Treatment of Castleman's disease

Castleman disease and paraneoplastic pemphigus in a pregnant woman: A case report

RATIONALE

Orogenital ulcers can be observed in various conditions, such as Behcet disease, infection and also paraneoplastic pemphigus (PNP). Castleman disease (CD), which is a rare cause of paraneoplastic pemphigus represents a heterogenous lymphoproliferative disorder of unknown etiology. Paraneoplastic pemphigus associated with CD in pregnancy is rare and has not been reported yet.

PATIENT CONCERNS

We report a rare case of CD in a 26-year-old pregnant woman with orogenital ulcers. The patient suffered from mucosal erosions and uveitis at 23 weeks of gestation. A retroperitoneal mass (9.7×7.3×11.8 cm) was identified by CT scan.

DIAGNOSES

According to histological and immunohistological findings, a diagnosis of unicentric CD, hyaline vascular type, and PNP was formulated.

INTERVENTION

High dose methylpredisonlone was given for the therapy. Pancreatic uncinatectomy, portal vein and superior mesenteric vein repair, pancreaticojejunostomy, and caesarean section were performed on the patient to remove the tumor and the fetus.

OUTCOMES

The fetus did not survive after surgery. The patient did not achieve remission and she died from epidermolysis and sepsis several months later.

LESSONS

PNP associated with CD is a rare lymphoproliferative disorder and needs to be differentiated from other orogenital diseases by histological features.

ETHICS AND DISSEMINATION

Written informed consent was obtained from the patient for publication of this case report and accompanying images. Ethical approval of this study was granted by the Ethics Committee of West China Hospital of Sichuan University. (Ethics Reference No: 2021143).

Castleman Disease Masquerading as the Posterior Mediastinal Mass on 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography

A 28-year-old female presented with an incidentally detected mediastinal mass, found on routine chest X-ray. ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was advised to plan course of further management. FDG-PET/CT findings were suggestive of an FDG-avid soft-tissue mass in the left posterior mediastinum in paravertebral location with left pleural effusion. Overall, PET/CT scan findings favored the possibility of a nerve sheath tumor. However, histopathology along with immunohistochemistry confirmed the diagnosis of Castleman disease.

Clinical, laboratory and imaging findings in Castleman's disease - The subtype decides

Castleman's disease (CD) is a rare lymphoproliferative disorder with its distinct unicentric (uCD) and multicentric (mCD) entities. The present work aimed at characterizing CD in more detail. From the 775 articles found by a PubMed search, 1133 cases were extracted. Two own cases were included. UCD was identified in 719 (42% males) and mCD in 416 (63% males) cases. Age in uCD was 34±17 and in mCD 48±18years. The hyaline-vascular type predominated in uCD and the plasma cell type in mCD. Clinical symptoms were more common in mCD. The head and neck region was most frequently affected in uCD and the axillary region in mCD. Prevalence of human immunodeficiency virus (HIV) and human herpesvirus-8 (HHV-8) positivity was higher in mCD. In CT scans, high contrast enhancement and calcifications were more frequent in uCD (all p<0.0001). The two forms of CD not only differ markedly in their clinical, laboratory and imaging findings, but also in treatment response and prognosis.

Laparoscopic treatment of abdominal unicentric castleman's disease: a case report and literature review

Background

Castleman’s disease is a rare lymphoproliferative disorder of unknown etiology that most commonly presents as a mediastinal nodal mass. It is exceptionally uncommon for Castleman’s disease to present in the mesentery and, only 53 cases have ever been described in the literature. Standard treatment for this lymphoproliferative disorder involving a single node is a complete “en bloc” surgical resection which has proven to be a curative approach in almost all cases without recurrence after 20 years of follow up. All 53 reported cases of mesenteric Castleman’s disease, except one, were treated with laparotomy.

Case presentation

We report on a case of mesenteric Castleman’s disease localized in the mesentery which is the second reported case if its kind and was treated by a laparoscopic-assisted procedure. Our female patient had an uneventful postoperative course and was discharged in the 5^th post-operative day. No signs of recurrence were present as evidenced by physical examination and total body CT scan 24 months after the operation. We compare our case with the other reported cases in which Castleman’s disease presented as an isolated mass in the abdomen.

Conclusion

Although a rare disease, Unicentric Castleman’s disease should always be considered when a solid asymptomatic abdominal mass is occasionally presented. The laparoscopic approach (LA) allows for the achievement of better results than open surgery, including a reduction in postoperative pain and length of hospital stay. In cases of masses of an uncertain nature, LA must be considered the last diagnostic tool and the first treatment one.

Patient-reported Outcomes for Multicentric Castleman's Disease in a Randomized, Placebo-controlled Study of Siltuximab

Background

Multicentric Castleman’s disease (MCD) is a rare lymphoproliferative disorder driven by dysregulated interleukin-6 production. MCD has a poor prognosis, and treatment is generally noncurative and aimed at symptom relief. Siltuximab is a novel, monoclonal interleukin-6 antibody recently shown to be effective in a registration clinical trial. MCD symptoms, such as fatigue, pain, and weakness, are most appropriately quantified using patient-reported outcome (PRO) measures. We assessed the effect of siltuximab on patient perception of symptoms, functional status, and wellbeing using PRO instruments.

Methods

We analyzed results of a randomized, double-blind trial comparing siltuximab 11 mg/kg every 3 weeks with placebo to treat MCD. Subjects (N = 79) completed the recently developed MCD–Symptom Scale (MCD–SS), the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT–Fatigue) scale, and the Short Form (SF)-36 at predetermined time points throughout the treatment period. Scores were compared at baseline and over time between the treatment arms and PRO instruments.

Results

At baseline, the mean number of symptoms reported was 9.2 (standard deviation 3.76) out of 16 total, as measured by the MCD–SS. Fatigue was a key symptom across all PRO instruments. Siltuximab-treated subjects reported early improvements in symptoms compared with subjects in the placebo arm on both the MCD–SS and FACIT–Fatigue scale. Statistically significant improvements in five SF-36 domains were observed in siltuximab-treated patients, namely role physical, role emotional, vitality, bodily pain, and mental health.

Conclusions

Patients with MCD commonly report impairments in functioning, wellbeing, and fatigue at baseline. Siltuximab-treated patients reported significant improvements in these outcomes after treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-015-0120-5) contains supplementary material, which is available to authorized users.

Hyaline-Vascular Type Castleman's Disease, Sarcoidosis, and Crohns Disease

Sarcoidosis and Crohns disease have been associated with increased long term risk of lymphoproliferative disorders, including lymphomas. Newly developed lymphadenopathy in a patient with these disorders should prompt pathological evaluation. Castleman's disease is a lymphoproliferative disorder characterized by enlarged hyperplastic lymph nodes with regressed follicles surrounded by expanded mantle zones of small lymphocytes, and interfollicular vascular proliferation in the hyaline-vascular type. Similar to sarcoidosis and Crohns disease, its etiology is incompletely understood, although immune dysregulation, genetic factors and infectious and environmental factors are thought to play a role in all three diseases. Interleukin-6 is a possible pathological common factor between these three disease processed. Unicentric, hyaline-vascular type Castleman's disease can be treated successfully with complete surgical resection. We report a patient with long history of sarcoidosis and Crohns disease with newly developed lymphadenopathy which was found to be due to Castleman's disease.

[Pseudo-adult Still's disease, anasarca, thrombotic thrombocytopenic purpura and dysautonomia: An atypical presentation of multicentric Castleman's disease. Discussion of TAFRO syndrome]

INTRODUCTION

Multicentric Castleman's disease can mimic adult-onset Still disease. It is exceptionally associated with anasarca, thrombotic microangiopathy and dysautonomia.

CASE REPORT

We report a 32-year-old woman with an association of oligoanuria, anasarca, thrombotic microangiopathy with features compatible with adult-onset Still disease. The outcome was initially favorable with corticosteroids, immunoglobulins and plasmapheresis but with the persistence of relapses marked by severe autonomic syndrome and necessity of high dose corticosteroids. The diagnosis of mixed type Castleman's disease, HHV8 and HIV negative, was obtained four years after the onset of symptoms by a lymph node biopsy. The outcome was favorable after tocilizumab and corticosteroids but tocilizumab had to be switched to anakinra to ensure a proper and long-lasting control of the disease.

CONCLUSION

Our patient partially fits the description of TAFRO syndrome (Thrombocytopenia, Anasarca, myeloFibrosis, Renal dysfunction, Organomegaly), a MCM rare variant, recently described in Japanese patients.

Multicentric Castleman disease mimicking IgG4-related disease: A case report

A 50-year-old woman was referred to our hospital for shoulder joint stiffness. She had a history of polyclonal hypergammaglobulinemia and an elevated C-reactive protein level. Her laboratory data revealed an elevated serum immunoglobulin G4 (IgG4) level, hypergammaglobulinemia, and rheumatoid factor positivity in the absence of anticyclic citrullinated peptide antibody. [18^F]-Fluorodeoxyglucose positron emission tomography showed significant [18^F]-fluorodeoxyglucose uptake in multiple lymph nodes (axillary, hilar, para-aortic, and inguinal). Biopsy of the inguinal lymph node showed expansion of the interfollicular areas by heavily infiltrating plasma cells, consistent with multicentric Castleman disease (MCD). Immunohistochemical analysis revealed a 37.3% IgG4-positive:IgG-positive plasma cell ratio, indicating overlapping IgG4-related disease. However, serological cytokine analysis revealed elevated levels of interleukin-6 (9.3 pg/ml) and vascular endothelial growth factor (VEGF) (1210 pg/ml), which are compatible with MCD. Corticosteroid treatment resolved the serological and imaging abnormalities. IgG4-related disease can mimic MCD, and it is crucial to distinguish between these two diseases. Serum interleukin-6 and VEGF levels may help to discriminate MCD from IgG4-related disease.

Multicentric castleman disease with ocular involvement: a clinicopathologic case report

PURPOSE

To describe an ocular manifestation of Castleman disease, a rare lymphoproliferative disorder characterized by sheets of abundant plasma cells in the interfollicular spaces of lymph nodes, most commonly in the abdomen, mediastinum, and cervical chain.

METHODS

Clinicopathologic case report.

PATIENT

A 69-year-old man with lymphadenopathy and bilateral choroidal infiltrates.

RESULTS

Initially, we suspected systemic lymphoma with ocular involvement. Lymph node biopsy revealed Castleman disease without a monoclonal component. Choroidal biopsy showed lymphocytic and plasma cell infiltration.

CONCLUSION

To our knowledge, this is the first clinicopathologic report of multicentric Castleman disease involving the eye.

A case report of retroperitoneal pararenal Castleman's disease associated with myasthenia gravis

Background

Castleman’s disease (CD) is a relatively rare disorder characterized by the benign proliferation of lymphoid tissue. The combination of an occurrence of retroperitoneal pararenal CD with myasthenia gravis (MG) is extremely rare.

Case presentation

The patient was admitted to our hospital for investigation of a retroperitoneal pararenal tumor which had been coincidentally diagnosed at a local hospital where he was admitted because of MG. The patient subsequently underwent an exploratory laparotomy and suffered from postoperative myasthenic crisis. Pathological examination revealed a left retroperitoneal mass of CD (hyaline vascular type). There was no recurrence of disease found after 7 months.

Conclusions

CD with MG is a rare condition. Postoperative myasthenic crisis is a severe complication. The possibility of its occurrence must be in physicians’ minds and the risk of postoperative myasthenic crisis must be carefully considered when evaluating MG patients undergoing surgery.

Use of a claims database to characterize and estimate the incidence rate for Castleman disease

Castleman disease (CD) is a rare lymphoproliferative disorder affecting single (unicentric; UCD) or multiple (multicentric; MCD) lymph nodes. The incidence of this difficult to diagnose disease is poorly understood, as no International Classification of Diseases, Ninth Revision (ICD-9) code is available. This study utilized a unique strategy to estimate its incidence using two commercial claims databases, IMS LifeLink™ and Truven Health Analytics MarketScan(®). Patients with an index diagnosis of lymphadenopathy (ICD-9 code 785.6) were followed longitudinally for 1 year prior to and 2 years post-index diagnosis date. An algorithm that identifies potential patients with CD was developed to determine the incidence rate in person-years. The incidence rate for CD was calculated as 21 (IMS LifeLink™) and 25 (MarketScan(®)) per million person-years. Additionally, 23% of patients with CD were identified as potentially suffering from MCD. These results are consistent with the definition of an orphan disease, and the low incidence of the disease estimated in the literature.

Widespread hypermetabolic lesions due to multicentric form of Castleman disease as the cause of fever of unknown origin revealed by FDG PET/CT

A 46-year-old male patient presented with fever for over 5 months. An FDG PET/CT was acquired to evaluate the source of the fever. The images showed many hypermetabolic foci throughout the imaged regions, which mainly corresponded to enlarged lymph nodes. Pathological examination demonstrated that the patient suffered from a multicentric form of Castleman disease.

Iron-refractory microcytic anemia as the presenting feature of unicentric Castleman disease in children

Chronic, iron-refractory, microcytic anemia can be a diagnostic and therapeutic challenge. We report the cases of 2 children with occult, unicentric Castleman disease whose primary presenting feature was a chronic, unexplained, iron-refractory, microcytic anemia. Diagnosis was delayed because neither child had palpable lymphadenopathy and the lymphoproliferation was intra-abdominal. Surgical resection cured the anemia and the Castleman disease. A diagnostic clue to Castleman disease is an elevated concentration of interleukin-6 in blood, which causes anemia by inducing the expression of the iron-regulatory hormone hepcidin.

Castleman disease in the parapharyngeal space: a case report and review of the literature

Castleman disease is most commonly found in the mediastinum, while the head and neck is the second most common location. The disease exists in a unicentric and multicentric variety and is usually successfully treated with surgical resection alone. Early identification is important for treatment planning. Castleman disease has been reported to mimic other disease processes, however there has been only one report of the disease mimicking a nerve sheath tumor in the parapharyngeal space. Here we report the second case of Castleman disease mimicking a schwannoma in the parapharyngeal space.

Small bowel obstruction caused by a large B-cell lymphoma in a patient with multicentric Castleman's disease: An unusual occurrence

Multicentric Castleman's disease is a rare condition of systemic nonclonal lymph node hyperplasia. Because of its strong association with human herpes virus 8 (HHV8), the multicentric, more aggressive, form may progress to Kaposi sarcoma or non-Hodgkin lymphoma. While surgery is curative in the treatment of localized Castleman's disease, operative treatment of the diffuse form has as yet been unsatisfactory. We report the case of a patient presenting with postprandial vomiting of 1 month duration consistent with partial small bowel obstruction secondary to terminal ileum intussusception. Resection of the small bowel showed a stenosing tumor triggering the intussusception. On pathological examination, the tumor was found to be composed of HHV8-positive plasmablastic lymphoma cells. To our knowledge, this represents the first case of a complication due to the progression of multicentric Castleman's disease requiring surgical intervention for intussusception.

Multicentric plasma cell type of castleman disease in a child: difficulty in diagnosis and treatment

Multicentric plasma cell variant of Castleman disease (CD) has rarely been reported and the optimal therapeutic approach is unknown, especially in childhood. In this case report, we discuss the case of a 7-year-old boy with multicentric plasma cell variant of CD, who presented with cervical lymphadenopathies, autoimmune hemolytic anemia, bone marrow insufficiency, pulmonary, renal, hepatic, and gastrointestinal involvement, emphasizing the difficulty in diagnosis and treatment approach.

Successful tocilizumab treatment in a patient with human herpesvirus 8-positive and human immunodeficiency virus-negative multicentric Castleman's disease of plasma cell type nonresponsive to rituximab-CVP therapy

We present and discuss the case of a HIV-negative female finally diagnosed upon histopathologic and molecular biologic evaluations with human herpesvirus 8 (HHV8)-positive multicentric Castleman's disease (MCD) of plasma cell type, but with no detectable HHV8-DNA in peripheral blood. She failed to respond to combination immunosuppressive therapeutic trials of corticosteroids and azathioprine, and neither an immunochemotherapy of rituximab-CVP (R-CVP) induced disease resolution. However, monoclonal anti-IL-6R antibody (tocilizumab) immunotherapy resulted in beneficial disease stabilization. A control lymph node biopsy indicated mild polyclonal plasmacytosis, and a negative HHV8 determination. The patient is still receiving tocilizumab. This case emphasizes the individual nature of MCD requiering more personalized disease management.

Multicentric Castleman's disease: a challenging diagnosis

Multicentric Castleman's disease (MCD) is a sytemic disorder with flares of non-specific symptoms suggestive of a chronic inflammatory syndrome. It is typically accompanied by generalized lymphadenopathy and multiorgan involvement. Histologically, two main variants of Castleman's disease exist, the hyalin vascular type and the plasma cell variant. Upon localization unicentric (localized), and multicentric (diffuse, systemic) subtypes can be distinguished with more different disease outcomes. Patients often exhibit acute phase reactions and several autoimmune phenomena, and are at high risk for developing malignancies. Both the idiopathic and the HHV-8-driven infectious forms of MCD represent distinct disease entities with a less favorable prognosis. The induction of human IL-6 excess via yet unknown upstream mechanisms, and overexpression of viral IL-6 by HHV-8 can pivotally influence MCD biology. Based on the role of IL-6 in pathogenesis, MCD is also designated as IL-6 lymphadenopathy. To date there are no direct therapeutic evidences, but having been translated to daily practice the main regulatory factors may serve as promising therapeutic targets.

Localized Castleman's disease in the breast

INTRODUCTION

Castleman's disease (CD) is a rare disease with unknown etiology and is clinically associated with lymph nodes enlargement. Primary axillary localization of CD represents 2% of the cases. CD rarely occurs in the breasts.

PRESENTATION OF CASE

We herein describe a rare case of CD that initially presented in the breast intramammary lymph node and demonstrated axillary adenopathy. Pathologic analysis showed the hyaline vascular form. The patient underwent axillary lymphadenectomy. The natural history was irregular because the localized CD progressed to a systemic form of CD. At 4.6years of follow-up a Hodgkin's lymphoma appeared.

DISCUSSION

This is the fourth published case of localized breast CD published. It is important to evaluate other clinical lymphadenopathies at the time of diagnosis, and computed tomography is important for disease evaluation and follow-up.

CONCLUSION

Patients must undergo axillary lymphadenectomy when showing clinical symptoms. Irregular progression prompts new lymph node biopsy because of the potential presence of associated diseases.

Castleman disease

Castleman and Towne described a disease presenting as a mediastinal mass resembling thymoma. It is also known as "giant lymph node hyperplasia", "lymph node hamartoma", "angiofollicular mediastinal lymph node hyperplasia", and "angiomatous lymphoid hyperplasia". The pathogenesis is unknown, but the bulk of evidence points toward faulty immune regulation, resulting in excessive B-lymphocyte and plasma-cell proliferation in lymphatic tissue. In addition to the mediastinal presentation, extrathoracic involvement in the neck, axilla, mesentery, pelvis, pancreas, adrenal gland, and retroperitoneum also have been described. There are 2 major pathologic variations of Castleman disease: (1) hyaline-vascular variant, the most frequent, characterized by small hyaline-vascular follicles and capillary proliferation; and (2) the plasma-cell variant, in which large lymphoid follicles are separated by sheets of plasma cells. The hyaline-vascular cases usually are largely asymptomatic, whereas the less common plasma-cell variant may present with fever, anemia, weight loss, and night sweats, along with polyclonal hypergamma-globulinemia. Castleman disease is a rare lymphoproliferative disorders. Few cases have been described world widely. In this article we reviewed the classification, pathogenesis, pathology, radiological features and up to date treatment with special emphasis on the role of viral stimulation, recent therapeutic modalities and the HIV-associated disease.

Castleman's Disease with Myasthenia Gravis

Castleman's disease is a rare disorder characterized by benign tumors that may develop in the lymph node tissue throughout the body. Castleman's disease associated with myasthenia gravis is an especially rare disease. Only less than 10 cases have been reported in the world literature. The cause of Castleman's disease is associated with immune mediated reaction, and myasthenia gravis also develops due to an antibody-mediated process. The cause of myasthenia gravis is the immune activity of Castleman's disease, which may be the promoter of the antibody-mediated process. We report here a case of Castleman's disease, which was incidentally found in a patient diagnosed with myasthenia gravis.

Clinical Manifestations of Kaposi Sarcoma Herpesvirus Lytic Activation: Multicentric Castleman Disease (KSHV-MCD) and the KSHV Inflammatory Cytokine Syndrome

Soon after the discovery of Kaposi sarcoma (KS)-associated herpesvirus (KSHV), it was appreciated that this virus was associated with most cases of multicentric Castleman disease (MCD) arising in patients infected with human immunodeficiency virus. It has subsequently been recognized that KSHV–MCD is a distinct entity from other forms of MCD. Like MCD that is unrelated to KSHV, the clinical presentation of KSHV–MCD is dominated by systemic inflammatory symptoms including fevers, cachexia, and laboratory abnormalities including cytopenias, hypoalbuminemia, hyponatremia, and elevated C-reactive protein. Pathologically KSHV–MCD is characterized by polyclonal, IgM-lambda restricted plasmacytoid cells in the intrafollicular areas of affected lymph nodes. A portion of these cells are infected with KSHV and a sizable subset of these cells express KSHV lytic genes including a viral homolog of interleukin-6 (vIL-6). Patients with KSHV–MCD generally have elevated KSHV viral loads in their peripheral blood. Production of vIL-6 and induction of human (h) IL-6 both contribute to symptoms, perhaps in combination with overproduction of IL-10 and other cytokines. Until recently, the prognosis of patients with KSHV–MCD was poor. Recent therapeutic advances targeting KSHV-infected B cells with the anti-CD20 monoclonal antibody rituximab and utilizing KSHV enzymes to target KSHV-infected cells have substantially improved patient outcomes. Recently another KSHV-associated condition, the KSHV inflammatory cytokine syndrome (KICS) has been described. Its clinical manifestations resemble those of KSHV–MCD but lymphadenopathy is not prominent and the pathologic nodal changes of KSHV–MCD are absent. Patients with KICS exhibit elevated KSHV viral loads and elevation of vIL-6, homolog of human interleukin-6 and IL-10 comparable to those seen in KSHV–MCD; the cellular origin of these is a matter of investigation. KICS may contribute to the inflammatory symptoms seen in some patients with severe KS or primary effusion lymphoma. Additional research is needed to better define the clinical spectrum of KICS and its relationship to KSHV–MCD. In additional, research is needed to better understand the pathogenesis and epidemiology of both KICS and KSHV–MCD, as well as the optimal therapy for both of these disorders.

Rare presentation of unicentric Castleman's disease in the parotid gland

Castleman's disease is a rare benign lymphoproliferative disorder of unknown etiology; however, recent data have suggested a strong association with human herpesvirus type 8 and hypersecretion of the cytokine interleukin 6. Castleman's disease can present anywhere throughout the body; however, it is most commonly detected in the chest, neck, or abdomen. Two main forms of the disease have been identified according to location: unicentric and multicentric. Unicentric Castleman's disease differs from the multicentric form in that patients are often asymptomatic, and surgical resection of the lesion is considered curative. This unicentric or multicentric nature often serves as a distinguishing feature between benign or potentially malignant presentations. The diagnosis of Castleman's disease is challenging because of its nonspecific manifestation. The most reliable diagnosis is achieved though surgical resection and histopathologic confirmation. We report a rare case of unicentric Castleman's disease in the parotid gland and emphasize its importance in the differential diagnosis of oral-facial masses.

A case of cervical multicentric Castleman disease treated with intensity-modulated radiation therapy using helical tomotherapy

Castleman disease (CD) is a rare lymphoproliferative disorder. Two clinical entities are described: a unicentric form with disease confined to a single lymph node region and a multicentric form characterized by generalized lymphadenopathy and systemic symptoms. Although surgery is regarded as standard therapy for the unicentric form, no consensus has been reached concerning the standard treatment for multicentric CD. We report here a case of cervical multicentric CD treated with intensity-modulated radiation therapy (IMRT), using helical tomotherapy to minimize xerostomia in comparison with conventional radiotherapy. A 29-year-old woman complained of neck swelling. Computed tomography showed lymphadenopathy in both sides of the neck. The patient was diagnosed with the plasma cell subtype of CD on biopsy. After initial treatment with prednisone, IMRT was planned to avoid normal structures, for example the parotid gland. The cervical lymphadenopathy shrank gradually during IMRT with 44 Gy in 22 fractions. Four years and 3 months after IMRT, regrowth of cervical lymph nodes has not been detected. The parotid function improved dramatically on quantitative salivary scintigraphy between 3 and 12 months after IMRT. Radiotherapy could be an option for multicentric CD, and IMRT is an effective means of minimizing xerostomia in head and neck lesions.

Mixed-type multicentric Castleman's disease developing during a 17-year follow-up of sarcoidosis

Multicentric Castleman's Disease (MCD) is a systemic disease characterized by generalized lymphadenopathy and the proliferation of plasma cells. The development of MCD in a patient with preexisting sarcoidosis has not been previously reported. We herein describe a case of MCD developing in a 78-year-old woman with a 17-year history of sarcoidosis. The patient's serum interleukin-6 (IL-6) levels were only slightly elevated; however, the IL-6 levels in the fluid of both pleural effusion and ascites were markedly elevated. The administration of steroid-pulse therapy and prednisolone was ineffective in treating the MCD, although treatment with tocilizumab proved highly effective.

Surgically curable non-iron deficiency microcytic anemia: Castleman's disease

BACKGROUND

Castleman's disease (CD) is a rare, benign lymphoproliferative disorder that can involve single lymph node stations or can be systemic. Unicentric CD in patients with microcytic anemia is rarely described in the English literature.

CASE REPORT

We describe the case of a 19-year-old Chinese woman with hyaline vascular type of unicentric CD presenting as severe non-iron deficiency microcytic anemia. We report the clinical course from the initial presentation to diagnosis and surgical cure, and discuss the most up-to-date information on CD.

CONCLUSIONS

CD should be included in the differential diagnosis of microcytic anemia. Imaging tools and pathological studies should be considered in order to make a more accurate diagnosis and to avoid the use of ineffective treatments.

Castleman's disease: systematic analysis of 416 patients from the literature

BACKGROUND

Castleman's disease is a rare primary disease of the lymph nodes with limited available clinical information.

METHODS

A systematic literature search identified 416 cases amenable to detailed analysis.

RESULTS

In HIV(-) patients, centricity, pathology type, the presence of symptoms, gender, and age all predict outcome in univariate analyses. The 3-year disease-free survival (DFS) rate for patients with unicentric hyaline vascular disease (49.5% of cases, class I) was 92.5%, versus 45.7% for those with multicentric plasma cell disease (20.2% of cases, class III) and 78.0% for those with any other combination (22.6% of cases, class II) (p < .0001). HIV(+) patients (class IV) exclusively presented with multicentric plasma cell disease and had a 3-year DFS rate of only 27.8%. Kaposi's sarcoma and lymphoma were observed in 59.3% and 9.4% of HIV(+) patients and in 2.6% and 3.6% of HIV(-) patients (p < .0001). Paraneoplastic pemphigus and the syndrome of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes were observed exclusively in HIV(-) patients at a rate of 1.3% and 1.8%, respectively.

CONCLUSION

Clinical, pathological, and viral markers allow for the classification of Castleman's disease into groups with markedly different outcomes and disease associations.

Clinical dissection of multicentric Castleman disease

This study investigated the prognostic factors of Castleman disease (CD) and focused specifically on multicentric CD (MCD). Seventy patients with CD were studied. Forty-three patients (61.5%) had unicentric CD (UCD) and 27 patients (38.5%) had MCD. Thirty-six patients with UCD (83.7%) underwent surgical excision, and 25 patients with MCD (92.6%) received systemic treatment, including corticosteroids and combination chemotherapy. In the patients with MCD, age >60 years and the presence of splenomegaly were prognostic factors for progression-free survival (hazard ratio [HR] 9.01, 95% confidence interval [CI] 2.64-30.83 and HR 4.32, 95% CI 1.16-16.09) as well as overall survival (OS) in MCD (HR 8.7, 95% CI 2.83-26.84 and HR 2.9, 95% CI 0.95-9.02, respectively). Patients  ≤ 60 years old without splenomegaly showed better OS than patients  > 60 years old or with splenomegaly (71.4% vs. 10.8% for 5-year OS). MCD might be dissected clinically by the simple parameters of age and presence of splenomegaly.

Castleman's disease: from basic mechanisms to molecular therapeutics

Castleman's disease is a rare lymphoproliferative disorder in which there has been recent progress in elucidating underlying mechanisms with potential therapeutic implications. Unicentric Castleman's disease is an indolent condition that is often treated with local approaches. In contrast, patients with multicentric Castleman's disease (MCD) have a less favorable prognosis and require systemic treatment. Cytotoxic chemotherapy, with its attendant risk for toxicity, has been widely used to treat MCD, with variable efficacy. The discovery of putative etiologic factors and targets in MCD, particularly human herpes virus 8, CD20, and interleukin (IL)-6, has been translated into the use of rituximab and anti-IL-6-based therapy, as well as antiviral agents. In this article, we review the current state of the art of our understanding of Castleman's disease and its treatment and we provide insight into future treatment strategies based on disease biology.

The spectrum of Castleman's disease: mimics, radiologic pathologic correlation and role of imaging in patient management

Castleman's disease (CD) is a rare benign lymphoid disorder with variable clinical course. The two principal histologic subtypes of CD are hyaline-vascular and plasma cell variants and the major clinicoradiological entities are unicentric and multicentric CD. Management of CD is tailored to clinicoradiologic subtype. In this review, we describe the CT, MR and PET/CT findings in Castleman's disease which can help suggest a diagnosis of CD as well as emphasize role of imaging in management of patients with CD.

Neoadjuvant radiotherapy of primary irresectable unicentric Castleman's disease: a case report and review of the literature

Background

Castleman disease (CD) is a rare benign disorder characterised by hyperplasia of lymphoid tissue that may develop at a single site or throughout the body. The etiology of this disorder is unclear, although the histopathological presentation can be differentiated into a hyaline vascular variant, a plasma cell variant and a mixed variant. Clinically, it has been recorded that 3 manifestations of CD are characterized: a localized unicentric type, a generalized multicentric type and a mixed form. Surgery remains the main treatment for resectable unicentric CD, since removal of the large node is possible without further complications. No consensus has been reached concerning the most adequate treatment for irresectable unicentric CD.

Methods

Case report of a 67 year old woman.

Results

This report, describes the case of a 67-year-old woman with unicentric Castleman disease located in the right lower abdomen. The patient had symptoms of fatigue, dyspnoea and pain in the right lower abdomen. Computed tomography (CT)- examination revealed a tumour, which had grown to form a close relationship with the common iliac vessels and the sacral bone. A Laparotomy procedure revealed that the tumour was an irresectable mass. Neo-adjuvant radiotherapy (40 Gy) was administered in order to downsize the tumour. Six weeks later a new CT-scan revealed a major reduction of the tumour, which enabled a successful radical resection of the tumour to be performed. Histopathological analysis of the tumour showed the hyaline vascular type of CD.

Conclusions

Neo-adjuvant radiotherapy should be considered in case of an irresectable unicentric CD.

Irreversible Kidney Damage due to Multicentric Castleman's Disease

Castleman's Disease (CD) is a rare lymphoproliferative disorder accompanied by marked systemic inflammatory response. Morphological diagnosis of CD requires biopsy of the whole of the involved lymph node tissue. Three histologic variants have already been described in CD morphology (hyaline vascular, plasma-cell, and mixed). In this study, we report a case of a multicentric Castleman's disease of the plasma cell variant type with negative Herpes Virus 8. The clinical presentation of this patient was of systemic amyloidosis as a result of both a delayed diagnosis and medical management. Previously described cases of CD with secondary amyloidosis have been of the localized type. Regardless, long-standing clinical remission of CD by cytotoxic drugs and anti-CD20 antibody therapy was achieved, but the nephrotic syndrome remained irreversible.

Prospective study of rituximab in chemotherapy-dependent human immunodeficiency virus associated multicentric Castleman's disease: ANRS 117 CastlemaB Trial

PURPOSE

Single-agent chemotherapy is usually effective in HIV-associated multicentric Castleman's disease (MCD). However, in most patients, chemotherapy cannot be discontinued.

PATIENTS AND METHODS

To evaluate the efficacy of four weekly rituximab infusions (375 mg/m(2)) after discontinuation of chemotherapy in HIV-associated MCD, 24 patients were enrolled onto a prospective open-label trial.

RESULTS

At study entry, the median time from MCD diagnosis was 21 months. All patients had stable disease on chemotherapy and were dependent on chemotherapy for a median time of 13 months. The median CD4 cell count was 270 x 10(6)/L, and the plasma HIV RNA was less than 50 copies/mL in 18 patients. One patient died with progressive disease at day 15, and 23 patients completed the four cycles of rituximab. Sustained remission (SR) off treatment at day 60 (primary end point) was achieved in 22 patients (92%). From day 60 to day 365, one patient died with acute respiratory failure of undetermined origin, and four patients experienced relapse. Seventeen patients (71%) were alive in SR at day 365 without specific treatment, and the overall survival rate was 92% (95% CI, 71% to 98%). Rituximab was well tolerated, and the majority of adverse events were mild to moderate infections. Mild exacerbation of Kaposi's sarcoma (KS) lesions was observed in eight of 12 patients with previous KS.

CONCLUSION

Rituximab was both effective and safe in HIV-infected patients with chemotherapy-dependent MCD.

Anti-interleukin-6 receptor antibody (tocilizumab) treatment of multicentric Castleman's disease

We report three cases of multicentric Castleman's disease (MCD) successfully treated with anti-interleukin-6 receptor antibody (tocilizumab). Tocilizumab was administered intravenously at a dose of 8 mg/kg every 2 weeks. In each case, tocilizumab alleviated symptoms, including generalized fatigue, pyrexia, and alleviated biochemical abnormalities, including anemia, hypoalbuminemia, hypergammaglobulinemia, and increased C-reactive protein (CRP). Side effects included hypercholesterolemia, acute pyelonephritis, mild inflammation of the parotid glands, and upper respiratory system inflammation. Other severe side effects were not observed. These results indicate that tocilizumab is effective for the treatment of MCD. This is the first report on tocilizumab efficacy for Castleman's disease after approval for use for Castleman's disease.