The great mimickers: Castleman disease

Diagnostics différentiels de la maladie de Castleman

Clinicians are sometimes confronted with the diagnostic difficulties of the idiopathic form of Castleman's Disease (iMCD). As this review reports with demonstrative clinical cases, iMCD can mimic various serious systemic pathologies such as certain autoimmune diseases, Still's disease, POEMS syndrome, and malignant lymphoproliferations, sharing a very similar histology and identical symptoms. To make a diagnosis of iMCD, the clinician must eliminate all the pathologies mentioned above, but he must first think of it and evoke this diagnosis of rare disease before the first symptoms but also know how to evoke this diagnosis again even after several years of evolution of a disease like those mentioned above whose evolution is not favorable. © 2022 Published by Elsevier Masson SAS on behalf of Société nationale française de médecine interne (SNFMI).

Human Oncoviruses and Thoracic Tumors: Understanding the Imaging Findings

Approximately 1.4 million virus-induced cancers occur annually, representing roughly 10% of the cancer burden worldwide. Seven oncogenic DNA and RNA viruses (ie, oncoviruses) are implicated in approximately 12%-25% of all human cancers owing to a variety of mechanisms as uncommon consequences of the normal viral life cycle. These seven well-recognized human oncoviruses are Epstein-Barr virus (EBV), human T-lymphotropic virus 1, hepatitis B virus, hepatitis C virus, HIV, human papilloma virus (HPV), and human herpesvirus 8 (HHV-8). Several viruses-namely, EBV, HPV, and Kaposi sarcoma herpesvirus or HHV-8-are increasingly being recognized as being related to HIV and/or AIDS, the growing number of transplant cases, and the use of immunosuppressive therapies. Infectious and inflammatory processes, and the accompanying lymphadenopathy, are great mimickers of human oncovirus-related tumors. Although it is often difficult to differentiate these entities, the associated clinical setting and radiologic findings may provide clues for an accurate diagnosis and appropriate management. Malignant lymphoid lesions are best evaluated with multidetector chest CT. The radiologic findings of these lesions are often nonspecific and are best interpreted in correlation with clinical data and histopathologic findings. ^©RSNA, 2022.

[Multicentric Castleman's disease combined with polyserositis and POEMS syndrome: case report and review article]

Castleman disease (CD) is a very rare disorder characterised by hyperplasia of the lymphoid tissue. The aetiology varies considerably and includes autoimmunological, infectious, autoinflammatory and paraneoplastic diseases (e.g. MGUS with POEMS syndrome). What they all have in common is usually a dysregulation/overproduction of certain cytokines and growth factors (including interleukin 6 and VEGF). The sum of these changes sometimes causes very heterogeneous symptoms and thus often makes early diagnosis difficult. The prognosis of unrecognised and untreated disease is very serious and has an average 5‑year survival rate of 55-77%. The present paper describes the case of a 79-year-old patient with refractory polyserositis who was correctly diagnosed after > 8 years.

The value of multiparameter 18F-FDG PET/CT imaging in differentiating retroperitoneal paragangliomas from unicentric Castleman disease

The aim of this study was to investigate the value of multiple parameters retrieved from the FDG PET/CT studies, including SUVmax, SUVmean, SUVpeak, MTV, TLG, tumour size in differentiating retroperitoneal paragangliomas from UCD. 28 patients with solitary retroperitoneal masses who had undergone preoperative 18F-FDG PET/CT were retrospectively evaluated. Histopathology by surgical resection confirmed 17 paragangliomas and 11 UCDs. SUVmax, SUVmean, SUVpeak, MTV, TLG, and tumour size of 18F-FDG PET/CT were measured for each patient. Mann-Whitney U-test was used to assess differences in multiple parameters between paragangliomas and UCDs. The ROC curve analysis was performed to determine the differential diagnostic value of these parameters. Paragangliomas presented significantly higher SUVmax (P < 0.001), SUVmean (P = 0.001), SUVpeak (P < 0.001), and TLG (P = 0.024) than UCDs, whereas no significant difference was observed in MTV. The AUCs for differentiating paragangliomas and UCDs were 0.920, 0.888, 0.909, and 0.765 for SUVmax, SUVmean, SUVpeak, and TLG, respectively. The SUVmax cut-off of 7.75 yielded 82.4% sensitivity and 100% specificity for predicting paragangliomas. This study indicated that 18F FDG PET/CT-derived multiple metabolic parameters are useful in distinguishing between paragangliomas and UCDs. SUVmax showed the best result for the differential diagnosis of these two diseases among multiple metabolic parameters.

Retroperitoneal Castleman Disease Invading Iliac Vein and Inferior Vena Cava Treated by Tumorectomy with Vascular Repair: A Case Report

Unicentric Castleman disease, a rare lymphoproliferative disorder, is always known as a solitary, well-defined lymph node enlargement. We reported an extraordinary case of retroperitoneal Castleman disease, which invades wall of right iliac vein and inferior vena cava, treated successfully by tumorectomy with vascular repair.

Emergent high fatality lung disease in systemic juvenile arthritis

OBJECTIVE

To investigate the characteristics and risk factors of a novel parenchymal lung disease (LD), increasingly detected in systemic juvenile idiopathic arthritis (sJIA).

METHODS

In a multicentre retrospective study, 61 cases were investigated using physician-reported clinical information and centralised analyses of radiological, pathological and genetic data.

RESULTS

LD was associated with distinctive features, including acute erythematous clubbing and a high frequency of anaphylactic reactions to the interleukin (IL)-6 inhibitor, tocilizumab. Serum ferritin elevation and/or significant lymphopaenia preceded LD detection. The most prevalent chest CT pattern was septal thickening, involving the periphery of multiple lobes ± ground-glass opacities. The predominant pathology (23 of 36) was pulmonary alveolar proteinosis and/or endogenous lipoid pneumonia (PAP/ELP), with atypical features including regional involvement and concomitant vascular changes. Apparent severe delayed drug hypersensitivity occurred in some cases. The 5-year survival was 42%. Whole exome sequencing (20 of 61) did not identify a novel monogenic defect or likely causal PAP-related or macrophage activation syndrome (MAS)-related mutations. Trisomy 21 and young sJIA onset increased LD risk. Exposure to IL-1 and IL-6 inhibitors (46 of 61) was associated with multiple LD features. By several indicators, severity of sJIA was comparable in drug-exposed subjects and published sJIA cohorts. MAS at sJIA onset was increased in the drug-exposed, but was not associated with LD features.

CONCLUSIONS

A rare, life-threatening lung disease in sJIA is defined by a constellation of unusual clinical characteristics. The pathology, a PAP/ELP variant, suggests macrophage dysfunction. Inhibitor exposure may promote LD, independent of sJIA severity, in a small subset of treated patients. Treatment/prevention strategies are needed.

Castleman Disease in a Patient with Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency due to a disorder of the adaptive immune system which causes hypogammaglobulinemia and therefore an increased susceptibility to infection; noninfectious, inflammatory conditions including systemic autoimmunity and lymphoproliferative complications are also commonly associated with CVID. Castleman disease (CD) is a systemic disease clinically characterized by diffuse lymphadenopathy, splenomegaly, anemia, and systemic inflammatory symptoms. This makes CD a great mimicker of more common benign and malignant masses in the neck, chest, abdomen, and pelvis. A novel case of primary immunodeficiency (CVID) in a middle-aged woman, who developed multicentric CD (MDC) with splenomegaly, is described. The authors suggest that the onset of MCD and of the correlated splenomegaly was due to incorrect management of the hypogammaglobulinemia as immunoglobulin G (IgG) levels were not kept within normal ranges. Correct management of the hypogammaglobulinemia allowed splenectomy to be performed without any infectious surgical complications. MCD is reported for the first time in association with an adult case of CVID. The above reported case highlights the need for a timely correct diagnosis and treatment of CVID to avoid complications, which could cause recourse to splenectomy, such as in our case or development of malignancies.

Rare finding in peripheral nerve surgery: an unicentric Castleman disease presenting as median nerve tumour

A 51 year old man presented with progressive swelling in the upper arm. MRI revealed a solitary mass extending from the median nerve. Intraoperative finding was a tumour extending within the nerve in its proximal fibres. The histological result showed a Castleman disease.

Castleman disease versus lymphoma in neck lymph nodes: a comparative study using contrast-enhanced CT

BACKGROUND

The purpose of this study was to determine the contrast-enhanced CT characteristics for differentiating between Castleman disease (CD) and lymphoma in neck lymph nodes.

METHODS

This retrospective study evaluated the number (solitary or multiple), strength of contrast-enhancement, type of contrast-enhancement, surrounding vessels, contrast-enhanced Hounsfield unit (HU) values, and anatomical distributions of lymph nodes in 34 patients with confirmed CD and 55 patients with newly diagnosed untreated lymphoma. Independent t-tests, receiver operating characteristic (ROC) curve analysis, and chi-square tests were used to evaluate the variables and CT features.

RESULTS

Several significant differences were found between CD and lymphoma. The interval between first contrast-enhanced CT and biopsy/surgery was significantly longer in the CD group (mean 72 ± 105 days, median 60 days) than in the lymphoma patients (mean 30 ± 2 days, median 12 days; p = 0.015). The lymphoma patients presented significantly more often with fatigue and fever (p = 0.023 and p = 0.016 respectively) than did the CD subjects. HU values of nodules after enhancement were significantly higher in the CD patients than in the lymphoma patients. In cases involving multiple lymph nodes, in all the CD cases, all affected nodes were located in only the left or right side of the neck, not bilaterally. ROC analysis showed a significant difference in contrast-enhanced CT attenuation values between lymphoma and CD (p < 0.001, area under the curve = 0.954), with a cut-off value of 92.5 HU. We constructed a decision tree according to these imaging characteristics.

CONCLUSIONS

Contrast-enhanced CT can be useful for differentiating between CD and lymphoma.

IgG4-related disease involving polyserous effusions with elevated serum interleukin-6 levels: a case report and literature review

Immunoglobulin G4-related disease (IgG4-RD) is a recently described immune-mediated fibroinflammatory disease with a characteristic histopathologic appearance that can affect various organs. We report a 43-year-old Chinese female patient with IgG4-RD involving polyserous effusions with reports of worsening exertional dyspnea for 3 months. Laboratory blood tests revealed that serum interleukin (IL)-6, carbohydrate antigens (CA-199 and CA-125), and alpha-fetoprotein levels were significantly increased, but serum IgG4 levels were normal. Repeat pleural effusion and ascite analysis showed lymphocyte-predominant exudates. In addition, computed tomography scan showed massive pleural effusion in the right pleural cavity, abdominal effusion, and some pericardial effusion with a partial compression atelectasis. Further, medical thoracoscopy was performed to examine the pleural cavity and found multiple nodules on the pleura and partly thickened pleura with a reddish color. Histopathologic and immunohistochemical examination revealed marked lymphocytes and IgG4-positive plasma cell infiltration. The patient was finally diagnosed with IgG4-RD according to the comprehensive diagnostic criteria, although the patient presented similar serological and pathological manifestations of Castleman disease (CD). Our case suggests that IgG4-RD may be one of the causes of polyserous effusions and shows the difficulties in differentiating between IgG4-RD and CD.

Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment

Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.

Case report: Castleman's disease in trachea

Castleman’s disease (CD) in trachea is rarely reported to date. This report introduces a case of CD in trachea with emphasis on its radiological presentation onCT. A female patient was admitted at our emergency department with dyspnoea. Plain and enhanced CT revealed a mass with distinct border and marked enhancement. Tracheotomy was planned and it turned out to be CD of hyaline type on pathological examination. Two similar case reports on intratracheal CD from 1954 to 2015 were reviewed as we searched in PubMed using key words “endotracheal Castleman’s disease” or “Castleman’s disease in trachea” or “Castleman’s disease in tracheal”. This will be the third case report of CD in trachea in English literature. In this case report, the radiological appearance of CD on multiple imaging modes is reviewed. Lesions that should be taken into consideration in differential diagnosis are mentioned. The two main surgical methods for such lesions are briefly described.

Castleman Disease: A Rare Condition with Endocrine Manifestations

Castleman disease (CD) most commonly affects lymphoid tissues in the thorax, abdomen, pelvis, and neck. Extralymphatic tissues, such as lacrimal glands, lung, pancreas, larynx, parotid, meninges, and even muscles, have also been reported as sites. The etiology is unknown and its incidence has not been reported in the literature. Castleman disease can be classified clinically into a unicentric or multicentric form, depending on the number of lymph nodes involved, and histologically into a hyaline vascular variant, plasma cell, mixed cellular, or plasmablastic variant. The disease has a predominantly inflammatory background, reflected in high levels of vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6). The role of cytokines in CD explains the clinical presentation. The clinical scenario varies widely, based mainly on the histologic type. Unicentric CD usually presents without symptomatology, whereas multicentric manifests with fatigue, abdominal or thoracic pain, cytopenias, and/or B- symptoms (10% weight loss in the last six months, nocturnal diaphoresis, and fever). The endocrinopathy has a wide range of manifestations, affecting either the pituitary or other target organs. Achieving the diagnosis is complicated and there is no laboratory or imaging pathognomonic for this disease. The gold standard is an excisional biopsy from an affected lymph node. The treatment depends on the type of CD. Unicentric CD has a good response to excisional surgery. However, in multicentric CD (MCD), surgery may provide transient relief of symptoms but with a rebound effect, so it is not considered a good method. The use of chemotherapy, monoclonal antibodies, glucocorticoids, and thalidomide has shown some improvement in MCD.