[Eosinophilic granuloma of the cervical spine: case report]

Eosinophilic granuloma (EG) is a benign condition of histocytes proliferation localized or multifocal. It is presents in the cervical spine in 1.5%-20% of the cases of EG. We report the case of a seven-year-old girl that presented with a one month history of cervical pain, persistent wryneck and vicious posture of the neck. A computerized tomography was performed and confirmed the presence of spreading lesion, ostheodestructive to the level of the left laminae of C2, with invasion of the spine and the muscular tissue. A laminectomy was underwent for removal of the lesion. The patient had a good post-operative recovery with improvement of the symptoms. Chemotherapy with prednisone, vinblastine and ethoposide was administred. After six months, this protocol was repeated associaded to methotrexate. The patient improved and had no new symptoms in a follow-up of 36 months.

Eosinophilic granuloma of the orbit: a paradox of aggressive destruction responsive to minimal intervention

PURPOSE

To describe the findings and outcomes in eosinophilic granuloma (unifocal Langerhans cell histiocytosis [LCH]) of the orbit, and to explain the paradox of aggressive bone destruction responsive to minimal intervention.

METHODS

Retrospective, consecutive, interventional case series of patients treated from 1985 through 2001. Minimum inclusion criteria were demonstration of CD1a positivity or Birbeck granules, treatment by a single surgeon, systemic evaluation by a pediatric oncologist, and follow-up of 12 months. A pathogenetic construct was assembled from general LCH concepts and the specific orbital findings.

RESULTS

Seven patients met study criteria. All were male, 2 to 16 years of age. All had eyelid or forehead swelling and osteolytic defects, with symptoms of 2 to 6 weeks' duration. All underwent incisional biopsy, with frozen-section examination suggestive of LCH in 6 of 7 cases. The 2 earliest patients received low-dose irradiation after simple biopsy. The 5 most recent patients had subtotal curettage at the time of biopsy; 4 of 5 received simultaneous intralesional corticosteroid injection. In all cases, systemic evaluation showed no other focus of LCH, reossification was timely, and no local recurrence or additional focus was noted in follow-up of 1 to 17 years.

CONCLUSIONS

Transient immune dysfunction may provoke the cytokine-mediated proliferation of pathologic Langerhans cells within the hematopoietic marrow of the anterolateral frontal bone. These cells cause osteolysis through elaboration of interleukin-1 and prostaglandin E2. Corticosteroids can inhibit the mediators. We recommend incisional biopsy, frozen-section provisional diagnosis, subtotal curettage, intralesional corticosteroid instillation, postoperative systemic evaluation, and long-term follow-up.

[Treatment concepts of benign bone tumors and tumor-like bone lesions]

The indications for surgical treatment of benign bone tumors and tumor-like lesions depend on the biological activity, clinical symptoms and anatomic location of the the lesion. Clinically silent lesions ("leave me alone Lesions") lacking any scintigraphic enhancement and without danger of pathologic fracture or malign transformation only need surveillance and do not require surgery.However, tumors becoming symptomatic, displaying progression after termination of skeletal growth or radiographic signs of malignancy should be scheduled for surgical intervention. For most benign tumors intralesional curettage and subsequent bone grafting is the treatment of choice, maintaining structural integrity and functional stability of the bone and adjacent joint. In case of uncertain histopathological diagnosis an open biopsy should be performed followed by definitive either marginal or en-bloc resection, preferably at a single procedure. Depending on the tumor-specific risk of recurrence, adjuvant measures as phenol instillation or cryotherapy using liquid nitrogen may additionally be applied. As for the unicameral juvenile bone cyst or osteoid osteoma alternative minimal invasive techniques like corticoid injection and CT-guided percutaneous eradication of the nidus have been successfully introduced into clinical practice. Depending on the activity of the tumor recurrent lesions are recommended to be treated by marginal or enbloc resection. The radical and aggressive mode of surgical therapy has to be balanced with the treatment-related morbidity, i.e. complication rate, possibilities for reconstructive stabilizations and resultant functional deficits,making the decision a responsible challenge to the orthopedic surgeon.

Distraction osteogenesis of basal mandibular bone for reconstruction of the alveolar ridge

Alveolar distraction is being used increasingly for alveolar bone reconstruction in patients with severe mandibular defects. When there has been total loss of alveolar bone, distraction of the mandibular basal bone is necessary. Distraction osteogenesis is considerably more challenging in mandibular basal bone than in alveolar bone. The low level of the cut increases the technical difficulty and may result in a poor outcome. We describe three cases in which more than 10 mm of distraction of mandibular basal bone was required. Semirigid distraction devices were used to reconstruct the alveolar structures in each case.

Eosinophilic granuloma. A different behaviour in children than in adults

Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine. We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.

Eosinophilic angiocentric fibrosis as a cause of nasal obstruction

We present the tenth case of Eosinophilic Angiocentric Fibrosis (EAF) in the english literature, which presented as nasal obstruction in a patient of Indian descent. The histopathological and clinical features of this underreported condition is discussed as well as other lesions that may show similar features to EAF.

Eosinophilic granuloma with acute epidural hematoma: a case report

The most common symptoms of eosinophilic granuloma are local tenderness and an enlarged skull mass. The presence of epidural hematoma is a very rare symptom of eosinophilic granuloma. To our knowledge, this is only the second reported case of eosinophilic granuloma with epidural hematoma. A 2-year-old boy with a soft tumor on the occipital scalp, palpable at the age of 3 months, yet with no obvious history of trauma, was admitted due to a sudden onset of loss of consciousness. A brain computed tomography scan showed a lytic lesion on the occipital skull with a large epidural and subcutaneous hematoma, causing brain compression. He underwent an emergency craniectomy with removal of both the tumor and hematoma. The patient regained consciousness and had no residual neurological damage. Pathological reports showed abnormal proliferation of Langerhans' cells, eosinophilic cells and multinucleated cells. A whole-body bone nuclide scan revealed no other bone lesions. The patient was discharged uneventfully. The causes of hematomas are not very clear. They may be due to tumor necrosis or minor trauma. In our presented case, the cause of the epidural hematoma may have been tumor bleeding which ruptured into the epidural space. A solitary eosinophilic granuloma of the skull with acute epidural hematoma and loss of consciousness is extremely uncommon. Craniectomy with removal of the tumor and hematoma decompression may produce good results.

Occipital aneurysmal bone cyst secondary to eosinophilic granuloma

We describe the case of a 2-year-old male patient with an aneurysmal bone cyst (ABC) of the occiput secondary to unifocal eosinophilic granuloma (EG). The lesion presented as a painless mass of the scalp which had grown rapidly over the 2 weeks prior to admission. Radiologically, the lesion was osteolytic and multicystic with fluid-fluid levels. On histology, the cyst wall contained hemosiderin-laden histiocytes, spindle cells, multinucleated giant cells, Langerhans' cells and eosinophils. Surgical treatment consisted of en bloc resection. Fourteen months after surgery, the patient was well with no local recurrence. Association between EG and ABC is rare. To our knowledge, this is the first case involving the skull.

Anterior cervical corpectomy and fusion using miniplate and screws in a 7-year-old child with eosinophilic granuloma of the cervical spine

STUDY DESIGN

This is a case report of a 7-year-old child with eosinophilic granuloma in the cervical spine, which underwent anterior cervical corpectomy and fusion by using Miniplate and screws.

OBJECTIVES

To describe the use of Miniplate and screws for pediatric cervical anterior fusion.

SUMMARY OF BACKGROUND DATA

Eosinophilic granuloma is a rare disease causing destructive bony lesions of the cervical spine in children. A complete resection and fusion were considered to be the preferable treatment in our case. However, cervical spinal fusion and instrumentation in children may be technically difficult because of the size of the vertebral body and the iliac bone. In addition, a proper device for an internal fixation in pediatric patients is not yet available.

METHODS

A case of eosinophilic granuloma in pediatric spine was presented.

RESULTS

We confirmed successful bony fusion and the restoration of the normal cervical curvature without recurrence of the tumor 2 years after the procedure.

CONCLUSIONS

For proper internal fixation and prevention of dislodgement of the grafted bone, we used the Miniplate and screws as internal fixator after intralesional resection of the tumor mass.

[Langerhans's cell histiocytosis in otorhinolaryngology]

Langerhans's cell histiocytosis (LCH) is an uncommon disease characterized by an accumulation of abnormal histiocytes, together lymphocytes and eosinophils in various organs and tissues. The head and neck are frequent sites of initial presentation. We present two cases of LCH with otorhinolaryngologic symptoms. Current recommendations for diagnosis, evaluation and treatment of LCH are also discussed.

Eosinophilic angiocentric fibrosis affecting the nasal cavity. A mucosal variant of the skin lesion granuloma faciale

Eosinophilic angiocentric fibrosis (EAF) is an unusual fibrotic condition affecting the mucosa of the upper respiratory tract, of which there have been eight reported cases. The condition is thought to be associated with the rare skin disorder granuloma faciale, which is histologically identical, and was present in two cases of EAF. We report the third case where EAF and granuloma faciale occurred together, to highlight this type of intranasal fibrosis as a distinct pathological entity.

Eosinophilic granuloma of the stomach mimicking gastric cancer, report of a case

We report a rare case of eosinophilic granuloma of the stomach mimicking gastric cancer. A 49-year-old man was admitted to our hospital to undergo surgery for gastric tumor. Radiologic and endoscopic examination showed a protruding tumor with a deep ulcer at the anterior wall of the pylorus. Although malignant cells were not histologically confirmed in the biopsy specimens, subtotal gastrectomy with lymphadenectomy was performed because gastric cancer was strongly suspected. The gross appearance of the tumor seemed to be that of a gastric cancer, but the histological diagnosis was eosinophilic granuloma. If submucosal tumor of the stomach is suspected, eosinophilic granuloma should be considered as one of the differential diagnoses. Endoscopic removal of the tumor may be useful to make a precise diagnosis before surgery.

Back pain caused by benign tumors and tumor-like lesions of the thoracolumbar spine

Twenty-two patients with benign tumors or tumor-like lesions of the spine (vertebral echinococcal cysts, eosinophilic granuloma) presented with back pain and deformity. The duration of pain ranged from 1 to 6 years. Five patients had incomplete paraplegia at admission. Spine deformity was observed in patients with osteoid osteoma, osteoblastoma, hemangioma, and vertebral echinococcal involvement. All patients underwent clinical evaluation, laboratory studies, and histologic studies. Electromyogram studies were performed in patients who had a neurologic deficit or nerve root irritation. Imaging evaluation consisted of plain films, bone scans, computed tomography scans, and magnetic resonance imaging scans. Fifteen patients had lumbar involvement; 7 had thoracic involvement. For 18 patients, management included tumor excision and thorough debridement of the lesion. Spinal instrumentation and fusion were used to correct the deformity and treat the instability in 5 patients. Patients were followed for 1 to 8 years. Of the 5 patients with incomplete paraplegia, 4 recovered completely, and the fifth (who had spinal cord hemangioma) improved 2 grades on Frankel's scale. The remaining patients were disease free and returned to routine daily activities. Benign tumors or tumor-like lesions of the thoracolumbar or lumbar spine are very rare and easily misdiagnosed in patients with persistent back pain. Patients whose symptoms progress or fail to respond over an appropriate period of time should be evaluated further. Complete excision of the tumor followed by spinal instrumentation in the presence of deformity or instability is the treatment of choice.

Eosinophilic granuloma of spine in adults: a case report and review of literature

A rare case of eosinophilic granuloma in an adult is reported. Eosinophilic granuloma (EG) is a lesion observed more frequently in adults. CT and MRI showed a lytic lesion of the T11 vertebral body. A transpedicular excisional biopsy of the lesion revealed EG. Spinal EG in adults is rare and differs from the childhood disease by the spinal level involvement. Vertebra plana, a condition of spondylitis in which the body of the vertebra is reduced to a sclerotic disc, is not a roentgenographic feature in the 14 cases reported in literature. It should be included in the differential diagnosis of the solitary lytic lesion of vertebrae in adults.

[Radiotherapy in Langerhans-cell histiocytosis. 2 case reports and review of the literature]

The use of radiotherapy in the treatment of Langerhans' cell histiocytosis was first reported in the literature in 1930 and has been proven as effective in numerous studies. We present the results of two female adults with eosinophilic granuloma of bone who underwent conventionally fractionated radiation therapy with total doses of 7 x 1.8 Gy and 7 x 2.0 Gy in four different sites. After observation periods raging from three months to six years local control of the disease was achieved in all treated locations. A review of 18 previously published studies include a total of 310 sites of eosinophilic granuloma of bone in 216 patients. It was demonstrated in 13 studies that the patients had complete relief of symptoms. An average of 94.3% had local control of the symptoms. Furthermore, in 12 studies for a total of 344 cases with involvement of other organs local control was reported in an average of 64.8% (range: 14.3-100%). Based on our own observations and on the literature review we conclude that low dose radiation therapy plays an important role in the management of localised Langerhans' cell histiocytosis. In order to minimise the risk of radiation induced neoplasms an accurate and precise radiation technique is required.

[Pulmonary eosinophilic granuloma associated with recurrent pneumothorax: report of a case]

A 25-years-old male, current smoker, was referred to our department for treatment of the right pneumothorax due to pulmonary eosinophilic granuloma. He underwent thoracoscopic partial resection of the right lung. Immunostaining of the specimen revealed a lot of Langerhans cells positive for S 100 protein, suggesting active lesion. After cessation of smoking, no recurrence of pneumothorax or progression of disease have been observed for 13 months.

Magnetic resonance imaging of calvarial eosinophilic granuloma with pericranial soft tissue reaction--case report

A 4-year-old girl presented with an eosinophilic granuloma in the cranial vault. Magnetic resonance (MR) imaging showed the mass as slightly low intensity on T1- and high intensity on T2-weighted images. The pericranial soft tissue was densely enhanced after gadolinium-diethylenetriaminepenta-acetic acid infusion. The mass was soft and successfully removed. Histological examination disclosed Langerhans' cell histiocytosis. MR imaging is useful for the diagnosis of calvarial eosinophilic granuloma with soft tissue involvement.

[Beneficial effects of cryosurgical treatment in benign and low-grade-malignant bone tumors in 120 patients]

BACKGROUND

Benign and low-grade malignant bone tumours are generally treated with intralesional curettage. At microscopic level tumour cells are left behind and may be responsible for a recurrence. Therefore adjuvant local treatment is necessary.

METHOD

By spraying liquid nitrogen into the remaining cavity, tumour cells are frozen very rapidly. Ice crystals formed in the (tumour) cell will mechanically damage the cell resulting in cell necrosis. This combined treatment of surgery and freezing is called cryosurgery.

RESULTS

In 120 patients with a follow-up of at least 1 year the treatment results were good. The tumours were: aneurysmatic bone cyst (n = 32), simple bone cyst (n = 13), chondroid tumour (n = 43), giant-cell tumour (n = 13), eosinophilic granuloma (n = 7) and monostotic fibrous dysplasia (n = 12). There were 10 recurring tumours, some of them very small; 6 recurrences were treated successfully by cryosurgery again; in 2 recurrences marginal resection was carried out; 2 recurrences remained (as yet) untreated.

CONCLUSION

Cryosurgery as a therapy of benign and low-grade malignant bone tumours yields results nearly as good as marginal resection, and has the advantage that segmental bone resections, which need extensive reconstructions are avoided.

[A case of eosinophilic granuloma localized in the bronchial wall]

A case of eosinophilic granuloma of the lung in a 24 years old male is presented. The initial manifestations were hemoptysis and cough. During hospitalization the bronchoscopy was performed, which revealed granuloma in the right bronchus. Computer tomography showed tumour in the right bronchus, without pulmonary changes characteristic for histiocytosis X. The granuloma was removed by bronchoscopy, but control examination performed after three months showed the residue. Once again residual tumor was removed by bronchoscopy and oral steroids were ordered. Unfortunately the next local residue was observed and the residual tumour was finally removed by thoracotomy. Now patient is free of symptoms.