Multifocal osseous involvement as the sole manifestation of Rosai-Dorfman disease

A novel entity of massive multifocal osteolyses in the elderly

Osteolyses are common findings in elderly patients and most frequently represent malignant or locally aggressive bone tumors, infection, inflammatory and endocrine disorders, histiocytoses, and rare diseases such as Gorham-Stout syndrome. We here report on a novel entity of massive multifocal osteolyses in both shoulders, the right hip and left knee joint and the dens of an 83-year-old patient not relatable to any previously known etiopathology of bone disorders. The soft tissue mass is of myxoid stroma with an unspecific granulomatous inflammatory process, aggressively destroying extensive cortical and cancellous bone segments and encroaching on articulating bones in diarthrodial large joints. Radiological, nuclear medical, serological, histological, and immunohistochemical analyses were incapable of further classifying the disease pattern within the existing scheme of pathology. Quantitative polymerase chain reaction and next generation sequencing revealed that mutations are not suggestive of any known hereditary or acquired bone disease. Possible treatment options include radionuclide therapy for pain palliation and percutaneous radiation to arrest bone resorption while surgical treatment is inevitable for pathological fractures. This case study shall increase the awareness of the musculoskeletal community and motivate to collect further information on this rare but mutilating disorder.

Primary intraosseous Rosai-Dorfman disease: An analysis of clinicopathologic characteristics, molecular genetics, and prognostic features

Background

Rosai-Dorfman disease (RDD) is a rare histiocytic proliferative disorder of uncertain pathogenesis. Most patients present with proliferation in the lymph nodes manifesting as adenopathy; however, RDD may primarily arise in a variety of extranodal sites, including the bone, which is a great challenge in the diagnosis. The clinicopathological characteristics and prognostic features of primary intraosseous RDD have not been well characterized.

Methods

We retrospectively analyzed the clinicopathologic and prognostic features of four cases of primary intraosseous RDD during the past 10 years in our hospital, with a review of an additional 62 cases with complete follow-up data from the literature.

Results

Primary intraosseous RDD was identified in 0.14% (4/2,800) of total bone biopsies performed at our institution over the study period. According to our retrospective analysis, a total of 18 cases of primary lymph node, skin, or other non-osseous site-based RDD were diagnosed in our hospital. The ages of the 66 total patients ranged from 1.5 to 76 years, with a median age of 25 years. There were 31 male and 35 female patients, with a male-to-female ratio of 0.89:1. Primary intraosseous RDD occurred most often in the bones of the extremities (60.6%, 40/66), with the proximal tibia being the most common location; 39.4% (26/66) of the cases arose in the axial skeleton, predominantly in the vertebra and craniofacial bones. Solitary masses and multiple tumors were present in 84.8% (56/66) and 15.2% (10/66) of the cases, respectively. Pain of the affected area was the most common presenting symptom. Radiographically, the lesions were lytic with well-defined and usually sclerotic margins. Immunohistochemistry showed that large histiocytes from patients with RDD were positive for OCT2, in addition to S100 and CD68. Molecular tests were performed in seven reported cases and four of our cases. All the 11 cases were non-decalcified. PCR results showed that there were no BRAF-V600E, KRAS, or NRAS mutations in primary intraosseous RDD; only one case with both RDD and Langerhans cell histiocytosis showed BRAF-V600E mutation. The survival data showed that 22.7% (15/66) of the patients experienced recurrences or developed RDD at distant sites during the follow-up period (median follow-up, 13 months; range, 1-106 months). The 5-year progression-free survival (PFS) of the patients with primary intraosseous RDD was 57.5%. We found that there was a significant difference in PFS between female and male patients (p = 0.031). However, there was no statistically significant difference in PFS between patients with solitary masses and multiple tumors (p = 0.698). Similarly, no statistically significant differences in PFS were found between the different age groups (p = 0.908) or tumor locations (p = 0.728).

Conclusion

Primary intraosseous RDD is an extremely rare disease. The diagnosis of RDD may be quite challenging because of its non-specific clinical presentation and imaging. Immunohistochemistry showed that large histiocytes were positive for OCT2 in addition to S100 and CD68, which may be helpful for differential diagnosis. Molecular detection showed that RDD may be related to the MAPK pathway, though these results are also ultimately not specific. The pathogenesis of RDD is yet to be elucidated, but recent studies suggest possible clonality of hyperproliferative histiocytes.

Radiological features of Rosai-Dorfman disease: case series and review of the literature

AIM

To improve the accuracy of diagnosis of Rosai-Dorfman disease (RDD) by summarising the computed tomography (CT) and magnetic resonance imaging (MRI) characteristics.

MATERIALS AND METHODS

The clinical manifestations, imaging findings, and pathological characteristics of 14 patients with histopathologically confirmed RDD were analysed retrospectively and a literature review was undertaken.

RESULTS

Of the 14 patients, nine had multiple lesions and five had single lesions. Eight patients had extranodal lesions, while six had mixed-type lesions. In patients with head and neck lesions, plain CT/MRI revealed irregularly shaped, well-defined, homogeneous, and mainly progressive lesions, with marked homogeneous enhancement on multiphasic contrast-enhanced imaging. One patient had dural lesions, one of which iso-intense to grey matter, with patchy hypo-intensity on T2-weighted imaging, meningeal tail signs, and characteristic crabfoot-like enhancement. Three patients with skeletal system involvement exhibited osteolytic bone destruction without sclerosis at the edges, associated soft-tissue masses, or periosteal reactions. Two patients had well-defined subcutaneous lesions, inhomogeneous density, and progressive parenchymal enhancement on contrast-enhanced CT. One patient had multiple intestinal lesions with inhomogeneous nodular thickening of the blind ascending colon and ileum, with marked and progressive enhancement.

CONCLUSION

RDD involvement is mainly multifocal, primarily in the head and neck regions. Plain CT/MRI revealed well-defined, irregularly shaped lesions with homogeneous density/signal, with marked and progressive enhancement on multiphasic contrast-enhanced imaging; however, histopathology is still required to confirm the diagnosis of RDD.

Primary Bone Lesions in Rosai–Dorfman Disease, a Rare Case and Diagnostic Challenge—Case Report and Literature Review

Rosai–Dorfman Disease (RDD), also known as sinus histiocytosis, is included in the group of rare diseases, characterized by proliferation and accumulation of histiocytes in the lymph nodes (lymphadenopathy), most often involving the cervical ganglion chains (nodal form). RDD bone involvement is rare, estimated at 10% of cases, but primary bone involvement (extranodal form), is very rare—2–8%. Usually they are solitary lesions, with multifocal primary bone manifestations being extremely rare. Histopathological analysis is of high value for a correct diagnosis. We present the case of a Caucasian woman, 42 years old, initially treated in another clinic, for an osteolytic tumor formation in the right tibial shaft. An excisional biopsy with bone trepanation was performed, the histopathological diagnosis being the chronic inflammatory tissue. The evolution was atypical, with tumor growth, extraosseous, subcutaneous. A needle biopsy was repeated in our clinic, the result being similar to the original one. Evolution of the tumor, and the radiological and imaging aspect (periosteal reaction, eroded and thin bone cortex) suggested a more aggressive disease, these being in inconsistency with the result obtained. The biopsy was repeated, as an excision type this time. The histopathological result and immunohistochemistry indicated an RDD primary bone lesion. Based on this result, and corroborated with the data from the literature, we initiated the surgical treatment, curettage and grafting with bone substitute plus safety osteosynthesis with locked plaque, the patient registering a favorable evolution. RDD primary bone lesions are in fact an atypical manifestation of a rare disease. The correct diagnosis is very difficult due to the non-specific imaging aspect. Histopathological examination errors, especially in the case of needle biopsies can lead to errors in diagnosis and treatment with negative results for the patient.

Rosai-Dorfman Disease of Bone and Soft Tissue

Context.—

Rosai-Dorfman disease is a rare histiocytic proliferative disorder of unknown pathogenesis that may be diagnostically difficult in extranodal sites. It is commonly an unsuspected diagnosis when arising in bone and soft tissue, especially when it presents without associated lymphadenopathy. Its variable clinical presentation and nonspecific imaging findings make the diagnosis quite challenging, particularly in small biopsies. The problem is compounded by its less-characteristic histomorphologic features in comparison with nodal disease. Awareness of the potential diagnostic pitfalls in Rosai-Dorfman disease of bone and soft tissue should raise the degree of diagnostic accuracy.

Objective.—

To review the clinical manifestations, imaging characteristics, and histomorphologic features of Rosai-Dorfman disease of bone and soft tissue along with a brief discussion of its differential diagnosis, pathogenesis, and current management.

Data Sources.—

Thorough review of the literature with focus on clinical manifestations, imaging findings, key histomorphologic features, pathogenesis, and treatment.

Conclusions.—

The diagnosis of Rosai-Dorfman disease of bone and soft tissue may be quite challenging because of its variable clinical presentation and nonspecific imaging findings. It may be asymptomatic without systemic manifestations or associated lymphadenopathy. The definitive diagnosis relies on histopathologic identification of the characteristic S-100–positive histiocytes demonstrating emperipolesis. Bone and soft tissue lesions tend to have lower numbers of characteristic histiocytes and less conspicuous emperipolesis and often demonstrate areas of fibrosis or storiform spindle cell areas resembling fibrohistiocytic lesions. Awareness of these unusual features is necessary in order to consider Rosai-Dorfman disease in the differential diagnosis when confronting these rare and often misleading lesions.

Rosai-Dorfman Disease of the Talus in a Child: A Case Report

BACKGROUND

Primary Rosai-Dorfman disease of bone is a rare disorder. Radiologic and clinical evaluation is insufficient in differentiating malignancy from these lesions.

METHODS

We present a talar lesion in a 17-month-old boy who presented with deterioration in gait pattern, limping, pain, and swelling of the left ankle of 4-months' duration. Curettage and demineralized bone matrix grafting were performed.

RESULTS

At 1 year after surgery, complete clinical and radiological healing was obtained.

CONCLUSIONS

Primary RDD of bone may present a diagnostic challenge. The condition must be included in the differential diagnosis of lytic or lucent lesions of the skeleton. Curettage and grafting provide satisfactory outcomes in talar RDD lesion in the pediatric age group.

Potential role of 18F-FDG PET/CT in a case of progressive Rosai Dorfman disease

Rosai Dorfman disease is a rare form of nonlangerhans cell histiocytosis, presenting with extensive lymphadenopathies. Treatment in most cases of nodal disease, involves close observation; however, extranodal involvement requires a more definitive treatment strategy. Herein, we report a case of extensive Rosai Dorfman disease in a 43-year-old woman presenting for evaluation of treatment response by 18F-FDG PET/CT after frequent relapses and disease progression. In addition to extensive lymphadenothapies in cervical, supraclavicular, superior mediastinum, axillary, abdominopelvic and inguinofemoral regions, the patient had metabolically active bone and subcutaneous lesions which were not previously recognized. Following this 18F-FDG PET/CT study, the patient management was changed to sirolimus and prednisolone. To choose the best treatment option for Rosai Dorfman patients, knowledge of the full extent of disease is important. Compared with conventional imaging, 18F-FDG PET/CT has the advantage of being a whole-body imaging modality and can recognize disease involvement prior to any anatomical changes.

Multimodality imaging manifestations of Rosai-Dorfman disease

Background

Rosai-Dorfman disease (RDD) is a rare lympho-histiocytic disorder of indeterminate etiology usually presenting with lymph node involvement, and infrequently with extra-nodal manifestations. The diagnosis of this condition is challenging due to the wide spectrum of disease manifestations.

Purpose

To elucidate the radiologic features of this disease using multimodality imaging in histopathologically proven cases and to identify characteristic features that would enable its differentiation from its mimics.

Material and Methods

We retrospectively evaluated imaging studies of 19 patients with histopathologically confirmed RDD presenting to our institute between January 2004 and March 2016. Imaging modalities included magnetic resonance imaging (MRI), computed tomography, FDG-positron emission tomography (PET) CT, mammography, and ultrasonography.

Results

Lymphadenopathy was the most common imaging feature in our study, seen in 11 (57.8%) cases followed by sino-nasal involvement in 7 (36.8%) cases and intracranial masses in 5 (26.3%) cases. Bilateral homogeneously enhancing cervical lymphadenopathy with avidity on FDG-PET scans was the predominant abnormality on imaging. Sino-nasal involvement manifested as homogeneously enhancing soft-tissue masses occupying the paranasal sinuses. Intracranial disease manifested as sellar/suprasellar masses, dural-based lesions along the cerebral hemispheres and choroid plexus enlargement. Unusual disease manifestations included spinal, osseous, and breast lesions.

Conclusion

Due to the high likelihood of multifocal involvement, the recognition of RDD at one site necessitates screening of other sites for disease. Homogeneously enhancing, FDG-avid lymphadenopathy and sino-nasal masses in association with hypointense extra-nodal lesions on T2-weighted MRI are imaging features which could aid the diagnosis of RDD and facilitate its differentiation from pathologies that present in a similar manner.

Primary Rosai-Dorfman disease of bone arising in the infantile ilium: A case report

Rosai-Dorfman disease (RDD) is an extremely rare benign histiocytic disorder that usually affects young adults. Extranodal involvement of the RDD is common and may occur in >40% of patients, but bone involvement occurs in <10% of cases. Furthermore, primary bone RDD is extremely rare. The present study reports a case of primary bone RDD arising in the infantile ilium. Plain radiographs and computed tomography (CT) revealed an osteolytic lesion at the peri-acetabular region of the patient's right ilium. Fluorodeoxyglucose positron emission tomography indicated an abnormal accumulation only in the right iliac bone, without any other accumulation. An open biopsy was performed and the diagnosis of primary RDD of bone in the ilium was made. The bone lesion exhibited spontaneous regression on radiography, and the patient was able to walk without any limping or pain at 8 months after the biopsy. After 18 months of follow-up, the bone lesion had completely disappeared, and no joint deformity was observed on radiography or CT. The present report described the clinicopathological details of this rare case and reviewed the relevant literature.

Rosai-dorfman disease of the fibula: A case report

Rosai–Dorfman disease (RDD) is usually characterized by painless bilateral cervical lymphadenopathy associated with fever and leukocytosis. Although the disease may occur outside lymphnodes, manifestation of skeletal system occurs in less than 8% of cases. In addition, presentation of this disease in a purely skeletal form without lymph nodes involvement is extremely uncommon. This case report describes a 17-year-old female with a pure skeletal presentation of RDD in the fibula. Trocar biopsy was performed, and immunohistochemical staining using S100 and CD68 was done to confirm the diagnosis.

Rare diseases of bone: Erdheim-Chester and Rosai-Dorfman non-Langerhans cell histiocytoses

Non-Langerhans cell histiocytosis (N-LCH) summarizes a group of rare diseases with different clinical presentations, pathogenesis and morphology. These include primary cutaneous N-LCH, cutaneous N-LCH with systemic involvement, and primary extracutaneous systemic forms with occasional cutaneous involvement.

The juvenile (JXG) and non-juvenile xanthogranuloma (N-JXG) family of histiocytoses are N-LCH: the JXG family consisting of the JXG (cutaneous), xanthoma disseminatum (cutaneous and systemic) and Erdheim-Chester disease (ECD; systemic); and the N-JXG family consisting of the solitary reticulohistiocytoma (cutaneous), multicentric reticulohistiocytosis (cutaneous and systemic) and Rosai-Dorfman disease (RDD; systemic).

ECD is a clonal disorder from the JXG family of N-LCH; RDD is a reactive proliferative entity from the non-juvenile xanthogranuloma family of N-LCH.

ECD and RDD N-LCH are rare disorders, which are difficult to diagnose, with multi-organ involvement including bone and systemic symptoms, and which respond to therapy in an unpredictable way.

The key to successful therapy is accurate identification at tissue level and appropriate staging. Patients should be observed and monitored in a long-term pattern. Prognosis depends on disease extent and the organs involved; it is generally good for RDD disease and variable for ECD.

Cite this article: EFORT Open Rev 2018;3:381-390. DOI: 10.1302/2058-5241.3.170047

Primary Rosai-Dorfman disease of the femur

We report a 19-year-old man with the rare occurrence of primary osseous Rosai-Dorfman disease (RDD). The patient presented with a painful, solitary, bone marrow-replacing lesion in the distal femur. A diagnosis of chronic osteomyelitis was initially made on tissue from a CT-guided needle biopsy of the lesion; however, the diagnosis of RDD was eventually made after histological and immunohistochemical analysis of material from a subsequent curettage. No lymphadenopathy or other sites of involvement were found on clinical evaluation and PET-CT. To our knowledge, this is the first report of solitary osseous RDD based on systemic staging with PET-CT. We review the clinical, imaging, and histological features of primary osseous RDD, including pitfalls in diagnosis.

A 38-Year-Old Woman With an Osteolytic Rib Lesion

A 38-year-old black woman with a medical history significant for hypertension and depression presented to the emergency department with a 2-week history of lower back pain. This visit was her second in 1 week with the same symptoms, after attaining minimal pain relief with cyclobenzaprine.

A rare case of extra nodal Rosai-Dorfman disease with isolated multifocal osseous manifestation

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai–Dorfman disease is a non-neoplastic condition which typically presents as massive, bilateral cervical lymphadenopathy and can involve multiple extranodal organ systems such as skin, eyes, and upper respiratory tract in about 28% cases. Bone lesions in association with nodal disease are seen in less than 10% cases. Isolated bone involvement as the only manifestation of SHML is extremely rare, with less than 50 cases reported in the literature. We report a very uncommon case of Rosai–Dorfman disease with isolated multifocal osseous involvement as the only presenting feature, involving about 10 different sites with no lymphadenopathy or other organ system involvement.

Primary Rosai-Dorfman disease of the bone in a patient with history of breast cancer: appearance on 99mTc-MDP scintigraphy, CT, and X-ray

A 49-year-old woman with history of breast cancer presented with pain at the level of the left anterior proximal tibia. An x-ray of the tibia demonstrated a lytic cortical lesion that prompted a whole-body 99mTc-MDP bone scan. The bone scan revealed intense bone remodeling at the level of the tibial lytic lesion and in the cervical spine. CT demonstrated an expansile lesion eroding the vertebral bodies of C6 and C7 with a large soft tissue component. A biopsy of the cervical spine mass demonstrated features diagnostic of Rosai-Dorfman disease without evidence of neoplastic cells.

Whole-body diffusion-weighted MRI in a case of Rosai-Dorfman disease with exclusive multifocal skeletal involvement

Rosai-Dorfman disease (RDD) is a rare disorder and usually presents with painless bilateral cervical lymphadenopathy. About 43% of RDD patients show extranodal involvement, including bones (8%). As RDD is a systemic disease, which can involve lymph nodes, bones, skin, kidneys, respiratory tract, parotid gland, orbital cavity and the central nervous system, whole-body imaging may be useful for the assessment of extent, distribution and follow-up of disease. Whole-body diffusion-weighted MRI is able to demonstrate lesions and to assess therapy response without the need for radiation or intravenous contrast agent. Here, we report a case of a 15-year-old boy with primary skeletal RDD without lymphadenopathy, who was staged and followed by whole-body diffusion-weighted MRI.

Unusual presentation of Rosai-Dorfman disease (RDD) in the bone in adolescents

Rosai-Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy (SHML), is a rare idiopathic histiocytic disorder. The usual presentation of RDD is painless bilateral cervical lymphadenopathy. Extranodal RDD with lymphadenopathy occurs in almost 50% of patients but extranodal RDD, without lymphadenopathy, is very rare. Isolated RDD in the bone occurs in only 2% of patients but it is histologically similar to its nodal counterpart. There are only 14 previously reported cases of RDD in the bone without lymph node involvement in children. Here we describe two new patients--one with rib and lung involvement and the other with multi-osseous involvement.

Rosai-Dorfman disease following bone marrow transplantation for pre-B cell acute lymphoblastic leukemia

A child with acute pre-B cell lymphoblastic leukemia underwent haploidentical bone marrow transplantation (BMT) after first relapse. Approximately 8 months after the BMT, he developed a soft tissue mass overlying a defect in the left frontal bone. He was found to have several additional osteolytic lesions but no evidence of lymphadenopathy or organomegaly. A biopsy of the presenting lesion demonstrated a polymorphous infiltrate composed predominantly of S-100 protein and CD68 immunoreactive histiocytic cells. Together with the presence of emperipolesis, the process was interpreted as Rosai-Dorfman (R-D) disease. He received chemotherapy with vinblastine, prednisone, 6-mercaptopurine and methotrexate and has been in remission for over 4 years. Only one previous example of acute lymphoblastic leukemia in childhood has been reported with R-D disease.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): a clinicoradiological profile of three cases including two with skeletal disease

Originally described as sinus histiocytosis with massive lymphadenopathy, Rosai-Dorfman disease (RDD) is a rare histiocytic proliferative disorder with a distinctive microscopic appearance. A rare entity, RDD is often under-diagnosed because of a low index of suspicion by both radiologist and pathologist. Through this article, we wish to apprise radiologists of the spectrum of disease that can be encountered in this disorder. RDD can mimic other common childhood skeletal diseases including benign Langerhans cell histiocytosis and lymphoma. The clinical and radiological manifestations of RDD vary depending upon organ involvement, and its imaging features are often confused with those of other disorders. RDD should be considered in the differential diagnosis of unifocal and multifocal skeletal involvement caused by granulomatous diseases, infections, pseudogranulomatous lesions and malignancy. As long-term outcome is usually good, a conservative approach is justified in most cases. Contrasted with its typical appearance, presenting with bilateral symmetrical cervical adenopathy (as shown in one patient), we also report extranodal involvement of bone in two patients. Extranodal disease occurs along with concomitant nodal disease in about 43% of patients. In 23% of patients, isolated extranodal RDD can be seen, most commonly in the head and neck. In two of our patients, we observed extranodal involvement with skeletal involvement away from the head and neck not associated with lymphadenopathy. Skeletal involvement in RDD without lymphadenopathy is rare, occurring only in 2% of all the patients reported to date.