Histiocytosis X--current controversies

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.

Eosinophilic granuloma: resolution of lesion after biopsy

Langerhans cell histiocytosis is a collective term used to describe a group of enigmatic proliferative disorders. Three disease variants include eosinophilic granuloma, Letterer-Siwe disease, and Hand-Schuller-Christian syndrome. Eosinophilic granuloma is reported to be the most benign type of the triad. In this report, a 7-year-old child with an eosinophilic granuloma of the left side of her mandible is presented. There was a painless, hard, tender mass arising from the left side of the molar region. Panoramic radiographs showed a radiolucent area at the molar region. The lesion was resolved 2 weeks after the biopsy. The 1.5 years of radiographic and clinical follow-up was satisfactory.

Multifocal intraparenchymal Langerhans' cell histiocytosis concomitant with an arachnoid cyst in a child: case report and review of the literature

Langerhans' cell histiocytosis is a disease usually found in children and characterized by idiopathic proliferation of histiocytes in the reticuloendothelial system. Intracranial Langerhans' cell histiocytosis presenting as multifocal intraparenchymal lesions is very rare. In this article, the authors report on a 4-year-old boy diagnosed with multifocal intraparenchymal Langerhans' cell histiocytosis concomitant with an arachnoid cyst. After a series of laboratory examinations, the right frontal mass was surgically excised. Histological examinations confirmed the diagnosis of intracranial Langerhans' cell histiocytosis. The patient's intracranial hypertension symptoms were alleviated, and the remaining foci were treated by Langerhans' cell histiocytosis-directed standard chemotherapy. At the 8-month follow-up visit, no recurrence of the excised lesion was found, and no change in the size of other lesions was seen. Supratentorial intracerebral lesions with mass effect and enhancement have rarely been described; in this report, the histological features of and therapeutic options for such a case are discussed.

Langerhans' cell histiocytosis of the temporal lobe and pons

Intracerebral Langerhans' cell histiocytosis (LCH) is rare and tends to involve the hypothalamus. The authors report a rare case of LCH in the temporal lobe that subsequently was followed by a brainstem lesion. This appears to be the first case of temporal lobe and brainstem LCH that has been treated successfully and published. A 24-year-old man complained of cacosmia and nausea with a slight headache. He had a left temporal LCH, which was removed completely, but developed a brainstem lesion a year later. The pontine LCH was treated with radiosurgery. The follow-up period was 4 years without any neurological or radiological symptoms or signs. The 12 cases of solitary intracranial non-hypothalamic LCH reported previously are reviewed. Gamma knife radiosurgery effectively controlled the local growth of the pontine LCH without adverse effect.

Langerhans cell histiocytosis

The clinical manifestations of Langerhans cell histiocytosis have been recognized for more than a century. For most of that time, physicians have viewed the disease from different perspectives, interpreting portions of its clinical spectrum as if they were distinct and unrelated entities. More recently, Langerhans cell histiocytosis has been unified into a single concept, though the disease continues to defy traditional classification. By most accounts, Langerhans cell histiocytosis appears to be a morphologically benign proliferation of inflammatory cells that escapes regulatory control mechanisms. Studies from patients with all stages of the disease, however, document clonal proliferation of immune processing cells (i.e., Langerhans cells), suggesting a malignant disease process. The most common ophthalmic manifestation of Langerhans cell histiocytosis is a solitary lesion of orbital bone, which typically responds to minimally invasive therapy. The best management of solitary orbital Langerhans cell histiocytosis is debatable and has been complicated by its recent designation as a risk factor for central nervous system disease. This article summarizes recent developments in understanding the biology of Langerhans cell histiocytosis, reviews its ophthalmic manifestations, prognosis, and the controversy surrounding treatment of isolated orbital disease.

Langerhans cell histiocytosis of the spine in children. Long-term follow-up

BACKGROUND

Langerhans cell histiocytosis causes destructive lesions in a child's spine. Few large, long-term studies have evaluated the clinical and radiographic presentation, natural history, outcomes of modern treatment approaches, and maintenance of normal spinal growth and stability after the diagnosis of this disease in children.

METHODS

Twenty-six children with biopsy-proven Langerhans cell histiocytosis involving the spine were treated at our institution between 1970 and 2003. They had a total of forty-four involved vertebrae (twenty cervical, fourteen thoracic, and ten lumbar). Vertebral body collapse was measured on radiographs and classified as grade I (0% to 50% collapse) or grade II (51% to 100% collapse) and subclassified as A (symmetric collapse) or B (asymmetric collapse). Lesions of the posterior elements of the spine were classified as grade III. Twenty-three children were followed for two years or more (mean, 9.4 years), and the analyses of treatment and long-term outcomes were performed in that group of patients.

RESULTS

There was a predominance of lesions in the cervical spine (p </= 0.02). Sixteen (62%) of the twenty-six children were found to have multifocal skeletal disease. Cervical and lumbar lesions were more commonly associated with multilevel spinal disease. The extent of the initial collapse seen radiographically was grade IA for twenty vertebrae, IB for three, IIA for ten, IIB for nine, and III for two. Grade-I lesions were more likely to be associated with symmetric collapse than were grade-II lesions. Spinal deformity developed in four children, and two later required spinal fusion. No relationship was observed between the grade of the initial collapse and the subsequent development of spinal deformity. Despite heterogeneous treatment, all patients were alive and well with resolution of all presenting signs and symptoms and no evidence of active disease at the time of the most recent follow-up.

CONCLUSIONS

We found a particularly high prevalence of lesions in the cervical spine and a high prevalence of multiple skeletal lesions. In contrast to the classic finding of vertebra plana, we found that more severe lesions often led to asymmetric collapse; yet, asymmetric collapse was not found to be associated with the development of subsequent spinal deformity. The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance.

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.

Langerhans cell granulomatosis: a case report of polyostotic manifestation in the jaw

We report the case of a 43-year-old woman who suffered from a polyostotic form of Langerhans cell granulomatosis (LCG) in the mandible and maxilla. The course of the disease was followed for more than 14 years. The disease's progression finally required subtotal resection of the mandible and reconstruction with a microvascular fibula graft. The literature is reviewed for diagnostic and treatment concepts based on the different stages of LCG.

Cyclosporine A therapy for multisystem langerhans cell histiocytosis

BACKGROUND

Treatment of multisystem Langerhans cell histiocytosis (LCH) remains difficult. Various regimens of single and multiagent chemotherapy have been used, but a significant proportion of patients fail to respond to treatment.

PROCEDURE

We have evaluated the use of cyclosporine A (CSA) in a controlled group of patients, who had received a systematic primary therapy (LCH-I). Patients received CSA either as a single agent (10 patients) or in combination with vinblastine, etoposide, prednisolone, and/or antithymocyte globulin (16 patients).

RESULTS

Among the total of 26 patients treated, a single patient developed a complete response and three a partial response, whereas 85% (22 patients) had no response to CSA.

CONCLUSIONS

CSA is at best of limited value in the treatment of patients with multisystem LCH, particularly those who had progressive disease while receiving chemotherapy.

Microsurgical excision of a primary isolated hypothalamic eosinophilic granuloma. Case report

Solitary focal eosinophilic granuloma (EG) is one element in the spectrum of diseases associated with Langerhans' cell histiocytosis (LCH). This report documents the occurrence of a primary isolated hypothalamic EG in a man who presented with diabetes insipidus and panhypopituitarism. His treatment consisted of complete microsurgical excision of the lesion. After a 13-month follow-up period, no residual tumor was evident on magnetic resonance imaging and no other lesions were present in peripheral tissues. This case is unique in several respects: 1) it is the third documented case of a primary isolated hypothalamic LCH granuloma diagnosed in a living patient; 2) it is the only known example of complete microsurgical excision of such a lesion in the hypothalamic region; and 3) it demonstrates the efficacy of direct surgery in this scenario, as compared with other treatment modalities such as biopsy and irradiation, suggesting that complete surgical excision may represent the treatment of choice for isolated intracerebral LCH granulomas, being curative in most instances. Also, the literature is reviewed for information about the diagnosis and treatment of this particular type of unifocal brain lesion.

Head and neck Langerhans cell histiocytosis

Among the potential sites of involvement by Langerhans cell histiocytosis (LCH), the head and neck region is the most commonly cited. Though principally a pediatric disease, LCH can affect any age group. It can be unifocal (skeletal) or multifocal (skeletal and/or visceral); it appears as though the presence of visceral lesions is more common in the youngest patients, and may be associated in some with a rapidly progressive course resulting in death. Head and neck manifestations may mimic such varied entities as eczema, otitis media, osteomyelitis, and cholesteatoma. Current approaches to therapy are less aggressive than they were in the past, and are particularly intended to monitor for and treat any complicating secondary infections (which may develop in the youngest patients with multifocal disease including visceral involvement). The prognosis is very good for unifocal skeletal system disease, and poor for multifocal disease with involvement of tissues other than bone.

Histiocytosis-X of fronto-ethmoid region

Histiocytosis-X is a rare disease. It occurs mostly in children. Aetiology is unknown. Treatment is by surgery, Radiotherapy and Chemotherapy, either singly or in combination. Prognosis depends on the degree of involvement. One such case is reported and discussed.

Langerhans cell histiocytosis in children under 2 years of age

This is a retrospective study of 55 children under the age of 2 years diagnosed with Langerhans cell histiocytosis (LCH). They were classified according to age and organ function and dysfunction following Lahey's criteria. The studied population was divided into four groups by age of diagnosis (0-6, 7-12, 13-18, and 19-24 months). Statistical analysis showed no significant difference in outcome between age groups, although the population under 6 months had a 81.3% fatality rate. The presence of organ dysfunction was a major cause of death in all age groups, being statistically significant in outcome (P > 0.005) compared with patients without organ dysfunction. The presence of thrombocytopenia and/or respiratory dysfunction was also highly associated with a fatal outcome. In the surviving population, no second malignancies have been reported. The late secondary effects of therapy include endocrine, orofacial, and osseous pathologies.

Etoposide in Langerhans cell histiocytosis in children: a preliminary experience

Treatment of Langerhans cell histiocytosis (LCH) is yet to be established. We treated seven patients with etoposide alone at a dose of 100 mg/m2/day for 3 days given every 3 to 4 weeks for six cycles. Three patients had received prior chemotherapy, two patients were less than 2 years of age, and two had liver dysfunction. A positive response to therapy was seen in five patients. There was no major toxicity. Etoposide therapy is safe and effective in the treatment of LCH.

Langerhans' cell histiocytosis: head and neck manifestations in children

BACKGROUND

Langerhans' cell histiocytosis (LCH) is an uncommon, poorly understood granulomatous disease, characterized by the idiopathic proliferation of Langerhan's cells or their marrow precursors. In 1985, the Philadelphia Work-shop adopted the term "Langerhans' cell histiocytosis" (LCH) to differentiate it from reactive and neoplastic causes of histiocytosis.

METHODS

This study includes 73 pediatric patients diagnosed with this condition in Dublin, Ireland, and Nottingham, England, during a 34-year period (1959 to 1993). These patients are reviewed with respect to clinical presentation, difficulty with making a histological diagnosis, their management, and outcome.

RESULTS

A total of 49 patients (67%) had head and neck involvement. Bony involvement was the most frequent sign, most frequently located in the skull. There were 11 deaths (15%) in this series, all associated with multisystem disease, and nine of these deaths were in children younger than 2 years of age.

CONCLUSIONS

The role of otolaryngologists is important in the early and accurate evaluation, staging, and diagnosis of LCH. It may mimic more common diseases, such as otitis externa, acute mastoiditis, skin rash, gingivitis, or cervical lymphadenopathy. Patients with multisystem disease may be so ill at presentation that the head and neck lesions may be overlooked. The current management of LCH has become increasingly conservative, and in the 1990s, fewer cases are given chemotherapy or radiotherapy. The prognosis is very good for single-system disease and poor for multisystem disseminated disease with early onset.

Simultaneous occurrence of viral-associated hemophagocytic syndrome and Langerhans cell histiocytosis: a case report

Langerhans cell histiocytosis (LCH) is a class I histiocytosis characterized by the presence of the pathologic Langerhans cell, an unique histiocyte. In contrast to LCH, class II histiocytosis is characterized by the proliferation of mononuclear phagocytes other than Langerhans cells and includes sinus histiocytosis with massive lymphadenopathy, viral-associated hemophagocytic syndrome, and familial hemophagocytic lymphohistiocytosis. Until now, these two classes have been considered separate, if related, entities. We report a 10-month-old girl who presented with pyrexia, hepatosplenomegaly, an eczematous skin rash, anemia, thrombocytopenia, and a markedly elevated serum IgG and IgM antibody level to cytomegalovirus. Histologic proof of both hemophagocytosis in the liver and bone marrow and LCH in the skin was obtained at presentation. The clinical course and response to treatment over 6.5 years is recorded. Although the etiology of both class I and class II histiocytosis remains unknown, we speculate that the monocytic/macrophage disorder, as well as the LCH, were both triggered by virus or viral-related monokines secreted by activated macrophages.

Treatment of Langerhans-cell histiocytosis in children. Experience at the Children's Hospital of Nancy

Forty children who had Langerhans-cell histiocytosis were followed for an average of six years (range, excluding patients who died of the disease, two to fifteen years). The patients were divided into two diagnostic groups: those who had localized disease (involving one bone or more only) and those who had multifocal disease (an osseous lesion and a soft-tissue mass, a skin rash, diabetes insipidus, or generalized disease). Methods of treatment included curettage, bone-grafting, chemotherapy, local or systemic corticosteroids, and radiotherapy. Nineteen of the thirty patients who had localized disease had a complete response to the therapy, four had a partial response, and seven had no response. Twenty-one of these thirty patients had not had a recurrence by the time of the latest follow-up examination; nine had a local recurrence within four years after the initial therapy but had no additional recurrences after treatment of the local recurrence. No recurrence occurred more than four years after the time that the initial diagnosis had been made. Five of the ten patients who had multifocal disease had a complete response to the therapy, two had a partial response, and three had no response. Six patients had a recurrence; four did not. Two patients died of the disease. As a result of this study, we recommend the avoidance of intensive measures of treatment, if possible, and we advise long-term follow-up of these patients.

Treatment of Langerhans cell histiocytosis--evolution and current approaches

Optimal treatment of Langerhans cell histiocytosis remains problematic. The absence of controlled studies and the lack of standard diagnostic and evaluation criteria have impeded therapeutic progress even though knowledge of basic aspects of LCH have advanced. Historical analysis of outcome suggests little improvement until very recently, but marked differences in outcome according to extent of disease. Consequently, major and now successful efforts have been made to stratify LCH patients into different 'risk groups'. Recent findings suggest that combination chemotherapy for multisystem disease is beneficial and that VP-16 is a useful new agent for treating LCH, despite controversies regarding its side effects. The first randomised international treatment study, LCH-1, being conducted by the Histiocyte Society, should resolve some of these controversies. Other experimental therapies may be considered for children with severe, unresponsive LCH.

Langerhans cell histiocytosis--clinical and epidemiological aspects

Langerhans cell histiocytosis is a disease which frustrates both clinician and scientist. Its aetiology is unknown, its pathogenesis is ill understood and the clinical course is unpredictable. Historically, the different nomenclatures reflecting the first clinical descriptions by Hand (1893, 1921), Schuller (1915) and Christian (1920), and subsequently by Letterer (1924) and Siwe (1933), led to confusion only partially resolved by Lichtenstein (1953) who recognised that the disease in each of these clinical syndromes were components of a spectrum of disease involving the histiocyte. He proposed his unifying concept of Histiocytosis X--'X' being the unknown aetiological factor. In 1973, Nezelof recognised the lesional cell as a 'Langerhans-like' cell but it took another decade for the disease to be recognised as a single entity and the term Langerhans cell histiocytosis to be internationally accepted. The publication, by the Histiocyte Society (1987), of their classification of the histiocyte disorders together with criteria for pathological diagnosis and clinical evaluation of Langerhans cell histiocytosis have consolidated the position. This article details the wide variety of clinical manifestations of the disease and its sequelae and discusses possible epidemiological factors. Finally it looks at the potential implications of recent scientific research on the management of the disease.

Multifocal Langerhans' cell histiocytosis in a 4-year-old child: a case report

A 4-year-old girl presented with pain associated with a mobile mandibular left permanent first molar. The mandibular left primary second molar was also found to be mobile and the gingiva buccal to these teeth was inflamed. A well-defined radioluceny of the left posterior mandible was detected radiographically. Langerhans' cell histiocytosis had been diagnosed 10 months previously when she had presented with an isolated tibial lesion. Curettage of the mandibular lesion and extraction of four adjacent teeth was performed. Post-operatively, radiographic skeletal screening revealed osteolytic lesions in the right parietal bone and right eighth rib. A 6-month course of chemotherapy was instigated which resulted in bony healing of all the osteolytic lesions.

Aural symptoms as primary presentation of Langerhan's cell histiocytosis

Langerhan's cell histiocytosis is an uncommon granulomatous disease, characterized by the idiopathic proliferation of Langerhan's cells or their marrow precursors. It encompasses the diseases previously associated with histiocytosis X-eosinophilic granuloma, Hand-Schuller-Christian syndrome and Letterer-Siwe syndrome. A series of 54 patients were diagnosed with this condition in Dublin over a 33-year-period (1959-1992). Twenty-seven patients had aural symptoms, of whom 15 had no other lesions at the time of presentation. Otorrhoea was the most frequent otological symptom, followed by lesions in the temporal bone. LCH may mimic common aural conditions such as otitis externa, otitis media or acute mastoiditis and a high index of suspicion is required to recognize it on clinical presentation. The clinical presentation of multi-focal disease may be so dramatic that the otologic findings may be initially overlooked. The mortality rate was 14.8%. Therapeutic regimes included no treatment, curettage, chemotherapy, radiotherapy or multi-modality treatment.

Association of malignancy and Langerhans' cell histiocytosis: report of three cases

Among 44 children with Langerhans' cell histiocytosis (LCH) seen at the Pediatric Department of the A.C. Camargo Hospital, São Paulo, Brazil, three developed malignancy, two before and one after the diagnosis of LCH. Malignancy could be attributed to treatment in one of the three children. Whether the cancer in the other two children represents a chance association of the two processes or is treatment-related, is unknown.

Treatment of adult Langerhans cell histiocytosis with etoposide

BACKGROUND

Langerhans cell histiocytosis (LCH) is a reactive disease in which abnormal Langerhans cells accumulate in various body sites and cause damage to affected organs. Adults often do not respond to conventional therapy with local or systemic steroids.

OBJECTIVE

Our purpose was to investigate intravenous etoposide as monotherapy in the treatment of adult patients with severe or resistant LCH.

METHODS

In an open study, three adult patients with LCH (one with single-system skin disease and two with multisystem disease) were treated with etoposide, 100 mg/m2/day, for 3 days. This was repeated every 3 or 4 weeks for three or four cycles.

RESULTS

All patients achieved clinical remission that persisted during a 12- to 14-month follow-up. No serious side effects were noted.

CONCLUSION

We recommend the use of etoposide monotherapy in severe or restricted LCH in adults.

Malignant Langerhans cell tumour

We report the case of a 49-year-old woman suffering from a malignant neoplasm of Langerhans cells (LC), documented by immunohistochemical and ultrastructural analysis, and review the literature to examine and characterize the clinical and laboratory features, therapy, and prognosis of malignant neoplasms of LC. Langerhans cell histiocytosis is now regarded as a disorder of immune regulation or an inflammatory process, rather than as a malignant neoplasm. Although LC share certain features in common with ordinary histiocytes or interdigitating dendritic cells, they also differ significantly from these cells in other respects. Therefore, we propose designating a malignant neoplasm of LC 'malignant Langerhans cell tumour' and that it should be considered as a separate entity from Langerhans cell histiocytosis or other malignant histiocytoses.

Langerhans cell histiocytosis--a 31 year review

Forty-one patients with Langerhans Cell Histiocytosis (LCH) were treated over a thirty-one year period in our institution. These children were classified according to the number of systems involved: twenty-two had unisystem disease while nineteen had multisystem disease. A histological diagnosis was reached in 82% of cases, the remainder being diagnosed on both radiological and clinical grounds. 68% of those with multisystem disease had a rash at diagnosis whilst 64% had a persistent ear discharge. The diagnosis was established accidentally in 25% of those with unisystem disease. The mortality rate was 21% and was confined to those who were under two years of age at diagnosis, all of whom had multisystem disease. Morbidity was 20% and was restricted to patients with multisystem disease. Only one patient died within the last 10 years; there were no therapy related deaths. Treatment related morbidity was seen in only three children. In keeping with other series, our review has identified the following adverse prognostic factors a) age under 2 years at presentation, b) multisystem disease and c) major organ dysfunction. In view of the natural history of the disease, it is suggested that chemotherapy only be used in those patients who have major organ dysfunction or progressive disease and that radiotherapy is rarely indicated.

Langerhans cell histiocytosis in monozygotic twins

Langerhans cells histiocytosis, one of a group of histiocytosis syndromes characterized by Langerhans cell infiltration, has many clinical manifestations. In the past 30 years, numerous cases of presumed Letterer-Siwe disease, the acute multiorgan variant, have been reported in twins and siblings. Only recently has the Histiocyte Society established a criterion for a "definitive diagnosis" of Langerhans cell histiocytosis--the presence of Birbeck granules within the cells of the histiocytic infiltrate. We report the fatal outcome of Langerhans cell histiocytosis in monozygotic twin infants. There is no satisfactory explanation why Langerhans cell histiocytosis occurs concurrently in twins. We suggest that cytokines may provide an endogenous signal that triggers the pathologic proliferation of Langerhans cells.

Multi-system Langerhans-cell histiocytosis in adults

Multi-system Langerhans-cell histiocytosis is rare in adults. We report five cases under our care and advocate a conservative approach to the treatment of such patients.

Langerhans cell histiocytosis: the case for conservative treatment

Fifty eight children with Langerhans cell histiocytosis who were referred to this hospital between 1980 and 1987 were studied. Fourteen had single system disease, and 44 had multisystem disease, of whom 22 had vital organ dysfunction. A conservative approach to treatment was adopted, and when systemic treatment was indicated a short course of prednisolone was used first. Eight of the patients with single system disease required no treatment, while six received local treatment alone. Eight of the patients with multisystem disease did not require systemic treatment, 17 were given prednisolone alone, and 19 were given cytotoxic drugs. Of the 14 with single system disease 13 had no long term after effects. Eight of the patients with multisystem disease died, 24 had long term after effects, and 12 had none. Outcome was related to age and Lahey score. These results compare favourably with other series in which more aggressive approaches were used, and support our conservative approach to treatment.

Spontaneous NBT reduction by monocytes as a marker of disease activity in children with histiocytosis

In an attempt to define a biological marker of monocyte hyperactivation in the course of infantile histiocytosis, the spontaneous nitroblue tetrazolium (NBT) reduction assay was applied to monocytes from 13 children with Langerhans cell histiocytosis (LCH), familial haemophagocytic lymphohistiocytosis (FHL), juvenile xanthogranuloma or malignant histiocytosis. Significant increase in NBT reduction was observed in the patients with both active LCH and FHL in comparison with control subjects, who were either healthy or affected by different conditions. A close relationship between spontaneous reduction rate and clinical condition of the patients was evident in patients tested at diagnosis, during remission and during the course of disease reactivation. Interleukin-1 (IL-1) production by monocytes was also evaluated: the patients with LCH and FHL displayed a significant increase in in vitro IL-1 production by lipopolysaccharide-stimulated monocytes. In our experience the spontaneous NBT reduction assay was a sensitive, quite specific, low-cost and reproducible test for the evaluation of children with histiocytosis. Useful information may be obtained at diagnosis but also during the clinical course of disease by using this marker of monocyte spontaneous activation.

The frequency and natural history of diabetes insipidus in children with Langerhans-cell histiocytosis

Diabetes insipidus is a well-recognized complication of Langerhans-cell histiocytosis (histiocytosis X), but its frequency and natural history are not well defined. Of 52 children with histiocytosis whom we studied, 12 (23 percent) had diabetes insipidus. Only two children had diabetes insipidus at presentation with histiocytosis, but the cumulative risk that it would develop during the first four years after the presentation and diagnosis of histiocytosis was found to be 42 percent. Diabetes insipidus occurred most often among children with multisystem disease and those with proptosis. To determine the natural history of diabetes insipidus in children with histiocytosis, we measured the response of urinary arginine vasopressin to water deprivation every six months in 21 children who did not have diabetes insipidus and who had had histiocytosis for less than four years. Five of the 21 children (24 percent) had subnormal responses during the initial test. One subsequently had spontaneous improvement in the functioning of the posterior pituitary, and diabetes insipidus subsequently developed in two, as it did in one of the children who initially had normal function of the posterior pituitary. Two of the children received irradiation to the pituitary within two to four weeks after diabetes insipidus developed, but they had no improvement in pituitary function. However, diabetes insipidus improved transiently during prednisolone therapy in one of these children and improved permanently after etoposide therapy in another child. We conclude that prospective study with the use of a simple water-deprivation test will allow partial defects of posterior-pituitary function to be detected in patients with histiocytosis and will permit a more appropriate evaluation of the effects of therapeutic intervention.

Langerhan's cell histiocytosis in the sphenoid sinus: a case of diabetes insipidus

We present a case of diabetes insipidus in a young man caused by Langerhan's cell histiocytosis of the sphenoid sinus with involvement of the pituitary gland. Diagnosis and management of this rare condition is discussed, along with a brief view of the literature.

A flow cytometric study of Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH), or histiocytosis X, is now generally considered to be a non-malignant condition. A flow cytometric (FCM) study of a single case has, however, been published which claimed to provide evidence to contradict this. The presence of DNA-ploidy as detected using this technique is a feature of malignant and pre-malignant disease. In this reported single case, DNA-ploidy was present but the clinical features of this patient were atypical for LCH. We have performed a FCM study of the DNA of nine biopsies of LCH lesions from six patients with well-established disease. In addition, in one of these, fresh tissue studies including the use of an anti-CD I monoclonal antibody to specifically label the LCH cells were performed. In all cases the DNA content of the cells was entirely normal. We therefore found no evidence that LCH is a neoplastic disorder.

Etoposide (VP16) in the treatment of multisystem Langerhans cell histiocytosis (histiocytosis X)

Ten children with Langerhans cell histiocytosis (histiocytosis X) either resistant to or intolerant of corticosteroids received etoposide (VP16). Nine responded. In one instance, partial diabetes insipidus was temporarily reversed. There was no major toxicity. Etoposide should be seriously considered as therapy for patients with LCH in whom the toxicity/benefit ratio of steroid therapy is unacceptably high.

Letterer-Siwe disease in adults

Histiocytosis X (HX) is a rare disorder of histiocytic proliferation characterized by a broad spectrum of clinicopathologic disease. An unusual case of Letterer-Siwe disease (LSD) or subacute disseminated HX in a 71-year-old woman is presented. The patient had a 3-year history of splenomegaly before skin lesions developed. She presented to our clinic at 1.5 years later and the diagnosis of HX was made by skin biopsy. Topical nitrogen mustard (NM) therapy resulted in complete clearing of cutaneous lesions. Her condition was stable over the next 10 months. However, she subsequently suffered a rapid and fatal dissemination of her disease. Systemic treatment with prednisone, vinblastine sulphate, and suppressin A (SA) (a calf thymus derived hormone preparation that specifically induces suppressor T-cells) was ineffective. Characteristic histopathologic, immunohistochemical, and electron microscopic findings of HX are illustrated. A review of the adult cases of LSD and treatment options for HX are presented and discussed.

Etoposide in recurrent childhood Langerhans' cell histiocytosis: an Italian cooperative study

Eighteen evaluable children with recurrent Langerhans' cell histiocytosis (LCH) which was resistant to standard therapy, were treated with etoposide (VP 16-213), 200 mg/m2/day for 3 days every 3 weeks, to study the efficacy and toxicity of this drug. Complete and partial responses were demonstrated in 15 patients (83.3%). Only one of the 12 children achieving a complete remission has relapsed. No dose-limiting major toxicities were registered. Although etoposide might be an effective treatment in recurrent LCH which needs a chemotherapeutic approach, it is emphasized that this drug must be used carefully.

Comparison of peanut agglutinin and S100 stains in the paraffin tissue diagnosis of Langerhans cell histiocytosis

We compared peanut agglutinin and S100 stains on paraffin embedded material from a variety of sites involved in Langerhans cell histiocytosis (LCH). The two techniques were comparable in terms of ease of performance, time taken and cost. Peanut agglutinin produced dense cell surface and paranuclear staining of the characteristic LCH cells seen in lesions, which was easier to distinguish than the more diffuse cytoplasmic staining produced by the S100 technique. This characteristic staining pattern is more specific than that for the S100 protein which is present in a variety of different cells, including some malignant histiocytes. We recommend that peanut agglutinin be used as a routine diagnostic test for all samples suspected of being LCH.

Globe luxation in histiocytosis X

A boy with histiocytosis X, first diagnosed at the age of 9 months, presented at the age of 5 years with left globe luxation. Under general anaesthesia the globe was reduced and a temporary paracentral tarsorrhaphy carried out. He was started on a course of oral steroids. Two years later he had normal visual acuity, full ocular movements, and healthy fundi.

Solitary eosinophilic granuloma (histiocytosis X) of the gingiva. A report of two cases

Two cases are reported in which the patients presented with solitary ulcers on the gingiva. The lesions were excised and examined histologically. A connective tissue infiltrate of large mononuclear cells was identified with immunohistochemical staining as Langerhans cells and a diagnosis of histiocytosis X was made. Further medical evaluation revealed no other lesions in one of the patients but did locate an infiltrate in the right mastoid of the other patient. Solitary lesions of histiocytosis in oral mucosa are extremely rare. The manifestations of the disease, pathogenesis, and treatment are discussed.

Radiation therapy in soft-tissue lesions in histiocytosis X (Langerhans' cell histiocytosis)

Langerhans' cell histiocytosis (LCH) (previously histiocytosis X) is an infrequent disease with protean clinical manifestations and an unpredictable course. The role of radiotherapy in the soft tissue complications of LCH was evaluated in this retrospective study of 40 patients seen in two major Philadelphia institutions between 1970 and 1984. The patients were divided into two groups according to the extent of disease: unifocal versus multifocal. There was a higher rate of complete response in the unifocal form (4 of 12 patients), but this was associated with a high rate of spontaneous remissions (6 out of 12 patients). Multifocal LCH has a more aggressive course, and the major organs involved (lung, liver, and spleen) did not respond to radiotherapy. Eight patients had diabetes insipidus, and none of them responded to radiotherapy or chemotherapy. Autopsies were performed in two patients with diabetes insipidus who died of disease. There were no pathologic changes in the pituitary gland or stalk, hypothalamus, or supraoptic nuclei.