Langerhans cell histiocytosis of the female genital tract: a literature review

Genital Ulcer Disease: A Review of Pathogenesis and Clinical Features

Genital ulcer disease can be caused by a wide variety of sources. Most commonly, genital ulcer disease is grouped into infectious and noninfectious causes. HSV, syphilis, lymphogranuloma venereum, and chancroid represent some common infectious ulcers. Noninfectious causes on the other hand can be inflammatory, noninflammatory, or malignant (eg, squamous cell carcinoma). Depending on the etiology, genital ulcers may present with unique features that can help clinicians identify the etiology and start treatment in a timely manner. The clinical presentation and management of infectious and noninfectious genital ulcers will be discussed in this review.

Management of adult primary vulvar Langerhans cell histiocytosis: review of the literature and a case history

Primary vulvar Langerhans cell histiocytosis (LCH) is extremely rare and there are no standard treatment options. This review of the published literature with a case report aimed to clarify the optimal treatment for patients with this condition. Medline and PubMed were searched and all cases of primary vulvar LCH reported as single case reports or small case series were reviewed. A patient with vulvar LCH treated in this department is also reported. Twenty-seven cases, including the reported case, were reviewed. First-line treatments included surgery, radiotherapy, chemotherapy, thalidomide and local treatment. The mean follow-up time was 21.1±17.7 months. Although no patient died from the disease, recurrence rates were high (62%) and the mean time to relapse was 10.9±11.8 months (range 1-36 months). Treatment with thalidomide was successful, resulting in long-lasting remission. Disease recurrence is likely after surgery and or radiotherapy, and these treatments together with chemotherapy affect the patient's wellbeing adversely. Although definitive conclusions await further work, thalidomide has minimal adverse effects, is easy to administer and should be considered as a first-line treatment or as maintenance therapy in some patients.

Myometrial xanthomatosis: possible relationship to prior pregnancy procedure

We report 3 unique cases of extensive myometrial infiltration by foamy histiocytes in uteri removed for benign conditions. The histologic findings were similar and consisted of diffuse infiltration of myometrium by clusters, cords, and sheets of CD163-positive histiocytes with no other significant inflammatory cell component. Most of the histiocytes had pale, vacuolated, or foamy cytoplasm, but in 1 case eosinophilic granular cytoplasm was also present. In all cases, the nuclei were small and eccentric. No mitotic figures were identified. All cases involved young, parous women who had remote prior surgical interventions involving the uterus; 2 patients had a prior cesarean section and 1 had a prior therapeutic abortion. There was no associated neoplastic or infectious condition in any of the cases, and no patient had a prior history of pelvic inflammatory disease. Although we were unable to obtain more detailed obstetric history, an exuberant and persistent reaction to the surgical procedure and/or to a carrier substance for uterotonic intramyometrial injection may be the basis for this unusual reaction, which we designate as myometrial xanthomatosis.

A patient with lichen sclerosus, Langerhans cell histiocytosis, and invasive squamous cell carcinoma of the vulva

We report a patient with vulvar lichen sclerosus, Langerhans cell histiocytosis (LCH), and later vulvar cancer. In LCH, high amounts of non functional Langerhans cells are present in the affected tissue, making it possible that LCH may have contributed to vulvar cancer development in this patient.

Langerhans cell histiocytosis: Current concepts and treatments

Langerhans cell histiocytosis (LCH) is a rare proliferative disorder of cells with the phenotype of activated Langerhans cells. The diagnosis of LCH is often delayed or missed. Many questions about LCH remain to be answered, including whether it is caused by a malignancy or by immune dysregulation. Data from the early 1990s showed that LCH consisted of an accumulation of monoclonal LCH cells, suggesting a neoplastic disorder. However, further investigations with current sophisticated techniques have not shown consistent genomic aberrations. Recent data which suggests a role for an IL-17A dependant pathway of dendritic cell fusion in LCH remains to be proven. The most recent data taken together swing the pendulum towards an immunologic aberration. The clinical course of LCH is highly variable, ranging from a self-healing solitary bone lesion to widely disseminated life-threatening disease. Patients with multisystem (MS) disease with organ dysfunction, particularly those refractory to front line therapy, and those with multiple reactivations of disease associated with significant permanent sequelae represent the greatest challenge. Early switch of refractory patients to salvage therapies has contributed to the improvement in survival of MS-LCH patients. Due to the rarity of LCH in children and adults, patients must be enrolled on multi-national clinical trials, whenever possible, to advance our knowledge of the optimal therapeutic strategies and long-term outcomes.

Smooth Muscle Tumors of the Female Genital Tract

Smooth muscle tumors are the most common among mesenchymal tumors in the female genital tract. The vast majority of these neoplasms are clinically benign and easy to diagnose. In contrast, leiomyosarcomas are highly aggressive tumors that may pose considerable diagnostic problems when they display unusual (myxoid or epithelioid) morphology, ambiguous histologic features for malignancy, or an unusual anatomic distribution. Diagnostic criteria for these problematic tumors vary depending on the site and type of histologic differentiation, and are based on a combination of 3 major criteria: (1) moderate to severe cytologic atypia; (2) increased mitotic index; and (3) tumor cell necrosis. Certain benign smooth muscle proliferations may show worrisome histologic features or unusual growth patterns, causing concern for leiomyosarcoma. Furthermore, other tumors, including perivascular epithelioid tumors, may mimic leiomyosarcoma. Careful attention to the clinical and anatomic setting, cytologic and architectural features, and immunohistochemical characteristics are helpful in distinguishing these entities. This article discusses conventional smooth muscle tumors as well as unusual subtypes, with emphasis on the diagnostic criteria and problems in differential diagnosis that arise at each site within the female genital tract.

Clinical and immunohistochemical evaluation of the vulvar Langerhans cell histiocytosis

We present the case of a woman with diabetes insipidus with subsequent genital and multiorgan Langerhans cell histiocytosis (LCH). A monolateral and slightly infiltrated erythematous plaque of the vulva was observed. Hematoxylin and eosin and immunophenotypic studies were performed. The primary antibodies used were monoclonal antibody to S100, CD1a, CD34, HLA-DR, PCNA, CD45Ro, CD40, and langerin. The histology of the infiltrates revealed a granulomatous reaction pattern, with extensive aggregates of histiocyte proliferation. The histiocytes, morphologically characterized by a pale staining of cytoplasm surrounding a grooved reniform nucleus, sometimes contained small distinct nucleoli. Lymphocytes, eosinophils, macrophages, and both plasma cells and giant cells typically infiltrated the lesions. Cells CD1a+ and S100+ infiltrated the epidermic and were dispersed over the infiltrates as well as in clusters, and around the vessels. A considerable number of CD40-expressing cells were restricted to CD1a+ LCH cells. The specimen contained a high percentage of langerin+ cells in both the dermis and the epidermis. The clinical manifestations of LCH affecting the genital area can be diverse, and in most patients take the form of ulcers or erythematous plaques. Histopathologic examination of the lesion evidences a mixture of Langerhans cell histiocytes (CD1a+, S100+, HLADr+, CD207+, CD 40+), lymphocytes (predominantly helper [CD4] CD 45 Ro+), eosinophils, and macrophages. Each of the cell types produces a "cytokine storm." Many of the cytokines favor recruitment of Langerhans cell progenitors and rescue the Langerhans cell histiocytes from apoptosis.

Drug therapy for the treatment of Langerhans cell histiocytosis

Langerhans cell histiocytosis results from the abnormal accumulation of a class of dendritic cells normally found in the skin, which proliferate in many organ systems along with lymphocytes, macrophages and eosinophils. Standard therapy for Langerhans cell histiocytosis includes vinblastine and prednisone with or without methotrexate and mercaptopurine, depending on the extent of disease. Effective therapies for patients unresponsive to the above include cytosine arabinoside and cladribine. Thalidomide has proven useful for patients with Langerhans cell histiocytosis of the skin and/or bone. Emerging therapies include the use of monoclonal antibodies against the CD1a or CD52 epitopes found on Langerhans cells. Specific therapies directed against the cytokines that are apparently critical to the abnormal proliferation have not yet been defined.

A case of disseminated Langerhans' cell histiocytosis treated with thalidomide

Tumor necrosis factor alpha (TNF-alpha) seems to play a key role in the pathogenesis of Langerhans' cell histiocytosis (LCH). Thalidomide is an immunomodulator agent of inflammatory cytokines including TNF-alpha. To our knowledge this is the first case of disseminated LCH successfully treated with thalidomide.

Unusual recurrence in ureters and maxillary sinus of Langerhans cell histiocytosis involving mastoid bone

We present a case of Langerhans cell histiocytosis (LCH) diagnosed in the mastoid bone. The tumor recurred in the ureter and maxillary sinus mucosa two years later. The diagnosis of LCH was based on morphology and immunohistochemistry. Involvement of the ureter and the maxillary sinus in LCH is extremely rare. To the best of our knowledge, this is the first case of LCH affecting the mastoid bone in a 16-year-old boy and recurring later in the ureter and maxillary sinus mucosa.