Solitary eosinophilic granuloma of the lumbar spine in an adult. Case report

Langerhans cell histiocytosis at L5 vertebra treated with en bloc vertebral resection: a case report

BACKGROUND

Langerhans cell histiocytosis (LCH) in adult lumbar spine is extremely rare, and optimal treatments remain unclear. In literature, only a few cases of lumbar spine LCH were treated using surgery but en bloc vertebral resection has not been used.

CASE PRESENTATION

A 50-year-old man presented with unbearable radiating pain at his right leg. Radiological studies revealed a solitary osteolytic lesion, which was moderately enhanced on contrast MR imaging and hyper-metabolic on PET/CT, at the right L5 vertebral body and arch. In biopsy, Langerhans cells were observed, but findings were insufficient to establish a diagnosis of LCH. A modified L5 en bloc vertebral resection via anterior and posterior approaches was performed to remove the right 2/3 portion of the L5 vertebra. The left 1/3 vertebral body and left pedicle of L5, which were not affected, were kept in situ to allow short instrumentation and reconstruction. His leg pain disappeared after the surgery, and a precise diagnosis of LCH was established after a throughout histological study of the removed vertebra. The patient further accepted 1 cycle of low-dose radiotherapy postoperatively. At 18-month follow-up, the lumbosacral spine was fused and no local reoccurrence was noticed.

CONCLUSIONS

For lumbar spine LCH, surgery should be considered if there are neurological symptoms or histological diagnosis is indefinite in biopsy. En bloc vertebral resection can be used to alleviate neurological symptoms and prevent local reoccurrence.

[A lumbar vertebral eosinophilic granuloma with spinal instability in an adolescent]

This is a case report of a rare isolated eosinophilic granuloma of vertebra L3, in a 15-year-old adolescent. Vertebral instability, due to aggravation of the osteolysis, occurred without neurological symptoms despite orthopedic treatment. Surgery was necessary to correct and stabilize the spinal deformation. Postoperative chemotherapy (vinblastine and corticoids) was given as recommended for Langerhans cell histiocytosis (HL2010). No recurrence was observed after 5 years of follow-up.

Current concepts for the diagnosis and management of eosinophilic granuloma of bone

This review summarizes current concepts in the diagnosis and management of the patients with eosinophilic granuloma. Given the benign biology, the clinical course, and the pediatric group of patients that this condition more commonly affects, a treatment approach that carries a lower risk of complications while ensuring a successful cure is desirable. Variable treatment options have been reported with satisfactory results and a recurrence rate of less than 20 %. In this setting, symptomatic lesions that are accessible in the spine or the extremities may be treated with intralesional methylprednisolone injection after tissue biopsy for histological diagnosis.

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.

Eosinophilic granuloma of the lumbar spine in an adult

Eosinophilic granuloma of the spine is a common benign disease in children and adolescents that rarely affects adults.This article describes the case of a 32-year-old woman with a solitary eosinophilic granuloma presenting as a local lytic lesion at the L4 vertebral body. She presented with a 2-month history of low back pain without neurological deficits. Plain radiographs showed a lytic lesion of the L4 vertebral body. Computed tomography scans showed an osteolytic lesion surrounded by partial sclerotic change of the L4 vertebral body. Magnetic resonance imaging revealed a low-intensity lesion on T1-weighted images and a high-intensity lesion on T2-weighted images. A computed tomography-guided transpedicular needle biopsy of the L4 vertebral body was performed. The histological specimen stained with hematoxylin-eosin revealed features of eosinophilic granuloma with aggregates of Langerhans cells. On immunological studies, the diagnosis of eosinophilic granuloma was facilitated by diffuse immunoreactivity of S-100 protein and CD1a. For the 3-month period after biopsy, the patient was fitted with a corset and allowed to walk. Four months after biopsy, computed tomography scans showed that remodeling of the destructive lesion of the L4 vertebral body was occurring. Two years after initial onset, the patient had complete relief of low back pain and no neurologic deficit. Computed tomography scans showed full reconstitution of the lesion. This was a rare case of successful conservative treatment of eosinophilic granuloma of the lumbar spine in an adult. Conservative treatment may be considered in a patient with an eosinophilic granuloma with no neurological deficit or spinal instability.

CT-guided corticosteroid injection for solitary eosinophilic granuloma of the spine

OBJECTIVE

To evaluate the clinical and imaging outcome of patients with symptomatic eosinophilic granuloma of the spine treated with CT-guided intralesional methylprednisolone injection after biopsy.

MATERIALS AND METHODS

Patients (n =19) with symptomatic solitary eosinophilic granuloma of the spine treated by CT-guided intralesional methylprednisolone injection were retrospectively studied. There were 12 males and seven females with a mean age of 17 years (range, 3-43 years). The mean follow-up was 6 years (median, 4 years; range, 0.5-19 years). Spinal location included the cervical (two patients), thoracic (seven patients), lumbar spine (eight patients), and the sacrum (two patients). Vertebra plana was observed in two patients. All patients had biopsies before treatment.

RESULTS

Complete resolution of pain and healing of the lesion was observed in 17 patients (89.5%); none of these patients had recurrence at the latest examination. Reconstitution of the T1 and L1 vertebra plana was observed in both patients. Two patients initially diagnosed and treated for a solitary eosinophilic granuloma had constant pain after the procedure; in these patients, 6 and 12 months after the procedure, respectively, imaging showed multifocal disease and systemic therapy was administered. Complications related to the procedure were not observed. General anesthesia was administered in two patients because of intolerable pain during the procedure.

CONCLUSIONS

In view of the benign clinical course of eosinophilic granuloma, in patients with symptomatic lesions, CT-guided intralesional corticosteroid injection is a safe and effective outpatient treatment with a low complication rate.

Langerhans' cell histiocytosis of the spine in children with soft tissue extension and chemotherapy

The objectives of this paper were to look into the possible incidence of obvious soft tissue extension from Langerhans' cell histiocytosis (LCH) of the spine in children and to evaluate the effects of chemotherapy for those patients. Eighteen patients with histopathological diagnosis of LCH were reviewed and nine with obvious paravertebral soft tissue extension were included in this study. Soft tissue extension was involved in the spinal canal and/or around the vertebral body in eight cases and posterior involvement was prevalent in one case. Eight patients experienced neurological symptoms. All received chemotherapy and one had surgical treatment. The mean follow-up time was 30.3 months. Soft tissue extension disappeared completely in all patients. No clinical evidence of disease was observed at the most recent follow-up. The incidence of LCH of the spine in children with obvious soft tissue extension was up to 50%. Chemotherapy is safe and effective, and surgical decompression was probably not necessary for most patients.

The Langerhans' cell histiocytosis (eosinophilic granuloma) of the cervical spine: a rare diagnosis of cervical pain

We present the case of a 44-year-old man who complained of cervical pain. He was treated with physiotherapy and analgetics. Because of persistent pain, computed tomography (CT) scan and MRI were performed. They revealed an osteolytic destruction of the fourth cervical vertebra. The patient was treated surgically for removal of the tumor and stabilization of his cervical spine. Histology of the osteolytic material led to the diagnosis of an eosinophilic granuloma of the cervical spine. This case report describes the incidence, clinical significance, background and therapy of an eosinophilic granuloma of the spine.

Eosinophilic granuloma of the cervical spine

STUDY DESIGN

A meta-analysis was performed based on 53 cases of cervical eosinophilic granuloma reported in the literature and 1 in an adult treated by the authors.

OBJECTIVE

To stress the clinical and radiologic differences between cervical and thoracolumbar spinal eosinophilic granuloma and to point out differences between adults and children with cervical eosinophilic granuloma to avoid false diagnosis.

SUMMARY OF BACKGROUND DATA

Until now, cervical eosinophilic granuloma has been reported in 43 children and 9 adults. In 1 case the age is unknown. In previous studies, differences between adults and children with cervical eosinophilic granuloma have not been analyzed, nor has cervical eosinophilic granuloma been compared with thoracolumbar eosinophilic granuloma.

METHODS

All reported cases of cervical eosinophilic granuloma were analyzed concerning age and sex distribution, clinical and radiologic presentation, therapy, and outcome. The authors' case in a 46-year-old patient is discussed.

RESULTS

The presenting symptoms of cervical eosinophilic granuloma are usually pain and restricted range of motion. In contrast to eosinophilic granuloma of the thoracic spine and lumbar spine, the neurologic symptoms are less frequent, and the first radiographic sign is an osteolytic lesion. Vertebra plana is a rare sign in cervical eosinophilic granuloma. In children, the middle cervical spine is most often affected, whereas in adults it is the second vertebra. The outcome of the patients has been good in most cases, independently of treatment.

CONCLUSION

In most cases of cervical eosinophilic granuloma, immobilization is an adequate therapy. If the process continuous to progress, radiotherapy is recommended. Surgical treatment should be reserved for cases with instability or neurologic defects.

Cervical spine cord compression by eosinophilic granuloma. Case report

Eosinophilic granuloma is a term reserved for the most often and benign form of disorder known as Langerhans cells histiocytosis. It is a disease of children and adolescents that very rarely affects adults, representing the localized form of a pathological proliferation of histiocytes in bones, like skull and long bones. Vertebral involvement is uncommon, approximately 8% of the cases, being the cervical localization the least affected. Moreover, the involvement of the spinal cord and roots remains a rare occurrence. Only five cases characterized by signs of cervical spinal cord compression have been reported. We report the sixth case in a 42-year-old-man who evolved with resolution of symptoms, and has remained asymptomatic after treatment. The clinical, radiological and histological features and, also, the value, in selected cases, of surgical treatment followed by low-dose radiation therapy is discussed. A review of the pertinent literature is also presented.