Multifocal eosinophilic granuloma of the jaw: long-term follow-up of a novel intraosseous corticoid treatment for recalcitrant lesions

Percutaneous CT-guided corticosteroid injection for the treatment of osseous Langerhans cell histocytosis: a three institution retrospective analysis

PURPOSE

The aim of this study is to evaluate the safety and effectiveness of CT-guided corticosteroid injection for the treatment of osseous Langerhans cell histiocytosis (LCH) in a multi-institutional study.

MATERIALS AND METHODS

This IRB-approved study included patients from three institutions. We retrospectively reviewed clinical, procedural, and imaging data for corticosteroid injections performed to treat osseous LCH. Location of the lesion, lesion maximum dimension and volume, corticosteroid type and dose, and time interval between injection and change in lesion size/volume and symptoms were recorded. Generalized estimating equations (accounting for multiple lesions per subject) were used to evaluate the association between predictors (dose, maximum lesion dimension, and lesion volume) and outcomes (time to partial and complete radiographic resolution, and time to pain control). This analysis was adjusted by anatomic site.

RESULTS

Forty corticosteroid injections were performed in 36 patients (20 (56%) females, and 16 (44%) males, ages 12 ± 11 (2-57) years). Mean lesion maximum dimension was 3.2 ± 1.7 cm, and volume was 10 ± 17 cm³. Imaging and clinical follow-up were available for 22/40 (55%) and 34/40 (85%) of injections, respectively. All lesions responded to corticosteroid injection. Times to partial and complete imaging resolution were 13 ± 9 and 32 ± 13 weeks, respectively, and time to pain resolution was 22 ± 14 weeks. There were no complications.

CONCLUSION

CT-guided corticosteroid injection is a safe and effective treatment for LCH. Pain resolution was achieved in all patients and imaging did not show progressive disease in any of the patients.

Multifocal eosinophilic granuloma of the jaws with long-term follow-up: a case report

Eosinophilic granuloma, a rare disease, has various clinical manifestations and no specific X-rays features and is thus easily misdiagnosed. This paper reports a case of multifocal eosinophilic granuloma of jaw with long-term follow-up. The patient initially presented with periodontal tissue destruction.The diagnosis, treatment and prognosis of multifocal eosinophilic granuloma of jaw were discussed in combination with the literature to alert this disease in clinical practice.

Eosinophilic Granuloma of the Mandible

Eosinophilic granuloma (EG) is a rare histiocytic disorder resulting from clonal proliferation of Langerhans cells. Eosinophilic granuloma, the most benign of the three entities of Langerhans cell histiocytosis, may be multiple or solitary. This lesion can affect any bones but commonly involves the mandible when the jaws are affected. It is difficult to make a correct diagnosis on it without proof of a pathological diagnosis, which correlates with the diverse clinical and radiographic presentations of EG in the jaws. This report describes a case of unifocal EG of the mandible occurring in a 6-year-old boy whose initial presentation led to confusion of any solitary bony lesion. A final diagnosis of EG was established after histopathological examination of the biopsy specimen.

Intra-Lesional Medicaments for the Management of Intra-Osseous Lesions of Maxilla and Mandible - Systematic Review

Aims and Objectives:

This study aimed to review the success or remission of intralesional medicaments in the management of intraosseous lesions in the oral cavity.

Materials and Methods:

A comprehensive search was performed in two databases (PubMed and Scopus). Research articles, case reports, case series, and clinical trials were included. Review articles, lesions not involving the bone, incomplete reporting, any other treatment other than intralesional medicaments to treat intraosseous bone lesions, publications without any treatment, and letter to editor were excluded. Data on remission (complete, partial, or no remission), details and regimen of the intervention, number of participants, and follow-up in months were recorded.

Results:

A total of 653 publications were available for title and abstract screening after the removal of duplicates. Seven articles were excluded, which were not in English. After title and abstract screening, a total of 88 publications were available for full-text screening. Fifty-five articles were included in qualitative synthesis. A total of 168 patients from 55 publications were evaluated. Minimum follow-up was 1 month and maximum was 264 months. More than two-third (n = 38) of the publications were case reports on single patient. More than two-third (n = 38) of the publications had complete remission.

Conclusion:

Intralesional medications have shown variable success rates. Extensive lesions may undergo intralesional medications followed by surgical management.

Outcome of Surgery as Sole Treatment of Eosinophilic Granuloma of Jaws

Langerhans cell histiocytosis (LCH) is characterized by the congregation of proliferating langerhans cells (LC). Langerhans cells are a part of dendritic cell system of primary immune response that is responsible for presenting antigen to lymphocytes. Being a rare disease, the total incidence of LCH is reported to be 1 in 2 million people. LCH mainly affects children and young adults, with a slight male predilection. LCH is clinically divided into three groups namely Letter-Siwe disease (multiple multi organ affecting LCH at very young age), Hand-Schuler-Christian disease (LCH of bone involvement exophthalmos and diabetes insipidus), and Eosinophilic granuloma (LCH of bone, solitary or multiple). The extent of involvement influences the treatment planning. In this retrospective study, we survey five patients with eosinophilic granuloma in jaws (bony LCH). The diagnosis was confirmed by tissue biopsy and histopathologic examination. Surgery and curettage of the lesions were carried out under general or local anesthesia. After surgery, the patients were examined clinically every 6 month in the first year and then once in a year. The overall outcome was excellent. According to the results, it can be concluded that surgical curettage of localized eosinophilic granuloma is an appropriate and sufficient treatment.

Intralesional Triamcinolone for Treating Mandibular Langerhans Cell Histiocytosis: A Case Report and Literature Review

Langerhans cell histiocytosis is a rare condition ranging in manifestation from a focal boney lesion to multisystem involvement. Several treatment modalities have been proposed including curettage, low-dose radiotherapy, chemotherapy and intralesional injection of corticosteroids. These treatment options can be used as a single or combined approach. Prognosis depends on the extent of systemic involvement, and solitary lesions respond favorable to treatment. Here, the authors report a case of a 10-year-old male patient with Langerhans cell histiocytosis affecting his right posterior mandible that was successfully treated with intralesional injection of triamcinolone in multiple sessions. Complete recovery was confirmed clinically and radiographically in 18 months from the time of diagnosis.

Reconstruction of a severe mandibular pathological fracture caused by Langerhans cell histiocytosis using a free fibula osteocutaneous flap:a case report

Langerhans cell histiocytosis (LCH) is a rare disease in which Langerhans cells, which are bone marrow-derived antigen-presenting cells, proliferate in single or multiple organs. We successfully treated a patient with unifocal LCH of the mandible with malocclusion due to a severe pathological fracture, using reconstruction with a vascularised free bone.

Multifocal Eosinophilic Granuloma of Jaws and Skull with Classical and Unusual Radiographic/Imaging Findings

Eosinophilic granuloma is basically a disorder of reticuloendothelial system and is one of the variants of langerhans cell histiocytosis. Multifocal eosinophilic granuloma affecting jaws and skull is relatively a rare disorder. We hereby report a case of multifocal eosinophilic granuloma involving mandible, maxilla and several skull bones. The present case has mixture of classical floating teeth appearance and an unusual radiographic/imaging finding of periosteal remodeling, which is rarely seen in adult patients of eosinophilic granuloma and pseudo-multilocular appearance in anterior mandibular region in coronal sections and moth-eaten appearance of skull was appreciated in axial slices of Computed Tomography (CT).

Spontaneous remission of eosinophilic granuloma of the maxilla after incisional biopsy: a case report

Background

Langerhans cell histiocytosis (LCH), previously known as Histiocytosis X, is an infrequent disease that congregates a wide spectrum of clinical presentations with variable systemic involvement. Unification of these diseases under only one category is based on the almost identical histopathologic features of the lesions, but the etiology and proper approach for each presentation remains controversial. The localized alternative of Langerhans cell histiocytosis (LLCH), known as Eosinophilic Granuloma (EG) of bone, is the predominant clinical presentation of LCH. The maxilla is involved in 1 % of the head and neck region cases, representing an uncommon condition in this area.

Case Presentation

In this clinical case report, it is described a case of a 16-year-old male patient with an asymptomatic osteolytic lesion at first upper left molar apical level, a finding detected on control radiographic images was reported as “Monostotic Eosinophilic granuloma of the maxillary bone”, which was later confirmed through an incisional biopsy. A surgical excision was initially planned, but finally it was not performed due to a spontaneous healing of the lesion after the incisional biopsy.

Conclusions

The presented case supports a conservative approach in the management of solitary EG of maxillary and mandibular bone lesions and even supports an expectant attitude in the course of treatment given the possibility of a spontaneous regression after the biopsy, especially in small lesions.

Treatment of mouth and jaw diseases with intralesional steroid injection

Many lesions of the oral region are treated with surgical methods such as curettage and resection. Chemotherapy and radiation therapy with or without surgical intervention can be used as an adjunct in some cases. Intralesional steroid injection is a conservative procedure which is already used in various regions of the body and joints. This technique is used also for a number of mouth and jaw lesions. Localized langerhans cell histiocytosis, central giant cell granuloma, oral submucous fibrosis, oral lichen planus, lichen sclerosus of the oral mucosa, lymphatic malformations and orofacial granulomatosis can be considered among these diseases. The purpose of this review is to investigate the effects of intralesional steroid injections in the treatment of oral diseases.

Adult onset asynchronous multifocal eosinophilic granuloma of bone: an 11-year follow-up

Multifocal eosinophilic granuloma (EG) is a rare observation within the spectrum of histiocytosis X, generally described in children. We report the case of a 33-year-old man with multifocal EG showing an asynchronous evolution of bone lesions during a follow-up of 11 years. We also present the therapeutic approach chosen for this patient and the repeated magnetic resonance imaging (MRI) examinations used to monitor the disease with a final favorable outcome.

Eosinophilic granuloma of the mandible: a diagnostic dilemma

Eosinophilic granuloma (EG) is a rare histiocytic disorder resulting from clonal proliferation of Langerhans cells. It accounts for less than 1% of all osseous neoplasms and has a predilection for involving the axial skeleton. Although suspicion of the disease may arise from clinical features and radiographic demonstration of destructive bone lesions, it is still difficult to make a correct diagnosis without proper pathological evaluation. This is more evident when common differentials mimicking EG, both clinically and radiologically, need to be ruled out. This report describes a case of unifocal EG of the mandible occurring in a 4-year-old boy whose initial presentation led to confusion between osteomyelitis, primary bone tumour and lymphoma. A final diagnosis of EG was established after histopathological examination of the biopsy specimen.

Treatment of localized Langerhans' cell histiocytosis of the mandible with intralesional steroid injection: report of a case

Localized Langerhans cell histiocytosis (LLCH), formerly known as eosinophilic granuloma, mainly affects the skull, mandible, vertebrae, and ribs in children and the long bones of adults. Symptoms range from none to pain, swelling, and tenderness over the site of the lesion. General malaise and fever occasionally are present. Radiographically, lesions appear as radiolucent areas with well demarcated borders. LLCH may resolve spontaneously after biopsy in a period of months to years. However, if features include continuous pain, decrease of function, pathologic fractures, migration and resorption of teeth, or rapid progression, then active treatment needs to be considered. Treatment approaches include surgery, radiotherapy, chemotherapy, and intralesional injection of corticosteroids. In children with mandibular LLCH, 1 dose of methyprednisolone succinate injection has proven to be adequate. However, injections have not been performed in cases involving pathologic fracture. We report a new case of LLCH of the mandible that caused a pathologic fracture in an adult patient. Repeated intralesional corticosteroid injections resulted in fracture line disappearance within 14 months and lesion healing by the end of the 36-month follow-up.

Intralesional corticosteroid therapy for mandibular Langerhans cell histiocytosis preserving the intralesional tooth germ

BACKGROUND

Langerhans cell histiocytosis (LCH, histiocytosis X, ICD-O 9751/1) refers to a neoplastic proliferation of Langerhans cells. The course of the disease determines the treatment and prognosis. Solitary forms (eosinophilic granuloma) and limited multilocational lesions may be treated successfully with local surgical intervention and intralesional corticosteroid injection.

PURPOSE

Presentation of our own case will review LCH, a very rare disease entity in oral-facial surgery and will document that intralesional corticosteroid injection is a less invasive alternative to the classical surgical curettage and local radiation therapy.

CASE REPORT

In a 10-year-old boy, a progressive, pressure-sensitive swelling had developed within 1 week in the left paramandibular and submandibular area. Dental status was good. Diagnostic imaging demonstrated a diffusely contoured osteolysis caudal to tooth germ 37 with infiltration of the adjacent chewing muscles. Histological evaluation of the intraoral biopsy sample established an LCH. Having excluded a multifocal form of LCH, treatment with intralesional injection of methylprednisolone 200 mg was chosen. Symptoms of pain were quickly relieved and the swelling receded. Follow-up visits 6 weeks, 3 months, and 6 months after corticosteroid injection revealed continuous regression of mandibular osteolysis. OPG and MRI after 17 months demonstrated a good osseous consolidation in the left mandibular angle area, but a still discernible bone marrow edema. Development of the intralesional tooth germ 37 appeared normal.

CONCLUSION

Local surgical interventions continue to be central to the range of accepted therapeutic measures. However, the increasing numbers of reports on the successful treatment of solitary LCH by intralesional corticosteroid injection suggest that this treatment option should be considered especially in children to preserve tooth germs.

Eosinophilic granuloma of the jaws: an analysis of clinical and radiographic presentation

Eosinophilic granuloma (EG) is the localized and mildest form of histiocytosis-X group of diseases. In this study, 22 patients of pathologically proven EG involving the jaws were retrospectively studied concerning the clinical and radiographic presentation. The clinical and radiographic presentation of the 22 cases was quite varied, and the accuracy of clinical and radiographic diagnosis was low. However, the clinical and radiographic presentation correlated with the lesion site, and accordingly all the jaw lesions could be divided into three types (Alveolar Type, Intraosseous Type, and Mixed Type). Our classification based on the lesion sites reveals the correlation between the clinical and radiographic presentation of EG and the lesion sites, and may be useful in the identification of lesions of EG in the jaws.

Langerhans cell histiocytosis: current insights in a molecular age with emphasis on clinical oral and maxillofacial pathology practice

Langerhans cell histiocytosis (LCH) commonly involves the oral and maxillofacial region, and comes to the attention of dental practitioners when a patient presents with orofacial pain and a bony or soft tissue lesion. This is a relatively rare entity, which has made it difficult to investigate the clinical, biologic, and molecular aspects of the disease. Treatment protocols are not well defined, particularly in adults. During the past decade, the Histiocyte Society has formulated various LCH categories, based on risk stratification, and treatment protocols for the pediatric population. Adult trials are currently available through the Histiocyte Society. Although there has been considerable controversy, the neoplastic nature of LCH has been established by demonstrating clonality. LCH symptoms and the development and persistence of LCH lesions have been ascribed to a "chemokine/cytokine storm" due to autocrine and paracrine mechanisms. Discovery of biologic, cytogenetic, and molecular abnormalities in LCH have already affected treatment by providing novel therapeutic targets.

Intralesional infiltration of corticosteroids in the treatment of localised langerhans' cell histiocytosis of the mandible Report of known cases and three new cases

Langerhans' cell histiocytosis (LCH) can involve virtually any site and organ of the body, either as an isolated lesion or as a widespread systemic disease. Bone can be involved as a part of generalised disease or as a separate entity, formerly known as eosinophilic granuloma. The clinical cause of localised LCH (LLCH) to bone is generally benign. Solitary bone lesions may resolve spontaneously after diagnostic biopsy in a period of months to years. If treatment is indicated, as in larger lesions with pain, swelling and risk for spontaneous fracture, the disease can be controlled by chemotherapy or local measures such as surgical curettage, low-dose radiotherapy and intralesional injection of corticosteroids. There are no controlled studies in the literature comparing outcomes of these treatment modalities because of low incidence of the disease and general tendency to regress. Three patients (female, 28 months; male, 9 years; male, 15 years) with LLCH of the mandible were treated in an one stage procedure with intralesional injection of 80, 40 and 80 mg methylpredisolone succinate, respectively, as the primary form of treatment. Patients were seen for clinical and radiological evolution 1, 3, 6, 9 and 12 months after treatment, and yearly thereafter. The overall outcome was excellent. The lesions showed clinically and radiologically complete remission approximately 6 months after treatment. There were no complications nor morbidity of the treatment. After a follow-up period of 12 months, the patients are well with no evidence of residual disease on radiographs. Local injection of corticosteroids should be the initial choice of treatment of LLCH of the mandible, because of the favourable treatment outcome in this disease and possible complications and lasting effects of surgery, radiotherapy and chemotherapy.

Eosinophilic granuloma: resolution of maxillofacial bony lesions following minimal intervention. Report of three cases and a review of the literature

INTRODUCTION

Langerhans' cell histiocytosis is a collective term used to describe a group of enigmatic proliferative disorders. The natural history of the disease varies from a slow, benign, localized symptomatic bony or soft tissue lesion, to a rapidly progressive widespread multiple organ disorder which is often fatal. Eosinophilic granuloma accounts for 60-70% of all cases of Langerhans' cell histiocytosis and can present as solitary (50-75%) or multifocal defects in bone. It occasionally presents as a localized soft tissue lesion. There are multiple treatment options but the response is unpredictable.

AIMS

We present three separate cases, of the maxillofacial skeleton where the lesions of eosinophilic granuloma resolved following incisional biopsy only.

PATIENTS AND RESULTS

Three patients presented with solitary lesions of the maxillofacial skeleton. All were diagnosed as Langerhans' cell histiocytosis following open curettage, which also resulted in resolution of the lesions. Follow-up has thus far been disease free.

CONCLUSION

For some solitary Langerhans' cell histiocytosis lesions, simple curettage is the only treatment required. The paper discusses the need to confirm the solitary nature of the disease and the need for follow-up. Reviewing the literature on the disease, the authors suggest that perhaps cellular immaturity holds the cells of the lesion in a disease state until pushed to maturity by the trauma of open curettage surgery, resulting in a complete resolution of the disease.

Eosinophilic granuloma of the bone: ultrasonographic imaging

Eosinophilic granuloma is a rare disease of unknown aetiology that affects the bones. Two cases of eosinophilic granuloma are presented. Ultrasonographic, CT and histopathological findings are described. Ultrasonographic-guided core-needle biopsy was performed. Treatment was initiated by installing steroid suspension into the lesions, which resulted in complete healing of the bone in both cases.

Langerhans' cell histiocytosis diagnosed through periodontal lesions: a case report

BACKGROUND

Langerhans' cell histiocytosis (LCH) is a rare disorder in which a neoplastic proliferation of cells similar to the Langerhans' cell of the epidermis is observed. The disease may affect different organs as solitary or multiple lesions with a complete dissemination in different organs such as the bone (jaws), lung, hypothalamus, skin and mucous membranes, lymph nodes, liver, and other tissues. Although LCH is considered a childhood or juvenile disease, the diagnosis is often made in adults, and in many cases, a juvenile form progresses into adult life. Hand-Schuller-Christian disease (HSCD) is an LCH form in which the typical lesions Involve the cranial bones, the eyes, and the pituitary gland.

METHODS

This article describes a case of a patient diagnosed, through periodontal lesions and diabetes insipidus, as having Langerhans' cell histiocytosis.

CONCLUSION

As far as LCH lesions appearing in periodontal tissues, the periodontist should be involved in the detection of oral lesions.

A rare condition of Hand-Schüller-Christian disease

The authors present the clinical case of a 61-year-old patient with Hand-Schüller-Christian disease associated with multisystemic involvement. The onset of such puzzling symptoms and the extremely rarity of this disease in a patient of such advanced age resulted in a delayed diagnosis and subsequently delayed treatment of the patient.

Oral Langerhans cell histiocytosis

AIM

Our aim is to compare the different methods of treatment available for Langerhans cell histiocytosis (LCH) in the oral and maxillo-facial region. A classification based on clinical and immunohistochemical data is proposed and a grading for the severity of the disease is proposed.

PATIENTS AND METHODS

Records and clinical data of 12 patients were evaluated retrospectively. The patients' ages ranged from 20 months to 47 years. Nine had manifestations in the maxillo-facial region, of which six had a single oral lesion only, with the three remaining patients having multiple lesions in this region. Three patients had lesions in the upper thorax in addition to their oral lesions. Eleven patients were treated surgically with one having been treated previously with steroid-therapy. One patient had already been treated with chemotherapy. The longest follow-up was 16 years. Immunohistochemical stains for antigen-CD-1a, antigen-S-100 and antigen-Ki-67 were performed. A proposal for staging the lesions in the oro-maxillo-facial region was made. The intensity of the antigen-Ki-67 stains was evaluated.

RESULTS

Eleven patients exhibited no signs of recurrence whilst only one patient had a recurrence implying that surgical treatment was very effective in eradication and cure of the disorder. It is felt that the number of antigen-Ki-67 positive cells is related to the activity of the disease.

CONCLUSION

Langerhans cell histiocytosis should be treated surgically. Only in very severe cases should surgical treatment be complemented with either radio-therapy or chemotherapy. Especially in disseminated cases, chemotherapy would appear to improve the outcome. The antigen Ki-67 as proliferation marker is suggested as a grading parameter of this disease.