Eosinophilic granuloma of the calvarium: is conservative management a valid option? Illustrative case and systematic review of the literature

INTRODUCTION

Eosinophilic granuloma (EG) is the most common form of Langerhans cell histiocytosis, presenting as a single osteolytic lesion of the calvarium. Its diagnosis is based on typical clinical and radiological features. While surgical resection has been the standard treatment for EG, growing evidence favors watchful waiting, as unifocal calvarial lesions appear to frequently undergo spontaneous remission. However, histopathological confirmations of this hypothesis are still very limited.

METHODS

Methods. Here, we report a case of EG with typical clinical and radiological features which, due to intervening circumstances, was resected in a delayed fashion. Moreover, we perform a systematic review of the literature on conservative management of EG.

RESULTS

In our case, histological examination showed ongoing bone regeneration with no traces of the disease. Through our literature review, we found 47 cases of calvarial EG managed with watchful waiting. No active intervention was required in 43 cases (91%). Four patients (9%) received surgery or chemotherapy due to the persistence/progression of symptoms or family request. Three reports other than ours documented spontaneous disease remission in surgically resected EG upon histopathological examination.

CONCLUSION

Our report provides further evidence that watchful waiting can be a reasonable option in the management of single calvarial EG.

Eosinophilic granuloma of the clavicle in an 11-year-old Chinese girl: A case report

RATIONALE

Eosinophilic granuloma (EG) - the most common form of Langerhans cell histiocytosis - occurs rarely, and manifestations with only rib and clavicle involvement are extremely rare. EG symptoms often include pain, swelling, and soft tissue mass. The clinical diagnosis of bone EG is complex, and the differential diagnosis includes Ewing sarcoma, tuberculosis, multiple myeloma, lymphoma, primary bone malignancy, and other osteolytic lesions.

PATIENTS CONCERN

The patient was an 11-year-old female who found a subcutaneous mass at the junction of the right clavicle and sternum 2 days before presenting at the clinic without apparent triggers. Initially, we considered a subcutaneous cyst or inflammatory mass. Color ultrasound and computed tomography examination revealed osteomyelitis. Finally, the patient was diagnosed with EG after a pathological tissue biopsy, and the child recovered after surgery and anti-infective treatment.

DIAGNOSIS

The patient underwent surgery to remove the tumor at a specialist hospital and was diagnosed with EG by pathological examination.

INTERVENTION

The patient went to a specialist hospital for surgery to remove the mass and underwent anti-infective treatment.

OUTCOMES

The patient recovered after surgical resection and antibiotic treatment.

LESSONS

In this report, we emphasize that the clinical presentation of EG in children is not specific. Furthermore, examining age, history, presence of symptoms, and the number of sites is essential to make a correct diagnosis, and a histological examination is necessary to confirm the diagnosis.

Eosinophilic Granuloma of the Liver Mimicking Metastatic Liver Tumor

We herein report a case of coagulation necrosis with granulation and eosinophilic infiltration of the liver. A 37-year-old woman was diagnosed with a new mass lesion in the liver 1 month after breast cancer surgery and admitted for a further examination. Because the tumor occurred immediately after surgery, it was considered essential to determine whether or not it was a metastatic liver tumor from breast cancer. A percutaneous liver tumor biopsy revealed eosinophilic granuloma of the liver, which is considered to have a high possibility of visceral larva migrans with suspected gnathostomiasis infection. A detailed medical history and histological diagnosis are important for making a differential diagnosis.

Pandora's box: eosinophilic granuloma at the cerebellopontine angle-should we open it?

BACKGROUND

Langerhans cell histiocytosis (LCH) is a disorder of immature LCH cells, eosinophils, macrophages, lymphocytes, and multinucleated giant cells. Eosinophilic granuloma (EG) is a focal form of LCH that presents mostly in the skull, femur, vertebrae, pelvis, mandible, and ribs. Intracranial presentation of EG is very rare in the literature.

CASE DESCRIPTION

A 17-year-old boy visited our clinic with headache, dizziness, and tinnitus that were present for 2 months. Brain MRI depicted a lesion at the right cerebellopontine angle. The lesion was hypointense on T1-weighted and hyperintense on T2-weighted brain MR images. The lesion enhanced homogenously after I.V. contrast material administration. Pre-operative diagnoses were vestibular schwannoma and meningioma. Surgery was planned. Retrosigmoid approach was preferred in the surgery. The lesion was excised partially. Pathological analysis depicted cell infiltration composed of eosinophils besides histiocytes, plasma cells, and lymphocytes in different amounts. CD1a was positive yet S100 was negative. Final diagnosis was eosinophilic granuloma. Post-operative course was uneventful. The patient was referred to pediatric oncology unit, and steroid therapy was initiated. Post-operative follow-up brain MRIs showed that the lesion had regressed further than immediate post-operative images by only steroid use. In long-term follow-up, new lesions appeared on the patient's skin in multiple locations and in the sclera of his left eye. At the last follow-up (3 years post-operatively) skin and scleral lesions were noticed to have regressed spontaneously and the intracranial structures were tumor free.

DISCUSSION AND CONCLUSION

To the best of our knowledge, EG at the cerebellopontine angle has not been presented in the literature. What makes our case further unique is its negativity for S-100 antigen. Eosinophilic granuloma should be kept in differential diagnosis of mass lesions presented at the cerebellopontine angle, especially in children and young adults with high eosinophils and lymphocytes in their peripheral blood. Sole steroid trials could be conveyed in suspicious cases before any further intervention. If the lesions do not regress or enlarge with time, surgery should be considered. However, long-term follow-up of these patients is necessary since natural history of the disease has not been defined, yet.

Thoracoscopic Transillumination in Chest Wall Resection

Determining the extent of chest wall resection during en bloc lung cancer operations is often difficult secondary to the location of these tumors. We describe a hybrid technique that employs video-thoracoscopy and chest wall transillumination to determine the appropriate margin of resection.

Multifocal Langerhans Cell Histiocytosis in an Adult

Eosinophilic granuloma (EG) is the most common and benign form of the spectrum of disorders referred to as Langerhans cell histiocytosis (LCH). Langerhans cell histiocytosis is primarily regarded as a pediatric disease, with few adult cases of multifocal EG of bone reported. We report a case of multifocal EG in a 48-year-old woman, who presented with right knee pain. Radiographs showed a small lytic lesion in the medial femoral condyle. Diagnosis was confirmed by ultrasound-guided biopsy. She had had a previous EG lesion excised from her skull. Whole-body bone scan demonstrated a new skull lesion in the right diploic space, which was confirmed by magnetic resonance imaging. The patient underwent curettage, bone grafting, and prophylactic internal fixation of the right distal femur lesion. The skull lesion was treated with repeat craniectomy. Two years later, she developed a new lesion in the right distal femoral metaphysis, which was treated with intralesional corticosteroid injections. Now, more than 1 year later, the patient is pain-free with no evidence of new or recurrent disease. Because multifocal EG is a rare diagnosis in adults, appropriate clinical suspicion, in combination with radiographic findings and histologic examination, is essential for correct diagnosis and treatment.

Resection of benign vertebral tumors by minimally invasive techniques

BACKGROUND CONTEXT

Benign tumors of the vertebrae are generally an uncommon cause for surgery. Complete removal of these tumors requires in most cases extensive surgical technique that consists of generous surgical exposure followed by laminectomy, facetectomy, and sometimes even an instrumented fusion.

PURPOSE

The aim was to describe our experience in performing resection of benign vertebral tumors, using a minimally invasive surgical (MIS) approach.

STUDY DESIGN

This was a retrospective review of case records.

PATIENT SAMPLE

Patients who underwent MIS, resection of benign vertebral tumors.

OUTCOME MEASURES

Complete neurologic examination and pain evaluation, as measured by the visual analog scale (VAS). Secondary outcomes included postoperative spinal instability assessment and surgical margins examinations.

METHODS

Patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months intervals clinically and radiographically using plain radiographs and postoperative computed tomography (CT) scans. Final pathologic report, operative time, blood loss, complications, and hospital length of stay were also recorded.

RESULTS

Between 2009 and 2013, 14 patients underwent MIS, resection of benign vertebral tumors at our institution. Mean follow-up time was 4 years. There were eight men and six women with a mean age of 27 years (range 16-68 years). For tumors located in the posterior elements, a direct posterior approach was used. Tumors located at the pedicle of the vertebra were excised using a transpedicular approach, and tumors protruding into the foramen were excised using the transforaminal approach. The transcanal approach was used when decompression of the thecal sac or nerve root was required, and the retroperitoneal transpsoas approach was used for tumors located in the vertebral body. Complete removal of these tumors was achieved in all cases, and was verified by a follow-up CT scan. Pathology revealed osteoid osteoma in five patients, osteoblastoma in three patients. Eosinophilic granuloma, fibrous dysplasia, and fibroid adenoma were found in one case each. Average VAS pain score improved from 7.7 (7-9) to 2.8 (0-7) after surgery.

CONCLUSIONS

Minimally invasive techniques are a valuable choice for the treatment of benign osseous tumors of the spine. A larger, long-term study is in progress. In the meantime, we suggest surgeons experienced with both open and MIS surgery should consider these techniques.

Ependymosarcoma with eosinophilic granular cells

Ependymosarcoma is a new entity of malignant gliomas composed of ependymal and sarcomatous components. Were port a rare case of ependymosarcoma with eosinophlic cells which occurred to the right trigon of the lateral ventricle.A 62-year-old man complained of headaches over a 2-month period. A hard, gray mass was found in the right trigon of the lateral ventricle during the operation.Although he received radiation and chemotherapy, the patient died due to tumor disseminating through the whole brain within 7 months after the operation. The histological examination revealed that the anaplastic glial components intermingled with the sarcomatous components. Immunohistochemically, sarcomatous cells were positive for α smooth muscle actin and desmin. However, anaplasticglial cells were not positive for these markers. In addition, Masson trichrome stain showed a plethora of collagen fibers between sarcomatous cells, but no collagen fibers were produced by the glial tumor cells. Solid focal papillary lesions of the glial tumor showed dot-like epithelial membrane antigen and diffuse cytoplasmic D2-40 immunoreactivity. Based on the above findings, these anaplastic glial tumor cells should show focal ependymal differentiation, and sarcomatous cells show myofibroblastic differentiation. In addition, almost 10%of the tumor cells in the neoplasm showed bright eosinophilic granules in the cytoplasm. These cytoplasmic eosinophilic granules and bundles were negative on PAS staining. Intracytoplasmic eosinophilic granules of tumor cells were strongly positive for αB-crystallin, HSP 27 and GFAP, respectively. These findings suggest that the clinicopathological characteristics of the present case should be consistent with the criterion of ependymosarcoma by Rodriguez et al.

[Surgical treatment combined with oral administration of indomethacin for eosinophilic granuloma of the skull: report of a pediatric case]

A 13-year-old girl presented headache for 5 d upon admission to hospital. An initial CT revealed 3 lesions located in her skull, the sizes of which were 2.5 cm×3.2 cm,1.2 cm×1.0 cm,0.3 cm×0.3 cm, respectively. The largest lesion was resected by surgery and confirmed as eosinophilic granuloma by pathology. After surgery, she took oral indomethacin 25 mg b·i·d for 3 months and tolerated it well. CT scan was performed 3 months and 1 year later, and the results showed that the unresected lesions shrank progressively and the defected bones were regenerated and healed one year later after operation.

Eosinophilic granuloma of the temporal bone in an adult: controversies in the management

Eosinophilic granuloma is a rare, benign, lesion characterized by uncontrolled proliferation of Langerhan's cells. It is commonly found in a bone and has been described in almost every bone in the body. It usually affects children and is seldom found in adults. A case of 60-year-old adult male with an eosinophilic granuloma of the right temporal bone with infiltration of the temporal and infratemporal fossa and osteolysis of the squama of the temporal bone is presented. Diagnostic procedure and course of treatment are described. Controversies in the management and different approaches in therapy of such lesion are discussed because there is no agreed treatment protocol established.

Surgical treatment of eosinophilic granuloma of the infratemporal fossa: a successful treatment option

The patient was a 16-year-old girl complaining about progressive swelling on the right side of her face, right headache, and right orbital proptosis. A CT scan revealed a lytic mass centered in the greater wing of the right sphenoid bone with extension into the orbit, middle cranial fossa, and infratemporal fossa. The patient underwent a subtemporal-preauricular infratemporal fossa approach, which allowed complete resection of the tumor, with a low morbidity. The pathological diagnosis was eosinophilic granuloma. At 36 months after the initial treatment the patient is free of disease. We conclude that lesions of this complex anatomic area are a challenge to biopsy and treat and they could be treated only with radical surgery with low morbidity, at centers with expertise in skull base surgery.

Operative case of Langerhans'cell histiocytosis of the skull with dural invasion. An immunohystochemical study of ki-67 expression of eosinophilic granuloma: case report and review of the literature

Eosinophilic granuloma (EG), Letterer-Siwe disease and Hand-Schuller-Christian disease are collectively called Langherans-cell histiocytosis (LCH). While the latter two are systemic diseases, the former is a localized form of histiocytosis. Solitary EG of the skull are rare lesions characterized by a natural history not well defined yet. In this context, we report a case of a 23-year-old male suffering for a recurrent and progressive right parietal headache. On computed tomography (CT) it was observed an ostelytic lesion which on magnetic resonance imaging (MRI) appeared as an hyperintense soft mass on both T1 and T2 weighted images. The lesion showed a marked and heterogeneous enhancement after gadolinium administration. The surgical excision was complete and the severe headache disappeared. Immunohistochemical analysis of the specimen indicated an eosinophilic granuloma characterized by Ki-67 nuclear antigen expression with a labeling index of 20%. In the pertinent literature we have found two aggressive cases of EG showing the Ki-67 expression with a respectively 6.2% (occipital bone granuloma) and 10% (parietal bone granuloma) labeling index. That high proliferative activity suggests a local Langherans' cell proliferation along with an exuberant inflammatory response and also explains the aggressive clinical course and the rapid expansion of the lesion observed in some rare cases of solitary EG. This is the third case-report of calvarial EG characterized by Ki-67 nuclear antigen expression.

Traumatic ulcerative granuloma with stromal eosinophilia. A case report and short literature review

We introduce a case of 53-year-old female with rapidly developing tongue ulceration clinically mimicking squamous cell carcinoma of the oral mucosa. After a microscopic examination traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) was diagnosed. In a short literature review, we characterize this entity, analyse its aetiology and nature. Differential diagnosis is also discussed.

[Diagnosis and treatment of eosinophilic granuloma of long bones in children]

OBJECTIVE

To investigate the operative procedure and the effectiveness of eosinophilic granuloma (EG) of long bones in children.

METHODS

Between January 2005 and December 2009, 14 patients with EG of long bones were treated. There were 9 boys and 5 girls, aged from 1 to 13 years (mean, 6.5 years). The locations were femur in 5 cases, humerus in 4 cases, tibia in 2 cases, fibula in 1 case, and femur complicated with tibia in 2 cases. The disease duration was 7 days to 10 months (median, 2 months). X-ray films showed that osteolytic destruction had clear boundary, which did not involve the epiphyseal plate. Of 14 cases, 12 cases of tumor were treated by curettage, autologous iliac bone or combined artificial bone graft repair, and 2 cases were treated by resection, autologous iliac reconstruction, plate and screw fixation. Five cases complicated with pathological fracture underwent reduction and fixation.

RESULTS

All cases were diagnosed pathologically as having EG. All incisions healed by first intention. A total of 12 patients were followed up 1 to 4 years (mean, 2 years). The X-ray films showed tumor focus and pathological fracture healed within 3 to 4 months (mean, 3.5 months). Tibial lesion was found in 1 case of femoral tumor after 8 months, and was cured after reoperation. No recurrence occurred in other 11 cases. According to comprehensive assessing standard of X-ray film and joint function, the results of all cases were excellent.

CONCLUSION

EG of long bones in children is more common in the femur and humerus. Tumor curettage and autologous iliac bone graft repair is an effective method, and postoperative prognosis is good. There may be multiple lesions, so long-term follow-up is needed.

Vanek's polyp or inflammatory fibroid polyp. Case report and review of the literature

BACKGROUND

Intussusception in an adult must make us suspect the presence of a tumor (benign or potentially dangerous) as the most frequent cause. Accurate diagnosis is of great importance in order to provide appropriate treatment and improve patient prognosis.

CLINICAL CASE

We report the case of a 42-year-old male with abdominal pain. We performed a CT and found a small bowel intussusception. Definitive diagnosis according to the surgical specimen was inflammatory fibroid polyp (Vanek's polyp).

CONCLUSIONS

Vanek's polyp is a benign lesion that occurs most frequently in the stomach and secondarily in the small bowel. Generally, it is uncommon, and its etiology is not completely known. Accurate diagnosis is done with immunohistochemistry. Because of the consequences that depend on the size and location of the lesion, it may be considered a malignant lesion. Treatment is resection.

Langerhans cell histiocytosis of the sphenoid sinus: a case report

Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare disorder characterized by clonal proliferation and excess accumulation of pathologic Langerhans cells causing local or systemic effects. Bone is the most common organ involved and a single skull lesion is the most frequent presentation of childhood LCH. However, sphenoid sinus is an uncommon condition of involvement in LCH. Here we report a case of LCH in the sphenoid sinus, which occurred in a seven-year-old girl who presented initially with headache. The girl had suffered from headache for one month before she went to an otorhinolaryngologist one week before. Magnetic resonance imaging (MRI) showed a lesion of inflammatory granuloma. Surgery was performed and the disease was diagnosed pathologically as single-site LCH via hematoxylin-eosin (H&E) and immunohistochemical staining.

Resolution of eosinophilic granuloma after minimal intervention. Case report and review of literature

Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare, proliferative disorder in which the accumulation of pathologic Langerhans cells leads to local tissue infiltration and destruction. The incidence of LCH is estimated to be one case per 200,000 children per year. The role of the dentist is important in early and accurate evaluation, staging and diagnosis of LCH, because it may mimic more common diseases, such as juvenile periodontitis and osteomyelitis. There are multiple treatment options, but the response is unpredictable. The aim of this paper is to give a short, introductory overview on current diagnostic and treatment strategies for LCH in the oral and maxillofacial region and to present a case of LCH that mimicked juvenile periodontitis and was resolved following extraction of affected teeth. The history, radiological appearance, differential diagnosis, histopathology and treatment options for the patient are discussed.

[Surgical management of solitary eosinophilic granuloma of the calvaria. Two case reports]

Langerhans cell histiocytosis is a systemic disease resulting from the oligoclonal proliferation of Langerhans cells, occurring most commonly in children and young adults. The focal form of the disease, also known as eosinophilic granuloma, most frequently involves the calvaria. We present two cases of calvarial eosinophilic granulomas that were surgically removed. These tumors are reputed to have an excellent prognosis, even if local recurrences and systemic dissemination can occur during the follow-up. The authors discuss the pathogenesis and the evolutive profile but also the therapeutic management of solitary eosinophilic granuloma of the calvaria.

[Eosinophilic granuloma of the mandible--a case report]

BACKGROUND

Langerhans cell histiocytosis is characterized by a clonal proliferation of Langerhans cells. The clinical manifestation varies from a localized lesion (eosinophilic granuloma) to a systemic disease. The diagnosis can only be confirmed histopathologically. A comprehensive staging is necessary to determine the extent of the disease and to establish an adequate therapy.

CASE REPORT

We report on a 27 years old patient who was referred to our clinic with the diagnosis of an osteomyelitis of the mandibular angle and a pathological fracture after extraction of tooth 38 one month before. Curettage and primary bone grafting were performed. In the histological examination of the specimen infiltrates of a Langerhans cell histiocytosis were found. The clinical and radiological staging demonstrated a solitary mandibular lesion (eosinophilic granuloma). After wound healing a low-dose radiotherapy with 6 Gray was performed. Two years after completion of the therapy the patient is asymptomatic and does not show any evidence of recurrence.

CONCLUSION

Langerhans cell histiocytosis has to be included in the differential diagnosis of osteolytic lesions of the mandible. A low-dose radiotherapy is a reasonable and well-tolerated treatment option.

[Operative case of eosinophilic granuloma of the skull with dural invasion]

Eosinophilic granuloma is the localized form of Langerhans' cell histiocytosis. There are several reports of magnetic resonance (MR) imaging of eosinophilic granuloma of the skull, however there are few reports about dural enhancement. We report an operative case of eosinophilic granuloma of the skull with dural invasion. A 42-year old man was admitted to our hospital. He was neurologically intact and there were no other osseous or soft tissue lesions. CT showed an osteolytic lesion in the left parietal bone. MR images showed the lesion as isointense on T1-weighted, and high intense on T2-weighted images. T1-weighted images with Gd-DTPA demonstrated the mass which was enhanced with dural surface and subgaleal tissue. The angiogram demonstrated a tumor stain fed by the left occipital artery. Bone scintigraphy demonstrated a solitary lesion showing peripheral uptake with a central defect. The patient underwent craniectomy with removal of the dura and a subgaleal lesion. Histological examination revealed characteristic eosinophilic granuloma with dural invasion. No recurrence of the lesion was demonstrated 6 months after surgery.

Percutaneous vertebroplasty for eosinophilic granuloma of the cervical spine in a child

We report a case of eosinophilic granuloma at the fourth cervical vertebra in a 10-year-old girl presenting with a 1-month history of cervical pain and stiffness. This lesion was histologically diagnosed by needle biopsy and then treated by percutaneous vertebroplasty. After the procedure, the cervical pain and stiffness resolved rapidly. The height of the vertebral body remained stable without further collapse over a 6-month follow-up period.

Eosinophilic granuloma of the orbit: report of two cases

We present clinical, radiological, and histopathological findings and treatment results of two infants with orbital eosinophilic granuloma. Both patients presented at 1 year of age with unilateral proptosis, periorbital edema, and a superotemporally located, ill-defined orbital mass on computed tomographic (CT) imaging, with bone erosion in one patient. After subtotal excision, histopathological examination revealed eosinophilic granuloma, and the proptosis resolved with no sign of orbital tumor recurrence or systemic involvement at 12 and 23 months follow-up. Eosinophilic granuloma is a rare childhood orbital tumor that may or may not present with osteolytic change.

[Ischemic eosinophilic granuloma and pulmonary histiocytosis with a regressive course]

Langerhans' histiocytosis or histiocytosis X is a rare intrinsically benign disease producing a destructive tumor with a variable clinical presentation and an often unpredictable clinical course. Focal forms such as eosinophilic granuloma of the bone only require minimal care but the gravity of multisystem forms causing organic dysfunction sometimes require aggressive chemotherapy. Bone involvement is generally observed in children mostly boys. Both sporadic and chronic forms are noted. We report a case observed in a 17-year-old adolescent who presented an exceptional association of bony destruction of the pelvis with extended asymptomatic pulmonary involvement. The lung disease led to the initial diagnosis and optimal surgical, pathological and radiological management.