Langerhans Cell Histiocytosis of the Skull in a Burr Hole Site Covered with Hydroxyapatite Material

Calvarial Langerhans cell histiocytosis in an adult presenting rapid growth

Background

Langerhans cell histiocytosis (LCH) arising in the skull is rare in adulthood.

Case Description

A 58-year-old woman experienced a durable headache. Cerebral magnetic resonance imaging (MRI) at presentation showed no abnormalities; however, MRI and computed tomography (CT) performed 6 weeks later revealed the emergence of a well-demarcated, heterogeneously enhancing calvarial tumor accompanied by irregular-shaped bone erosion. On MRI, the temporalis muscle and subcutaneous tissue adjacent to the tumor were extensively swollen and enhanced. The patient underwent en bloc resection. The microscopic appearance of the tumor was consistent with that of LCH. Postoperative systemic 18F-fluorodeoxyglucose positron emission tomography/CT did not detect any abnormal accumulation.

Conclusion

LCH may develop within a short period. It should be considered as a differential diagnosis when a rapidly growing calvarial tumor is encountered, even when the patient is an adult. Prompt histological verification is recommended in such cases.

A rare case of calvarial tuberculosis from the Avar Age (8th century CE) cemetery of Kaba-Bitózug (Hajdú-Bihar county, Hungary) - Pathogenesis and differential diagnostic aspects

The aim of our paper is to present and discuss in detail the bony changes indicative of tuberculosis (TB) that were identified in a skeleton (KB67), unearthed from grave 67 of the 8th-century-CE cemetery of Kaba-Bitózug (Hungary). Furthermore, to provide the differential diagnoses of the observed alterations, with special attention to the cranial osteolytic lesions. During the macro- and micromorphological examinations of KB67, the skull revealed three small, well-circumscribed, punched-out osteolytic lesions accompanied by endocranial granular impressions, abnormal blood vessel impressions, periosteal appositions, and cortical erosion. The postcranial skeleton exhibited osteolytic lesions, cortical remodelling and erosion, and signs of hypervascularisation in the spine. Based on the differential diagnosis of the cranial osteolytic lesions and their co-occurrence with endocranial and vertebral bony changes indicative of TB, they most likely resulted from tuberculous involvement of the frontal and left parietal bones. The morphologically established diagnosis was confirmed by a PCR analysis that provided evidence for the presence of Mycobacterium tuberculosis DNA in KB67. KB67, the first reported archaeological case with calvarial TB from the present-day territory of Hungary, gives us a unique insight into the occurrence of a rare manifestation of TB in the Avar Age of the Great Plain.

Short-Term Resorption of Grafted Bone After Split Calvarial Bone Grafting for an Occipital Skull Defect in a Patient With Multisystem Langerhans Cell Histiocytosis

ABSTRACT

Langerhans cell histiocytosis (LCH) is a rare disease in which LCH cells derived from myeloid dendritic cells proliferate and invade single or multiple systems. We have encountered a case of short-term resorption of the grafted bone after split calvarial bone grafting for an occipital skull defect in a 6-year-old girl with multisystem LCH in remission who was referred to our department for reconstructive surgery. We performed cranioplasty using a split calvarial bone graft. Two months after surgery, computed tomography scans revealed that most of the grafted bone had been resorbed. To our knowledge, there have been no such reports previously. There are 2 possible explanations for the resorption of an autologous bone graft in this patient. The first possibility is that the recipient site contained an active lesion and the second is that the bone resorption occurred because the bone graft was placed on the periosteum.

Adult Langerhans Cell Histiocytosis Diagnosed by Biopsy of the Skull Tumor Generated after Craniotomy

Langerhans cell histiocytosis (LCH) is a disease characterized by the proliferation of Langerhans cells. Most cases of LCH occur in children, although it can be seen in adults as well. We encountered an adult case of LCH. A 44-year-old woman who was diagnosed as diabetes insipidus underwent a magnetic resonance imaging (MRI) of the head which revealed sellar and suprasellar gadolinium-enhanced mass. Prolactin level was high and cabergoline was prescribed. The size of this mass had reduced, so we supposed the tumor was prolactinoma. However, after 4 years of observation, it had increased once again. The biopsy of pituitary stalk lesion was performed via transcranial approach. The histological diagnosis was initially gangliocytoma. The patient complained of back pain after surgery. Three months after the biopsy, a computed tomography (CT) scan revealed multiple osteolytic lesions throughout the entire body. One of the osteolytic lesions of the skull was removed to determine the diagnosis. The pathological examination of the skull led to a diagnosis of LCH. We concluded retrospectively that the lesion of the pituitary stalk was LCH mimicking gangliocytoma though classical pathological findings were not obtained. In conclusion, LCH should be considered as a differential diagnosis in adult cases of diabetes insipidus with hypothalamic-pituitary lesion.

Giant skull vault defect in a child caused by Langerhans cell histiocytosis: the "calvaria-eating disease"

Langerhans cell histiocytosis (LCH) is a rare disease of young children that can be difficult to diagnose and treat. Clinical manifestations can sometimes be quite unusual, and bony lesions can reach a large size before treatment is sought. We present a unique case of a 3-year-old male child with a painless giant calvarial defect and cystic swelling. Complete removal of the cyst with curettage of the involved bone margins and cranioplasty was done using bone cement (polymethyl methacrylate, PMMA). However, there was a flare up of the disease due to abnormal inflammatory reaction to PMMA, and cranioplasty bone flap had to be removed. The child did well after PMMA bone flap removal.LCH should be suspected in a male child presenting with a large calvarial defect and no history of trauma. The use of materials, viz., hydroxyapatite, poly-DL-lactide (PDLLA), and PMMA for cranioplasty in LCH, may cause reactivation of the disease process and therefore must be used cautiously in these patients.

Recurrent Langerhans cell histiocytosis at the site of prior craniotomy: case report

Tumors of the CNS represent the largest group of solid tumors found in the pediatric patient population. Langerhans cell histiocytosis (LCH) is an inflammatory lesion that may present in bone and/or soft tissue, including the CNS. Management depends on the extent of multisystem involvement, which determines resection with or without systemic chemotherapy. The authors report on the case of a child who underwent an open craniotomy for biopsy of a pituitary stalk lesion followed by neuropathological assessment, procedures used to diagnose LCH. The patient then underwent 12 months of systemic chemotherapy with subsequent resolution of the pituitary stalk lesion. Two years following pathological diagnosis, the patient presented with frontal orbital pain at the site of the prior craniotomy. Advanced imaging revealed MRI enhancement and radiotracer uptake of a soft-tissue growth at the frontal burr-hole site and MRI enhancement at a posterior burr-hole site without soft-tissue growth. The patient then underwent open biopsy and curettage that revealed LCH recurrence at the site of prior craniotomy. This case demonstrates that LCH may represent an abnormal reactive clonal proliferation of dendritic cells, rather than a de novo malignant neoplasm that can occur at sites of prior craniotomy despite systemic chemotherapy. The authors advocate close follow-up with contrast-enhanced imaging. Special attention should be given to sites of prior surgical manipulation to avoid missing distant sites of recurrence.

A Self-Made, Reusable, and Adjustable Device for Making Burr Hole Bone Plugs: Doing More with Less

BACKGROUND

Burr hole craniotomy is a daily procedure in neurosurgery. Defects after burr hole craniotomies will not spontaneously heal and can result in skin dents and cosmetic dissatisfaction. We have introduced a self-made, reusable, and adjustable bone plug packer to use in the repair of burr holes via packing of autologous bone dust. Our bone plug packer is free of charge and can be readily available in neurosurgical operating rooms.

METHODS

We have produced a stainless steel bone packer device that can be assembled without the use of a special wrench. The instrument consists of a container plate and a main cylinder for packing, in which an adjustable airtight piston is placed to compress the bone dust and create a bone plug of the desired dimensions.

RESULTS

Some recent studies have shown that burr holes filled by autologous bone dust will result in good cosmetic and osteogenic outcomes. Although we did not perform a long-term follow-up assessment of the burr holes filled with bone plugs, in the short term, we have not seen any local reactions or infections in our patients. The autologous bone plug is a more affordable and available option with no technical or clinical complications in the short term.

CONCLUSION

We have introduced a practical, convenient, and cost-effective bone packer device. Bone plugs formed using our device can be a potential substitute for expensive covering materials in countries with limited access to other repair options. Providing proper evidence will require the performance of large studies to assess our suggested method in the long term and, possibly, compare it with the usual options in controlled studies.