Langerhans cell histiocytosis--a 31 year review

A possible case of Langerhans-cell histiocytosis? Differential diagnosis in a rare case from the Late Antiquity Bavaria (Germany)

OBJECTIVE

To outline the importance of accurate diagnosis in ancient rare diseases by presenting a possible case of Langerhans-cell histiocytosis.

MATERIALS

Skeletal elements from a well-preserved skeleton of a nine to eleven-year-old, probably female child who lived around 300-400 AD Late Roman Neuburg / Donau (Germany).

METHODS

Macroscopic, radiologic, light and scanning-electron microscopic and physical techniques were used.

RESULTS

Resorptive defects, particularly in the cranium, but also in the left hip bone and the right femur, suggest the presence of Langerhans-cell histiocytosis macroscopically and radiologically. The presence of morphological changes along the edges of osteolytic lesions and in the diploic spaces appear to be post-mortem artifacts based on microscopic investigation and elemental analysis.

CONCLUSIONS

Re-evaluation of morphological structures and elemental constitution of lesions is critical to differential diagnosis. In the case examined here, the identification of post-mortem structures rules out the former diagnosis of Langerhans-cell histiocytosis. Re-evaluation of cases of rare diseases require applying a range of methods during the analysis, as every single case makes a difference in the numbers of this very small group of diseases.

SIGNIFICANCE

This study emphasizes the importance of utilizing different analytical techniques to avoid false diagnoses.

LIMITATIONS

Not all morphological features can reliably be diagnosed using microscopic and elemental techniques.

SUGGESTIONS FOR FURTHER RESEARCH

In the case of rare diseases that are difficult to diagnose, the widest possible spectrum of techniques should always be used, particularly microscopy.

Eosinophilic granuloma in the anterior mandible mimicking radicular cyst

Eosinophilic granuloma is a common expression of Langerhans cell histiocytosis and corresponds with typical bone lesions. The radiographic appearance of eosinophilic granuloma in the jaw is variable and not specific. It may resemble periodontitis, radicular cyst, or malignancies. The purpose of this report is to describe the characteristic radiographic features of eosinophilic granuloma of a 39-year-old male. The lesion in the anterior mandible was first diagnosed as radicular cyst because the radiographic findings were ovoid radiolucent lesion with well-defined border. However, careful interpretation revealed a non-corticated border and floating tooth appearance that were the characteristic radiographic features for the differential diagnosis. Early clinical signs of eosinophilic granuloma can occur in the jaw and a bony destructive lesion might be mistaken for periodontitis or an odontogenic cystic lesion; therefore, careful interpretation of radiographs should be emphasized.

Sonography of biopsy-proven Langerhans cell histiocytosis in lymph nodes of the neck

OBJECTIVE

The purpose of this series is to describe the sonographic findings of lymph nodes of the neck involved by Langerhans cell histiocytosis (LCH).

METHODS

We reviewed and interpreted available images of lymph nodes in patients with cervical lymphadenopathies involved by LCH for the past decade. In all patients, each abnormal lymph node was pathologically confirmed by the use of a sonographically guided core needle biopsy or an incisional biopsy.

RESULTS

We characterized 3 different kinds of imaging findings for cervical lymph nodes involved by LCH: (1) a lymphomalike lesion, (2) a lesion similar to reactive lymphadenopathy, and (3) a cystic lymph node.

CONCLUSIONS

There was no specific imaging finding to diagnose lymphadenopathy involved by LCH. In our study, we characterized 3 different imaging patterns of lymph node involvement by LCH. This study represents an initial step to organize specific findings for LCH.

Ear involvement in childhood Langerhans' cell histiocytosis

BACKGROUND

Ear involvement (EI) in Langerhans' cell histiocytosis (LCH) occurs quite often. We reviewed the Italian pediatric population of 251 children with LCH diagnosed between 1982 and 1995, focusing on EI, to highlight the prevalence, the clinical presentation, the outcome during follow-up, and the prognostic impact of otologic LCH.

METHODS

EI was defined by chronic otorrhea and/or mastoid infiltration, external auditory meatus lesions, and middle/internal EI. The age at diagnosis, sex, system involved, organ dysfunction, treatment, disease control, and outcome were recorded.

RESULTS

EI was noted at presentation in 34 children (13. 5%). They had a younger age at diagnosis (p=.0013) and near totality of multisystem disease (93.8% of patients with EI). Among patients with multisystem disease, children with EI seemed to have a higher risk of poor response and a higher percentage of second line treatment (p=.003).

CONCLUSIONS

EI seems to identify patients with a particular disease behavior, which requires a more accurate evaluation at diagnosis, staging and treatment, and a strict follow-up, considering the possibility of an unfavorable outcome.

Langerhans cell histiocytosis: diagnosis, natural history, management, and outcome

BACKGROUND

The objective of this descriptive analysis of a large cohort of patients with Langerhans cell histiocytosis (LCH) was to add to the understanding of the natural history, management, and outcome of this disease.

METHODS

Three hundred fourteen Mayo Clinic patients with histologically proven LCH were categorized into those patients with multisystem disease and those patients with single system disease. Clinical features, treatment, and outcome were determined from the case history notes and tumor registry correspondence. Treatment included chemotherapy, radiotherapy, and surgical excision. The end points were disease free survival, active disease, or death. The median time of follow-up was 4 years (range, 1 month to 47.5 years).

RESULTS

The age of the patients ranged from 2 months to 83 years. Of the 314 patients, there were 28 deaths. Multisystemic LCH was found in 96 patients, 25 of whom had continuing active disease after treatment. Isolated bone LCH lesions were observed in 114 of the 314 patients, 111 of whom (97%) achieved disease free survival after treatment. The most common sites of osseous LCH were the skull and proximal femur. Of the 87 patients with isolated pulmonary involvement, only 3 were nonsmokers. After treatment with corticosteroids (+/- cyclophosphamide or busulphan), 74 patients achieved disease free survival, but 10 patients died. Pituitary-thalamic axis LCH, characterized by diabetes insipidus, was found in 44 patients. After treatment, 30 of these patients had disease free survival, but all required long term hormone replacement with desmopressin acetate. Lymph node involvement was found in 21 patients, and mucocutaneous involvement was found in 77 patients.

CONCLUSIONS

Patients with isolated bone LCH lesions have the best prognosis compared with patients with LCH involvement of other systems. By contrast, 20% of patients with multisystem involvement have a progressive disease course despite treatment. The identification of prognostic indicators to facilitate appropriate treatment and long term follow-up surveillance is recommended.

Langerhans cell histiocytosis (histiocytosis X)

There has been a renewed interest in Langerhans cell histiocytosis in recent years due both to advances in basic research and to improvements in diagnostic and treatment approaches. In this article, we review the various aspects of the disease and the potential implications of these recent scientific researches for our understanding and management of the disorder.

A multicentre retrospective survey of Langerhans' cell histiocytosis: 348 cases observed between 1983 and 1993. The French Langerhans' Cell Histiocytosis Study Group

In a retrospective study involving 32 haematology/oncology departments in France, 348 cases of Langerhans' cell histiocytosis diagnosed between 1983 and 1993 were collated. The percentage of males was 56.4%. Median age at diagnosis was 30.2 months. The median follow up was 35.5 months. Initially, 108 patients (31%) had isolated unifocal or bifocal bone involvement, 67 (19%) had isolated multifocal bone involvement, 136 (39%) had soft tissue involvement without organ dysfunction, and 37 (11%) had organ dysfunction. Two thirds of the sites of involvement diagnosed throughout the course of the disease were present at diagnosis, while the remaining one third appeared during a relapse. Treatment was tailored to the individual patient and was extremely varied, hampering any comparison of regimens. Vinblastine with or without steroids was the most common regimen when systemic chemotherapy was used for the first episode (246/348). Twenty four of the 216 patients received VP 16 as first line treatment. Two patients with progressive multiorgan relapse, despite the use of several drugs, underwent bone marrow transplantation and are alive and disease free 60 and 22 months later. Altogether 21.9% of patients had sequelae, including diabetes insipidus in 17.5% of cases. The overall survival rate is 91.7% (confidence interval 90.7 to 95%) three years after diagnosis. In the univariate analysis, age less than 1 year, ear, nose, and throat, cutaneous, lymph node, liver, spleen, lung, marrow and intestinal involvement, male sex, progressive episodes, the absence of response, and partial responses, were associated with a poor vital prognosis. In a multivariate analysis of prognostic factors, poor early outcome emerged as the most important parameter, closely linked to other poor outcome features such as young age and organ dysfunction. It identified a small number of patients with a poor initial response to treatment, for whom intensive treatment should be assessed in a phase II trial.

Langerhan's cell histiocytosis complicating small bowel Crohn's disease

Langerhan's cell histiocytosis is a rare infiltrative disorder of unknown aetiology. A variety of tissues may be affected, but clinically evident intestinal involvement is unusual. An adult patient is described with Crohn's disease of the terminal ileum who subsequently developed Langerhan's cell histiocytosis with extensive infiltration of the small bowel.

Otitis externa in Langerhans' cell histiocytosis--the successful use of topical nitrogen mustard

Otitis externa is a common symptom of Langerhans' cell histiocytosis, and occurs in half of all children with the disease. Previous treatment regima have been either unsuccessful, or associated with undesirable side-effects. This study describes the successful use of topical 20% nitrogen mustard ear drops in the management of five children who had Langerhans' cell histiocytosis with otitis externa. All of them had previously been resistant to other forms of treatment. The children were aged between 6 months and 6 years. The otitis externa fee period to date is up to 5 years. Topical nitrogen mustard ear drops are rapidly effective, can be administered at home, have not caused any adverse effects, and are of long-term benefit.