, calcifications of the falx cerebri and frontal bossing (Table 1). tient, was clearly affected by NBCCS, showing the main clinical and his- Gorlin's triad of original criteria was later enlarged with other addi- tological features of the syndrome. tional features such as other skeletal anomalies and the presence of A relationship between developmental defects and multiple basal palmo-plantar pits. The description of palmo-plantar pits was done by cell carcinoma was reported by Binkley and Johnson in 1951 (Binkley Calnan, that defined this feature as a peculiar dyskeratosis of the and Johnson, 1951), and Howell and Caro, 1959 (Howell and Caro, palms and soles (Calnan, 1953). More precisely, these alterations are 1959). Only in 1960, Gorlin and Goltz described that the association of caused by the partial or complete absence of the stratum corneum in multiple nevoid basal cell carcinoma, cysts of the jaw and skeletal areas with diameter from 1 to 3 mm. anomalies, most commonly bifid rib, was consistent enough to consider Diagnostic NBCCS clinical criteria were defined by Evans DG (Evans their occurrence as a distinct syndrome (Gorlin and Chaudhary, 1960; et al., 1993) and revised by Kimonis in 1997 (Kimonis et al., 1997). Ac- Gorlin et al., 1963). The clinical criteria for the diagnosis of NBCCS 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 the five major criteria the bone stigmata comprise the lamellar calcification of Table 1 the falx cerebri under age 20 and the histologically confirmed NBCCS signs and symptoms with their relative frequency proposed by Gorlin R in 1963. odontogenic (jaw) keratocyst; among the seven minor criteria the skel- From the original tabulation we here report only the skin, oral and skeletal manifestations. etal abnormalities include the macrocephaly, the cleft lip/palate and Signs and symptoms Relative frequency

Skin A1 Multiple nevoid basal-cell carcinoma +++ Table 2 A2 Palmar dyskeratosis (porokeratosis of Mantoux) ++ Diagnostic criteria for NBCCS proposed by Kimonis in 2004 (2 major or 1 major A3 Milia; cysts, especially extremities ++ and 2 minor criteria, or a ﬁrst degree relative with NBCCS and 1 major or 2 mi- A4 Fibromas and/or neuroﬁbromas, especially extremities + nor features).

Oral manifestations Major criteria B1 Multiple jaw cysts +++ More than 2 BCCs or one BCC under the age of 20 years B2 Mild mandibular prognathism ++ Odontogenic keratocysts of the jaw proven by histology B3 Fibrosarcoma jaws (?) + Three or more palmar or plantar pits B4 Ameloblastoma + Lamellar calcification of the falx cerebri Rib anomalies (bifid, synostosed, hypoplastic) Skeletal system Ovarian fibroma fi C1 Rib: bi d, synostosis, partial agenesis, or cervical rudimentary +++ Medulloblastoma C2 Vertebrae: scoliosis, cervical or thoracic fusion ++ Flame shaped lucencies of the phalanges C3 Frontal and biparietal bossing ++ Brachymetacarpaly in all 4 limbs C4 Shortened metacarpals ++ First degree relative with NBCCS C5 Deformed chest + Minor features Central nervous system Any one of the following features: fi D3 Calcification dura (falx, tentorium) choroid ++ Spina bi da occulta or other vertebral anomalies Brachymetacarpaly in at least one limb Eye Hypertelorism or telcanthus Dystopia canthorum, hypertelorism ++ Frontal bossing 106 G. Ponti et al. / Gene 589 (2016) 104–111 vertebral/rib anomalies including bifid vertebrae/ribs, extra ribs, and/or population vs. estimated prevalence of 26% in the NBCCS patients) splayed ribs. (Kimonis et al., 2004, Lo Muzio, 2008), and suggested their inclusion as However, clinical and radiologic analyses led to many revisions of a novel major criteria which may be useful for the recognition and char- the diagnostic criteria over time. Regarding the skeletal anomalies, acterization of misdiagnosed cases (Ponti et al., 2014)(Fig 2). Kimonis in his NBCCS families reported odontogenic keratocysts in Further clinical and radiologic evaluations of a wider population of 74% of patients, calcification of the diaphragm of sella turcica in 68% of PTCH1 mutated gene-carriers would be helpful to establish the clinical patients, calcification of the falx cerebri in 65% of patients, coarse face impact of the different skeletal stigmata among the NBCCS major and in 54% of patients, macrocephaly in 50% of patients, hypertelorism in minor diagnostic criteria which should be considered dynamic entities 42% of patients, frontal bossing in 27% of patients, calcification of the that can be improved and better characterized. tentorium cerebelli in 20% of patients, sternal abnormalities in 13% of The molecular pathogenesis of NBCCS has been known since the dis- patients, bifid ribs in 26% of patients, hemivertebrae in 15% of patients covery in 1996 of the germline mutations on the PTCH1 gene. Since then, and vertebral fusion in 10% of patients (Kimonis et al., 1997). about 280 germline mutations have been described worldwide so far In 2004 the same authors (Kimonis et al., 2004) enlarged the popu- (Pastorino et al., 2012). The PTCH1, or the human homolog 1 of the Dro- lation studying additional skeletal features in NBCCS syndrome patients, sophila Patched gene, which is mapped on chromosome 9q22.3, consists with the following results: bifidribswereconfirmed in 26% of patients, of 23 exons and encodes an integral membrane protein of 1447 amino nuchal ligament calcification was present in 18%, other ribs anomalies acids, Patched 1 (PTCH1) with 12 transmembrane regions, 2 extracellu- (fusion, hypoplasia or aplasia) were present in 16%, hemivertebrae lar loops, and a putative sterol-sensing domain (Ponti et al., 2012b). were confirmed in 15%, deformations were present in 14%, clavear ab- The SHH signaling pathway plays an important role in the mamma- normalities were present in 12%, vertebral fusion were confirmed in lian embryonic development of many structures such as the neural tube, 10% of patients, phalangeal foot polydactyly was present in 4%. In axial skeleton, limbs, lungs, skin, hair follicles, and teeth. SHH signaling 2011, Bree AF and Shah MR (Bree and Shah, 2011) proposed less strin- also regulates growth and determines the shape of teeth (Dassule gent criteria for NBCCS diagnosis suggesting that medulloblastoma et al., 2000). PTCH1 mutation spectrum includes point mutations, should be considered a major and not a minor criteria, increasing small and large deletions, insertions and splicing mutations (Jones early detection of the underlying syndrome, since it typically manifest et al., 2011). Heterozygosity for PTCH1 due to inherited germline muta- in children aged 2 years and younger (Table 2). tion is likely to give rise to the developmental anomalies seen in NBCCS. In our report published in 2012, we proposed a restoration of a Subsequent postnatal loss of the other allele by mutation or silencing neglected criterion for NBCCS recognition: the ameloblastoma (AML) can lead to unregulated downstream proliferative activity, which in- (Ponti et al., 2012a, 2012c). In fact, although manuscripts in the literature duces the cutaneous phenotype and other neoplasm (Levanat et al., reported the association between AML and NBCCS (Jensen and Roser, 1996). 1978; Schultz et al., 1987; Eslami et al., 2008; Ackermann et al., 1988), in- The PTCH1 mutations are responsible for the clinical expression of cluding the first cases reported by Gorlin R et al. which suggested that the disease and can be found in a large amount of patients exhibiting AML as associated Gorlin–Goltz sign (Gorlin et al., 1963), the most recent a classic phenotype. Differently from other cancer predisposing syn- wider criteria do not include this odontogenic tumor among the NBCCS dromes, NBCCS doesn't show the correlations between genotype–phe- criteria yet (Kimonis et al., 2004). In 2014, we performed a clinical and ra- notype (Ponti et al., 2012b, 2013b) and its wide phenotypic variation diologic characterization of the NBCCS related cranio-facial and other does not appear to be related to the type of PTCH1 mutation, nor to skeletal anomalies using 3D and helical CT scan reporting skeletal stigma- any founder effect. Normally the founder effect is defined as an ancestral ta as macrocephaly, positional plagiocephaly, skull base and sphenoid mutation, that was introduced in the same population by a common an- asymmetry, bifidity of multiple ribs and giant multilocular odontogenic cient progenitor, and that can be found in different affected families ap- jaw cysts and extensive multilamellar calcifications of falx cerebri, parently unrelated by any kinship, and living in the same geographic tentorium, falx cerebelli and of the atlanto-occipital ligament (Fig. 2). In area. This is partly due to the relatively recent identification of the the same study, in addition to the sphenoid asymmetry, we focused our gene responsible of the syndrome and partly to the difficulty of attentiononthevalueofbifid ribs, which are very uncommon in the gen- extracting “pure” DNA from the ancient bones that are suggestive of pa- eral populations (estimated prevalence of 0.15–3.4% in the general 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), biﬁdribs(H–L). G. Ponti et al. / Gene 589 (2016) 104–111 107

3. Gorlin–Goltz skeletal stigmata in the ancient Egypt Over the centuries, in addition to the architectonical structures, the archeological remains comprised many items of the common life, such Although the spectrum of signs and symptoms associated with as furnitures and pottery, mingled with human and animal bones. Some- Gorlin Syndrome was described in detail by Gorlin in 1960, some times it was possible to isolate the whole skeleton, or to create identical archeologic findings document the presence of this syndrome in the an- molds, other times only separate skeletal segments were isolated and cient Egypt, more than 3000 years before Gorlin's manuscript. found. Three Egyptian skeletons of the Dynastic period (between the V and To date there are few paleogenetic studies that analyzed the animal XI dynasty, 2450–1955 BC) present bone aberrations compatible with remains (especially horse's) (Di Bernardo et al., 2004). Only a minority the diagnosis of Gorlin Syndrome. They came from the graves of Assyut of them focus on the anthropometric values of human bones, and and Gebelein and were collected among the skeletons that belong to the even less studies explore the molecular-genetic aspects (Di Bernardo “G. Marro” Egyptian anthropological collection (Museum of Anthropol- et al., 2009; Cipollaro, 2011). ogy and Etnography of Turin). The specimens were collected during the One of our recent studies at the University of Modena and Reggio excavation of the Italian Archeological Mission in Egypt (1903–1937), Emilia, in collaboration with the Superintendence of Pompei, was under the direction of the Turin Egyptian Museum. The collection con- conducted in order to characterize the clinical and genetic features sists of mummified specimens (20 complete mummies and 80 heads) of the skeletal remains collected in the Forum Baths from Pompeii and bones (650 complete skeletons and 1300 isolated skulls) (Leigh, archeological site. The anthropometric analysis of the skeletal 1934; Boano et al., 2006; Ponti et al., 2014). remains was aimed to the identification of the likely presence of The two skeletons excavated at Assyut (case 1, E225 and case 2, hereditary syndromes (especially the Gorlin syndrome) affecting E235) were characterized by frontal bossing, multiple bony cavities the roman population in A.D. 79. The specific aim of the study was (probably cysts) of mandible and maxilla; multiple bifid ribs (in the the identification of the skeletal alteration characteristic of the case 2 six bifid ribs are present); sacrum with incomplete fusion of the NBCCS. The analysis of 100 skulls stored in the Forum Baths was con- dorsal laminae; occipital asymmetry; relative shortening of 4th meta- ducted in order to measure the main anthropometric values of the carpals; scoliosis and enlargement of the sella turcica (Satinoff and horizontal cranial index and the vertical cranial index, also called Wells, 1969)(Figs. 3, 4): these findings support the diagnosis of index of Broca (ICOB), that are useful in order to quantify some mor- NBCCS with different major criteria met (odontogenic keratocysts, phologic features of the head. The anthropometric data were bifid ribs, affected family members, etc.). collected from 100 skulls and 20 mandibular bones of adults stored The other skeleton with bifid rib compatible with the diagnosis of in the Forum Baths in archeological site from Pompeii. The measure- Gorlin Syndrome (GED 44, E22) come from a single grave at Gebelein ment comprised the determination of the horizontal cranial index (upper Egypt) and are referable to a child of around 4 years (Boano and the vertical cranial index, also named horizontal and vertical et al., 2006). Although in this skeleton the bifid rib is not associated cranial indices of Broca. In particular, the vertical cranial index with any other skeletal alteration in the axial or appendicular skeleton, (ICOB) was measured on 60 intact skulls and the respective values the suspicion of the Gorlin syndrome is clear due to the crucial role of were analyzed in accordance with the seven categories defined by these coast anomalies in establishing a diagnosis of the genetic disease, Garson (in Martin and Saller, 1956-1959). particularly in young children (Veenstra-Knol et al., 2005). At the archeological bone collection of Pompeii, our preliminary study, allowed to define a significative heterogeneity of the anthropo- 4. Gorlin–Goltz bone stigmata in the Pompeian and Herculaneum metric cranial parameters: even though the majority of the population archeological bones collection 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- The archeological excavations in Pompeii officially started in 1748 viduals having hyperdolicocranic skulls. It was among the dolicocranic due to the will of the Emperor Charles III of Spain, king of the Two Sicilies. 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), biﬁdribs(E–G), incomplete fusion of the sacral laminae (H). 108 G. Ponti et al. / Gene 589 (2016) 104–111

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). presenting also different non-metric traits characteristics of the NBCCS that dolichocephalic skulls were found in the 14% cases, mesocephalic (Fig. 5). skulls were found in the 43% population and brachycephalic skulls This observation, that led us to hypothesize that some individuals of were found in the remaining 43% cases. the Pompeii population were affected by NBCCS, was probably the focus The same ideas were presented in a recent study published by E. of the hypothesis of the anthropologist Stefano Delle Chiaie, that in Laser, that in addition to the metric evidences, also assessed the non- 1853, analyzed the Pompeian skulls collections and asserted that the metric parameters, concluding that the observed statistical deviations ancient population of Pompeii was composed by many ethnic groups in the measurement of the cranial indices, derived from intra- (Delle Chiaie, 1854). In fact, it was well known that the population in population variability (of the same ethnic group) rather than inter- Pompeii consisted of multiethnic society because of the high number population variability (of different ethnic group) (Lazer, 2011). of slaves of the African or Eastern descent. It's important to underline that our anthropometric results were ob- The first official publication of the human skeletal remains from tained from a different skeletal collection respect to the ones evaluated Pompei was published in 1882 by Giustiniano Nicolucci (Nicolucci, by the aforementioned authors, in fact, the collection that we analyzed 1882), that was the founder of the Institute of Anthropology of the Uni- were lacking some of the more unusual skeletal skulls that Nicolucci versity of Naples. Nicolucci didn't agree with Delle Chiaie when he de- took to Naples (D'Amore, 1979), but comprised the new skeletal re- scribed that “some skull were globular, other ovoid and that a few were mains that were found and added to the collection in the last decades. oblong in form; the final type of skull observed in this work was interpreted Even though a high frequency of macrocephaly and frontal bossing as African, probably representing slaves who were in the service of the was observed in the population of Pompeii, the disarticulated nature wealthy citizen of Pompei”. Nicolucci though that the population of of the Pompeian samples constituted an important limit to the analysis Pompei in AD 79 was heterogeneous, but autochthonous reporting of the systemic skeletal anomalies that is necessary to diagnose NBCCS

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. G. Ponti et al. / Gene 589 (2016) 104–111 109 with high confidence. Even though the finding of isolated skull anoma- the mutational status of PTCH1, after the laboratory procedures of an- lies don't lead unequivocally to the NBCCS diagnosis, because it is not cient DNA extraction. sufficient to define the patient as being affected by NBCCS, the high frequency of those abnormalities in the dolicocranic population represent 5. Conclusions an important clue to hypothesize that at least some individuals were affected by NBCCS. In detail, some skulls were characterized by marked The combination of concomitant skeletal abnormalities in multiple frontal bossing and parieto-occipital bossing (signs already described anatomic sites of involvement is an important aid to the diagnosis of by Gorlin in 1963), asymmetry of the cranial base, and presence of mul- NBCCS. Some important semiology signs affecting the facies, as the tiple odontogenic cysts in the mascellary bone (Fig. 6). The analysis of presence of facial asymmetry, hypertelorism, frontal and parietal the mandible and of the ribs of those subjects would have been of bossing, are the result of the corresponding alterations of the neuro- great scientific value, but unfortunately it was not possible. Regarding and splanchnocranium (Fig. 8). Those signs are important clues both the mandibular cysts, it is worth mentioning that Capasso observed for the clinician and the archeologist to suspect the diagnosis of many skeletons with multiple mandibular cysts and among these four NBCCS, which should be confirmed through biomolecular investiga- individuals with four–five odontogenic abscesses while an individual tions, DNA extraction and PTCH1 sequence analysis. In particular, bone had a total of 8 oral abscesses (Lazer, 2011). findings are essentials to establish a diagnosis in children, in fact in The observed tendency to macrocephaly and the presence of multi- the pediatric population it is very common that the other clinical diag- ple cases with clear asymmetry of the cranial base, with fronto– nostic criteria are lacking because they have not manifested yet. The temporo-parietal bossing in the ancient population of Pompeii is longevity of the syndrome can be demonstrated through the analysis unusual if compared to the anthropometric data found in the near city of ancient bones, which are fundamental to make paleopathological of Herculaneum, where it was reported a presence of 47% of mesocranic studies and to diagnose the syndrome. Many congenital skeletal alter- skulls, more than 25% of brachicranic skulls and a relatively low inci- ations recovered from the remains of ancient populations that lived in dence of hyperdolicocranic skulls (13.7%) (Capasso, 2001). The analysis Egypt about 3000 years ago, and in Pompeii and Herculaneum about conducted by Capasso of the 162 skeletons, extracted from 1982 to 2000 years ago, shed some light on the history of the syndrome, that 1985, took 7 years of accurate examinations and studies. In his manu- was identified as a clinically defined entity only in 1963 AD. The finding script, entitled “I fuggiaschi di Ercolano”, Capasso focused on the paleo- of NBCCS phenotype in many old populations demonstrates the rela- biology of the remains and tried to reconstruct the most frequent tively benignity of NBCCS that allows the survival of the affected indi- diseases, the alimentary habits, and the life and work activities also in viduals to the fertile age, so that the germline mutations has been children (Capasso, 2001). Among the 162 Herculaneum skeletal re- preserved throughout millenniums. mains it is possible to find a skeleton in relatively good conditions, The sequencing of the gene PTCH1 from ancient DNA, extracted form where it can be described one of the skeletal abnormalities that is skeletal remains and mummified bodies, is a necessary step for the con- more specific for the NBCCS: the presence of bifid ribs in association clusive diagnosis of NBCCS, and will probably allow the analysis of the with cranial base asymmetry (Fig. 7). phylogenesis and of the founder effects of the mutations. The subsequent steps of our paleo-pathologic research, will be possible thanks to the friendly attitude of the, Prof. Massimo Osanna, and 6. Summary of the Head of the Applied Biology Laboratory, dr. Ernesto De Carolis, and his patient technicians, will lead to the documentation through There are several genetic diseases with a wide spectrum of congen- 3D TAC of the most relevant skeletal remains and the determination of 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. 110 G. Ponti et al. / Gene 589 (2016) 104–111

Fig. 7. Pictures of skeletal anomalies reproduced from the manuscript by Capasso (2001). In detail, the presence of bifid ribs (A,B), asymmetric skull base (C,F) and fronto-parietal bossing (D,E). malignant neoplasms. Gorlin–Goltz syndrome, also named nevoid basal during Dynastic Egyptian times, as revealed by a constellation of skeletal cell carcinoma syndrome, is an autosomal dominant systemic disease findings compatible with the syndrome in mummies dating back to with an almost complete penetrance and high intra-familial phenotypic 3000 years ago and, most likely, in the ancient population of Pompeii. variability, caused by germline mutations of the gene PTCH1. The These paleogenetic and historical evidences, together with the clinical syndrome is characterized by unusual skeletal changes and high predis- and biomolecular modern evidences, confirm the quite benign behavior position to the development of multiple basal cell carcinomas, of the syndrome and the critical value of the multiple and synchronous odontogenic keratocysts tumors and other visceral tumors. The Gorlin skeletal anomalies in the recognition of these rare and complex genetic syndrome, clinically defined as distinct syndrome in 1963, existed disease.

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. G. Ponti et al. / Gene 589 (2016) 104–111 111

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