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Wojciechowska N, Burke S, Ray A. MEK Inhibition in the Treatment of Congenital Langerhans Cell Histiocytosis: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2024:00043426-990000000-00472. [PMID: 39101723 DOI: 10.1097/mph.0000000000002927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/25/2024] [Indexed: 08/06/2024]
Abstract
Langerhans cell histiocytosis (LCH) is a histiocytic disorder that predominantly affects young children, with congenital manifestations being exceedingly rare. Here, we report a male infant with congenital LCH harboring a driving mutation within the mitogen-activated protein kinase pathway, specifically MAP2K1 Q56P. First-line use of targeted therapy with oral MEK inhibitor trametinib led to rapid and complete resolution of the infant's widespread cutaneous disease. This patient remains clinically well with normal growth and development and no sign of progressive disease or medication intolerance. This case demonstrates the impact that targeted therapy can have as an alternative to systemic chemotherapy in an age group known to experience more extensive disease.
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Affiliation(s)
| | - Sydney Burke
- University of North Texas Health Science Center, Texas College of Osteopathic Medicine, Fort Worth, TX
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Taneyama Y, Morimoto A, Ochiai H, Ando K, Kakuda H, Naruke Y, Yokoi S. Trametinib for a child with refractory Rosai-Dorfman-Destombes disease harboring a novel somatic mutation in MAP2K1. Int J Hematol 2024:10.1007/s12185-024-03818-9. [PMID: 39003680 DOI: 10.1007/s12185-024-03818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 06/25/2024] [Accepted: 07/08/2024] [Indexed: 07/15/2024]
Abstract
Rosai-Dorfman-Destombes disease (RDD) is a rare histiocytosis characterized by accumulation of S100 + , CD68 + , and CD1a- histiocytes, with emperipolesis. It occurs predominantly in black adolescents and young adults, but rarely in Japanese children. Recently, oncogenic mutations in mitogen-activated protein kinase (MAPK) pathway genes were reported in 30-50% of patients with RDD, and several studies have described treatment of adult patients with MAPK inhibitors. Here, we present the case of a Japanese boy with refractory RDD without signs of cardiofaciocutaneous (CFC) syndrome who harbored MAP2K1 p.Lys59del and responded to trametinib. The patient had lymph node, nasal cavity, kidney, upper respiratory tract, and intracranial involvement. RDD progressed after multi-agent chemotherapy, but responded to trametinib (0.025 mg/kg). Trametinib did not eliminate the mass lesions, but trametinib plus minimal prednisolone (0.1 mg/kg) resulted in a good outcome for more than 15 months, without significant adverse effects. MAP2K1 p.Lys59del has been described as a germline mutation in a patient with CFC syndrome, but not as a somatic mutation in patients with malignancies. Trametinib may be a promising drug for children with RDD that is refractory to multi-agent chemotherapy. Its long-term efficacy and safety alone and in combination with chemotherapy should be investigated.
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Affiliation(s)
- Yuichi Taneyama
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Akira Morimoto
- Division of Pediatrics, Showa Inan General Hospital, 3232 Akaho , Komagane, Nagano, 399-4117, Japan.
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan.
| | - Hidemasa Ochiai
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Kumiko Ando
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Harumi Kakuda
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Yuki Naruke
- Department of Pathology, Chiba Children's Hospital, Chiba, Japan
| | - Sana Yokoi
- Division of Genetic Diagnostics and Cancer Genome Center, Chiba Cancer Center, Chiba, Japan
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Talasila S, Teichner EM, Subtirelu RC, Talasila NCP, Mannam S, Werner T, Alavi A, Revheim ME. Comprehensive considerations for dermatologists: the application of FDG-PET in evaluating cutaneous lesions in pediatric Langerhans cell histiocytosis. Front Med (Lausanne) 2024; 11:1378638. [PMID: 39071084 PMCID: PMC11273510 DOI: 10.3389/fmed.2024.1378638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Langerhans cell histiocytosis (LCH) is a complex disorder characterized by the clonal proliferation of Langerhans cells, primarily affecting children and adolescents. This condition exhibits a wide spectrum of clinical presentations, necessitating a multidisciplinary approach for diagnosis, treatment, and follow-up. Cutaneous manifestations of LCH are significant, mimicking common dermatoses and posing diagnostic challenges. [18F]Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) has emerged as an important tool in the evaluation of pediatric LCH, offering insights into disease activity, extent, and therapeutic response. Moreover, FDG-PET provides a non-invasive means to distinguish between active LCH skin lesions and other dermatological conditions with similar clinical appearances, enhancing diagnostic accuracy and aiding in disease monitoring. This educational review summarizes the utility of nuclear imaging techniques, with a focus on PET scans, in the diagnosis and management of cutaneous pediatric LCH. A comprehensive literature search identified seven relevant articles, including retrospective studies and case reports. These studies highlight the efficacy of FDG-PET in localizing active LCH skin lesions, monitoring disease activity, and guiding treatment decisions. FDG-PET represents a valuable imaging modality for dermatologists, oncologists, and pediatricians managing pediatric LCH patients with cutaneous involvement. This non-invasive technique contributes to improved diagnostic accuracy and facilitates early intervention, ultimately enhancing patient care and outcomes.
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Affiliation(s)
- Sahithi Talasila
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Eric M. Teichner
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert C. Subtirelu
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Sricharvi Mannam
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Thomas Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mona-Elisabeth Revheim
- The Intervention Center, Division of Technology and Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Daifu T, Umeda K, Yokoyama A, Yoshida T, Saida S, Kato I, Hiramatsu H, Kudo K, Higuchi Y, Takita J. Juvenile xanthogranuloma manifesting with LCH-associated neurodegenerative disease-like radiological findings. Pediatr Blood Cancer 2024; 71:e31043. [PMID: 38679849 DOI: 10.1002/pbc.31043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
Here, we describe two patients with juvenile xanthogranuloma (JXG) manifesting with Langerhans cell histiocytosis (LCH)-associated neurodegenerative disease (ND)-like radiological findings. One patient showed typical radiological abnormalities at onset, which worsened with progressing central nervous system symptoms 7 years after LCH-oriented chemotherapy. Another showed spontaneous regression of clinical symptoms, with a transient radiological change 1 year after salvage chemotherapy for recurrence of JXG. These data regarding JXG-associated ND will facilitate future investigation of the disease, as well as development of therapeutic interventions.
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Affiliation(s)
- Tomoo Daifu
- Department of Pediatrics, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yokoyama
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Yoshida
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Saida
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Itaru Kato
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ko Kudo
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoshihisa Higuchi
- Department of Pediatrics, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Junko Takita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Sedky MSM, Hamoda A, Taha H, Zaky I, Hassanain O, ElHaddad A. High risk Langerhans cell histiocytosis in children: the role of salvage in improving the outcome. A single center experience. Orphanet J Rare Dis 2024; 19:242. [PMID: 38910253 PMCID: PMC11195005 DOI: 10.1186/s13023-024-03232-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND In pediatric multi-system high risk organs (RO +) Langerhans cell histiocytosis (LCH), failing 1st line treatment has the highest mortality. We aim to present the outcome of failure of 1st line whether due to disease progression (DP) at end of induction or reactivation (REA) after initial better status response. PATIENTS AND METHODS Sixty-seven RO + LCH patients with hemopoietic, hepatic or splenic involvement, treated between 2007 and 2019 were retrospectively analyzed. The median follow-up (IQR) is 6 years (4-8.8 y).They were subjected to 2 eras of treatment; one with salvage by 2-Cda based regimen (2-CdABR) and another without. RESULTS Of 67 patients, M/F 40/27, median age 1.74 y (0.2-10 y), 42 failed 1st line (62.7%). Of them DP n = 22 (52%) and REA n = 20 (48%). Of those with DP, 9/22 patients received 2-CdABR, where 5 survived in better status. While the remaining 13 did not receive 2-CdABR and all of them died. Otherwise, of those with REA, 12/20 reactivated on RO + mode. Of them, 8/12 received 2-CdABR, where only one survived in better status and the remaining 4 received vinblastine-based regimen,where 2 died and 2 were rescued. RO + 5-year overall survival (OS) was 65% (CI 95% 54 -78) while the event free survival (EFS) 36% (26.3-50.1). The OS of DP 27% (14-54) versus REA 67% (49-93) p 0.004. OS of DP with 2-CdABR 56% (31-97.7) versus 8% without (2-51), p < 0.001. While OS of REA with 2-CdABR 38% (13-100) versus 74% without (53-100) p 0.7. CONCLUSION Survival of RO + remains limited. Failure of 1st line in RO + due to DP carries worse prognosis in relation to REA. In DP those who were not salvaged by 2-CdABR, showed dismal outcome. This could not be shown when applied in REA.
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Affiliation(s)
- Mohamed Sedky M Sedky
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt
| | - Asmaa Hamoda
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt.
| | - Hala Taha
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt
| | - Iman Zaky
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt
| | - Omayma Hassanain
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt
| | - Alaa ElHaddad
- Children's Cancer Hospital Egypt 57357 and National Cancer Institute, 1, Sekket Al-Imam St., Al Sayyeda Zeinab, Cairo, 26386, Egypt
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Ono R, Sakamoto K, Kudo K, Sato A, Kudo K, Fujino H, Kawahara Y, Hashimoto H, Doi T, Yanagisawa R, Kawamata T, Miyazaki O, Nakazawa A, Ota Y, Kanegane H, Nakazawa Y, Horibe K, Saito AM, Manabe A, Usuki K, Kiyoi H, Morimoto A, Tojo A, Shioda Y. Phase II study in children and adults under 40 years with newly diagnosed Langerhans cell histiocytosis: protocol for an LCH-19-MSMFB clinical trial in Japan. BMJ Open 2024; 14:e084159. [PMID: 38910000 DOI: 10.1136/bmjopen-2024-084159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION Although the prognosis of Langerhans cell histiocytosis (LCH) is excellent, the high recurrence rate and permanent consequences, such as central diabetes insipidus and LCH-associated neurodegenerative diseases, remain to be resolved. Based on previous reports that patients with high-risk multisystem LCH show elevated levels of inflammatory molecules, we hypothesised that dexamethasone would more effectively suppress LCH-associated inflammation, especially in the central nervous system (CNS). We further hypothesised that intrathecal chemotherapy would effectively reduce CNS complications. We administer zoledronate to patients with multifocal bone LCH based on an efficacy report from a small case series. METHODS AND ANALYSIS This phase II study (labelled the LCH-19-MSMFB study) is designed to evaluate the significance of introducing dexamethasone and intrathecal chemotherapy for multisystem disease and zoledronate for multifocal bone disease in previously untreated, newly diagnosed children, adolescents (under 20 years) and adults under 40 years. The primary endpoint is the 3-year event-free survival rate by risk group of under 20 years and the 3-year event-free survival rate of 20 years and over. ETHICS AND DISSEMINATION This study was approved by the Central Review Board of the National Hospital Organisation Nagoya Medical Centre (Nagoya, Japan) on 21 January 2022 and was registered in the Japan Registry of Clinical Trials (https://jrct.niph.go.jp/en-latest-detail/jRCTs041210027). Written informed consent will be obtained from all patients and/or their guardians. TRIAL REGISTRATION NUMBER jRCTs041210027.
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Affiliation(s)
- Rintaro Ono
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Kenichi Sakamoto
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ko Kudo
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Aki Sato
- Department of Hematology and Oncology, The Institute of Medical Science Research Hospital, The University of Tokyo, Tokyo, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hisanori Fujino
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Yuta Kawahara
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Hiroya Hashimoto
- Clinical Research Center, NHO Nagoya Medical Center, Nagoya, Japan
| | - Takehiko Doi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Ryu Yanagisawa
- Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan
| | - Toyotaka Kawamata
- Department of Hematology and Oncology, The Institute of Medical Science Research Hospital, The University of Tokyo, Tokyo, Japan
- Department of Hematology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Department of Clinical Research, Saitama Children's Medical Center, Saitama, Japan
| | - Yasunori Ota
- Department of Diagnostic Pathology, The Institute of Medical Science Research Hospital, The University of Tokyo, Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Keizo Horibe
- Clinical Research Center, NHO Nagoya Medical Center, Nagoya, Japan
| | - Akiko M Saito
- Clinical Research Center, NHO Nagoya Medical Center, Nagoya, Japan
| | - Atsushi Manabe
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
- Department of Pediatrics, Showa Inan General Hospital, Komagane, Japan
| | - Arinobu Tojo
- Institute of Innovation, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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Ota M, Sato T, Nakano S, Yamazaki F, Ishii T, Hasegawa T. Potential indication of chemotherapy for hypodipsia and arginine vasopressin deficiency secondary to hypothalamic-pituitary Langerhans cell histiocytosis: a case report and literature review. Clin Pediatr Endocrinol 2024; 33:157-162. [PMID: 38993713 PMCID: PMC11234190 DOI: 10.1297/cpe.2024-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/25/2024] [Indexed: 07/13/2024] Open
Abstract
Hypothalamic-pituitary Langerhans cell histiocytosis (HP-LCH) is often associated with arginine vasopressin deficiency (AVD). Patients with AVD caused by HP-LCH rarely develop an impaired osmotic threshold for thirst (OTT). Improvement in OTT among such patients has not been reported in the literature. To our knowledge, here we report the first case of AVD due to HP-LCH in which hypodipsia resolved during chemotherapy. A nine-year-old Japanese girl presented with polydipsia, polyuria, anorexia, and hypernatremia (149.8 mEq/L) and was diagnosed with AVD secondary to HP-LCH. Visual analog scale examination showed a reduced OTT following the water deprivation test. During chemotherapy for Langerhans cell histiocytosis (LCH), serum sodium concentrations became stable between 138.9 and 142.9 mEq/L under the replacement of desmopressin. Repeated visual analog scale examinations showed that she experienced a sense of thirst at a serum sodium concentration of 142.3-144.6 mEq/L, at which she did not experience any thirst prior to the initiation of chemotherapy. These data suggest that chemotherapy directly improved the OTT in our patient. Improved mechanical compression or infiltration of the hypothalamus related to OTT may lead to the recovery of the sense of thirst. This report highlights the potential role of chemotherapy for solitary HP-LCH in patients with hypodipsia and AVD.
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Affiliation(s)
- Masashi Ota
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Satsuki Nakano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Fumito Yamazaki
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Morimoto A, Sakamoto K, Kudo K, Shioda Y. [Central nervous system disorders secondary to histiocytoses: neurodegeneration with potential for improvement]. Rinsho Shinkeigaku 2024; 64:85-92. [PMID: 38281751 DOI: 10.5692/clinicalneurol.cn-001899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Histiocytoses, including Langerhans cell histiocytosis (LCH) and Erdheim-Chester disease (ECD), are inflammatory myeloid tumors in which monocyte lineage cells aggregate in various organs, causing tissue damage. Most of these tumors harbor oncogenic mutations in mitogen-activated protein kinase (MAPK) pathway genes, typified by BRAFV600E. Some patients with LCH develop bilateral symmetrical cerebellar lesions and brain atrophy several years after diagnosis when the initial symptoms disappear, leading to cerebellar ataxia and higher cerebral dysfunction. A similar neurological disorder has also been reported in ECD. This neurological disorder can be improved with MAPK inhibitors. When patients with this neurological disorder are identified among neurodegeneration of unknown etiology or histiocytosis patients and treated early with MAPK inhibitors, the disorder can be reversible.
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Affiliation(s)
| | | | - Ko Kudo
- Department of Pediatrics, Hirosaki University School of Medicine
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development
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Wei M, Jiang W, Wang R, Xiao B, Zhan Q. Langerhans cell histiocytosis of the skull in 23 children. Eur J Med Res 2024; 29:136. [PMID: 38368348 PMCID: PMC10874530 DOI: 10.1186/s40001-024-01727-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
OBJECTIVE To explore the clinical features, diagnosis, treatment and prognosis of Langerhans cell histiocytosis (LCH) of the skull in children. METHODS This study retrospectively summarized the clinical manifestations, treatment methods and follow-up status of children with skull LCH who were admitted to the Department of Neurosurgery of Shanghai Children's Hospital from January 2014 to June 2021. RESULTS A total of 23 patients confirmed by histology as LCH received hospitalization treatment, including 14 males and 9 females, aged (5.76 ± 3.86) years old. The clinical manifestations were mostly incidentally discovered head masses that gradually enlarged (19 cases, 82.61%). Only 2 cases are affected by multiple systems, while the rest are affected by single systems. 9 patients were involved in multiple skull lesions, and 14 patients had local skull lesions. All patients underwent surgical intervention, with 17 patients undergoing total resection and 6 patients undergoing biopsy. 21 patients received chemotherapy after surgery. The median follow-up was 2.46 years (range 0.33-6.83 years). 21 patients had their symptoms and signs under control or even resolved, and 2 patients experienced recurrence during follow-up. The overall control rate reached 91.30%. CONCLUSION Personalized treatment plans according to different clinical types. Regular outpatient follow-up is crucial to monitor disease recurrence and late effects.
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Affiliation(s)
- Min Wei
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Luding Rd. 355, Shanghai, People's Republic of China
| | - Wenbin Jiang
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Luding Rd. 355, Shanghai, People's Republic of China
| | - Rui Wang
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Luding Rd. 355, Shanghai, People's Republic of China
| | - Bo Xiao
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Luding Rd. 355, Shanghai, People's Republic of China
| | - Qijia Zhan
- Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Luding Rd. 355, Shanghai, People's Republic of China.
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Lei J, Wang W, Lin D, Zhu C, Jia W, Weng W, Liu X, Ma Y, Wang Z, Yang L, He X, He Y, Li Y. Vemurafenib combined with chemotherapy achieved sustained remission in pediatric LCH: a multi-center observational study. J Cancer Res Clin Oncol 2024; 150:12. [PMID: 38231288 PMCID: PMC10794359 DOI: 10.1007/s00432-023-05551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Langerhans cell histiocytosis (LCH) is a myeloid neoplasia with potentially fatal consequences, and about 2/3 of cases involve the BRAFV600E kinase-activated mutation. Vemurafenib, a BRAF inhibitor, has demonstrated significant clinical improvements in LCH. However, the high relapse rate of LCH following cessation of vemurafenib therapy remains a major challenge, and alternative treatment strategies require further investigation. METHODS In this retrospective multi-center study, we evaluated the efficacy and safety of vemurafenib combined with conventional chemotherapy in patients with severe or refractory LCH. RESULTS Seventeen patients were enrolled in the study, with eleven classified as risk organ involvement (RO +). Six received the combination therapy as the primary treatment, and eleven after being refractory to prior chemotherapy. The overall response rate was 94.1%. Progression-free survival among all 17 patients was 70.6% (12/17) at a median follow-up of 32 months, and relapse-free survival among the 15 patients with discontinuation after a response was 73.3%(11/15) at a median follow-up of 34 months. Five of six patients (83.3%) with myeloid BRAFV600E mutations demonstrated molecular remission. The overall survival rate was 100%. Adverse events were mostly classified as grades 1 or 2. CONCLUSION Our data suggest that the combination of vemurafenib and chemotherapy can achieve sustained clinical and molecular level relief in children with LCH, and side effects are tolerable.
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Affiliation(s)
- Jiaying Lei
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Wenxia Wang
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Danna Lin
- Department of Pediatric Hematology and Critical Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
| | - Chengguang Zhu
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - Wenguang Jia
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Wenjun Weng
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Xiaoshan Liu
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Yuhan Ma
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Zhixuan Wang
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Lihua Yang
- Department of Pediatric Hematology and Critical Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China.
| | - Xiangling He
- Department of Pediatric Hematology and Oncology, Hunan Provincial People's Hospital, Changsha, 410005, China.
| | - Yunyan He
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China.
| | - Yang Li
- Department of Pediatric Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China.
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Wang W, Ge J, Ma H, Lian H, Cui L, Zhao Y, Li Z, Wang T, Zhang R. Treatment of children with refractory/relapse high risk langerhans cell histiocytosis with the combination of cytarabine, vindesine and prednisone. BMC Pediatr 2024; 24:1. [PMID: 38172736 PMCID: PMC10763196 DOI: 10.1186/s12887-023-04465-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The patients with multisystem and risk organ involvement Langerhans cell histiocytosis (MS-RO + LCH) have poor prognosis. The patients with MS-LCH who failed front-line therapy have a high mortality rate and the standard salvage treatment has not been established. The combination of cytarabine (Ara-c), vincristine (VCR) and prednisone might be effective for refractory/relapse MS-RO + LCH, with low toxicity. METHODS We retrospectively analyzed pediatric refractory/relapse MS-RO + LCH patients treated with the low-dose Ara-c (100mg/m2/d×5days) or high-dose Ara-c (500mg/m2/d×5days) combined with vindesine (VDS) and prednisone in a single center. The efficacy, outcomes and adverse events were analyzed. RESULTS From January 2013 to December 2016, 13 patients receiving the low-dose Ara-c chemotherapy (LAC) and 7 patients receiving the high-dose Ara-c chemotherapy (HAC) were included in the study. 11 (84.6%) of the 13 patients treated with the LAC regimen and 6 (85.7%) of the 7 patients treated with the HAC regimen had response after four courses of the therapy. All patients in the study were alive during follow-up and the 3-year event-free survival rate (EFS) was 53.7% and 85.7% in the LAC and HAC groups. The most frequent adverse event was Grade 1/2 myelosuppression, which was observed in 38.5% (5/13) and 42.9% (3/7) of the patients receiving the LAC and HAC regimen. CONCLUSIONS A combination of Ara-c, VDS and prednisone was effective and safe for some patients with refractory/relapse MS-RO + LCH. The high-dose Ara-c regimen was associated with a numerically higher EFS rate.
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Affiliation(s)
- Wenqian Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jian Ge
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Honghao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Hongyun Lian
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Lei Cui
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute,Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Disease in Children, Beijing Children's Hospital, National Key Discipline of Pediatrics,Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yunze Zhao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Zhigang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute,Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Disease in Children, Beijing Children's Hospital, National Key Discipline of Pediatrics,Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Tianyou Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Rui Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, Ministry of Education, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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12
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Aoyama S, Fukuoka K, Kubota H, Narita K, Kudo K, Mitani Y, Oshima K, Mori M, Arakawa Y, Ichimura K, Terui K, Tanami Y, Kawashima H, Nakazawa A, Niitsu T, Takahashi Y, Koh K. Early chemotherapeutic intervention to avoid thyroidectomy in pediatric Langerhans cell histiocytosis with thyroid involvement accompanying tracheal stenosis: a report of two cases. Int J Hematol 2024; 119:99-103. [PMID: 37740816 DOI: 10.1007/s12185-023-03662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
Thyroid involvement is rare in pediatric Langerhans cell histiocytosis (LCH). It may cause airway narrowing, leading to acute-onset respiratory distress. Severe cases may require emergent surgical interventions such as thyroidectomy, which should be avoided in children due to higher rates of complication, particularly in infancy. There is currently no consensus on the indications for surgical treatment in LCH with thyroid involvement. In this report, we describe the cases of two children who presented with tracheal stenosis caused by thyroid LCH, both of which were successfully treated by early induction of chemotherapy, and one of which was also treated for a shorter duration. Mutation analysis detected in-frame deletions of BRAF exon 12 in both cases. These cases suggest that timely diagnosis and administration of chemotherapy may alleviate severe airway obstruction and reduce the need for thyroidectomy in pediatric patients with thyroid LCH.
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Affiliation(s)
- Shuhei Aoyama
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan.
| | - Hirohito Kubota
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Kotaro Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ko Kudo
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Kayoko Ichimura
- Department of Pathology, Saitama Children's Medical Center, Saitama, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Atsuko Nakazawa
- Department of Pathology, Saitama Children's Medical Center, Saitama, Japan
| | - Takehiro Niitsu
- Department of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2, Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
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13
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Liu R, Guo Y, Han L, Feng S, Cao J, Sun Y, Cao Z, Cui X. Somatic ARAF mutations in pediatric Langerhans cell histiocytosis: clinicopathologic, genetic and functional profiling. Clin Exp Med 2023; 23:5269-5279. [PMID: 37572153 DOI: 10.1007/s10238-023-01134-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/29/2023] [Indexed: 08/14/2023]
Abstract
ARAF mutations have been identified in a limited subset of patients with Langerhans cell histiocytosis (LCH), a rare disorder characterized by abnormal proliferation of Langerhans cells. LCH is primarily instigated by mutations in the mitogen-activated protein kinase (MAPK) signaling pathway, with BRAFV600E and MAP2K1 mutations constituting most cases. ARAF mutations in LCH highlight the heterogeneity of the disease and provide insights into its underlying molecular mechanisms. However, the occurrence of ARAF-positive LCH cases is extremely rare, with only two reported globally. Although they may be linked to a more aggressive form of LCH and a more severe clinical progression, the clinical significance and functional consequences of these mutations remain uncertain. We performed next-generation sequencing (NGS) to explore driver mutations in 148 pediatric LCH patients and recognized a series of mutations, including an identical novel somatic ARAF mutation, c.1046_1051delAGGCTT (p.Q349_F351delinsL), in four pediatric LCH patients. It was considered an ARAF hotspot mutation. All reported ARAF-positive patients worldwide exhibited characteristic pathological features of LCH, albeit with involvement across multiple systems. In vitro functional studies showed that this mutation could trigger the MAPKinase pathway and phosphorylate its downstream effectors MEK1/2 and ERK1/2 (relatively weaker than BRAFV600E). Over-activation of mutant A-Raf kinase could be inhibited by the BRAF inhibitor vemurafenib. LCH is uncommon, and ARAF mutation is even rarer. In our study, we have identified a novel hotspot somatic ARAF mutation, which has been verified through functional analysis to be an activating mutation. LCH patients with ARAF mutation typically have an unfavorable prognosis due to limited treatment experiences, although they do not exhibit a high relapse rate. To aid in the development of personalized treatment approaches and prognostic markers for LCH patients, it is recommended to conduct typical pathological and immunohistochemical examinations, as well as genetic tests utilizing a targeted gene panel or whole exome sequencing (WES), for LCH diagnosis, thereby promoting the use of inhibitor treatment strategies.
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Affiliation(s)
- Rong Liu
- Department of Hematology, Capital Institute of Pediatrics, Chaoyang District, Beijing, 100020, China
| | - Yibing Guo
- GrandOmics Inc, Haidian District, Beijing, 100081, China
| | - Lin Han
- GrandOmics Inc, Haidian District, Beijing, 100081, China
| | - Shunqiao Feng
- Department of Hematology, Capital Institute of Pediatrics, Chaoyang District, Beijing, 100020, China
| | - Jing Cao
- Department of Hematology, Capital Institute of Pediatrics, Chaoyang District, Beijing, 100020, China
| | - Yanling Sun
- GrandOmics Inc, Haidian District, Beijing, 100081, China
| | - Zhenhua Cao
- GrandOmics Inc, Haidian District, Beijing, 100081, China.
| | - Xiaodai Cui
- Clinical Central Laboratory, Capital Institute of Pediatrics, Beijing, 100020, China.
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14
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Cai F, Peng Z, Xu H, Gao H, Liao C, Xu X, Guo X, Gu W, Zhu K, Shu Q, Shen H. Immune microenvironment associated with the severity of Langerhans cell histiocytosis in children. Cytokine 2023; 171:156378. [PMID: 37748334 DOI: 10.1016/j.cyto.2023.156378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/04/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
The aim of this study is to investigate the clinical potential of immune microenvironment in peripheral blood for the severity and therapeutic efficacy of Langerhans cell histiocytosis (LCH). A total of 200 newly diagnosed children with LCH during 10 years was enrolled for analysis in this study. Peripheral blood samples were acquired from patients before treatment in our hospital and immune indicators were detected by a four-color flow cytometer. The levels of CD3 + CD8 + T cell, CD3 + CD4 + HLA-DR + T cell, CD3 + CD8 + HLA-DR + T cell, IL-4, IL-6, IL-10 and IFN-γ in peripheral blood were markedly elevated in LCH patients vs. healthy controls. Patients with multiple system with risk organ involvement (MS-RO + ) exhibited higher levels in IL-6, IL-10 and IFN-γ, CD3 + CD4 + HLA-DR + T cell and CD3 + CD8 + HLA-DR + T cell, compared to those in patients without risk organ involvement (RO-). Patients who responded effectively to initial chemotherapy showed significantly lower levels of IL-4, IL-10, IFN-γ, CD3 + CD4 + HLA-DR + T cell and CD3 + CD8 + HLA-DR + T cell in peripheral blood, compared to those in patients who did not respond to initial chemotherapy. Furthermore, univariate analyses were performed that the higher levels of CD3 + CD4 + HLA-DR + T cells, CD3 + CD8 + HLA-DR + T cells and IL-10 in peripheral blood were related to non-response in LCH after initial chemotherapy. Immune microenvironment in peripheral blood may be associated with the severity and treatment response of LCH. The levels of CD3 + CD4 + HLA-DR + T cells, CD3 + CD8 + HLA-DR + T cells and IL-10 may be biomarkers to predict treatment response of LCH patients.
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Affiliation(s)
- Fengqing Cai
- Department of clinical laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhaoyang Peng
- Department of clinical laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hui Xu
- Department of clinical laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hui Gao
- Department of clinical laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Chan Liao
- Department of hematology-oncology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiaojun Xu
- Department of hematology-oncology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiaoping Guo
- Department of hematology-oncology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weizhong Gu
- Department of pathology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Kun Zhu
- Department of pathology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiang Shu
- Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China; Joint Research Center for Immune Landscape and Precision Medicine in Children, Binjiang Institute of Zhejiang University, China.
| | - Hongqiang Shen
- Department of clinical laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China; Joint Research Center for Immune Landscape and Precision Medicine in Children, Binjiang Institute of Zhejiang University, China.
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15
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Teshima R, Sakuragi Y, Saito-Sasaki N, Okada E, Sawada Y. Congenital Langerhans Cell Histiocytosis With the Skin and Lung Involvement: A Case and Literature Review. Cureus 2023; 15:e49453. [PMID: 38152801 PMCID: PMC10751249 DOI: 10.7759/cureus.49453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/29/2023] Open
Abstract
Langerhans cell histiocytosis (LCH) is a clonal proliferative disease of immature Langerhans cells that expand in various organs, leading to organ and tissue dysfunction. Although LCH is most commonly seen in children under the age of three, a small number of cases of congenital LCH have been described. With a review of the literature on congenital LCH with lung and skin lesions, we present a case of congenital LCH with involvement of skin and lung, which was effectively treated with chemotherapy without recurrence for 3 years during the observational period. In addition, we summarized previously published case studies of congenital LCH with skin and lung involvement.
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Affiliation(s)
- Romane Teshima
- Dermatology, Hospital of University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Yumiko Sakuragi
- Dermatology, Hospital of University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Natsuko Saito-Sasaki
- Dermatology, Hospital of University of Occupational and Environmental Health, Kitakyusyu, JPN
| | - Etsuko Okada
- Dermatology, Hospital of University of Occupational and Environmental Health, Kitakyushu, JPN
| | - Yu Sawada
- Dermatology, Hospital of University of Occupational and Environmental Health, Kitakyushu, JPN
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16
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Donadieu J. Comment on "Subcutaneous administration of cytarabine for pediatric patients with Langerhans cell histiocytosis decreases burden of patient travel and infusion center utilization". Pediatr Blood Cancer 2023; 70:e30661. [PMID: 37669241 DOI: 10.1002/pbc.30661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023]
Affiliation(s)
- Jean Donadieu
- Registre des histiocytoses Centre de Référence des Histiocytoses, Service d'Hémato-Oncologie Pédiatrique, APHP Hopital Trousseau, Paris, France
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17
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Sato A, Kobayashi M, Yusa N, Ogawa M, Shimizu E, Kawamata T, Yokoyama K, Ota Y, Ichinohe T, Ohno H, Mori Y, Sakaida E, Kondo T, Imoto S, Nannya Y, Mitani K, Tojo A. Clinical and prognostic features of Langerhans cell histiocytosis in adults. Cancer Sci 2023; 114:3687-3697. [PMID: 37364599 PMCID: PMC10475785 DOI: 10.1111/cas.15879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 04/18/2023] [Accepted: 05/21/2023] [Indexed: 06/28/2023] Open
Abstract
Langerhans cell histiocytosis (LCH) is a rare disease characterized by clonal expansion of CD1a+ CD207+ myeloid dendritic cells. The features of LCH are mainly described in children and remain poorly defined in adults; therefore, we conducted a nationwide survey to collect clinical data from 148 adult patients with LCH. The median age at diagnosis was 46.5 (range: 20-87) years with male predominance (60.8%). Among the 86 patients with detailed treatment information, 40 (46.5%) had single system LCH, whereas 46 (53.5%) had multisystem LCH. Moreover, 19 patients (22.1%) had an additional malignancy. BRAF V600E in plasma cell-free DNA was associated with a low overall survival (OS) rate and the risk of the pituitary gland and central nervous system involvement. At a median follow-up of 55 months from diagnosis, six patients (7.0%) had died, and the four patients with LCH-related death did not respond to initial chemotherapy. The OS probability at 5 years post-diagnosis was 90.6% (95% confidence interval: 79.8-95.8). Multivariate analysis showed that patients aged ≥60 years at diagnosis had a relatively poor prognosis. The probability of event-free survival at 5 years was 52.1% (95% confidence interval: 36.6-65.5), with 57 patients requiring chemotherapy. In this study, we first revealed the high rate of relapse after chemotherapy and mortality of poor responders in adults as well as children. Therefore, prospective therapeutic studies of adults with LCH using targeted therapies are needed to improve outcomes in adults with LCH.
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Affiliation(s)
- Aki Sato
- Department of Hematology and Oncology, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
| | | | - Nozomi Yusa
- Department of Applied Genomics, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
| | - Miho Ogawa
- Division of Hematopoietic Disease Control, Institute of Medical ScienceUniversity of TokyoTokyoJapan
| | - Eigo Shimizu
- Division of Health Medical Intelligence, Human Genome Center, Institute of Medical ScienceUniversity of TokyoTokyoJapan
| | - Toyotaka Kawamata
- Department of Hematology and Oncology, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
| | - Kazuaki Yokoyama
- Department of Hematology and Oncology, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
| | - Yasunori Ota
- Department of Diagnostic Pathology, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and MedicineHiroshima UniversityHiroshimaJapan
| | | | - Yasuo Mori
- Department of Medicine and Biosystemic ScienceKyushu University Graduate School of Medical SciencesFukuokaJapan
| | - Emiko Sakaida
- Department of HematologyChiba University HospitalChibaJapan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Seiya Imoto
- Division of Health Medical Intelligence, Human Genome Center, Institute of Medical ScienceUniversity of TokyoTokyoJapan
| | - Yasuhito Nannya
- Department of Hematology and Oncology, Institute of Medical Science Research HospitalUniversity of TokyoTokyoJapan
- Division of Hematopoietic Disease Control, Institute of Medical ScienceUniversity of TokyoTokyoJapan
| | - Kinuko Mitani
- Department of Hematology and OncologyDokkyo Medical UniversityTochigiJapan
| | - Arinobu Tojo
- Institute of Innovation AdvancementTokyo Medical and Dental UniversityTokyoJapan
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18
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Shimizu S, Sakamoto K, Kudo K, Morimoto A, Shioda Y. Detection of BRAF V600E mutation in radiological Langerhans cell histiocytosis-associated neurodegenerative disease using droplet digital PCR analysis. Int J Hematol 2023:10.1007/s12185-023-03588-w. [PMID: 37010809 DOI: 10.1007/s12185-023-03588-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023]
Abstract
Langerhans cell histiocytosis-associated neurodegenerative disease (LCH-ND) is the most serious late complication secondary to LCH and is gradually progressive, destructive, and irreversible. Detection of the BRAF V600E mutation in peripheral blood mononuclear cells (PBMCs), even in the absence of active LCH lesions, is considered a sign of clinical LCH-ND, presenting with both abnormal imaging findings and neurological symptoms. However, the detection of the BRAF V600E mutation in PBMCs of patients with asymptomatic radiological LCH-ND (rLCH-ND) without active LCH lesions who present only with abnormal imaging findings is unknown. In this study, we analyzed the BRAF V600E mutations in PBMCs and cell-free DNA (cfDNA) of patients with rLCH-ND without active LCH lesions (n = 5) using a droplet digital polymerase chain reaction (ddPCR) assay. The BRAF V600E mutation in PBMCs was detected in three out of five (60%) cases. The mutant allele frequencies in the three positive cases were 0.049%, 0.027%, and 0.015%, respectively. However, the cfDNA BRAF V600E mutation remained undetected in all patients. Detection of the BRAF V600E mutant allele in PBMCs may be helpful in identifying asymptomatic rLCH-ND in patients at high risk for developing LCH-ND, including those with relapses at CNS risk sites or central diabetes insipidus.
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Affiliation(s)
- Soichiro Shimizu
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kenichi Sakamoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan.
- Department of Pediatrics, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Ko Kudo
- Department of Pediatrics, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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19
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Morimoto A, Shioda Y, Kudo K, Kanegane H, Imamura T, Koh K, Kosaka Y, Yuza Y, Nakazawa A, Saito AM, Watanabe T, Nakazawa Y. Intensification of treatment with vinca alkaloid does not improve outcomes in pediatric patients with Langerhans cell histiocytosis: results from the JPLSG LCH-12 study. Int J Hematol 2023:10.1007/s12185-023-03568-0. [PMID: 36871086 DOI: 10.1007/s12185-023-03568-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023]
Abstract
Chemotherapy with cytarabine, vincristine (VCR), and prednisolone has achieved low mortality rates in pediatric patients with Langerhans cell histiocytosis (LCH). However, relapse rates remain high, making event-free survival (EFS) rates unsatisfactory. A nationwide clinical trial, LCH-12, tested a modified protocol in which the early maintenance phase was intensified with increasing dosages of VCR. Patients newly diagnosed with multifocal bone (MFB) or multisystem (MS) LCH and aged < 20 years at diagnosis were enrolled between June 2012 and November 2017. Of the 150 eligible patients, 43 with MFB were treated for 30 weeks and 107 with MS LCH were treated for 54 weeks. One patient with MS LCH died of sepsis during the induction phase. The 3-year EFS rates among patients with MFB LCH, risk organ (RO)-negative MS LCH, and RO-positive MS LCH were 66.7% (95% confidential interval [CI], 56.5-77.0%), 66.1% (95% CI 52.9-76.4%), and 51.1% (95% CI 35.8-64.5%), respectively, similar to previously observed rates. EFS rates were significantly lower in patients with disease activity scores > 6 than in those with scores ≤ 6. The strategy that included more intense treatment with VCR was not effective. Other strategies are required to improve outcomes in patients with pediatric LCH.
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Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan. .,Department of Pediatrics, Showa Inan General Hospital, 3230, Akaho, Komagane, Nagano, 399-4117, Japan.
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology/Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yuki Yuza
- Departments of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Atsuko Nakazawa
- Department of Clinical Research, Saitama Children's Medical Center, Saitama, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Tomoyuki Watanabe
- Department of Health and Nutrition, Faculty of Psychological and Physical Science, Aichi Gakuin University, Nisshin, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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Tokutsu A, Okada Y, Kurozumi A, Tanaka K, Kubo S, Tanaka Y. Possible involvement of CXCR3-CXCR6 + CD4 + T cells in Langerhans cell histiocytosis. J Bone Miner Metab 2023; 41:212-219. [PMID: 36629910 DOI: 10.1007/s00774-022-01397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Langerhans cell histiocytosis (LCH) is a condition characterized by proliferation of Langerhans cells and wide-range pathologies, ranging from single granulomatous lesions to multi-organ involvement, associated with tissue destruction. LCH pathogenesis remains obscure although association with interleukin (IL)-17A has been reported. We report here a case that illustrates the potential pathogenic role of helper T17 (Th17) cells in LCH-related bone destruction. MATERIALS AND METHODS The patient was a 66-year-old woman. The clinical course included craniectomy and bone mass excision in X-9, diagnosis of LCH confirmed by histopathology, followed by 26-month chemotherapy. In August X, the patient was diagnosed with complete central diabetes insipidus. Symptoms improved after treatment with desmopressin. Pituitary magnetic resonance imaging showed swelling extending from the suprasellar region to the pituitary stalk, suggestive of LCH recurrence. This was followed by chemotherapy combined with mercaptopurine hydrate. RESULTS: Subsequent peripheral blood lymphocyte analysis showed marked increase in activated Th17 cells (CXCR3-CXCR6+ CD4+ T cells). Double staining for CD4 and IL-17 by immunofluorescence of pathological tissue samples obtained during temporal bone mass excision, which confirmed the diagnosis of LCH in X-9, showed areas of combined presence of CD4-positive cells and IL-17-positive cells. Chemotherapy resulted in size reduction of the pituitary lesion and decrease in peripheral blood-activated Th17 cells. CONCLUSIONS We found abundant peripheral blood-activated Th17 cells and high percentages of IL-17-producing cells in osteolytic bone lesions in LCH. This finding, together with the decrease in peripheral blood-activated Th17 cells following chemotherapy, suggests the potential involvement of activated Th17 cells in LCH-related osteolysis.
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Affiliation(s)
- Akemi Tokutsu
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan
| | - Akira Kurozumi
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan
| | - Kenichi Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan
| | - Satoshi Kubo
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushyu-shi, Kitakyushu, 807-8555, Japan.
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Sakamoto K, Morimoto A, Shioda Y, Imamura T, Imashuku S. Relapses of multisystem/multifocal bone Langerhans cell histiocytosis in paediatric patients: Data analysis from the JLSG-96/02 study. Br J Haematol 2023; 200:769-775. [PMID: 36511451 DOI: 10.1111/bjh.18583] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/12/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022]
Abstract
We assessed relapse patterns in paediatric patients with relapsed Langerhans cell histiocytosis (LCH) who were initially treated with the JLSG-96/02 protocol. We analysed 187 relapse events in 101 relapsed LCH patients [31 with multifocal bone (MFB) and 70 with multisystem (MS) at LCH diagnosis] among a total 317 patients enrolled in JLSG-96/-02 studies. Relapse of LCH was defined as an exacerbation of the non-active disease (NAD) condition. Of the 317 patients, 101 (31.9%) had the first relapse at 1.5 years after initiation of therapy. The first relapse and subsequent relapses did not differ between patients with MFB and MS disease. Of the 187 relapse events, relapse occurred as a single-system disease (n = 159; 85%), in which isolated bone relapse (n = 104; 55%) was the most common. Relapse at MS disease with the risk of organ involvement is extremely rare. After relapse(s), most patients underwent chemotherapy (122/187; 65%) and 87% of them achieved NAD status again. The incidence of permanent consequences was significantly higher in patients with relapses than in those without relapses. In the JLSG cohort, bone relapse most occurred in both MFB and MS patients. Most relapses could be effectively controlled by repeated administration of the initial chemotherapy.
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Affiliation(s)
- Kenichi Sakamoto
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinsaku Imashuku
- Division of Laboratory Medicine, Uji-Tokushukai Medical Center, Uji, Japan
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22
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Sakamoto K, Kikuchi K, Sako M, Kato M, Takimoto T, Shioda Y. Pilot study to estimate the safety and effectiveness of hydroxyurea and methotrexate recurrent langerhans cell histiocytosis (LCH-HU-pilot). Medicine (Baltimore) 2022; 101:e31475. [PMID: 36550910 PMCID: PMC9771280 DOI: 10.1097/md.0000000000031475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This study was a non-blinded, multicenter, single-arm study. Recurrent (relapsed) LCH is defined as the appearance of new lesions or the enlargement of preexisting lesions due to LCH. In this study, all patients received hydroxyurea, and if the treatment response was unsatisfactory, methotrexate was added. The duration of treatment was 48 weeks. The primary endpoint was the rate of non-active disease achievement, which was 24 weeks after initiating hydroxyurea administration. No active disease is defined as the resolution of all the signs and symptoms related to LCH.
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Affiliation(s)
- Kenichi Sakamoto
- Children’s Cancer Center, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Kayoko Kikuchi
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Miho Kato
- Department of Cancer Data Management, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Takimoto
- Department of Cancer Data Management, National Center for Child Health and Development, Tokyo, Japan
| | - Yoko Shioda
- Children’s Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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23
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Optimal timing of liver transplantation for liver cirrhosis caused by sclerosing cholangitis in a patient with Langerhans cell histiocytosis: a case report. Int J Hematol 2022; 117:759-764. [PMID: 36469185 DOI: 10.1007/s12185-022-03500-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/20/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
Liver cirrhosis due to secondary sclerosing cholangitis caused by Langerhans cell histiocytosis (LCH) has a poor prognosis, and liver transplantation is the definitive treatment. However, the optimal timing has not been established. We report a 2-year-old girl with LCH-related liver cirrhosis who successfully underwent liver transplantation before progressing to severe liver dysfunction. Physical examination revealed a tumor on her palate. Biopsy was performed, and a diagnosis of LCH was established, together with hepatomegaly, splenomegaly, and rashes. Percutaneous liver biopsy before treatment revealed extreme fibrosis and absence of LCH cells. After beginning chemotherapy, she experienced several delays in treatment and dose reductions because of unacceptable bone marrow suppression, worsening liver dysfunction, and cholangitis. However, tumor shrinkage was observed in both magnetic resonance imaging and BRAF V600E mutant allele titers in her plasma. Given the good treatment response, liver transplantation was conducted. The postoperative course was uneventful, and chemotherapy was resumed 34 days after liver transplantation. Subsequent maintenance treatment was completed with no severe adverse effects. To prevent perioperative complications due to exacerbation of liver dysfunction and possible discontinuation of chemotherapy, liver transplantation should be considered before development of end-stage liver failure, provided that the original disease is well controlled.
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24
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Hu X, Buhtoiarov IN, Wang C, Sun Z, Zhu Q, Huang W, Yan W, Sun Y. Langerhans Cell Histiocytosis: A Population-based Study of Anatomical Distribution and Treatment Patterns. J Bone Oncol 2022; 36:100454. [PMID: 36204417 PMCID: PMC9530953 DOI: 10.1016/j.jbo.2022.100454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
LCH in bone marrow and lymph node are more likely to have multi-system involvement compared to LHC in other sites. Craniofacial osseous LCH is more likely to be treated with surgery, vertebral LCH is less likely to be treated with surgery. A racial disparity in surgery utilization is identified in pediatric patients with bone LCH.
Background Langerhans cell histiocytosis (LCH) is a rare monoclonal histiocytic neoplasm. Little is known about clinical factors associated with LCH single- vs multi-system involvement at the time of diagnosis. Methods Data on 1549 LCH patients diagnosed between years 2010 and 2018 were extracted from the Surveillance, Epidemiology and End Results Program. Patterns of single- vs multisystem involvement were examined using multivariable logistic regression analysis. Odd ratio (OR) and 95% confidence interval (CI) were reported. Results 968 children and adolescents (0–19 years; median: 4 years) and 581 adults (≥20 years; median: 49 years) were included in the analysis. Multi-system LCH was reported for 30.9 % patients. Bone marrow (BM) (OR = 3.776; 95 %CI = 1.939–7.351; P < 0.001) and lymph node (LN) (OR = 3.274; 95 %CI = 1.443–7.427; P = 0.005) involvement were most commonly associated with multi-system LCH at the time of diagnosis; similar pattern was also observed in adult patients (OR = 17.780; 95 %CI = 6.469–48.867; P < 0.001 for BM LCH; and OR = 5.156; 95 %CI = 2.131–12.471; P < 0.001 for LN LCH). Among pediatric patients, craniofacial osseous LCH was more likely to be treated with surgery (OR = 2.822; 95 %CI = 1.199–6.639; P = 0.018) compared to skeletal lesions in other sites, whereas vertebral body LCH was less likely to be treated with surgery (OR = 0.175; 95 %CI = 0.058–0.527; P = 0.002). In pediatric patients with bone LCH, the non-white patients were less likely to be treated surgically compared to the white patients (OR = 0.470; 95 %CI = 0.272–0.812; P = 0.007). Conclusions BM and LN LCH are associated with the highest risks of multi-system disease, which may require active surveillance. Furthermore, active attempts are needed to mitigate the racial disparity in surgery utilization in pediatric patients with skeletal LCH.
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25
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Cai HC, Chen J, Liu T, Cai H, Duan MH, Li J, Zhou DB, Cao XX. Langerhans cell histiocytosis in adolescent patients: a single-centre retrospective study. Orphanet J Rare Dis 2022; 17:268. [PMID: 35841042 PMCID: PMC9288061 DOI: 10.1186/s13023-022-02436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
Background Langerhans cell histiocytosis (LCH) is a myeloid dendritic cell disorder frequently affecting children more than adults. The presentation of LCH varies with age, however, the clinical characteristics and genetic profiles of adolescent LCH remain elusive. To address the knowledge gap, we performed a single-centre retrospective study of 36 adolescent LCH patients aged between 14 and 17 years at Peking Union Medical College Hospital. Results At the time of diagnosis, 10 patients were classified as unifocal single system LCH (27.8%), 2 patients had pulmonary single system LCH (5.6%), 5 patients had multifocal single system LCH with bone involvement (13.9%), and 19 patients had multisystem LCH (52.8%). The most prevalent involvement in multisystem patients was the pituitary gland (78.9%), followed by the bone (42.1%), lung (42.1%), and lymph nodes (42.1%). Eight (42.1%) patients had risk organ involvement. BRAFN486_P490 was detected in 50% of patients who underwent next generation sequencing, and BRAFV600E was detected in one patient. Chemotherapies were the first line treatment in 24 patients. One patient died and thirteen patients relapsed during the follow-up. The estimated 5-year OS rate and EFS rate were 94.7% and 59.0%, respectively. Conclusions In this study, we report a large series of adolescent LCH patients. The clinical characteristics of adolescent LCH patients may be close to adult LCH. Compared with pediatric cases, adolescent LCH tends to have more pituitary lesions and pulmonary involvement, fewer skin and hematopoietic involvement, a higher frequency of BRAF deletion mutation, and a lower frequency of BRAFV600E mutation. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02436-0.
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Affiliation(s)
- Hua-Cong Cai
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jia Chen
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ting Liu
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Cai
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ming-Hui Duan
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jian Li
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dao-Bin Zhou
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin-Xin Cao
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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26
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Lian H, Cui L, Yang Y, Wei A, Cheng H, Li N, Zhang L, Ma H, Zhao X, Wang T, Li Z, Zhang R. Second-line regimen for CNS-involved pediatric Langerhans cell histiocytosis. Pituitary 2022; 25:108-115. [PMID: 34302575 DOI: 10.1007/s11102-021-01176-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Langerhans cell histiocytosis (LCH) can affect any organ. Central nervous system (CNS) involvement is rare, and its management is poorly understood. This study aimed to analyze the clinical response and prognosis of pediatric LCH with central diabetes insipidus (CDI) treated with second-line therapy with cytarabine (Ara-c), cladribine (2-cdA), dexamethasone, and vindesine. METHODS This retrospective case series study included pediatric LCH with CDI treated at Beijing Children's Hospital affiliated with Capital Medical University (11/2012-01/2018). After the first-line 2009-LCH regimen, patients with active disease/worse response, relapse, or no significant improvement in risk organs, pituitary, or lung were given the second-line therapy. Baseline characteristics, clinical response and adverse reactions were observed. RESULTS Twenty-six children with CDI and disappearance of hyperintensity in the posterior pituitary were included. They received "Regimen A" Ara-c + dexamethasone + vindesine (n = 7) or "Regimen B" Ara-c + dexamethasone + vindesine + 2-cdA (n = 19) as second-line therapy. There were 14 patients with CDI but without pituitary stalk thickening (PST) and 12 with CDI and PST. In patients with CDI alone, 4/4 patients receiving Regimen A and 3/10 receiving Regimen B improved. All patients with CDI and PST showed improvement for PST. The reappearance of hyperintensity at the posterior pituitary was observed in 10 patients with CDI. All 26 children were alive after a median follow-up of 40.5 months. There were no chemotherapy-related deaths. CONCLUSION A combined therapy with Ara-c, 2-cdA, dexamethasone, and vindesine could partially alleviate pituitary disease conditions in pediatric LCH with CNS involvement, with good tolerance.
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Affiliation(s)
- Hongyun Lian
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Lei Cui
- Laboratory of Hematologic Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Ying Yang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Ang Wei
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Hua Cheng
- Radiology Department, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Na Li
- Laboratory of Hematologic Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Li Zhang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Honghao Ma
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Xiaoxi Zhao
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Tianyou Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Zhigang Li
- Laboratory of Hematologic Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China.
| | - Rui Zhang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China.
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Morimoto A, Shioda Y, Sakamoto K, Imamura T, Imashuku S. Bone lesions of Langerhans cell histiocytosis triggered by trauma in children. Pediatr Int 2022; 64:e15199. [PMID: 35770832 DOI: 10.1111/ped.15199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bone lesions of Langerhans cell histiocytosis (LCH) may be triggered by trauma. METHODS The characteristics of pediatric patients in the JLSG-02 study cohort who developed a bone lesion at the trauma site at diagnosis of LCH were analyzed retrospectively. RESULTS Of the 261 pediatric patients with LCH, 12 (4.6%), of median age 4.9 years, had trauma-triggered bone LCH lesions at diagnosis, making them significantly older than the remaining patients (P = 0.006). Trauma sites included the craniofacial regions in 10 patients and the lumbar spine and pelvis in one patient each. At the time of trauma, six patients had a bump at the site, whereas none had extradural hematomas or bone fractures. The median time from trauma to onset was 4 weeks. Of these 12 patients, three had isolated bone (IB) disease; four had multifocal bone (MFB) disease, including the bone lesion at the trauma site; and five had multisystem disease, including four with lesions in neighboring tissue and one with polyuria (posterior pituitary lesion) more than 1 year before the trauma-triggered bone lesion. Treatment responses were good in all 12 patients and none died, but relapses were observed in two patients, one each with IB and MFB disease. CONCLUSIONS About 5% of pediatric patients with LCH developed new trauma-triggered bone lesions at a relatively old age. These lesions can manifest as IB, or, in patients with underlying LCH diseases, as MFB or multisystem. Good clinical outcomes were observed in these patients.
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Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Showa Innan General Hospital, Komagane, Japan.,Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | | | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinsaku Imashuku
- Department of Laboratory Medicine, Uji-Tokushukai Medical Center, Uji, Kyoto, Japan
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Tang X, Gao J, Ma ZG, Guo X, Li Q, Wan Z, Sun JJ. Clinical and prognostic characteristics of 95 cases of Langerhans cell histiocytosis in children: a single-institute experience from 2013 to 2020. Ann Med 2021; 53:1537-1546. [PMID: 34459688 PMCID: PMC8409935 DOI: 10.1080/07853890.2021.1966085] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This study aimed to understand the clinical characteristics and outcomes of children with Langerhans cell histiocytosis (LCH) in China. METHODS We conducted a retrospective study of 95 paediatric patients with LCH in West China Second University Hospital of Sichuan University between July 2013 and August 2020. RESULTS The onset age of multisystem LCH (MS-LCH) patients with risk organ (RO) involvement was younger than that of MS-LCH without RO involvement (p = .002) and single system LCH (p < .001) patients; bone was the most frequently involved organ, followed by the skin. Of all, the BRAF-V600E mutation was detected in 48 out of 84 patients who underwent gene analysis. Additionally, in our study, BRAF p.N486_T491 > K, BRAF p.L485_P490delinsF, BRAF p.R506_K507insLLR, ARAF p.Q349_F351delinsL and MAP2K1 p.Q58_E62del were known mutations in the mitogen-activated protein kinase (MAPK) pathway. The BRAF-V600E genotype in the tissue and plasma prior to therapy were detected in 16 patients, and the concordance was only 37.5% (6/16). According to the modified LCH-III-based-protocol, JLSG-02 protocol chemotherapy, and vemurafenib, the estimated five-year overall survival, event-free survival (EFS) and cumulative reactivation rates of 95 patients were 98.8%, 74.6% and 24.5%, respectively. The EFS rate in good responders was better than that in poor responders at 12-week (HR = 0.022, 95%CI 0.002-0.231, p = .002), and EFS was not affected by age, RO involvement or BRAF-V600E mutation. Regarding sequelae, nine patients had central diabetes insipidus and two had growth retardation. CONCLUSIONS In this study, LCH was a highly heterogeneous disease characterized molecularly by MAPK-pathway activating mutations. Vincristine, prednisone and cytarabine-based chemotherapy combined with vemurafenib improved the prognosis of childhood LCH. In future, prospective clinical trials and novel therapeutic strategies should be developed to improve outcomes in paediatric patients with LCH.KEY MESSAGEChildren with Langerhans cell histiocytosis in China present highly heterogeneous clinical characteristics, with up to 60% of cases harbouring mutations in MAPK pathway.Treatment response at 12-week is associated with EFS in our study.Vincristine, prednisone and cytarabine-based chemotherapy combined with vemurafenib improved the prognosis of Chinese childhood LCH, but the reactivation rate is still high.
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Affiliation(s)
- Xue Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Ju Gao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Zhi-Gui Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Xia Guo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Qiang Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Zhi Wan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Jing-Jing Sun
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Rodriguez‐Galindo C. Clinical features and treatment of Langerhans cell histiocytosis. Acta Paediatr 2021; 110:2892-2902. [PMID: 34192374 DOI: 10.1111/apa.16014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
Langerhans cell histiocytosis (LCH) is caused by the expansion of CD1a+/CD207+ cells and is characterised by a wide spectrum of organ involvement and dysfunction, affecting all ages. While almost all organs and systems can be affected, only the involvement and dysfunction of liver, spleen, and haematopoietic system influence survival. The LCH pathogenic cells are defined by universal activation of the mitogen-activated protein kinase (MAPK) signalling pathway. The most common alteration is a somatic BRAFV600E mutation, which is present in approximately two-thirds of the cases, followed by MAP2K1 mutations. Treatment of LCH is risk-adapted; patients with single lesions may respond well to local treatment, whereas patients with multi-system disease require systemic chemotherapy. While survival for patients without organ dysfunction is excellent, mortality rates for patients with organ dysfunction may reach 20%. Despite progress made in the treatment of LCH, disease reactivation rates remain above 30%, and standard second-line treatment has yet to be established. Long-term effects, including neuroendocrine dysfunction and neurodegeneration, represent a major challenge for survivors. Treatment with BRAF or MEK inhibitors results in immediate responses, but reactivations are very common after discontinuation. Their role as single agents and in combination with chemotherapy is being explored.
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Affiliation(s)
- Carlos Rodriguez‐Galindo
- Departments of Global Pediatric Medicine and Oncology St. Jude Children’s Research Hospital Memphis TN USA
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Irie M, Nakano T, Katayama S, Suzuki T, Moriya K, Watanabe Y, Suzuki N, Saitoh-Nanjyo Y, Onuma M, Rikiishi T, Niizuma H, Sasahara Y, Kure S. Clofarabine monotherapy in two patients with refractory Langerhans cell histiocytosis. Cancer Rep (Hoboken) 2021; 5:e1579. [PMID: 34725963 PMCID: PMC9351665 DOI: 10.1002/cnr2.1579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/10/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022] Open
Abstract
Background Better therapeutic options other than conventional chemotherapy for pediatric patients with refractory Langerhans cell histiocytosis (LCH) remain undetermined. Case We successfully treated two patients with refractory and risk organ negative LCH with clofarabine (CLO) monotherapy after recurrence. We administered total 23 courses of CLO monotherapy in patient 1 and 4 courses in patient 2. Both patients had distinct clinical manifestations but achieved a durable complete response with acceptable adverse effects of transient myelosuppression. CLO monotherapy was still effective when he had the second recurrent lesion after first completion of CLO in patient 1. We could discontinue prednisolone to control his refractory inflammation of LCH after completing CLO chemotherapy in patient 2. Conclusion Although large‐scale studies are warranted, CLO monotherapy could be a therapeutic option for high efficacy and feasibility besides other intensive combination chemotherapies or allogeneic hematopoietic stem cell transplantation for refractory LCH without risk organ involvement in children.
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Affiliation(s)
- Masahiro Irie
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiro Nakano
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Saori Katayama
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tasuku Suzuki
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kunihiko Moriya
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuko Watanabe
- Department of Pediatric Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Nobu Suzuki
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Yuka Saitoh-Nanjyo
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Masaei Onuma
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Takeshi Rikiishi
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Hidetaka Niizuma
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoji Sasahara
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
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McClain KL, Bigenwald C, Collin M, Haroche J, Marsh RA, Merad M, Picarsic J, Ribeiro KB, Allen CE. Histiocytic disorders. Nat Rev Dis Primers 2021; 7:73. [PMID: 34620874 PMCID: PMC10031765 DOI: 10.1038/s41572-021-00307-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
The historic term 'histiocytosis' meaning 'tissue cell' is used as a unifying concept for diseases characterized by pathogenic myeloid cells that share histological features with macrophages or dendritic cells. These cells may arise from the embryonic yolk sac, fetal liver or postnatal bone marrow. Prior classification schemes align disease designation with terminal phenotype: for example, Langerhans cell histiocytosis (LCH) shares CD207+ antigen with physiological epidermal Langerhans cells. LCH, Erdheim-Chester disease (ECD), juvenile xanthogranuloma (JXG) and Rosai-Dorfman disease (RDD) are all characterized by pathological ERK activation driven by activating somatic mutations in MAPK pathway genes. The title of this Primer (Histiocytic disorders) was chosen to differentiate the above diseases from Langerhans cell sarcoma and malignant histiocytosis, which are hyperproliferative lesions typical of cancer. By comparison LCH, ECD, RDD and JXG share some features of malignant cells including activating MAPK pathway mutations, but are not hyperproliferative. 'Inflammatory myeloproliferative neoplasm' may be a more precise nomenclature. By contrast, haemophagocytic lymphohistiocytosis is associated with macrophage activation and extreme inflammation, and represents a syndrome of immune dysregulation. These diseases affect children and adults in varying proportions depending on which of the entities is involved.
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Affiliation(s)
- Kenneth L McClain
- Texas Children's Cancer Center, Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Camille Bigenwald
- Department of Oncological Sciences and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew Collin
- Human Dendritic Cell Lab, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Julien Haroche
- Department of Internal Medicine, Institut E3M French Reference Centre for Histiocytosis, Pitié-Salpȇtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, and University of Cincinnati, Cincinnati, OH, USA
| | - Miriam Merad
- Department of Oncological Sciences and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jennifer Picarsic
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karina B Ribeiro
- Faculdade de Ciȇncias Médicas da Santa Casa de São Paulo, Department of Collective Health, São Paulo, Brazil
| | - Carl E Allen
- Texas Children's Cancer Center, Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA
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Kitticharoenjit P, Supakul N, Rujkijyanont P, Traivaree C, Photia A, Monsereenusorn C. Clinical characteristics and outcomes of Langerhans cell histiocytosis at a single institution in Thailand: a 20-year retrospective study. ASIAN BIOMED 2021; 15:171-181. [PMID: 37551332 PMCID: PMC10388756 DOI: 10.2478/abm-2021-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Langerhans cell histiocytosis (LCH) is a rare disease characterized by the various systems involved and clinical manifestations with a wide range of symptoms. Objectives To describe clinical characteristics, imaging, treatment, and outcomes of pediatric LCH at Phramongkutklao Hospital, Bangkok, Thailand. Methods We conducted a 20-year retrospective review of the medical records of patients diagnosed with LCH from birth to 21 years old from January 1, 1997, to December 31, 2016. Results In all, 14 patients with median age of 2.5 years were studied. Six (43%) patients had single-system (SS) LCH. Five patients (63%) with multisystem (MS) LCH (n = 8. 57%) had risk-organ involvement (RO+). All patients had plain X-ray imaging of their skull with 11 (79%) showing abnormal findings. Tc-99m bone imaging and fluorodeoxyglucose F18 (FDG) positron emission tomography (PET)-computed tomography (CT) demonstrated abnormal findings in 8 (89%) and 4 (29%) patients, respectively. The 5-year event-free survival (EFS) for patients with RO+ MS-LCH was less than that for those without risk-organ involvement (RO-) MS-LCH and SS-LCH (20% vs. 100%, P = 0.005). Hematological dysfunction, hypoalbuminemia, and conjugated hyperbilirubinemia may be worse prognostic factors for RO+ MS-LCH. Conclusion FDG-PET-CT might have a greater accuracy to detect LCH disease than conventional plain X-ray and Tc-99m bone imaging. RO+ MS-LCH has been encountered with relapse and poor outcomes. Hematopoietic involvement, hypoalbuminemia, and conjugated hyperbilirubinemia may be worse prognostic factors for RO+ MS-LCH.
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Affiliation(s)
| | - Nucharin Supakul
- Department of Radiology and Imaging Science, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN46202, United States of America
| | - Piya Rujkijyanont
- Division of Hematology–Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok10400, Thailand
| | - Chanchai Traivaree
- Division of Hematology–Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok10400, Thailand
| | - Apichat Photia
- Division of Hematology–Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok10400, Thailand
| | - Chalinee Monsereenusorn
- Division of Hematology–Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok10400, Thailand
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Feng C, Li Y, Ke H, Peng X, Guo H, Zhan L, Xiong X, Weng W, Li J, Fang J. Immune Microenvironment in Langerhans Cell Histiocytosis: Potential Prognostic Indicators. Front Oncol 2021; 11:631682. [PMID: 34026610 PMCID: PMC8138578 DOI: 10.3389/fonc.2021.631682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/13/2021] [Indexed: 01/18/2023] Open
Abstract
In this study, the immune microenvironment in Langerhans cell histiocytosis (LCH) was characterized to determine if immune indices are predictive of severity. Serum samples from 54 treatment-naïve patients were analyzed quantitatively for inflammatory cytokines and immunoglobulins before and after the induction of chemotherapy. The initial serum sIL-2R, TNF-α, and IL-10 of untreated LCH patients with risk organ involvement (RO+) were significantly higher than those with single-system (SS) involvement. LCH patients with hematologic involvement exhibited a significantly higher sIL-2R, TNF-α, IL-10, and IL-1β expression, as compared to the group without involvement. sIL-2R, TNF-α, and IL-10 were increased in patients with liver or spleen involvement. Th cells have decreased in the liver+ and spleen+ group, and Ts cells were significantly decreased in non-response group after induction chemotherapy. The serum level of immune indices represents, to some extent, the severity of the disease. Pertinent laboratory inspections can be used to improve risk stratification and guide immunotherapy.
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Affiliation(s)
- Chuchu Feng
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Li
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huang Ke
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaomin Peng
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haixia Guo
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liping Zhan
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xilin Xiong
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenjun Weng
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jiaqiang Li
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jianpei Fang
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Uehara Y, Wada YS, Iwasaki Y, Yoneda K, Ikuta Y, Amari S, Maruyama H, Tsukamoto K, Isayama T, Sakamoto K, Shioda Y, Miyazaki O, Irie R, Yoshioka T, Mochimaru N, Yoshida K, Ito Y. Neonatal systemic juvenile Xanthogranuloma with Hydrops diagnosed by Purpura skin biopsy: a case report and literature review. BMC Pediatr 2021; 21:161. [PMID: 33823829 PMCID: PMC8022363 DOI: 10.1186/s12887-021-02632-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic juvenile xanthogranuloma is a very rare disease typically presents as skin lesions with yellow papules or nodules and is sometimes fatal. We report a case of congenital neonatal systemic juvenile xanthogranuloma with atypical skin appearance that made the diagnosis difficult. CASE PRESENTATION A preterm Japanese female neonate with prenatally diagnosed fetal hydrops in-utero was born with purpuric lesions involving the trunk and face. Since birth, she had hypoxemic respiratory failure, splenomegaly, anemia, thrombocytopenia, coagulopathy, and was transfusion dependent for red blood cells, fresh frozen plasma, and platelets. Multiple cystic lesions in her liver, part of them with vascular, were detected by ultrasound. A liver biopsy was inconclusive. A skin lesion on her face similar to purpura gradually changed to a firm and solid enlarged non-yellow nodule. Technically, the typical finding on skin biopsy would have been histiocytic infiltration (without Touton Giant cells) and immunohistochemistry results which then would be consistent with a diagnosis of systemic juvenile xanthogranuloma, and chemotherapy improved her general condition. CONCLUSIONS This case report shows that skin biopsies are necessary to detect neonatal systemic juvenile xanthogranuloma when there are organ symptoms and skin eruption, even if the skin lesion does not have a typical appearance of yellow papules or nodules.
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Affiliation(s)
- Yohji Uehara
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yuka Sano Wada
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Yuka Iwasaki
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kota Yoneda
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yasuhisa Ikuta
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Shoichiro Amari
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Hidehiko Maruyama
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Keiko Tsukamoto
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Tetsuya Isayama
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenichi Sakamoto
- Chilldren's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yoko Shioda
- Chilldren's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Rie Irie
- Department of Clinical Pathology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.,Department of Pathology, Nippon Koukan Hospital, 1-2-1 Koukandouri, Kawasaki-ku, Kawasaki City, Kanagawa, 210-0852, Japan
| | - Takako Yoshioka
- Department of Clinical Pathology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Naoko Mochimaru
- Department of Dermatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kazue Yoshida
- Department of Dermatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yushi Ito
- Department of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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Zhang J, Wang C, Lin C, Bai B, Ye M, Xiang D, Li Z. Spontaneous Thyroid Hemorrhage Caused by Langerhans Cell Histiocytosis: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2021; 12:610573. [PMID: 34093427 PMCID: PMC8170468 DOI: 10.3389/fendo.2021.610573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 04/30/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Langerhans cell histiocytosis (LCH) is a rare clonal disorder of Langerhans antigen-presenting cells. However, thyroid LCH involvement is relatively rare. We present the first case of spontaneous thyroid hemorrhage due to LCH progression and discuss the clinical features, diagnosis, and treatments of thyroid LCH in a literature review. METHODS Clinical data were collected. Previously published articles on thyroid LCH involvement were reviewed to assess the clinical features, diagnosis, and treatments for thyroid LCH. RESULTS A 54-year-old female presented with a multi-system LCH, affecting the uterus, liver, pituitary gland, and thyroid gland. Clinical stability was achieved after systemic chemotherapy. After 7 years of regular follow up, the patient complained of a sudden painful neck swelling and progressive dyspnea. Computed Tomography revealed bilateral goiter with hematoma, and the patient was diagnosed with spontaneous thyroid bleeding based on her clinical symptoms and radiological findings. The patient was incubated to relieve airway compromise and partial thyroidectomy was performed for definitive treatment. Pathological evaluation further confirmed the diagnosis of thyroid LCH. The patient recovered well after surgery. CONCLUSION Spontaneous thyroid bleeding due to thyroid LCH progression is extremely rare. Treatments for LCH vary depending on the severity of the disease. We suggest that, for patients with multi-system LCH with thyroid lesion, long-term active surveillance of thyroid hormone concentrations, and thyroid gland volume is required. Physicians should be alert of the potentially life-threatening spontaneous thyroid hemorrhage when aggravated diffuse goiter and hypothyroidism appear. Further investigation is required to establish the guidelines for thyroid LCH treatment.
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Affiliation(s)
- Jingying Zhang
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Chengchen Wang
- Department of General Surgery, Hangzhou Mingzhou Hospital, Hangzhou, China
| | - Chuanshuai Lin
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Binglong Bai
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Mao Ye
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Dapeng Xiang
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Zhiyu Li
- Department of Thyroid Surgery, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
- *Correspondence: Zhiyu Li,
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Sakamoto K, Morimoto A, Shioda Y, Imamura T, Imashuku S. Long-term complications in uniformly treated paediatric Langerhans histiocytosis patients disclosed by 12 years of follow-up of the JLSG-96/02 studies. Br J Haematol 2020; 192:615-620. [PMID: 33236384 DOI: 10.1111/bjh.17243] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/24/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022]
Abstract
Langerhans cell histiocytosis (LCH) is a rare inflammatory myeloid neoplasia derived from immature myeloid dendritic cells with the mitogen-activated protein kinase (MAPK) pathway gene mutation. LCH is rarely fatal, but patients develop various permanent consequences (PCs). We report the frequencies of LCH-related PCs in paediatric patients (n = 317) treated by the JLSG-96/02 AraC-containing regimens. One-third of LCH patients had at least one PC at a median follow-up of 12 years. Central nervous system (CNS)-related PCs (neurological and endocrinological) accounted for 21·5%, non-CNS-related 16·7%. We require novel therapeutic measures to further reduce the frequency of LCH-related PCs.
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Affiliation(s)
- Kenichi Sakamoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinsaku Imashuku
- Division of Laboratory Medicine, Uji-Tokushukai Medical Center, Uji, Japan
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Abstract
Langerhans cell histiocytosis (LCH) is caused by clonal expansion of myeloid precursors that differentiate into CD1a+/CD207+ cells in lesions that leads to a spectrum of organ involvement and dysfunction. The pathogenic cells are defined by constitutive activation of the MAPK signaling pathway. Treatment of LCH is risk-adapted: patients with single lesions may respond well to local treatment, whereas patients with multisystem disease require systemic therapy. Although survival rates for patients without organ dysfunction is excellent, mortality rates for patients with organ dysfunction may reach 20%. Despite progress made in the treatment of LCH, disease reactivation rates remain above 30%, and standard second-line treatment is yet to be established. Treatment failure is associated with increased risks for death and long-term morbidity, including LCH-associated neurodegeneration. Early case series report promising clinical responses in patients with relapsed and refractory LCH treated with BRAF or MEK inhibitors, although potential for this strategy to achieve cure remains uncertain.
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Wang DS, Lu MY, Yang YL, Lin DT, Lin KH, Chang HH, Jou ST. Clinical outcomes of childhood Langerhans cell histiocytosis in Taiwan: A single-center, 20-year experience. J Formos Med Assoc 2020; 120:594-601. [PMID: 32741735 DOI: 10.1016/j.jfma.2019.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/08/2019] [Accepted: 12/10/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/PURPOSE The Taiwan Pediatric Oncology Group (TPOG) initiated two consecutive protocols for treating pediatric patients with Langerhans cell histiocytosis (LCH) since 1994. However, the results have not been analyzed and reported. This study aimed to investigate the survival outcomes of childhood LCH at the National Taiwan University Hospital over the past 20 years. METHODS Treatment of pediatric patients with LCH according to TPOG protocols at the National Taiwan University Hospital began in 1994. During 1994-2003, patients were treated using the TPOG LCH-94 protocol. After 2003, patients were treated using the TPOG LCH-2003 protocol. Clinical data of these patients were obtained retrospectively by reviewing electronic medical records. Patients were followed up until July 31, 2018. RESULTS Fifty-three newly diagnosed pediatric patients with LCH were treated at National Taiwan University Hospital during 1994-2015. Twenty-nine (54.7%) were treated with the TPOG LCH-94 protocol, and 24 (45.3%) were treated with the TPOG LCH-2003 protocol. The 5-year event-free survival and overall survival rates were 96.2 ± 2.6% standard error (SE) and 98.1 ± 1.9% (SE), respectively. Overall survival and 5-year event-free survival between patients treated with the TPOG LCH-94 and TPOG LCH-2003 protocols showed no significant difference. Multisystem, liver, or spleen diseases were associated with significantly bad survival outcomes. Among at-risk-organ involvement in LCH, liver involvement was an independent factor for poor prognosis. CONCLUSION Clinical outcomes of children with LCH in Taiwan was good. The results of this study may help in the better classification of risk grouping for protocol designs in the future.
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Affiliation(s)
- Der-Shiun Wang
- Department of Pediatrics, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Hayase T, Saito S, Shioda Y, Imamura T, Watanabe K, Ohki K, Yoshioka T, Oh Y, Kawahara Y, Niijima H, Imashuku S, Morimoto A. Analysis of the BRAF and MAP2K1 mutations in patients with Langerhans cell histiocytosis in Japan. Int J Hematol 2020; 112:560-567. [PMID: 32654047 DOI: 10.1007/s12185-020-02940-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/11/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022]
Abstract
In Langerhans cell histiocytosis (LCH), somatic gene mutations in the mitogen-activated protein kinase pathway have been identified in more than 80% of cases in Western countries, in which mutually exclusive BRAF and MAP2K1 mutations are involved. Among them, BRAF V600E mutation is the major contributor (50-60%). In 59 patients (50 children and nine adults) with LCH (not including pulmonary LCH) in Japan, we first screened for BRAF V600E in all patients followed by target sequencing for other gene mutations in 17 of BRAF V600E-negative patients. As a result, BRAF V600E mutation was detected in 27/59 (46%) patients. We also identified BRAF mutations other than V600E in five and MAP2K1 mutations in nine patients. Thus, gene mutations in BRAF or MAP2K1 were identified in 41/44 (93%) of the fully tested patients. Regarding the correlation of clinical features and genotype in pediatric patients, we found that BRAF V600E mutation status was not correlated with sex, age at diagnosis, disease extent, response to first-line therapy, relapse, or CNS-related sequelae. Interestingly, MAP2K1 exon 2 in-frame deletion was related to the risk organ involvement; however, further studies are required to clarify the impact of these gene mutations on the clinical features of patients with LCH.
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Affiliation(s)
- Tomomi Hayase
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shiori Saito
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yoko Shioda
- Department of Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kentaro Ohki
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Yukiko Oh
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yuta Kawahara
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hitomi Niijima
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shinsaku Imashuku
- Division of Laboratory Medicine, Uji Tokushukai Medical Center, Uji, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Maeda M, Morimoto A, Shioda Y, Asano T, Koga Y, Nakazawa Y, Kanegane H, Kudo K, Ohga S, Ishii E. Long-term outcomes of children with extracutaneous juvenile xanthogranulomas in Japan. Pediatr Blood Cancer 2020; 67:e28381. [PMID: 32383820 DOI: 10.1002/pbc.28381] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/27/2020] [Accepted: 04/16/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Juvenile xanthogranuloma (JXG) is the most common non-Langerhans cell histiocytosis in children. The mortality and morbidity of JXG with extracutaneous lesions remain unclear. METHODS Data of patients aged < 18 years who were diagnosed with JXG between 2001 and 2010 were retrospectively collected through a nationwide survey. RESULTS Twenty patients (11 male and nine female) had extracutaneous lesions. The median observation time was 10 years (range, 0-17). Six patients presented with symptoms at birth. The median age at diagnosis was 8.5 months (range, 0 month-13 years). Fifteen patients underwent treatment for JXG, including chemotherapy (n = 11), and five did not receive treatment. All patients except one survived; 17 were disease-free and two survived with disease. One newborn-onset patient with liver, spleen, and bone marrow involvement died of the disease. Permanent sequelae included central diabetes insipidus, growth hormone deficiency, and panhypopituitarism detected at diagnosis in three, one, and two patients, respectively. Four patients had visual impairment (optic nerve compression and intraocular invasion in two each), three had epilepsy, one had mental retardation, and one had a skin scar. Eight patients who had intracranial lesions were older at diagnosis, and had a higher frequency of disease-related comorbidities and permanent sequelae than those without intracranial involvement. CONCLUSIONS Patients with extracutaneous JXG had good outcomes, although those with intracranial lesions had serious permanent sequelae. Effective and safe treatment regimens for patients with intracranial JXG need to be developed.
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Affiliation(s)
- Miho Maeda
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takeshi Asano
- Department of Pediatrics, Nippon Medical School Chiba Hokuso Hospital, Chiba, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University, Matsumoto, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Japan
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Morimoto A, Kudo K. Hematopoietic stem cell transplantation for Langerhans cell histiocytosis: clinical findings and long-term outcomes. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1778462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
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The combination of methotrexate and cytosine arabinoside in newly diagnosed adult Langerhans cell histiocytosis: a prospective phase II interventional clinical trial. BMC Cancer 2020; 20:433. [PMID: 32423455 PMCID: PMC7236107 DOI: 10.1186/s12885-020-06872-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 04/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Langerhans Cell Histiocytosis (LCH) is a rare disease puzzling both children and adults, however outcome of adult patients is unfavorable. This prospective interventional trial aims to test the efficacy and safety of the combination of methotrexate and cytosine arabinoside in adult LCH patients. METHOD A total of 36 patients enrolled diagnosed with LCH and treated in our center from 1st Jan, 2014 to 30th Jun, 2016. RESULT Nineteen patients underwent the detection of BRAF mutation, with a positive rate of 21.1%. The overall response rate was 100%, only 16.7% achieved complete response. The overall regression rate of osseous lesions was 100%. Regression of central nervous system involvement was also favorable. After a median follow-up of 44 months, the estimated event-free survival was 48.9 months, the overall survival rate was 97.2%. The risk organ involvement showed strong prognostic value, EFS was 34.1 or 54.6 months (p = 0.001) in groups with/without risk organ involvement respectively. Neutropenia and thrombocytopenia were the most common adverse effects. CONCLUSION The regimen of methotrexate and cytosine arabinoside (MA) is effective and safe in treating adult LCH patients, and timely preventions may be considered for the high incidence of hematological adverse effects. TRIAL REGISTRATION Trial No. NCT02389400 on Clinicaltrials.gov, registered on 10th Mar. 2015.
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Nationwide retrospective review of hematopoietic stem cell transplantation in children with refractory Langerhans cell histiocytosis. Int J Hematol 2019; 111:137-148. [DOI: 10.1007/s12185-019-02760-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 12/30/2022]
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Ito J, Shima H, Inoue K, Yamazaki F, Shimada H. Haploidentical stem cell transplantation with posttransplant cyclophosphamide for refractory systemic juvenile xanthogranuloma. Pediatr Blood Cancer 2019; 66:e27926. [PMID: 31309704 DOI: 10.1002/pbc.27926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/11/2019] [Accepted: 06/28/2019] [Indexed: 11/10/2022]
Abstract
Juvenile xanthogranuloma (JXG) is a generally benign, self-limited histiocytic disorder, which belongs to non-Langerhans cell histiocytoses (non-LCH). However, systemic JXG can be fatal in rare cases. We present the case of an 11-year-old female with systemic JXG, who experienced repeated vertebral compression fractures and did not fully respond to systemic chemotherapy. Based on its reported efficacy in LCH, the patient underwent human leukocyte antigen-haploidentical hematopoietic stem cell transplantation (HSCT) with posttransplant cyclophosphamide. The patient did not suffer major complications and has not experienced relapse for 13 months since HSCT. HSCT may be a potential treatment option for patients with refractory non-LCH.
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Affiliation(s)
- Jumpei Ito
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Haruko Shima
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kyohei Inoue
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Fumito Yamazaki
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Shimada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Successful treatment with 2-chlorodeoxyadenosine of refractory pediatric Langerhans cell histiocytosis with initial involvement of the gastrointestinal tract. Int J Hematol 2019; 110:756-762. [PMID: 31350665 DOI: 10.1007/s12185-019-02711-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
Gastrointestinal (GI) tract involvement in Langerhans cell histiocytosis (LCH) is extremely rare. Langerhans cell histiocytosis with GI tract involvement (GI-LCH) is frequently associated with multi-system disease, and usually presents with severe systemic symptoms, such as protein-losing enteropathy (PLE). Although the GI tract is not included among the organs at risk, the prognosis of GI-LCH is poor, and no effective chemotherapeutic regimen has been identified. Here, we report an infant case of primary refractory GI-LCH with PLE that showed marked improvement in response to 2-chlorodeoxyadenosine (2-CdA) therapy with no severe adverse events, even under conditions of deteriorating general health. The present findings indicate that 2-CdA may be effective for refractory GI-LCH with PLE. Further studies are warranted to determine the optimal therapeutic strategies for GI-LCH with PLE.
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Routray S, Adhya AK, John J, Dikhit P. Revealing a rare inflammatory oral manifestation in a 6-year-old child. BMJ Case Rep 2019; 12:12/7/e229483. [PMID: 31340944 DOI: 10.1136/bcr-2019-229483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 6-year-old child with an episodic history of ulcerations over buccal mucosa was found to have severe inflammation on the palatal aspect of permanent first molars with grade 2 mobility bilaterally. Radiographical features were suggestive of bone loss around permanent molars extending to the distal aspect of the deciduous first molars. The clinical and radiographical findings were indicative of periodontal degeneration without any apparent cause visible intraorally. Further biopsy was done from the rashes present on the malar prominences, which showed nodular aggregates of atypical cells in superficial dermis. These large histiocytic cells with vesicular nuclei and nuclear grooves were immunopositive for CD1a and S100, concluding the diagnosis of Langerhans cell histiocytosis. For treatment, patient was referred to Department of Haemato-oncology and chemotherapy was suggested as per protocol.
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Affiliation(s)
- Samapika Routray
- Department of Dentistry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Amit Kumar Adhya
- Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Joseph John
- Department of Paediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Punit Dikhit
- Department of Dentistry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Pulmonary Langerhans cell histiocytosis with thyroid involvement manifesting as recurrent bilateral pneumothorax and tension bullae in a 3-year-old child. Int J Surg Case Rep 2019; 60:239-243. [PMID: 31254905 PMCID: PMC6600041 DOI: 10.1016/j.ijscr.2019.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/30/2019] [Accepted: 06/13/2019] [Indexed: 12/03/2022] Open
Abstract
The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management. Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis. Positive-pressure ventilation should be performed with extreme caution in suspected PLCH.
Introduction Pulmonary Langerhans cell histiocytosis (PLCH) is a well known entity in adults but is exceedingly rare in children. The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management. Case presentation A 3-year-old child was diagnosed with PLCH with thyroid involvement. Chemotherapy was immediately initiated and continued with chest tube drainage for repeated bilateral PTX. Tension bullae developed in the right lung 1 month after initiating treatment. Emergency resection of the bullae and ligation of pulmonary cysts were performed. On the tenth postoperative day, she developed a tension bulla in the left lung. Emergency thoracotomy was performed. On the tenth postoperative day, chest X-ray and CT suggested return of the right bulla and mediastinal shift, and reoperation was performed. Repeated lung biopsy showed no sign of active LCH. Although her condition improved after the operation, subsequent repeated PTXs occurred and were difficult to treat. She was discharged home after four months. Currently, she is receiving maintenance therapy as an outpatient. During the 12-month follow-up, the pulmonary lesions also showed a tendency for improvement. Discussion Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis. Conclusion Treatment of PLCH accompanied by recurrent PTX and tension bullae is challenging. The condition can be resolved by treating the primary disease in parallel with combined modality treatment, including surgical operation for complications.
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Papo M, Cohen-Aubart F, Trefond L, Bauvois A, Amoura Z, Emile JF, Haroche J. Systemic Histiocytosis (Langerhans Cell Histiocytosis, Erdheim-Chester Disease, Destombes-Rosai-Dorfman Disease): from Oncogenic Mutations to Inflammatory Disorders. Curr Oncol Rep 2019; 21:62. [PMID: 31115724 DOI: 10.1007/s11912-019-0810-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Provide an overview of recent progress in decoding the pathogenesis and treatment of systemic histiocytoses. RECENT FINDINGS Advances in molecular techniques over the last few years, enabling the identification of several MAPK mutations in lesion histiocytes, have revolutionized our understanding of histiocytosis that led to a revised classification and new treatments. Since the 2010 discovery of the BRAFV600E mutation in 57% of Langerhans cell histiocytosis (LCH) lesions, several other kinase mutations have been found, mostly in the MAPK pathway, and also in other key signaling pathways, in LCH, Erdheim-Chester Disease (ECD) and, less frequently, Destombes-Rosai-Dorfman disease (RDD). Those revolutionary breakthroughs enhanced our understanding of the pathogenesis of histiocytosis and led to trials with targeted therapies that demonstrated notable efficacy.
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Affiliation(s)
- Matthias Papo
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Fleur Cohen-Aubart
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Ludovic Trefond
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Adeline Bauvois
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Zahir Amoura
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Jean-François Emile
- EA4340-BECCOH, Versailles University, & Département de Pathologie, Hôpital Ambroise Paré, AP-HP, 9 Avenue Charles de Gaulle, 92100, Boulogne, France
| | - Julien Haroche
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne 2, Centre National de Références des Histiocytoses, Hôpital Pitié-Salpêtrière, Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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Oh Y, Hayase T, Ito T, Kawahara Y, Morimoto A. Cladribine-related myelodysplastic syndrome in Langerhans cell histiocytosis. Pediatr Int 2019; 61:419-421. [PMID: 30993805 DOI: 10.1111/ped.13792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/07/2018] [Accepted: 01/31/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Yukiko Oh
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Tomomi Hayase
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Takane Ito
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Yuta Kawahara
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
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Sakamoto K, Morimoto A, Shioda Y, Imamura T, Imashuku S. Central diabetes insipidus in pediatric patients with Langerhans cell histiocytosis: Results from the JLSG-96/02 studies. Pediatr Blood Cancer 2019; 66:e27454. [PMID: 30207064 DOI: 10.1002/pbc.27454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/09/2022]
Abstract
PURPOSE We analyzed central diabetes insipidus (CDI) development in pediatric patients with Langerhans cell histiocytosis (LCH) treated according to the Japan LCH Study Group (JLSG) regimen, which is the combination chemotherapy including cytarabine (Ara-C). METHODS Retrospective data from 317 patients (multisystem disease (MS), n = 206; multiple focal bone (MFB), n = 111) treated according to the JLSG-96/02 regimens were analyzed. RESULTS The median follow-up duration was 10.6 years (range, 0.1-21.1). A total of 50/317 (15.8%) patients developed CDI (MFB, n = 4; MS, n = 46). Of the 50 cases, CDI was already present at the time of LCH diagnosis (pre-CDI) in 25, and it newly developed after the diagnosis and initiation of treatment (post-CDI) in the other 25 cases. The cumulative incidence of post-CDI at 10-year calculated by Kaplan-Meier analysis was 9.0% for total and 12.0% for MS patients. A positive correlation with LCH lesions at the CNS risk sites at diagnosis was found in pre-CDI cases (17/164 vs 8/171; P = 0.0359), but not in post-CDI cases (14/129 vs 11/163; P = 0.254). Multivariate analysis showed that relapse at the CNS risk sites was significantly associated with post-CDI development (hazard ratio: 4.70; 95% CI, 1.29-17.1, P < 0.05). CONCLUSIONS In the JLSG-96/02 studies, CDI developed in 15.8% of the cohort in which half as pre- and the other half as post-CDI. Relapse, particularly at the CNS risk sites, was linked with the development of post-CDI.
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Affiliation(s)
- Kenichi Sakamoto
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinsaku Imashuku
- Division of Laboratory Medicine, Uji-Tokushukai Medical Center, Uji, Japan
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- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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