Paediatric manifestations of Langerhans cell histiocytosis: a review of the clinical and radiological findings

Hepatobiliary involvement in Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a rare, proliferative disorder that occurs primarily in children. Periportal lesions were detected on ultrasound at different stages of evolution. In this article, we aim to discuss the sonographic findings in liver involvement of LCH.

Nonsyndromic Craniofacial Disorders

We describe the investigation and management of select pediatric craniofacial disorders their recent advances. Positional plagiocephaly: The incidence of positional plagiocephaly has increased since the institution of the "safe to sleep" campaign to reduce sudden infant death syndrome. Positional plagiocephaly may be associated with underlying developmental delay. Nonsyndromic craniosynostosis: Treatment of nonsyndromic craniosynostosis depends on the age of the patient and the suture involved. Pediatric skull lesions: Management of skull lesions depends on histologic diagnosis. Some benign skull lesions are managed conservatively, whereas erosive and malignant lesions may require surgical excision, radiotherapy, chemotherapy, or multimodality treatment.

Langerhans cell histiocytosis in the glenoid neck with rare mutation: A case report

Langerhans cell histiocytosis (LCH) is a rare disease that occurs mainly in children. It has several forms of clinical presentation. Early diagnosis is important for better results. A 17-year-old male patient presented with right sharp shoulder pain for 2 months. Magnetic resonance image (MRI) of the shoulder showed an expansile osseous lesion in the anterosuperior spine of the right scapula with significant edema that causes compression of the subscapular neurovascular bundle. A CT scan and X-rays were also performed. Overall, all the images suggested a lesion compatible with chondroblastoma; however, the pathology images documented a Langerhans cell histiocytosis with a mutation in the V600E/E2/D in the 15 exon of the BRAF gene. LCH is a difficult diagnosis, especially in cases where clinical presentation is not the most common. This case is unique as the lesion developed not only in the scapula which has a 3% prevalence in LCH, but also had radiographic and MRI characteristics of a chondroblastoma more than the typical LCH lesion. Additionally, it was accompanied by a BRAF V600E mutation which is uncommon in LCHs bone cases.

Imaging Findings of Pediatric Orbital Masses and Tumor Mimics

Pediatric orbital masses are not common but encompass a wide spectrum of benign and malignant entities that range from developmental anomalies to primary and secondary orbital malignancies and metastatic disease. Certain orbital tumors are unique to pediatric patients, such as retinoblastoma and neuroblastoma. Clinical symptoms and signs are often insufficient to differentiate between orbital lesions, and imaging is essential for narrowing the diagnostic considerations and determining the most appropriate management strategy. MRI is the primary imaging modality for evaluating orbital masses in children, with US and CT playing complementary roles. The authors review a spectrum of masses and tumor mimics that affect the pediatric globe and orbit. The shared and differentiating characteristics of pediatric orbital lesions are reviewed. Emphasis is placed on utilizing an orbital compartment-based approach to narrow the differential diagnosis. By using this organizational scheme, the authors describe intraocular processes (retinoblastoma, persistent fetal vasculature, and Coats disease), intraconal lesions (lymphatic malformation, schwannoma, optic nerve sheath meningioma, and optic pathway glioma), extraconal lesions (infantile hemangioma, rhabdomyosarcoma, idiopathic orbital inflammation, lymphoma, venous varix, plexiform neurofibroma, and pleomorphic adenoma of the lacrimal gland), and lesions involving the bony orbit (dermoid cyst, metastatic neuroblastoma, and Langerhans cell histiocytosis). The authors describe the basic management of each entity. Orbital infections and traumatic lesions are beyond the scope of this article. ^©RSNA, 2022.

Hepatobiliary and Gastrointestinal Involvement in Langerhans Cell Histiocytosis-Spectrum of Three Cases

Langerhans cell histiocytosis (LCH) is a rare group of disorder, due to clonal neoplastic proliferation of dendritic cells in the bone marrow expressing a Langerhans cell phenotype. 1 This disease particularly affects the pediatric age group and young adults and often presents with skin rashes, lung infiltrates, and bone lesions. It can also manifest with endocrine dysfunction and hematopoietic disorders. Involvement of gastrointestinal tract is very rare. Herein, we present a spectrum of three cases with gastrointestinal involvement.

Findings encountered in percutaneous cholangiography in a case of post-transplant recurrence of hepatic Langerhans cell histiocytosis with biliary involvement

This case report describes a four-year-old boy who presented with the diagnosis of LCH with liver involvement. This required a living-related liver transplant one year later. The primary disease recurred in the transplanted liver 6 months post-transplant and led to progressive biliary dilatation. A percutaneous trans-hepatic cholangiogram was performed five years after transplant, showing a pattern of multifocal biliary duct strictures mimicking the pattern of primary sclerosing cholangitis and a stenosis of the biliary-enteric anastomosis. Despite management with an internal-external biliary drain, the stenosis of the biliary-enteric anastomosis evolved to an occlusion one year after drain removal. This was associated with progression of the changes in the biliary tree, this time associated with significant saccular dilatations secondary to the multiple areas of stenosis. Due to these findings and progressive deterioration of the function of the graft, the patient required re-transplantation. This report illustrates the findings in imaging of the biliary tree secondary to the recurrence of LCH after liver transplantation, which may help to recognize this complication to physicians facing a similar clinical scenario.

Langerhans Cell Histiocytosis in the Adult Lumbar Spine - A Case Report and Literature Review

Introduction:

Langerhans cell histiocytosis (LCH) in spine is a benign disorder that mainly affects children and is rare in adults. The treatment of LCH in adults is still controversial. The literature is drought with reports regarding management of LCH in adults with pathological fracture. We report a case of LCH at L5 vertebra in an adult patient treated with posterior stabilization, decompression, and anterior corpectomy and reconstruction.

Case Presentation:

A 30-year-old manual laborer working in Middle East, presented to us with severe pain in the lower back (VAS-8) with the right lower limb radiculopathy for 6 months. Radiological investigations revealed to have a solitary osteolytic lesion with pathological fracture at L5 vertebral body. MRI showed hyperintense lesion in T2 sagittal images and hypointense in T1 sagittal images in L5 vertebral body. PET scan showed metabolically active lesion involving L5 vertebra body and right ischium. CT-guided biopsy from L5 vertebral body was performed, but was inconclusive. The patient underwent surgical management in the form of posterior stabilization L4-S1 and transpedicular biopsy. The sample was sent for frozen section and confirmed the presence of neoplasia but did not provide sufficient information about the nature of pathology. Intraoperatively, the decision was made to do anterior excision biopsy, corpectomy, and reconstruction with titanium mesh cage filled with cement. The precise diagnosis of LCH was established on histopathological examination and confirmed with immunohistochemistry positivity for CD1a and S100. The patient had immediate relief of his back pain and radicular pain. He was able to resume his daily activities at 1 month after the surgery. At 2-year follow-up patient was asymptomatic and no local recurrence was noticed.

Conclusion:

Surgical excisionfor LCH in adults should be considered in patients with refractory low back pain with pathological fracture, neurological deficits, or spinal instability.

Langerhans cell histiocytosis of the shoulder girdle, pelvis and extremities: a review of radiographic and MRI features in 85 cases

OBJECTIVES

To describe the radiographic and MRI features of histologically proven Langerhans cell histiocytosis (LCH) of the bone.

MATERIALS AND METHODS

A retrospective review of the radiographic and MRI features of 85 histologically proven cases of skeletal LCH over a 12-year period. Clinical data recorded included age, gender and location. Radiographic features evaluated included Lodwick grading, cortical/periosteal response and matrix mineralisation. MRI features assessed included lesion size and T1-weighted signal intensity (T1W SI), nature of margin, hypointense rim, enhancement pattern, bone marrow and soft tissue oedema, soft tissue mass, fluid-fluid levels, the penumbra sign and the budding and bulging signs.

RESULTS

The study included 85 patients, 54 males and 31 females with mean age of 13 years (range 1-76 years). The femur was the commonest bone involved (38.8%), followed by the scapula (9.4%), clavicle (8.2%), ilium (8.2%) and ischium (8.2%). The mean maximal lesion size was 40 mm (range 16-85 mm). The commonest radiographic appearance was of a lytic lesion with no appreciable sclerotic rim, an intact expanded cortex and either absent or laminated periosteal response. MRI demonstrated a hypointense rim (41.5%), the budding (31.7%) and bulging (36.6%) signs, eccentric extra-osseous mass (42.7%), prominent bone marrow (95.3%) and soft tissue oedema (84.1%). Rarer features included haemorrhage (2.4%), the penumbra sign (3.5%) and fluid-fluid levels (2.4%). Thirteen of 25 post-contrast studies showed peripheral/rim enhancement with central necrosis.

CONCLUSIONS

LCH classically presents as a moderately aggressive lytic bone lesion on radiography, with prominent reactive bone and soft tissue oedema being a characteristic feature on MRI.

Imaging of Lacrimal Gland Pathologies: A Radiological Pattern-Based Approach

Despite their unassuming size, lacrimal glands can have a variety of pathologies affecting them which often poses a diagnostic challenge clinically in view of their nonspecific presentation as palpable lump in the superolateral aspect of the orbit. There are a myriad of pathological entities ranging from inflammatory to neoplastic lesions that can affect the lacrimal glands. Cross-sectional imaging is must for the detection, characterization, and mapping of these lesions. In this pictorial review, we propose a radiological pattern-based approach for various lacrimal gland lesions that provides a working algorithm for radiologists in the evaluation of lacrimal gland pathologies.

Spinal epidural involvement in adult Langerhans cell histiocytosis (LCH): A case report

RATIONALE

Spinal involvement in adult Langerhans cell histiocytosis (LCH) is rare, and epidural involvement is unusual. LCH is mostly indistinguishable from other spinal lesions such as infection, lymphoma, and metastasis. So, it could be easily misdiagnosed without suspicion.

PATIENT CONCERNS

We report a case of a 33-year-old man who complained of gait disturbance with weakness in both legs and severe back pain.

DIAGNOSES

A continuous enhancing epidural lesion with cord compression from the T7 to L1 level was detected in magnetic resonance imaging. Laboratory analysis indicated the possibility of spinal infectious disease. We assumed that the lesion could be tuberculous spondylitis.

INTERVENTIONS AND OUTCOMES

The patient underwent posterior laminectomy with marginal excision of the epidural mass to relieve cord compression. Pathological examination confirmed the diagnosis of LCH. The 12-month follow-up evaluation revealed that the patient was neurologically intact and had no gait disturbance.

LESSONS

This case report presents a patient with epidural LCH of the thoracic spinal cord, which can mimic spinal infections such as tuberculous spondylitis with abscess formation. Therefore, LCH could be considered as a possible diagnosis when a patient presents with features of infectious spondylitis with vertebral involvement.

Twenty classic signs in oral and maxillofacial radiology

Teachers of radiology often employ the use of classic signs to help learners identify the typical appearance of various pathologies. This article is a compendium of simply-described classic signs in oral and maxillofacial radiology, including their use in differential diagnoses.

Adult Langerhans' cell histiocytosis with multisystem involvement: A case report

RATIONALE

Langerhans' cell histiocytosis (LCH), also called histiocytosis X, is an uncommon disorder manifesting in a variety of ways. Although LCH can involve various organs including bone, skin, and lymph nodes, multisystem involvement of LCH is rare in adults.

PATIENT CONCERNS

A 31-year-old woman first presented to our hospital with left leg pain. She had a history of a 20-kg weight gain over three months.

DIAGNOSES

X-ray, magnetic resonance imaging (MRI), computed tomography (CT), and bone scan images revealed enhancing lesions in the left femur and right temporal bone, multiple cystic lesions in the lung, enhancing mass in the pituitary stalk, and fat density lesions in the liver. The patient underwent excisional biopsy for the femoral lesion and histologic examination confirmed the diagnosis of LCH.

INTERVENTIONS

Excisional biopsy was performed for the bony lesion in the left femur. She received chemotherapy with vinblastine and prednisolone.

OUTCOMES

The patient expired after 21 months from initial admission following recurrent episodes of pneumothorax, pneumonia, and sepsis.

LESSONS

Our case showed LCH involvement in bone, lung, central nervous system (CNS), and liver. Although it is occasionally difficult to discriminate LCH from other disorders, systemic evaluation might be helpful for differential diagnosis. Familiarity with the various multisystemic involvements of LCH on imaging is vital for diagnosing and managing patients in daily practice.

The application of x-ray, computed tomography, and magnetic resonance imaging on 22 pediatric Langerhans cell histiocytosis patients with long bone involvement: A retrospective analysis

The studies focusing on x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) in pediatric Langerhans cell histiocytosis (LCH) patients were still rare. Therefore, we aimed to evaluate the application of x-ray, CT, and MRI in pediatric LCH patients with long bone involvement.Total 22 pediatric LCH patients were included in this study. The diagnosis of LCH was confirmed by pathological examination. All patients were followed up for 3 years. X-ray, CT, or MRI was performed and the results were recorded for further analyses.Among 22 pediatric patients, x-ray (n = 20), CT (n = 18), or MRI (n = 12) were used to scan the lesion on long bones affected by LCH. Femurs (n = 13, 38.24%), tibia (n = 11, 32.35%), humerus (n = 5, 14.71%), and radius (n = 4, 11.76%) were the most frequently affected anatomic sites. Ovoid or round radiolucent lesions, aggressive periosteal reaction, and swelling of surrounding soft tissues were characteristic image of long bones on x-ray, CT, and MRI in pediatric LCH.Femurs, tibia, humerus, and radius were the most commonly affected long bones of pediatric LCH. The application of x-ray, CT, and MRI on long bones could help with the diagnosis of pediatric LCH.

Atlantoaxial Langerhans cell histiocytosis radiographic characteristics and corresponding prognosis analysis

BACKGROUND

Langerhans cell histiocytosis (LCH) may affect atlas and axis, and there were very few published cases describing a characteristic of LCH of atlantoaxial.

OBJECTIVE

The objective of the study is to investigate the image manifestations of atlantoaxial LCH to improve the in-depth comprehension on it.

MATERIALS AND METHODS

A retrospective study was done of computed tomography (CT) and magnetic resonance imaging in atlas and axis and prognosis was analyzed.

RESULTS

The study included 41 patients (average age 12.9 years and median age 8 years) diagnosed with LCH, with 75.6% under 15 years old. Eighty-four lesions of LCH were identified including 47 in the atlas and 37 in the axis. The osteolytic bone destructions in the atlas and axis were characterized, 22% accompanied by sclerotic margins. Thirteen patients had a compression fracture, 11 in the lateral mass of the atlas and 2 in the C2 vertebral body. Sixteen and three patients had atlantoaxial malalignment and dislocation, respectively. On T2-weighted images, 68.9% showed iso- or low-signal intensity, 27.6% showed hyperintensity signal, and 3.4% showed heterogeneous signal. On postcontrast images, 81.9% showed significant enhancement, 12.5% showed moderate enhancement, and 6.3% showed mild enhancement. CT reexamination of 14 patients indicated atlantoaxial bone destruction relatively repaired in 12 patients. Thirty-three patients were a follow-up, 81.8% had no significant symptoms and 18.2% with remaining symptoms.

CONCLUSIONS

The atlas and axis were affected by LCH, mainly in children. The lateral mass was easily affected and compressed, destruction of the atlas and axis could lead to atlantoaxial joint instability. The prognosis was good in most of the patients.

Langerhans Cell Histiocytosis of the Thoracic Spine in an Adult

We report a case of a 45-year-old man with a complaint of both leg weakness and hypoesthesia. Radiological evaluation revealed an osteolytic lesion of the ninth thoracic vertebra. The patient underwent posterior corpectomy with total excision of the tumor, mesh cage insertion with posterior screw fixation and subsequent radiotherapy. Histology confirmed the diagnosis of Langerhans cell histiocytosis (LCH). This case report presents the diagnostic work-up, histopathological evaluation, and the treatment procedures of rare LCH in the thoracic spine.

Imaging of the Sella and Parasellar Region in the Pediatric Population

Masses in the sella and parasellar region comprise about 10% of all pediatric brain tumors but type and frequency differs from those in adults. Imaging is critical for diagnosis and characterization of these lesions. By assessing the site of origin, signal and contrast enhancement characteristics, and the presence or absence of characteristic patterns, differential diagnosis can narrow the possibilities. The clinical presentation is often characteristic for lesion type and should be considered. This article summarizes the characteristic imaging features of the most frequent pediatric tumors and tumor-mimicking lesions in children in this region.

Pediatric Suprasellar Tumors

The various childhood suprasellar tumors, while pathologically distinct, present similar clinical and surgical challenges as a result of their common anatomic location. These lesions are in close proximity to or may invade the optic nerve and chiasm, pituitary gland and infundibulum, hypothalamus, and third ventricle, leading to presenting features including visual field loss, impairment in visual acuity, endocrine dysfunction, and hydrocephalus. Though many suprasellar lesions are relatively benign in pathology, treatment may be complicated by high surgical morbidity resulting from damage to the hypothalamic-pituitary axis. Here we review the most frequent pediatric lesions occurring in the suprasellar region: craniopharyngioma, chiasmatic glioma, germ cell tumor, Rathke cleft and arachnoid cysts, pituitary adenoma, and histiocytosis. This review outlines both common presenting features and differentiating aspects of these lesions. It also includes classic radiographic presentations and treatment considerations for each lesion.

Langerhans cell histiocytosis in the adult lumbar spine: case report

Introduction

Langerhans cell histiocytosis (LCH) occurs rarely in the spine of adults. The radiological findings usually resemble vertebral tumors. Etiology of LCH has not been clearly established yet. Therapeutic approaches are still controversial. We describe a case of LCH in an adult spine.

Case description

A patient who presented with low back pain had an osteolytic lesion in the L1 vertebral body without neurological deficits, and fluoroscopy-guided needle biopsy of the L1 vertebral body was performed. The immunohistochemical diagnosis confirmed LCH. The patient was successfully treated with conservative methods.

Discussion

The choice of appropriate therapy is very important, with treatment options varying from watch-and to aggressive treatment.

Conclusion

LCH is considered as a pediatric disease that is extremely rare in the spine of adults and should be include in the differential diagnosis of osteolytic vertebral lesions. Conservative treatment is best choice for a patient with LCH without neurological deficit or spinal instability.

Localized Langerhans cell histiocytosis masquerading as Brodie's abscess in a 2-year-old child: a case report

Langerhans cell histiocytosis (LCH), formerly known as histiocytosis X, refers to a spectrum of diseases characterized by idiopathic proliferation of histiocytes that produce either focal (localized LCH) or systemic manifestations (Hand-Schüller-Christian disease and Letterer-Siwe disease). Localized LCH accounts for approximately 60-70 % of all LCH cases. Osseous involvement is the most common manifestation and typically involves the flat bones, along with lesions of the skull, pelvis, and ribs. Localized LCH in bone shows a wide spectrum of clinical manifestations and radiologic features that may mimic those of infections as well as benign and malignant tumors. The diagnostic imaging findings of localized LCH are also diverse and challenging. The penumbra sign is a common and characteristic magnetic resonance imaging (MRI) feature of Brodie's abscess, but is rarely seen in localized LCH. In this report, we describe a case of localized LCH misdiagnosed as Brodie's abscess in a 2-year-old child based on clinical symptoms, laboratory findings, and pre-diagnostic MRI findings (penumbra sign). Therefore, the penumbra sign is not sufficient to clearly establish the diagnosis of Brodie's abscess, and the differential diagnosis of localized LCH should be considered when a child with an osteolytic lesion presents with a penumbra sign.

Imaging of focal calvarial lesions

Focal calvarial lesions may present as a visible, palpable, or symptomatic lump; however, with increasing use of cross-sectional imaging they are often encountered as an incidental finding. Knowledge of the possible disease entities along with a structured approach to imaging is required to suggest an appropriate diagnosis and assist in management planning. Abnormalities range from common neoplastic lesions to rarer congenital conditions, benign pathologies, and calvarial defects that can mimic lesions. The aim of this article is to demonstrate the salient imaging features that may help to limit the differential diagnosis of a focal calvarial lesion.

Clinicopathological pattern of cranial unifocal Langerhans cell histiocytosis: A study at medical college hospital

Background:

Eosinophilic granuloma (EG) of bone refers to a generally benign form of Langerhans cell histiocytosis localized to the bone. Patients may present with a solitary lesion (monostotic) or multiple sites of involvement (polyostotic).

Materials and Methods:

This study was done to evaluate the clinicopathological pattern of 6 cases of EGs of the skull diagnosed at a tertiary care hospital. All patients of EG were included with the help of medical records over a 5-year period that is, November 2009 to November 2014. They all had been preoperatively evaluated by skull X-ray and computed tomography. To rule out a multifocal disease scintigraphy was performed in all cases preoperatively. Surgical excision was performed, and EG was diagnosed on histopathology and immunohistochemistry.

Results:

There was a male predominance. Parietal bone was the most common affected bone. Total excision of the lesion was performed in all cases. No patient received postoperative radiotherapy. The follow-up period ranged from 6 months to 3 years. No tumor recurrence was noted.

Conclusion:

With an unknown etiology, nonspecific clinical and radiological findings with diagnosis possible only on histopathological examination, EG needs to be considered in the differential diagnosis as a skull mass, especially in children.

Solitary Langerhans cell histiocytosis of the occipital condyle: a case report and review of the literature

BACKGROUND

Despite the recent advent of various radiographic imaging techniques, it is still very difficult to correctly distinguish a pediatric osteolytic lesion in the occipital condyle, which makes it further complicated to decide on the necessity of and the adequate timing for radical resection and craniocervical fusions. To establish a legitimate therapeutic strategy for this deep-seated lesion, surgical biopsy is a reasonable choice for first-line intervention. The choice of surgical approach becomes very important because a sufficient amount of histological specimen must be obtained to confirm the diagnosis but, ideally, the residual bony structures and the muscular structures should be preserved so as not to increase craniocervical instability. In this report, we present our experience with a case of solitary Langerhans cell histiocytosis (LCH) involving the occipital condyle that was successfully treated with minimally invasive surgical biopsy with a far lateral condylar approach supported by preoperative 3D computer graphic simulation.

CASE REPORT

An 8-year-old girl presented with neck pain. Magnetic resonance imaging and computed tomography (CT) revealed an osteolytic lesion of the left occipital condyle. At surgery, the patient was placed in the prone position. A 3-cm skin incision was made in the posterior auricular region, and the sternocleidomastoid and splenius capitis muscles were dissected in the middle of the muscle bundle along the direction of the muscle fiber. Under a navigation system, we approached the occipital condyle through the space between the longissimus capitis muscle and the posterior belly of the digastric muscle and lateral to the superior oblique muscle, verifying each muscle at each depth of the surgical field and, finally, obtained sufficient surgical specimen. After the biopsy, her craniocervical instability had not worsened, and chemotherapy was performed. Twelve weeks after chemotherapy, her neck pain had gradually disappeared along with her torticollis, and CT showed remission of the lesion and marked regeneration of the left occipital condyle. Within our knowledge, this is the first reported case of LCH involving the occipital condyle. Although very rare, our case indicated that LCH can be an alternative in the differential diagnosis of osteolytic lesions in the craniocervical junction, in which early bone regeneration with sufficient cervical stability is expected after chemotherapy.

CONCLUSIONS

In cases of pediatric osteolytic lesions, when they initially presented with apparent cervical instability, craniocervical fusion may possibly become unnecessary after a series of treatments. Thus, the effort to maximally preserve the musculoskeletal structure should be made until its histological diagnosis is finally confirmed.

Hand-Schüler-Christian disease presenting with recurrent, bilateral, symmetrical mandibular lesions in an 8-year-old boy: report of a case

INTRODUCTION

Hand-Schüller-Christian disease (HSC) is the unisystem multifocal form of Langerhans Cell Histiocytosis (LCH) and is primarily seen in infants and children.

CASE REPORT

An 8-year-old boy was referred for acute mandibular pain. His medical history included otic LCH and diabetes insipidus at age of 11 months. Intraorally, a pressure sensitive swelling, and radiographically, extensive bone loss were revealed on the area of lower second primary molars. The primary molars were extracted and histological examination confirmed the final diagnosis of HSC. The patient was treated with chemotherapy and the lesions decreased considerably. Two years later, a new swelling was recorded in the same area bilaterally. Biopsy confirmed recurrent HSC disease and the patient entered an alternative chemotherapy protocol. Six months later, improvement of the lesions was revealed.

CONCLUSIONS

Dentists can contribute to a timely and valid identification of HSC disease by correctly differentially diagnosing lesions of head and neck.

A different cause for respiratory disorder in children: cases with pulmonary Langerhans cell histiocytosis

BACKGROUND AND AIMS

In children, complaints of a respiratory disorder are very frequent. Etiology of respiratory illness is a broad spectrum that varies from a simple viral infection to a malignant disorder. Pulmonary Langerhans cell histiocytosis (PLCH) is one of these entities and it is truly rare in children. The aim of this study is to evaluate our patients with PLCH.

METHODS

Patients who had been diagnosed with PLCH were retrospectively evaluated. Features of medical history, onset of the complaints, date of the diagnosis, chest X-Ray and computed tomography (CT) findings, histopathology and other laboratory investigations were considered.

RESULTS

There were four cases with PLCH. All of them were male, ages were between 5 months and 16 years. In three cases, major complaints were chronic respiratory problems whereas in one of them there was acute respiratory distress beginning with cough and leading to pneumothorax. In all of the cases, multisystemic involvement was prominent. The diagnosis was proven by histopathology in all of the cases. In two children with smaller age, skin involvement was detected. Time from complaint to diagnosis was minimum 3 months and maximum 3 years.

CONCLUSION

PLCH is a rare disorder in children. Pulmonary involvement is generally a component of systemic involvement but in many cases it might have been detected with early respiratory complaints. So, children with chronic respiratory problems should be carefully evaluated and should be followed up for rare entities like PLCH.

Hepatic involvement of Langerhans cell histiocytosis in children--imaging findings of computed tomography, magnetic resonance imaging and magnetic resonance cholangiopancreatography

BACKGROUND

Langerhans cell histiocytosis is a rare disease that occurs mainly in children, and hepatic involvement is generally a poor prognostic factor.

OBJECTIVE

To describe CT and MRI findings of hepatic involvement of Langerhans cell histiocytosis in children, especially the abnormal bile duct manifestation on magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

Thirteen children (seven boys, six girls; mean age 28.9 months) were diagnosed with disseminated Langerhans cell histiocytosis. They underwent CT (n = 5) or MRI (n = 4), or CT and MRI examinations (n = 4) to evaluate the liver involvement.

RESULTS

Periportal abnormalities presented as band-like or nodular lesions on CT and MRI in all 13 children. The hepatic parenchymal lesions were found in the peripheral regions of the liver in seven children, including multiple nodules on MRI (n = 6), and cystic-like lesions on CT and MRI (n = 3). In 11 of the 13 children the dilatations of the bile ducts were observed on CT and MRI. Eight of the 13 children underwent MR cholangiopancreatography, which demonstrated stenoses or segmental stenoses with slight dilatation of the central bile ducts, including the common hepatic duct and its first-order branches. The peripheral bile ducts in these children showed segmental dilatations and stenoses.

CONCLUSION

Stenosis of the central bile ducts revealed by MR cholangiopancreatography was the most significant finding of liver involvement in Langerhans cell histiocytosis in children.

Primary eosinophilic granuloma of adult cervical spine presenting as a radiculomyelopathy

We report a case of 29-year-old man diagnosed as a primary eosinophilic granuloma (EG) lesion of the seventh cervical vertebra. He had paresthesia on both arms, and grasping weakness for 10 days. Cervical magnetic resonance image (MRI) showed an enhancing mass with ventral epidural bulging and cord compression on the seventh cervical vertebra. Additionally, we performed spine series MRI, bone scan and positive emission tomography for confirmation of other bone lesions. These studies showed no other pathological lesions. He underwent anterior cervical corpectomy of the seventh cervical vertebra and plate fixation with iliac bone graft. After surgical management, neurological symptoms were much improved. Histopathologic evaluation confirmed the diagnosis of EG. There was no evidence of tumor recurrence at 12 months postoperative cervical MRI follow-up. We reported symptomatic primary EG of cervical spine successfully treated with surgical resection.

Langerhans cell histiocytosis of spine: a comparative study of clinical, imaging features, and diagnosis in children, adolescents, and adults

BACKGROUND CONTEXT

Langerhans cell histiocytosis (LCH) of the spine has been well documented in the literature, but most studies concern management of the disease. No focused report on the differences in clinical and radiographic features of spinal LCH among children, adolescents, and adults exists.

PURPOSE

To review and stress the clinical and imaging differences of spinal LCH in children, adolescents, and adults to avoid false diagnosis.

STUDY DESIGN

A retrospective study of children and adults with LCH of the spine.

PATIENT SAMPLE

Consecutive patients treated at our institution.

OUTCOME MEASURES

Visual analog scale for pain, Frankel scale for neurologic status, and X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) for imaging.

METHODS

Seventy-six patients with pathology-proven LCH involving the spine were treated at our institution between 1996 and 2010. Only patients with spine involvement pathologically and/or radiographically were included. Two groups were identified based on the age. Group I comprised children and adolescents (age <18 years; n=40) and Group II comprised adults (age ≥18 years; n=36). Analysis included age and gender distribution, clinical presentation, and imaging features and diagnosis. Pathologic diagnosis was performed by needle or open biopsy of the lesions.

RESULTS

Of the 76 patients, 55 were male and 21 were female (ratio of 2.62:1). Neck or back pain was the most common symptom in all patients and was the only presenting symptom in some patients. Restricted motion of spine was the most frequent symptom secondary to pain. Thirty-seven patients presented with neurologic symptoms. Adult patients were more likely to suffer neurologic deficits (p<.005). The distribution of lesions revealed predominance in the cervical spine, followed by thoracic and lumbosacral spine. Plain radiology of children and adolescents with spinal LCH usually revealed a typical vertebral plana, but the adult patients represented different severity of vertebral collapse without typical features. The images of CT scans between the two groups were similar, and all revealed lytic lesions in vertebral bodies and/or posterior elements. In Group I, lesions showed hypointense on T1-weighted images in 15 cases and isointense in 25 cases. Nineteen patients presented as intermediate to slight high signal on T2-weighted images, and the remaining patients presented as hyperintense on T2-weighted images. In Group II, lesions showed hypointense on T1-weighted images in 29 cases, isointense on T1-weighted images in seven cases, and hyperintense on T2-weighted images in 36 cases. Paraspinal soft tissue mass was detected in 28 and 23 cases in Group I and Group II, respectively. Fifteen children and adolescent patients versus 23 adult patients had epidural spinal cord compression. Oversleeve-like or dumbbell sign was observed in 21 cases in Group I but only in four cases in Group II.

CONCLUSIONS

The most common clinical manifestations of LCH of the spine were neck or back pain, followed by restricted motion of spine, neurologic symptoms, and deformity. Neurologic deficits were more frequent in adult patients. Vertebral plana is the typical imaging feature in children and adolescent patients but seldom in adults. Computed tomography is best for characterizing anatomy of the involved vertebra, and MRI is best for delineating marrow and soft tissue. The oversleeve-like sign on MRI may be a feature of spinal LCH as well as vertebra plana in children and adolescents. Needle biopsy under CT guidance should be performed before a treatment strategy is determined.

Primary intramedullary Langerhans cell histiocytosis of the thoracic spinal cord

A 28-year-old male presented with a rare case of primary intramedullary spinal Langerhans cell histiocytosis (LCH) manifesting as the chief complaint of a 6-month history of gait disturbance and back pain, and difficulty with sphincter control. Serial T2-weighted magnetic resonance imaging of the thoracic spine revealed enlargement and intramedullary hyperintensity of the spinal cord at T2 to T4. Biopsy of the lesion was performed. Histological examination of the biopsy specimens verified vascular proliferation and remarkable infiltration of histiocytes that were positive for CD1a, suggesting a diagnosis compatible with LCH. The patient was treated successfully by steroid pulse therapy. LCH is a rare disease that occurs mainly in children and may cause a broad range of manifestations, from a single osseous lesion to multiple lesions involving more than one organ or system. The present case illustrates the unexpected occurrence and important differential diagnosis of primary intramedullary spinal LCH of the thoracic spine in adult patients presenting with progressive paraparesis and back pain.

The diagnostic value of 18F-FDG PET and MRI in paediatric histiocytosis

PURPOSE

To analyse the diagnostic value of (18)F-FDG PET and MRI for the evaluation of active lesions in paediatric Langerhans cell histiocytosis.

METHODS

We compared 21 (18)F-FDG PET scans with 21 MRI scans (mean time interval 17 days) in 15 patients (11 male, 4 female, age range 4 months to 19 years) with biopsy-proven histiocytosis. Primary criteria for the lesion-based analysis were signs of vital histiocyte infiltrates (bone marrow oedema and contrast enhancement for MRI; SUV greater than the mean SUV of the right liver lobe for PET). PET and MR images were analysed separately and side-by-side. The results were validated by biopsy or follow-up scans after more than 6 months.

RESULTS

Of 53 lesions evaluated, 13 were confirmed by histology and 40 on follow-up investigations. The sensitivity and specificity of PET were 67 % and 76 % and of MRI were 81 % and 47 %, respectively. MRI showed seven false-positive bone lesions after successful chemotherapy. PET showed five false-negative small bone lesions, one false-negative lesion of the skull and three false-negative findings for intracerebral involvement. PET showed one false-positive lesion in the lymphoid tissue of the head and neck region and two false-positive bone lesions after treatment. Combined PET/MR analysis decreased the number of false-negative findings on primary staging, whereas no advantage over PET alone was seen in terms of false-positive or false-negative results on follow-up.

CONCLUSION

Our retrospective analysis suggests a pivotal role of (18)F-FDG PET in lesion follow-up due to a lower number of false-positive findings after chemotherapy. MRI showed a higher sensitivity and is indispensable for primary staging, evaluation of brain involvement and biopsy planning. Combined MRI/PET analysis improved sensitivity by decreasing the false-negative rate during primary staging indicating a future role of simultaneous whole-body PET/MRI for primary investigation of paediatric histiocytosis.

Extracranial skeletal Langerhans cell histiocytosis: MR imaging features according to the radiologic evolutional phases

PURPOSE

The purpose was to describe the magnetic resonance (MR) findings of extracranial skeletal Langerhans cell histiocytosis according to the radiologic evolutional phases.

MATERIALS AND METHODS

Twenty-two patients with pathologically confirmed extracranial skeletal Langerhans cell histiocytosis were included. The lesions were classified as early, mid, and late phases according to the radiologic evolutional phases. MR images were retrospectively analyzed regarding signal intensity, internal hypointense band, fluid levels, periosteal reaction, adjacent bone marrow and soft tissue abnormal signal, and patterns of contrast enhancement in each phase.

RESULTS

According to the radiologic evolutional phases, there were 4 patients with early phase, 16 with mid phase, and 2 with late phase. All cases showed hypointense to intermediate signal intensity on T1-weighted images. On T2-weighted images, 12 (55%) of the 22 lesions were hyperintense, and 10 (45%) showed intermediate signal. All lesions showed diffusely heterogeneous signal on T2-weighted images. Internal low-signal bands of the lesions were observed in 13 cases (59%). There were two cases with fluid levels in mid phase. Periosteal reaction was observed in 13 (59%) cases. Adjacent bone marrow or soft tissue abnormal signal was observed in 20 cases (91%), respectively. According to early, mid, and late phases, bone marrow and soft tissue abnormal signals were observed in 100%, 100%, and 0% cases, respectively. Soft tissue mass was seen in eight cases (36%). Ten (46%) lesions showed cortical destruction, including one patient with a pathologic fracture. Among 21 patients with contrast infusion, diffuse enhancement was observed in 19 patients (90%), and marginal and septal enhancement was seen in 2 patients (10%).

CONCLUSION

MR imaging was helpful in the diagnosis of extracranial skeletal Langerhans cell histiocytosis, particularly in early and mid phases.

[Orbital location of multivisceral Langerhans-cell histiocytosis]

Langerhans-cell histiocytosis is a rare disease accounting for less than 1% of orbital tumours. We report the case of an 18-month-old infant presenting with exophthalmos of the left eye lasting for 3 months in a context of deterioration of the general condition, polydipsia, and polyuria. The computed tomographic scan revealed an orbital cellular mass with a lytic bone lesion within the orbital roof and infiltration of frontopalpebral soft tissue. In addition, other secondary lesions were found at the skull, ribs, skin, liver, and spleen. The cytological study after biopsy showed infiltrates of histiocytes derived from Langerhans cells. Because the disease was multivisceral, the child was treated with chemotherapy (vinblastine) combined with a steroid and progressed well. At 30 months of follow-up, there was no evidence of recurrence or systemic involvement.

Unifocal Granuloma of Femur due to Langerhans' Cell Histiocytosis: A Case Report and Review of the Literature

The radiological diagnosis of osteolytic lesions of the long bones in pediatric population constitutes a challenge when the case history and clinical data are uncharacteristic. We believe that the description of few clinically and histologically proven cases to verify the existence of radiological signs useful for diagnosis may be of interest. Here, we describe a case of Langerhans' cell histiocytosis (LCH) presenting as unifocal eosinophilic granuloma of femur along with a brief review of the literature.

Langerhans cell histiocytosis of the parietal bone with epidural and extracranial expansion - case report and a review of the literature

Langerhans cell histiocytosis is a rare neoplasm that belongs to the histiocytic and dendritic cell neoplasm group according to the 2008 WHO classification. It has been defined as neoplastic proliferation of Langerhans cells that express CD1a and S-100 proteins and have Birbeck granules on the ultrastructural examination. Clinical presentation and behaviour are heterogeneous and can range from a solitary lytic bone lesion with a favourable course to a fatal disseminated leukaemia-like form, with a wide spectrum of intermediate clinical presentations between these two extremes. Here, we present a case report of a solitary calvarial lesion in an adolescent boy along with a review of the literature. Presenting features, initial diagnostic evaluation and treatment protocol of a unifocal monosystemic calvarial location of LCH are presented.

Digestive system manifestations, diagnosis and treatment of Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a rare disease characterized by an abnormal proliferation of histiocytes, known as Langerhans cells (LCs). At present, the pathogenesis of LCH remains unknown. LCH often involves the bone, skin, lung, bone marrow and lymph nodes. Besides, the liver, bile duct and gastrointestinal tract may also be affected. LCH has no specific clinical manifestations compared to other digestive system diseases. Once digestive system involvement is diagnosed in LCH patients, prompt treatment (even liver transplantation) should be given. In this paper, we will review the digestive system manifestations, diagnosis and treatment of LCH.

Biliary dilatation secondary to lithiasis in a child affected by Langerhans' cell histiocytosis

Langerhans' cell histiocytosis (LCH) is a disease of unknown pathogenesis, caused by clonal proliferation of Langerhans' cells. Liver involvement results in a cholangiopathy, which has the radiologic appearance of sclerosing cholangitis. Only 1 case of obstructive jaundice due to common bile duct stone in a patient with LCH has been described. We present a case of a 31-month-old child with LCH and liver involvement on the waiting list for liver transplantation. During the follow-up, there was a rapid onset of jaundice due to sludge and lithiasis. The patient was treated first with an endoscopic biliary plastic stent and then with percutaneous biliary drainage and bilioenteric anastomosis.

Primary musculoskeletal Langerhans cell histiocytosis in children: an analysis for a 3-decade period

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare group of disorders of unknown etiology with a wide spectrum of clinical presentation. We sought to identify what, if any, has changed in the past 3 decades. This review outlines the current concepts in etiology and molecular biology, clinical manifestations, imaging features, treatment guidelines, and outcomes for skeletal LCH.

METHODS

A database of LCH cases diagnosed at a tertiary referral center during a 3-decade period was retrospectively reviewed to identify children with primary bone involvement. All patients' charts and available imaging examinations were reviewed, and the data collected included sex, age, number and location of the musculoskeletal lesions, presence of extraskeletal lesions and/or systemic disease, presence of clinical symptoms, treatment (medical and/or surgical), complications, and outcomes.

RESULTS

Seventy-nine children met the inclusion criteria. Forty-five (57%) of the 79 children had single-bone disease, with a mean age at presentation of 8.9 years, whereas 34 (43%) of the 79 children presented with multiple skeletal lesions (range, 2-7 lesions) at a mean age of 7.4 years. There were 165 skeletal lesions in the 79 patients (mean, 2 lesions per patient). The most common presenting symptom was pain at the lesion site (63 patients, 79%). On imaging, the lesion usually presented as a well-defined, radiolucent lesion located within the diaphysis or metaphysis. Among children with single-bone involvement, 11 underwent observation and symptomatic treatment, 17 had biopsy followed by observation and symptomatic treatment, and 17 had biopsy followed by excision. Eight children also received chemotherapy, and 2 had radiation (early in the series). Among children with multiple-bone disease, 10 underwent biopsy followed by symptomatic treatment, 24 underwent biopsy, followed by chemotherapy, and 3 also received radiation (early in the series).

CONCLUSION

There is variability of presentation in musculoskeletal LCH. Biopsy is usually indicated for diagnostic confirmation. Although the natural history for most lesions is of gradual healing, curettage and grafting are sometimes indicated to accelerate the healing process. Internal fixation for stability is occasionally necessary. Chemotherapy is used for multisystemic disease, and radiotherapy is no longer used.

[Clinical characteristics and survival of children with langerhans cell hystiocytosis]

INTRODUCTION

Langerhans cell histiocytosis is a rare disease in children, initial presentation is variable, clinical course, prognosis and survival are mostly unpredictable.

OBJECTIVE

To summarise clinical characteristics and treatment results in children with Langerhans cell histiocytosis.

METHOD

Retrospectively there were analysed patients with LCH diagnosed and treated at Haematology Department of University Children's Hospital in Belgrade from 1990 to 2006. Clinical presentation, therapy and survival according to Kaplan-Meier's statistical test was analysed.

RESULTS

30 patients were treated, aged from 4 months to 14 years, mean 3.9 years, median 2.3 years, 18 (60%) males, 12 (40%) females. A single system disease was diagnosed in 16 (53%) patients, of whom 6 patients with multifocal bone disease. All patients were in complete remission averagely following 162 and 82 months respectively. Multisystem disease was found in 14 (47%) patients. The lymph nodes and skin were more frequently involved organs than the central nervous system (diabetes insipidus), lung, liver and spleen. The number of involved organs ranged from 2 to 8, mean 4.2. Four patients died due to disease progression 3, 16, 36 and 66 months after diagnosis. Nine patents with multisystem disease were in remission with 117 months of follow-up. One patient was lost on follow-up.

CONCLUSION

The clinical course of patients with a single system disease is usually benign while a multisystem disease has to be aggressively treated with precise initial evaluation and staging before therapy.

Biliary wall calcification in Langerhans cell histiocytosis: report of two cases

Langerhans cell histiocytosis (LCH) is a disorder of unknown pathogenesis affecting one or more organs (unifocal or disseminated form) due to clonal proliferation of Langerhans cells. Liver involvement is more frequent in the disseminated form and the radiological findings of end-stage liver disease due to LCH are similar to those of sclerosing cholangitis. We present the multidetector CT findings in two children with LCH liver involvement and the unique finding of calcification of the biliary wall.

Extraosseous langerhans cell histiocytosis in children

Langerhans cell histiocytosis, a rare disease that occurs mainly in children, may produce a broad range of manifestations, from a single osseous lesion to multiple lesions involving more than one organ or system. The clinical course varies widely in relation to the patient's age. Multisystem disease may demonstrate especially aggressive behavior in very young children, with the outcome depending largely on the stage of disease and the degree of related organ dysfunction at the time of diagnosis. Extraosseous manifestations are less commonly seen than osseous ones and may be more difficult to identify. To accurately detect extraosseous Langerhans cell histiocytosis at an early stage, radiologists must recognize the significance of individual clinical and laboratory findings as well as the relevance of imaging features for the differential diagnosis. The pattern and severity of pulmonary, thymic, hepatobiliary, splenic, gastrointestinal, neurologic, mucocutaneous, soft-tissue (head and neck), and salivary involvement in Langerhans cell histiocytosis generally are well depicted with conventional radiography, ultrasonography, computed tomography, and magnetic resonance imaging. However, the imaging features are not pathognomonic, and a biopsy usually is necessary to establish a definitive diagnosis.