Management of eosinophilic granuloma in pediatric patients: surgical intervention and surgery combined with postoperative radiotherapy and/or chemotherapy

Clinical Characteristics of Pediatric Clavicular Lesions: A Retrospective Analysis of 20 Cases

Background This research aims to study the diagnostic patterns, anatomical locations, and age-related trends in pediatric clavicular lesions, filling a gap in pediatric-specific data for these conditions. Methodology A retrospective study of 20 pediatric patients (aged ≤14 years) with clavicular lesions was conducted based on inclusion and exclusion criteria emphasizing confirmed diagnosis and treatment specifics. The diagnostic process relied on open biopsy, followed by excision or curettage and histopathological examination. Results The study primarily involved patients with an average age of 7.1 ± 3.8 years. Eosinophilic granuloma was the most common diagnosis (30% of cases), particularly in the age group of 0-3 years. Clavicular lesions predominantly manifested as either a palpable lump or localized swelling with pain. The medial of the clavicle was the most frequent lesion location. No malignant tumors were found, and the functional outcomes post-treatment were satisfactory. Conclusions Pediatric clavicular lesions exhibit distinct diagnostic and anatomical characteristics compared to adults. Eosinophilic granuloma is significantly prevalent in early childhood, necessitating age-specific diagnostic and therapeutic approaches. The study advocates for multidisciplinary collaboration in the treatment and improved understanding of these lesions, which are vital for pediatric orthopedic oncology.

Application of cementoplasty in patients with symptomatic benign osteopathy disease

BACKGROUND

The optimal treatment for some symptomatic, benign osteopathy lesions is yet to be identified.

PURPOSE

To investigate the clinical efficiency of cementoplasty in managing symptomatic, benign osteopathy.

MATERIAL AND METHODS

Between June 2006 and January 2020, we retrospectively enrolled 31 patients (10 men, 21 women; mean age = 46.5 ± 16.6 years; age range = 20-85 years), accounting for 34 treatment sites, who underwent percutaneous osteoplasty (14 treatment sites) and percutaneous vertebroplasty (20 treatment sites) with digital subtraction angiography (DSA) or DSA combined with computed tomography (CT). All the participants experienced different degrees of clinical symptoms with benign osteopathy lesions. The technical success of the procedure and occurrence of complications were recorded. Follow-up examinations were conducted to assess the treatment outcome using the MacNab criteria.

RESULTS

All the participants had a diagnosis of benign osteopathy lesions before or after the cementoplasty. Surgery was successfully completed in all patients. Cement distributions were diffuse and homogeneous, with the complication of cement leakage occurring in 17.6% (6 of 34) of the lesions. The leakage occurred in the intervertebral disc (n = 1), the intra-articular space (n = 1), and the surrounding soft tissue (n = 4). Analysis of the treatment outcome using the MacNab criteria revealed that all patients showed improvement in their clinical symptoms to some extent and in the quality of life.

CONCLUSION

Cementoplasty is an effective treatment for symptomatic, benign osteopathy, with the advantage of favorable clinical outcomes, and low complication rate.

A possible case of orbital osteomyelitis from the medieval cemetery of Sant' Agostino in Caravate (Varese, Northern Italy)

OBJECTIVES

This paper aims to present one of the first osteoarchaeological cases of orbital osteomyelitis and provides the best diagnostic criteria to identify its pathophysiological changes.

MATERIALS

A well-preserved skeleton of an adult male from the medieval cemetery of Sant' Agostino in Caravate, Italy.

METHODS

Macroscopic, tomographic, and histological analyses were performed using standard methods.

RESULTS

The skeleton shows irregularities in the architecture of the left supraorbital margin. CT analysis reveals the presence of a radiotransparent area involving the diploe and the external cranial table. This area is lateromedially oval-shaped and bordered by a thick irregular radiodense rim, associated with the presence of a cloaca on the roof of the orbit and surrounding periosteal reaction. Microscopic examination shows the formation of a thin layer of cortical bone and an osteoid-like matrix.

CONCLUSION

A careful differential diagnosis based on macroscopic, radiological, and histological evidence suggests a case of orbital osteomyelitis.

SIGNIFICANCE

This case study represents one of the few osteoarchaeological evaluations of ocular chronic osteomyelitis diagnosed using macroscopic skeletal, computed tomography, and histological analysis. As such, it provides a reference and an investigative criterion for future cases.

LIMITATIONS

The diagnosis cannot be stated with certainty, and only probable diagnoses can be proposed. Although we referred especially to clinical literature, it is necessary to consider that the severity of conditions may be modified by modern medical intervention.

SUGGESTION FOR FURTHER RESEARCH

This case provides further insights into the presence of this condition in the past.

Primary Benign Tumors of the Spinal Canal

Benign tumors that grow in the spinal canal are heterogeneous neoplasms with low incidence; from these, meningiomas and nerve sheath tumors (neurofibromas and schwannomas) account for 60%-70% of all primary spinal tumors. Benign spinal canal tumors provoke nonspecific clinical manifestations, mostly related to the affected level of the spinal cord. These tumors present a challenge for the patient and healthcare professionals, for they are often difficult to diagnose and the high frequency of posttreatment complications. In this review, we describe the epidemiology, risk factors, clinical features, diagnosis, histopathology, molecular biology, and treatment of extramedullary benign meningiomas, osteoid osteomas, osteoblastomas, aneurysmal bone cysts, osteochondromas, neurofibromas, giant cell tumors of the bone, eosinophilic granulomas, hemangiomas, lipomas, and schwannomas located in the spine, as well as possible future targets that could lead to an improvement in their management.

Langerhans cell histiocytosis of the head and neck in the pediatric population in a tertiary center: Clinical presentation, classification and treatment

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a rare disease of unknown etiology with a heterogeneous and unspecific clinical presentation. Any organ or system may be involved but the most frequent is the skeleton. The diagnostic gold standard is done through histopathology combined with immunohistochemistry in the correct clinical setting. Treatment is still controversial. The objective of this study is to present a series of pediatric patients in order to contribute to the diagnosis and treatment of LCH.

MATERIAL AND METHODS

A longitudinal, descriptive and retrospective study was done in 20 pediatric patients histologically diagnosed of LCH int the last 10 years, in a tertiary center. A review of the medical history was done and data collection included: epidemiological data, clinical manifestations and classification, lesion characteristics, treatment employed, follow-up and evolution.

RESULTS

The mean age presentation was 6.5 years (2-12). The most frequent disease presentation was a palpable skull tumor followed by headache. Other otorhinolaryngologic presenting symptoms were bloody otorrhea and post auricular swelling. Single-systems LCH with skull tumors was the most frequent classification. Treatment options (surgery, chemotherapy and corticosteroid infiltration) were indicated according to disease classification.

CONCLUSION

LCH should be suspected in pediatric patients with a palpable cranial vault tumor, as well as in patients with chronic otorrhea with granulation tissue at the external ear canal. Management of LCH fundamentally includes chemotherapy and surgery, or the combination of both. High-risk organs lesions, including temporal bone lesions, and multi-system LCH are predictors of recurrence and should have a long-term follow-up.

Indicators of Quality of Care in Individuals With Traumatic Spinal Cord Injury: A Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVES

To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI).

METHODS

A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale.

RESULTS

A total of 87 indicators were identified from 60 studies screened using our eligibility criteria. We defined each indicator. Out of 87 indicators, 37 appraised the healthcare system structure, 30 evaluated medical processes, and 20 included individuals with TSCI related outcomes. The healthcare system structure included the impact of the cost of hospitalization and rehabilitation, as well as staff and patient perception of treatment. The medical processes included targeting physical activities for improvement of health-related outcomes and complications. Changes in motor score, functional independence, and readmission rates were reported as individuals with TSCI-related outcomes indicators.

CONCLUSION

Indicators of quality of care in the management of individuals with TSCI are important for health policy strategists to standardize healthcare assessment, for clinicians to improve care, and for data collection efforts including registries.

Better vertebrae remodeling in pediatric spinal eosinophilic granuloma patients treated with kyphoplasty and short-term posterior instrumentation: A minimal two-year follow-up with historical controls

OBJECTIVE

To assess the validity and safety of kyphoplasty combined with short-term posterior instrumentation to treat children with vertebrae plana due to eosinophilic granuloma (EG).

PATIENTS AND METHODS

Clinical data of EG patients, who received kyphoplasty and short-term instrumentation from March 2019 to March 2020, were retrospectively reviewed. The recovery of diseased vertebrae was assessed and compared with historical case data.

RESULTS

Nine patients with EG had received kyphoplasty and short-term posterior instrumentation. The mean age at initial treatment was 66.7 months old (range, 28-132 months). The average number of follow-up months was 26.7. (range, 24-30 months).Four and 5 cases presented with thoracic and lumbar vertebral destruction, respectively. Under Garg's classification, 7 and 2 cases were classified as Grade IIA and IIB, respectively. The average diseased vertebral heights at 1-year and 2-year after surgery were significantly higher than the preoperative heights. The average percentages of diseased vertebral heights to references at 1-year and 2-year after surgery were 72.0% and 86.0%, respectively. The average percentage of diseased vertebral heights to the references at 2-year after surgery was significantly higher than that of the historical cases at the same time. No minor or major adverse events were observed.

CONCLUSIONS

Transpedicular balloon kyphoplasty for the direct restoration of vertebrae plana seems feasible and safe in combination with short-term posterior instrumentation. Better short-time vertebrae remodeling was observed 2 years after surgery. Active surgical treatment is suggested for children who have vertebrae plana as a result of EG in order to maintain the ability to recover vertebral height.

First technical report of a pediatric case with thoracic Langerhans cell histiocytosis: Gross total tumor removal, corpectomy, and 360° stabilization via posterolateral approach at a single stage

Background:

Langerhans cell histiocytosis (LCH) is a rare nonmalignant disease characterized by a clonal proliferation of mononuclear cells called Langerhans histiocytes and infiltrates surrounding tissues, mostly self-limiting and usually occurring in the first two decades of life. Vertebral involvement is rare, mostly seen in the thoracic region, and involves the anterior elements of the corpus. In the literature, several treatment options and surgical approaches have been reported concerning the treatment of this disease and surgery.

Case Presentation:

We report an 18-month-old male with thoracic LCH who underwent surgery due to progressive neurological deficit. Gross total removal of the tumor with one level corpectomy in this patient was achieved via a posterolateral approach with postoperative functional improvement. The surgical cavity was supported by corpectomy cage and unilateral screw-rod fixation system at the same stage.

Conclusion:

Gross total tumor removal, corpectomy, and 360° stabilization via posterolateral approach at a single stage are safe, effective, and definite neurosurgical methods in terms of providing neurological recovery, long-term tumor-free survival, and spinal stability.

Long-term Follow-up of Eosinophilic Granulomas of the Axial and Appendicular Skeleton Managed With Biopsy Alone

BACKGROUND

This study aimed to evaluate the long-term clinical and radiologic follow-up results of eosinophilic granulomas (EGs) of the axial and appendicular skeleton managed with biopsy alone.

METHODS

Fifty-five patients with unifocal osseous EGs of the axial and appendicular skeleton were followed after biopsy. Patients were divided into 2 groups on the basis of localization of the lesions. In group 1, there were 32 (58.2%) children with extremity long bone involvement: femur, tibia, humerus, ulna, and radius. Group 2 included 23 (41.8%) patients with lesions located in other appendicular and axial skeleton bones: pelvis, scapula, clavicle, lumbar, and thoracic vertebrae. After confirming the diagnosis by a closed biopsy, no further surgical intervention was performed. Clinical recovery included regression of the localized symptoms, mainly pain resolution. Functional improvement was assessed by Musculoskeletal Tumor Society (MSTS) scoring. Radiologic healing was defined as ossification of the entire lesion with cortical thickening in long and flat bones, and restoration of vertebral body height in the spine. Complications, including local recurrence, were determined.

RESULTS

The patients comprised 28 boys and 27 girls with an average age of 9.2 years (range, 3 to 16 y). The average follow-up was 76 months (range, 28 to 132 mo). The median time from biopsy to clinical recovery was 17 days [95% confidence interval (CI), 13.3-20.6] and 36 days (95% Cl, 32.8-39.1) in group 1 and group 2, respectively. MSTS scores increased progressively till the end of 12 months in both groups. The median time from biopsy to radiologic healing was 16 months (95% CI, 11.5-20.4) and 42 months (95% Cl, 39.3-44.6) in group 1 and group 2, respectively. Both clinical recovery (P=0.021) and radiologic healing (P=0.009) were significantly faster in group 1 compared with group 2. No major complication was seen after biopsy. All lesions regressed without a local recurrence.

CONCLUSIONS

Unifocal osseous EGs have spontaneous healing potential and confirming the diagnosis by biopsy is enough to obtain good clinical and radiologic results without any additional surgical intervention.

TYPE OF STUDY

This was a therapeutic study.

LEVEL OF EVIDENCE

Level IV.

ODONTOLOGICAL EFFECTS OF IONIZING RADIATION (review)

BACKGROUND

Odontological effects of ionizing radiation (IR) as a result of radiotherapy, the consequences of accidents at nuclear power plants and industry, individual occupational exposure, etc. deserve significant attention interns of radiation medicine and radiation safety.

OBJECTIVE

to analyze and summarize clinical and experimental data on the odontological radiation effects.

MATERIALS AND METHODS

OBJECT

the pathological changes in the hard tissues of teeth, pulp, periodontium, mucousmembranes of the mouth and jaws due to exposure to IR.

METHOD

search in the PubMed / MEDLINE, Google Scholarabstract medical and biological databases, scientific libraries of the relevant sources of scientific information.

RESULTS

Radiobiological effects of IR due to its direct and indirect action are manifested throughout the period ofodontogenesis and formation of the facial skeleton. Experimental and clinical data (in children and adults) indicatethe increased risk of dental caries, reduction of pain threshold and vascularization of tooth pulp along with its fibrosis and atrophy, periodontal dysfunction, which predispose to a high probability of tooth loss. Abnormalities in theactivity of osteoblasts and cementoblasts of dental periosteum and osteoblasts of alveolar process in combinationwith circulatory disorders due to endothelial cell death, hyalinization, thrombosis and vascular obliteration increasethe risk of jaw osteoradionecrosis. Children who have undergone a prenatal exposure to IR as a result of theChornobyl NPP accident have a premature change of teeth. Deterioration of periodontal tissues and early development of acute and complicated dental caries are typical for children and adults affected by the Chornobyl disaster.

CONCLUSIONS

Summarized data on the effects of radiation exposure under different conditions on teeth primordia(i.e. immature teeth), their formation and eruption in experimental and clinical settings, as well as on the odontological radiation effects in adults are summarized. Condition of the teeth in the Chornobyl NPP accident survivorsis described. Understanding and taking into account the radiobiological odontological effects is necessary in thelight of planning, preparing, and conducting local radiation therapy and developing the standards of radiation safety and measures to protect professionals and the public in the event of possible radiation accidents at the nuclearpower plants and industry facilities.

Langerhans Cell Histiocytosis With Vertebral Involvement Diagnosed and Treated Over the Last 15 Years in a Single Canadian Pediatric Academic Institution

We report 11 children with vertebral lesion of Langerhans cell histiocytosis (LCH) diagnosed and treated between 2000 and 2015. Vertebral lesions were usually present at LCH diagnosis. No child developed neurologic symptoms. Among 29 vertebral lesions, only 2 were unstable. Chemotherapy was used in all children but 3. A LCH recurrence was observed in 6 patients, involving vertebrae in 4 cases. All children were disease-free at their last follow-up. Sequelae were more often radiologic than clinical. Since potential recurrences and incomplete bone regeneration exist, discussion about optimal treatment and long-term follow-up of vertebral lesions are essential.

Eosinophilic Granuloma of the Thumb Presenting in a 4-Month-Old Child: Case Report and Review of the Literature

Eosinophilic granuloma (EG) is a benign bone tumor of unknown origin usually seen in children. It is typically found in flat and long bones of the skull and of the appendicular skeleton, respectively. Small bones are rarely affected. The diagnosis and treatment of EG can be challenging as differential diagnosis includes several disorders that can cause osteolytic lesions. Moreover, surgical treatment can be difficult due to the small size of the bone and surrounding structures. Here we describe a case of EG of the proximal phalanx of the thumb (P1 D1) presenting in a 4-month-old boy with persistent swelling and limited range-of-motion of the interphalangeal joint in the left thumb. Over a 6-year follow-up, no sign of relapse was observed. Moreover, the curetted bone did regenerate, and it appeared homogenously dense as normal trabecular bone on the last plain radiographs; the patient was symptom-free at the last follow-up visit. Clinical presentation, treatment, pathoanatomy, localization, and complication of this form of tumor are discussed, and all previously reported cases are reviewed to give a more comprehensive picture of EG of the hand and fingers.

Comparison between low-dose chemotherapy and surgery for the treatment of extremity-associated solitary bone lesions in children with Langerhans cell histiocytosis in South China: A case-control study

Background

The treatment algorithm for solitary bone lesions of Langerhans cell histiocytosis (SBL-LCH) in children extremities still remains controversial. We conducted a retrospective case-control study to compare the feasibility of low-dose chemotherapy (LDC) and surgery for SBL-LCH in children extremities.

Patients and methods

This study compares 43 pediatric patients starting LDC with a surgery control group (n = 44), matched for gender, age, follow-up time, and lesion sites and sizes, treated between 2001 and 2015 at our institution. Hospital stay (HS), time to symptom relief (TTSR), recovery time (RT), complications, relapse-free survival (RFS), health-related quality of life (HRQOL) and cost-effectiveness were analyzed for each strategy.

Results

HS, TTSR and RT in the LDC group were shorter than those in the surgery group (p < 0.01). Chemotherapy-related complications included nausea (16.30%), aminotransferase elevation (9.30%), slight hair loss (11.63%), decline in immune function (23.26%), growth retardation (16.30%), and moon face (9.30%). Chemotherapy-related side effects were mild and well tolerated. Pathologic fractures (6.81%), loosening of instrumentation (6.00%,), surgical site infection (4.00%) and rejection of bone grafting (9.09%) developed in surgery patients. LDC treatment resulted in a longer RFS (87 months) than surgery alone (59 months) (p = 0.011). Furthermore, compared with surgery patients, patients in the LDC group had a better HRQOL at 3 months’ follow-up for the physical, role, emotional and social function domains assessed (p < 0.001, p = 0.001, p < 0.001 and p = 0.003, respectively) according to the European Organisation for Research and Treatment of Cancer QLQ-C30® survey. However, HRQOL scores at 2 years’ follow-up were similar between the two groups. The incremental cost-effectiveness ratio (ICER) was ¥−137,030/quality-adjusted life year (QALY) for LDC versus surgery.

Conclusions

Compared with surgery, LDC promotes more rapid recovery, is less invasive, is characterized by increased safety and a superior HRQOL, and is a more cost-effective treatment strategy for pediatric patients with SBL-LCH in the extremities.