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Aswani Y, Patel A, Zhan X, Ansari S, Marcelino LG, Aswani N, Patel DD, Kandemirli S, Averill S, Bhatt S. Imaging in Erdheim-Chester Disease. Radiographics 2024; 44:e240011. [PMID: 39172709 DOI: 10.1148/rg.240011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Erdheim-Chester disease (ECD) is a rare, multisystemic, inflammatory, non-Langerhans cell histiocytic neoplasm. The discovery of recurrent and somatic mutations in the mitogen-activated protein kinase signaling pathway, most commonly BRAFV600E, has led to a reclassification of ECD from an inflammatory disorder to a neoplastic process. It is now included in the revised 2016 World Health Organization classification of hematopoietic tumors and in the Langerhans group in the revised 2016 Histiocytosis Classification of the Histiocyte Society. When symptomatic, ECD most commonly manifests with bone pain and fatigue. Also, neurologic manifestations, central diabetes insipidus, exophthalmos, and periorbital xanthelasma-like lesions are frequently encountered. Pathologic findings may vary depending on the site of biopsy and may display a spectrum of features. Thus, due to the diverse clinical presentation and variable histologic findings, imaging can often show the first sign of the disease. Radiologic findings are, however, interpreted in conjunction with clinical and histologic findings to establish the diagnosis of ECD. From providing classic findings that facilitate diagnosis to helping radiologists determine the extent of disease and predicting a prognosis, the role of radiology in ECD has evolved with the understanding of the disease itself. Insights into the molecular pathogenesis and the development of targeted therapeutic agents along with approval of vemurafenib and cobimetinib have necessitated revision of the guidelines for the management of ECD. The authors discuss various radiologic findings of ECD and differential diagnoses by using an organ system-based approach and briefly describe the revised consensus recommendations for evaluation, diagnosis, and treatment based on the International Medical Symposia on ECD from a radiologist's perspective. ©RSNA, 2024 Supplemental material is available for this article. The full digital presentation is available online.
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Affiliation(s)
- Yashant Aswani
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Aditi Patel
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Xin Zhan
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Shehbaz Ansari
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Leonardo Gomes Marcelino
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Nishant Aswani
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Dhrumil Deveshkumar Patel
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Sedat Kandemirli
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Sarah Averill
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
| | - Shweta Bhatt
- From the Department of Radiology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, 3882 John Pappajohn Pavilion, Iowa City, IA 52242 (Y.A., A.P., X.Z., S.K., S. Averill); Department of Radiology, Rush University Medical Center, Chicago, Ill (S. Ansari); Department of Radiology, Radiology Institute of University of São Paulo, São Paulo, Brazil (L.G.M.); Department of Neurology, Geetanjali Medical College and Hospital, Udaipur, India (N.A.); Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India (D.D.P.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.)
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Usmael SA, Gebrehiywot AA, Bekele AL, Yezengaw SB, Tefera TT, Bote HB, Shibeshi KA, Fantaye AB. Erdheim-Chester disease: An elusive diagnosis in a 50-year-old Ethiopian man presenting with diffuse sclerotic bone lesion. Clin Case Rep 2024; 12:e9447. [PMID: 39301096 PMCID: PMC11411061 DOI: 10.1002/ccr3.9447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 08/11/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024] Open
Abstract
Key Clinical Message Diagnosis of Erdheim-Chester disease (ECD) requires the clinician to be familiar with its various manifestations, classic radiologic and histologic features. This case highlights the significance of considering ECD in any patient presenting with bone pain and symmetric osteosclerosis of long bones of extremities to allow for early diagnosis and treatment. Abstract Erdheim-Chester disease (ECD) is a rare non-Langerhans histiocytic disorder with diverse clinical manifestations, ranging from indolent, localized presentation to life-threatening, multi-systemic disease. Delayed or erroneous diagnosis is common. The presence of classic radiographic finding along with foamy histiocytes that is positive for CD68 but negative for CD1a on histologic examination establishes the diagnosis. We report a second case of ECD from Ethiopia. A 50-year-old Ethiopian man presented with a 13-year history of bilateral lower leg bone pain, cold intolerance, somnolence, constipation, impotence, decreased libido, and secondary infertility. The diagnosis was suspected when skeletal X-ray revealed bilateral symmetric sclerosis of metadiaphysis of femur, tibia, and humerus. The demonstration of foamy histiocytes that were positive for CD68 but negative for CD1a on histologic examination with immunohistochemical staining confirmed the diagnosis. Evaluation for the extent of the disease revealed coated aorta sign, hairy kidney sign, and cystic lesion with ground glass opacity of lung, primary hypothyroidism, and hypergonadotropic hypogonadism. ECD is rare histiocytic neoplasm with wide range of clinical features which often delay the diagnosis. Clinician should be mindful of the various presentations and the classic radiographic and histologic features of ECD. This case highlights the significance of entertaining ECD in any patient presenting with lower leg bone pain and symmetric osteosclerosis of long bones of lower extremities to allow for early diagnosis and treatment.
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Affiliation(s)
- Semir Abdi Usmael
- Department of Internal Medicine Haramaya University College of Health and Medical Science Harar Ethiopia
| | - Addisu Alemu Gebrehiywot
- Department of Pathology Haramaya University College of Health and Medical Science Harar Ethiopia
| | - Ashenafi Lemma Bekele
- Department of Radiology Haramaya University College of Health and Medical Science Harar Ethiopia
| | | | - Tekalign Tsegaye Tefera
- Department of Orthopedic and Trauma Surgery Haramaya University College of Health and Medical Science Harar Ethiopia
| | - Hunduma Bikila Bote
- Department of Orthopedic and Trauma Surgery Haramaya University College of Health and Medical Science Harar Ethiopia
| | | | - Anteneh Belachew Fantaye
- Department of Pathology Haramaya University College of Health and Medical Science Harar Ethiopia
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Kulkarni AM, Gayam PKR, Aranjani JM. Advances in Understanding and Management of Erdheim-Chester Disease. Life Sci 2024; 348:122692. [PMID: 38710283 DOI: 10.1016/j.lfs.2024.122692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/13/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Erdheim Chester Disease (ECD) is a rare histiocytic disorder marked by infiltration of organs with CD68+ histiocytes. ECD stems from mutations of BRAF and MAP2K1 in hematopoietic stem and progenitor cells (HSPCs), which further differentiate into monocytes and histiocytes. Histopathology reveals lipid-containing histiocytes, which test positive for CD68 and CD133 in immunohistochemistry. Signs and symptoms vary and depend on the organ/s of manifestation. Definitive radiological results associated with ECD include hairy kidney, coated aorta, and cardiac pseudotumor. Treatment options primarily include anti-cytokine therapy and inhibitors of BRAF and MEK signaling.
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Affiliation(s)
- Aniruddha Murahar Kulkarni
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Prasanna Kumar Reddy Gayam
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jesil Mathew Aranjani
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India.
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Rocamora-Blanch G, Climent F, Solanich X. [Histiocytosis]. Med Clin (Barc) 2023; 161:166-175. [PMID: 37263840 DOI: 10.1016/j.medcli.2023.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/03/2023]
Abstract
Histiocytosis is a group of rare diseases characterized by inflammation and accumulation of cells derived from monocytes and macrophages in different tissues. The symptoms are highly variable, from mild forms with involvement of a single organ to severe multisystem forms that can be life compromising. The diagnosis of histiocytosis is based on the clinic, radiological findings and pathological anatomy. A biopsy of the affected tissue is recommended in all cases as it may have therapeutic implications. During the last decade, some mutations have been identified in the affected tissue that condition activation of the MAPK/ERK and PI3K/AKT pathway, in a variable proportion depending on the type of histiocytosis. In this review we mainly focus on Langerhans Cell Histiocytosis, Erdheim-Chester Disease and Rosai-Dorfman Disease.
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Affiliation(s)
- Gemma Rocamora-Blanch
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España.
| | - Fina Climent
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España; Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Xavier Solanich
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España
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Qiao J, Ma R, Peng X, He W. Erdheim-Chester disease with bilateral orbital masses and multi-systemic symptoms: two case reports. World J Surg Oncol 2023; 21:233. [PMID: 37525276 PMCID: PMC10388563 DOI: 10.1186/s12957-023-03123-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Erdheim-Chester disease (ECD) is a rare histiocytic disorder characterized by multisystem xanthogranulomatous infiltration by lipid-laden histiocytes. We report two cases of ECD involving the orbit and describe their clinicopathologic factors, treatments, and prognosis. One was a rare case of ECD complicated with primary thrombocytosis. CASE PRESENTATION This study describes two patients with bilateral orbital ECD. Both presented with proptosis and visual loss; imaging findings showed bilateral intraorbital masses. Both had different degrees of systemic symptoms (pleural effusion, pericardial effusion, ascites, and heart failure) before the ocular symptoms and did not find the cause before ophthalmic tumor resection and pathological biopsy. The diagnosis of ECD was confirmed after pathological biopsy and detection of BRAFV600E mutation. Patient 2 also with primary thrombocytosis and had a CALR mutation as well as the BRAFV600E mutation. Both patients were recommended to receive targeted therapy. Patient 1 refused targeted therapy for financial reasons and was discharged after local radiotherapy only. The patient had no light perception in either eye and no improvement in systemic symptoms. Patient 2 began targeted treatment after diagnosis and reached the discharge criteria 2 weeks later. He is in good condition at present, but unfortunately, his eyesight has not improved because of the irreversible damage to his visual function. CONCLUSION ECD is easily misdiagnosed and missed because of its rarity and diverse clinical manifestations. Orbital involvement is common in ECD, and surgery is the most frequently employed approach. Despite the surgical resection is not curative, its significance lies in biopsy to establish diagnosis and/or surgical debulking to relieve mass effect, minimizing further impairment of visual function. Targeted therapy is the most effective treatment for patients with a positive BRAF mutation gene. Evaluation of a concomitant myeloid neoplasm is also critical before initiating targeted therapies for refractory ECD.
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Affiliation(s)
- JunYi Qiao
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China
| | - Ruixin Ma
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China
| | - Xiaolin Peng
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China
| | - Weimin He
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China.
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Giardino FR, Cuomo R, Pozzi M, Marcaccini G, Bacchini S, Marzouk El Araby M, Grimaldi L, Nisi G. Erdheim-Chester Disease of the Breast: First Review and First Case of Isolated Severe Gynecomastia. Diagnostics (Basel) 2023; 13:1239. [PMID: 37046457 PMCID: PMC10093613 DOI: 10.3390/diagnostics13071239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
(1) Introduction: Erdheim-Chester disease (ECD) is a life-threatening condition and often a diagnostic challenge. It has recently been classified as a hematopoietic tumour, and the cases of ECD reported in the literature has dramatically increased during the last 15 years. (2) Methods: We describe the case of a 57-year-old male patient with severe gynecomastia, with a detailed description of his diagnostic iter and consequent surgical operation. We provide the first systematic review of the literature of breast involvement in ECD, following PRISMA guidelines, including 13 studies and 16 patients. (3) Results: Our report resulted to be the first case of gynecomastia as a single clinical and imaging feature of ECD described in English literature. A total of 81.3% of patients included were female. Among them, 76.9% had unilateral and nodular presentation, while male patients presented bilateral heterogeneous breast enlargement. Globally, 87.5% expressed breast alterations as their first manifestations of ECD. Only 50% presented skeletal involvement. (4) Conclusion: The reported case represents a unique addition to the literature. We found two different patterns in ECD-related breast involvement between male and female patients, an unusual M/F ratio, and a lower rate of bone involvement. Breast involvement is frequently the first clinical feature; therefore, breast caregivers should be aware of this dangerous and most likely underestimated condition.
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Affiliation(s)
- Francesco Ruben Giardino
- Surgery and Neuroscience—Plastic Surgery Unit, Department of Medicine, University of Siena, Policlinico Santa Maria “Le Scotte”, 53100 Siena, Italy
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Capitanio JF, Mortini P. Other Less Prevalent Tumors of the Central Nervous System. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:607-643. [PMID: 37452956 DOI: 10.1007/978-3-031-23705-8_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The presented tumors in this chapter are somewhat very rare, and their management is still debated due to the scarcity of information about their cell of origin, behavior, and biology. Treatment options are still limited, but we are confident that in the near future by discovering the genetic and biological mechanisms that drive tumor growth we will be able to offer new target therapies that should be flanked by surgery, radiotherapy, and chemotherapeutic agents actually in use. The purpose of this chapter is to highlight the most important known characteristics of these tumors offering the chance to recognize the disease and then offer the best opportunity for treatment to patients. The 5th WHO Classification Central Nervous System features substantial changes by moving further to advance the role of molecular diagnostics in CNS tumor classification, but remaining rooted in other established approaches to tumor characterization, including histology and immunohistochemistry, and probably, the category of many tumors will change. Here, the most important characteristics of each neoplasm are summarized focusing on genetic mechanisms and molecular pathways, their histopathologic footprints, signs and symptoms, radiologic features, therapeutic approaches, and prognosis as well as follow-up protocols. Schematic classifications are also presented to offer a better understanding of the pathology.
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Affiliation(s)
- Jody Filippo Capitanio
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy.
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Chhetri S, Manandhar S, Neupane D, Subedi SS, Chhetri S, Acharya A, Chaudhary S, Khatiwada P, Shrestha S. A rare case of Erdheim-chester disease reported from Nepal. Ann Med Surg (Lond) 2022; 80:104232. [PMID: 36045778 PMCID: PMC9422295 DOI: 10.1016/j.amsu.2022.104232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Erdheim-Chester Disease (ECD) is a rare non-Langerhans cell histiocytosis with a propensity to involve multiple organs. Case presentation We report a case of a patient in mid-60s with occipital headache and ataxia. Following the radiological and immunohistochemical investigations and genomic studies, a diagnosis of ECD was made with two intracerebral lesions. Brain lesions were resected and the patient was discharged with the medication Vemurafenib. After 3 years of diagnosis and 13 years of initial presentation, patient passed away. Discussion ECD frequently presents with Diabetes Insipidus as initial presentation, long bone osteosclerosis as the most common presentation, and has multi-system predisposition. ECD can be differentiated from Langerhans Cell Histiocytosis (LCH) with immunohistochemistry images of the biopsy specimens. Further, with genomic analysis of ECD, the neoplastic nature has been highlighted and targeted therapies like Vemurafenib and Cobimetinib are shown to be effective. Conclusion Good clinical judgement and supporting investigations can aid in diagnosing rare entities like ECD even in resource-limited settings. Rare case of Erdheim-Chester disease with multi-system involvement presenting with initial features 10 years prior to diagnosis. Initially Diabetes Insipidus, followed by long bone and other multi-system involvement important cues for the diagnosis. Biopsy of the lesion and immunohistochemical analysis can help confirm the diagnosis. Genomic studies with mutational analysis further highlights the neoplastic nature of the disease. Advancement of genomic studies with targeted therapies like Vemurafenib and Cobimetinib key in of management of ECD.
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Vallejo Herrera MJ, Sánchez Torralvo FJ, Vallejo Herrera V, Olveira Fuster G, Pérez de Pedro I. Erdheim-Chester disease: Diagnosis in endocrinology. ENDOCRINOL DIAB NUTR 2022; 69:444-446. [PMID: 35787357 DOI: 10.1016/j.endien.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/05/2021] [Indexed: 06/15/2023]
Affiliation(s)
| | | | | | - Gabriel Olveira Fuster
- UGC Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, Spain
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Go RS, Jacobsen E, Baiocchi R, Buhtoiarov I, Butler EB, Campbell PK, Coulter DW, Diamond E, Flagg A, Goodman AM, Goyal G, Gratzinger D, Hendrie PC, Higman M, Hogarty MD, Janku F, Karmali R, Morgan D, Raldow AC, Stefanovic A, Tantravahi SK, Walkovich K, Zhang L, Bergman MA, Darlow SD. Histiocytic Neoplasms, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:1277-1303. [PMID: 34781268 DOI: 10.6004/jnccn.2021.0053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Histiocytic neoplasms are rare hematologic disorders accounting for less than 1% of cancers of the soft tissue and lymph nodes. Clinical presentation and prognosis of these disorders can be highly variable, leading to challenges for diagnosis and optimal management of these patients. Treatment often consists of systemic therapy, and recent studies support use of targeted therapies for patients with these disorders. Observation ("watch and wait") may be sufficient for select patients with mild disease. These NCCN Guidelines for Histiocytic Neoplasms include recommendations for diagnosis and treatment of adults with the most common histiocytic disorders: Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease.
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Affiliation(s)
| | - Eric Jacobsen
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Robert Baiocchi
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Ilia Buhtoiarov
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute Cleveland Clinic Children's Hospital
| | | | - Patrick K Campbell
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Aron Flagg
- Yale Cancer Center/Smilow Cancer Hospital
| | | | | | | | - Paul C Hendrie
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Filip Janku
- The University of Texas MD Anderson Cancer Center
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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O'Brien K, Dave R, Shekhar S, Hannah-Shmouni F, Comis LE, Solomon BI, Chen M, Gahl WA, FitzGibbon E, Gochuico BR, Estrada-Veras JI. Survivorship Issues in Adult Patients With Histiocytic Neoplasms. J Natl Compr Canc Netw 2021; 19:1312-1318. [PMID: 34781266 PMCID: PMC10481619 DOI: 10.6004/jnccn.2021.7096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
Adult-onset histiocytoses (AOH), primarily Rosai-Dorfman disease (RDD), Erdheim-Chester Disease (ECD), and adult Langerhans cell histiocytosis (ALCH), are a group of related histiocytic neoplastic disorders featuring multisystemic manifestations. The disorders are largely incurable, and are essentially chronic neoplastic diseases with a variable prognosis. Prompt diagnosis and treatment is important to prevent debilitating and even life-threatening complications. Survivorship issues abound in AOH, due to their multisystemic manifestations and the sometimes recalcitrant chronic inflammation, which can lead to other debilitating complications such as fatigue, weakness, and pain. Because these disorders are rare, few healthcare professionals are proficient in their management; therefore the aim of these guidelines is to offer guidance on how to manage patients, and how to create survivorship care plans through the efforts of an interdisciplinary team.
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Affiliation(s)
- Kevin O'Brien
- Office of the Clinical Director, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Rahul Dave
- Inova Fairfax-Virginia Commonwealth University College of Medicine, Falls Church, Virginia
| | - Skand Shekhar
- Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland
| | - Fady Hannah-Shmouni
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland
| | - Leora E Comis
- Rehabilitation Medicine Department, Clinical Center, NIH, Bethesda, Maryland
| | - Beth I Solomon
- Speech Language Pathology Section, Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, NIH, Bethesda, Maryland
| | - Marcus Chen
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland; and
| | - William A Gahl
- Office of the Clinical Director, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | - Bernadette R Gochuico
- Office of the Clinical Director, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Juvianee I Estrada-Veras
- Office of the Clinical Director, National Human Genome Research Institute, NIH, Bethesda, Maryland
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12
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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13
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Pituitary Imaging Abnormalities and Related Endocrine Disorders in Erdheim-Chester Disease. Cancers (Basel) 2021; 13:cancers13164126. [PMID: 34439280 PMCID: PMC8392147 DOI: 10.3390/cancers13164126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Erdheim–Chester disease (ECD) is a rare histiocytic neoplasm that is frequently associated with hypothalamic–pituitary gland involvement leading to endocrine dysfunctions. Frequently, endocrinopathy is permanent and precedes the diagnosis of ECD and may also develop during the course of treatment. However, the exact nature and frequency of hypothalamic–pituitary involvement are unknown. We studied a natural history cohort of 61 subjects with Erdheim–Chester disease and found abnormal pituitary imaging in 47.5% of cases, associated with panhypopituitarism, diabetes insipidus, and a higher median number of pituitary endocrinopathies. These data confirm and significantly extend previous reports of centrally occurring endocrine dysfunction and highlight the need for routine imaging and systematic assessment of hypothalamic–pituitary endocrine function in patients with ECD. Abstract Purpose: We examined abnormal pituitary imaging (API) and associated endocrine dysfunction in subjects with ECD. Methods: A cross-sectional descriptive examination of a natural history cohort study diagnosed with ECD was conducted at a clinical research center. Subjects underwent baseline endocrine tests of anterior and posterior pituitary function and dedicated pituitary gland MRI scans. We determined the frequency of various pituitary imaging abnormalities in ECD and assessed its relationships with age, sex, body mass index (BMI), BRAF V600E status, high sensitivity C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), pituitary hormone deficits and number, diabetes insipidus (DI), and panhypopituitarism. Results: Our cohort included 61 subjects with ECD [age (SD): 54.3 (10.9) y, 46 males/15 females]. API was present in 47.5% (29/61) of ECD subjects. Loss of the posterior pituitary bright spot (36.1%) followed by thickened pituitary stalk (24.6%), abnormal enhancement (18.0%), and pituitary atrophy (14.8%) were the most common abnormalities. DI and panhypopituitarism were more frequent in subjects with API without differences in age, sex distribution, hsCRP, ESR, and BRAF V600E status compared to normal pituitary imaging. Conclusions: We noted a high burden of API and endocrinopathies in ECD. API was highly associated with the presence of panhypopituitarism and DI. Therefore, a thorough assessment of hypothalamic–pituitary integrity should be considered in subjects with ECD.
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14
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He TH, Zhao AL, Niu N, Wang FD, Shi J, Li J, Cao XX. [Erdheim-Chester Disease presenting with exophthalmos, impaired vision, and retroperitoneal fibrosis: a case report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:673-676. [PMID: 34547874 PMCID: PMC8501279 DOI: 10.3760/cma.j.issn.0253-2727.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- T H He
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - A L Zhao
- West China Hospital, Sichuan University, Chengdu 611130, China
| | - N Niu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - F D Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - J Shi
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - J Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - X X Cao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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15
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Emile JF, Cohen-Aubart F, Collin M, Fraitag S, Idbaih A, Abdel-Wahab O, Rollins BJ, Donadieu J, Haroche J. Histiocytosis. Lancet 2021; 398:157-170. [PMID: 33901419 PMCID: PMC9364113 DOI: 10.1016/s0140-6736(21)00311-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
Histiocytoses constitute a heterogeneous group of rare disorders, characterised by infiltration of almost any organ by myeloid cells with diverse macrophage or dendritic cell phenotypes. Histiocytoses can start at any age. Diagnosis is based on histology in combination with appropriate clinical and radiological findings. The low incidence and broad spectrum of clinical manifestations often leads to diagnostic delay, especially for adults. In most cases, biopsy specimens infiltrated by histiocytes have somatic mutations in genes activating the MAP kinase cell-signalling pathway. These mutations might also be present in blood cells and haematopoietic progenitors of patients with multisystem disease. A comprehensive range of investigations and molecular typing are essential to accurately predict prognosis, which can vary from spontaneous resolution to life-threatening disseminated disease. Targeted therapies with BRAF or MEK inhibitors have revolutionised salvage treatment. However, the type and duration of treatment are still debated, and the prevention of neurological sequelae remains a crucial issue.
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Affiliation(s)
- Jean-François Emile
- EA4340 BECCOH, Université de Versailles SQY, Service de Pathologie, Hôpital Ambroise Paré, AP-HP, Boulogne, France.
| | - Fleur Cohen-Aubart
- Internal Medicine Department 2, French National Referral Center for Rare Systemic Diseases and Histiocytoses, Pitié-Salpêtrière Hospital, AP-HP and Sorbonne Université, Paris, France
| | - Matthew Collin
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sylvie Fraitag
- Pathology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Ahmed Idbaih
- UMR S 1127, CNRS/Inserm, Institut du Cerveau et de la Moelle Épinière, Hôpitaux Universitaires La Pitié Salpêtrière-Charles Foix, AP-HP and Sorbonne Université, Paris, France
| | - Omar Abdel-Wahab
- Human Oncology and Pathogenesis Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Barrett J Rollins
- Department of Medical Oncology, Dana-Farber Cancer Institute and Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean Donadieu
- EA4340 BECCOH, Université de Versailles SQY, Service de Pathologie, Hôpital Ambroise Paré, AP-HP, Boulogne, France; Service d'Hématologie Oncologie Pédiatrique, Centre de Référence des Histiocytoses, Hôpital Armand-Trousseau, AP-HP, Paris, France
| | - Julien Haroche
- Internal Medicine Department 2, French National Referral Center for Rare Systemic Diseases and Histiocytoses, Pitié-Salpêtrière Hospital, AP-HP and Sorbonne Université, Paris, France
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16
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Vallejo Herrera MJ, Sánchez Torralvo FJ, Vallejo Herrera V, Olveira Fuster G, Pérez de Pedro I. Erdheim-Chester disease: diagnosis in endocrinology. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00150-6. [PMID: 34244096 DOI: 10.1016/j.endinu.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 11/24/2022]
Affiliation(s)
| | | | | | - Gabriel Olveira Fuster
- UGC Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, España
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17
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Kanakis M, Petrou P, Lourida G, Georgalas I. Erdheim-Chester disease: a comprehensive review from the ophthalmologic perspective. Surv Ophthalmol 2021; 67:388-410. [PMID: 34081930 DOI: 10.1016/j.survophthal.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 01/18/2023]
Abstract
Erdheim-Chester disease (ECD) is a rare clonal histiocytic neoplasm with less than 1200 documented cases to date. The disease is life-threatening and difficult to recognize, although increasing awareness as well as the integration of clinical, imaging, pathology information , and genetic studies have led to a recent exponential increase in new reported cases. ECD affects multiple organs and systems, including skeletal, neurologic, and cardiovascular. Pulmonary, retroperitoneal, and cutaneous lesions have also been reported in various combinations. Until the discovery that more than half of ECD patients harbor the BRAF-V600E mutation or other mutations in the mitogen-activated protein kinase (MAPK) and RAS pathways, Interferon-a was the first-line treatment. Nowadays BRAF and MEK-inhibitors targeted therapies are the mainstay of treatment. Ophthalmologic involvement occurs in 25% -30% of ECD cases, usually in the form of orbital involvement presenting with exophthalmos and ophthalmoplegia. Other ophthalmologic manifestations include palpebral xanthelasmas, anterior uveitis and vitritis, optic disk edema, choroidal infiltration, recurrent serous retinal detachment, retinal drusen-like deposits and retinal pigment epithelial changes. ECD patients can also present with ocular symptoms as a result of adverse effects of the treatment regimens. In some cases with smoldering or protean symptoms, the emergence of eye manifestations triggered the diagnosis. Ophthalmologists have to be aware of the disease, recognize the constellation of ECD symptoms, and contribute to the diagnosis, treatment, and follow-up of ECD patients.
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Affiliation(s)
| | - Petros Petrou
- G. Genimatas General Hospital, National and Kapodistrian University of Athens, 1st University Eye Clinic, Athens, Greece
| | - Giota Lourida
- Department of Internal Medicine and Infectious Disease, Sotiria Hospital, Athens, Greece
| | - Ilias Georgalas
- G. Genimatas General Hospital, National and Kapodistrian University of Athens, 1st University Eye Clinic, Athens, Greece.
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18
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Angelousi A, Mytareli C, Xekouki P, Kassi E, Barkas K, Grossman A, Kaltsas G. Diabetes insipidus secondary to sellar/parasellar lesions. J Neuroendocrinol 2021; 33:e12954. [PMID: 33769630 DOI: 10.1111/jne.12954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/25/2022]
Abstract
Diabetes insipidus (DI) is a well-recognised transient or permanent complication following transsphenoidal surgery for pituitary adenomas or other sellar/parasellar lesions. However, data regarding the prevalence of pre-operative DI in sellar/parasellar lesions other than pituitary adenomas are scarce. We systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar/parasellar lesions, excluding pituitary adenomas and metastatic lesions. In total, 646 patients with sellar/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans's cell histiocytosis (18.9%) and Rathke's cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ-cell tumours (76.7%), abscesses (55.4%) and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions, and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumour and the early initiation of appropriate treatment.
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Affiliation(s)
- Anna Angelousi
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chrysoula Mytareli
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - Eva Kassi
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Barkas
- Department of Neurosurgery, General Hospital of Nikaia-Pireas, Agios Panteleimon, Athens, Greece
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - Gregory Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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19
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Erdheim-Chester disease: consensus recommendations for evaluation, diagnosis, and treatment in the molecular era. Blood 2021; 135:1929-1945. [PMID: 32187362 DOI: 10.1182/blood.2019003507] [Citation(s) in RCA: 193] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/04/2020] [Indexed: 01/18/2023] Open
Abstract
Erdheim-Chester disease (ECD) is a rare histiocytosis that was recently recognized as a neoplastic disorder owing to the discovery of recurrent activating MAPK (RAS-RAF-MEK-ERK) pathway mutations. Typical findings of ECD include central diabetes insipidus, restrictive pericarditis, perinephric fibrosis, and sclerotic bone lesions. The histopathologic diagnosis of ECD is often challenging due to nonspecific inflammatory and fibrotic findings on histopathologic review of tissue specimens. Additionally, the association of ECD with unusual tissue tropism and an insidious onset often results in diagnostic errors and delays. Most patients with ECD require treatment, except for a minority of patients with minimally symptomatic single-organ disease. The first ECD consensus guidelines were published in 2014 on behalf of the physicians and researchers within the Erdheim-Chester Disease Global Alliance. With the recent molecular discoveries and the approval of the first targeted therapy (vemurafenib) for BRAF-V600-mutant ECD, there is a need for updated clinical practice guidelines to optimize the diagnosis and treatment of this disease. This document presents consensus recommendations that resulted from the International Medical Symposia on ECD in 2017 and 2019. Herein, we include the guidelines for the clinical, laboratory, histologic, and radiographic evaluation of ECD patients along with treatment recommendations based on our clinical experience and review of literature in the molecular era.
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20
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Neuroendocrine manifestations of Erdheim-Chester disease. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:137-147. [PMID: 34238453 DOI: 10.1016/b978-0-12-820683-6.00010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neuroendocrine manifestations are common in Erdheim-Chester disease (ECD) patients. ECD is a rare non-Langerhans form of histiocytosis with multisystemic infiltration. The involvement of the hypothalamo-pituitary axis is common and central diabetes insipidus (CDI) is one of the most common endocrine manifestations in ECD patients. CDI is the first manifestation of ECD in 25%-48% of the cases. Suprasellar region extension, due to the infiltration of ECD lesions, can cause neurologic manifestations by mass effects, such as headache, visual disturbance, and cranial nerve palsies. Recent studies have revealed that disorders affecting anterior pituitary hormones are common in ECD patients. Secondary adrenal insufficiency, secondary hypothyroidism, (adult) growth hormone deficiency, hypogonadotropic hypogonadism, hyperprolactinemia, and hypoprolactinemia can develop as the neuroendocrine manifestations of ECD. Since the symptoms of anterior pituitary hormone deficiencies tend to be nonspecific, the diagnosis of anterior pituitary hormone dysfunctions can be delayed. Some anterior pituitary dysfunctions such as adrenocorticotropic hormone and/or thyroid-stimulating hormone deficiencies can be life-threatening without adequate hormone supplementation therapies. An endocrinological evaluation of the function of the pituitary gland should be performed at the initial diagnosis of ECD. It is important to recognize that endocrine dysfunctions can develop later during the follow-up of ECD.
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21
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McClain K. Histiocytic disorders: insights into novel biology and implications for therapy of Langerhans cell histiocytosis and Erdheim-Chester disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:395-399. [PMID: 33275721 PMCID: PMC7727507 DOI: 10.1182/hematology.2020000159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Langerhans cell histiocytosis (LCH) and Erdheim-Chester disease (ECD) are caused by mutations of the MAPK pathway, most often BRAFV600E, in myeloid dendritic cells that lead to some overlapping and other unique presentations of the two diseases. LCH occurs in both children and adults, but ECD is primarily found in the latter. The challenges in diagnosing these conditions relates to the rarity of the conditions and that they mimic diseases that are more widely understood, such as certain rashes; bone, lung, and renal diseases; and other malignancies. The histopathology of LCH is definitive, but not so for ECD. Treatment with BRAF and MEK inhibitors has become one of the important advances in the care of these patients.
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22
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Abstract
Erdheim-Chester disease (ECD) is characterized by the infiltration of tissues by foamy CD68+CD1a- histiocytes, with 1500 known cases since 1930. Mutations activating the MAPK pathway are found in more than 80% of patients with ECD, mainly the BRAFV600E activating mutation in 57% to 70% of cases, followed by MAP2K1 in close to 20%. The discovery of BRAF mutations and of other MAP kinase pathway alterations, as well as the co-occurrence of ECD with LCH in 15% of patients with ECD, led to the 2016 revision of the classification of histiocytoses in which LCH and ECD belong to the "L" group. Both conditions are considered inflammatory myeloid neoplasms. Ten percent of ECD cases are associated with myeloproliferative neoplasms and/or myelodysplastic syndromes. Some of the most striking signs of ECD are the long bone involvement (80%-95%), as well as the hairy kidney appearance on computed tomography scan (63%), the coated aorta (40%), and the right atrium pseudo-tumoral infiltration (36%). Central nervous system involvement is a strong prognostic factor and independent predictor of death. Interferon-α seems to be the best initial treatment of ECD. Since 2012, more than 200 patients worldwide with multisystem or refractory ECD have benefitted from highly effective therapy with BRAF and MEK inhibitors. Targeted therapies have an overall, robust, and reproducible efficacy in ECD, with no acquired resistance to date, but their use may be best reserved for the most severe manifestations of the disease, as they may be associated with serious adverse effects and as-yet-unknown long-term consequences.
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23
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Luna LP, Drier A, Aygun N, Mokhtari K, Hoang-Xuan K, Galanaud D, Donadieu J, Dormont D, Haroche J, Martin-Duverneuil N. MRI features of intra-axial histiocytic brain mass lesions. Clin Radiol 2020; 76:159.e19-159.e28. [PMID: 33077156 DOI: 10.1016/j.crad.2020.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
AIM To describe MRI features, including diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS), and perfusion-weighted imaging (PWI), of intra-axial tumour-like presentations of four different subtypes of histiocytosis. MATERIAL AND METHODS The brain MRI findings of 23 patients with histologically proven histiocytosis were reviewed retrospectively (11 Langerhans cell histiocytosis [LCH], eight Erdheim-Chester disease [ECD], one overlap form LCH/ECD, two Rosai-Dorfman disease [RDD], and one haemophagocytic lymphohistiocytosis [HLH]) with single or multiple enhancing intraparenchymal brain lesions. RESULTS Histiocytic brain mass lesions show some similar MRI features including Supra and/or infratentorial and/or paraventricular subcortical well-delineated masses, linear ependymal enhancement along the ventricles and brain stem lesions. Masses always present with mixed hyper- and hypointense signal on T2-weighted imaging (WI). Their enhancement is often homogeneous. Apparent diffusion coefficient (ADC) values are often normal or elevated. CONCLUSION The presence of multiple periventricular and subcortical enhancing lesions with mixed signal intensity on T2WI and normal or high ADC values should lead radiologists to consider the diagnosis of histiocytic lesions and search for associated systemic lesions.
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Affiliation(s)
- L P Luna
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, USA.
| | - A Drier
- APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - N Aygun
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - K Mokhtari
- APHP, Department of Neuropathology, Pitié-Salpêtrière Hospital, Paris, France
| | - K Hoang-Xuan
- APHP, Department of Neuro-oncology, Pitié-Salpêtrière Hospital, Paris, France
| | - D Galanaud
- APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - J Donadieu
- APHP, Department of Hematology, Trousseau Hospital, Paris, France
| | - D Dormont
- APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - J Haroche
- APHP, Department of Internal Medicine, Pitié-Salpêtrière Hospital, Paris, France
| | - N Martin-Duverneuil
- APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
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Shekhar S, Sinaii N, Irizarry-Caro JA, Gahl WA, Estrada-Veras JI, Dave R, Papadakis GZ, Tirosh A, Abel BS, Klubo-Gwiezdzinska J, Skarulis MC, Gochuico BR, O’Brien K, Hannah-Shmouni F. Prevalence of Hypothyroidism in Patients With Erdheim-Chester Disease. JAMA Netw Open 2020; 3:e2019169. [PMID: 33119105 PMCID: PMC7596581 DOI: 10.1001/jamanetworkopen.2020.19169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis affecting multiple organs and commonly caused by somatic pathogenic variants in BRAF V600E and mitogen-activated protein kinase genes. Clinical features of ECD result from histiocytic involvement of various tissues; while endocrine involvement in ECD occurs frequently, the prevalence of central or primary hypothyroidism has not been thoroughly investigated. OBJECTIVE To assess hypothalamus-pituitary-thyroid (HPT) dysfunction in patients with ECD. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 61 patients with ECD who were enrolled in a natural history study at a tertiary care center between January 2011 and December 2018. ECD was diagnosed on the basis of clinical, genetic, and histopathological features. Data were analyzed in March 2020. EXPOSURE Diagnosis of ECD. MAIN OUTCOMES AND MEASURES Main outcome was the prevalence of thyroid dysfunction in adults with ECD compared with community estimates. Patients underwent baseline evaluation with a thyroid function test, including thyrotropin, free thyroxine (fT4), and total thyroxine (T4), and sellar imaging with magnetic resonance imaging or computed tomography scan. The association of HPT dysfunction was assessed for differences in age, sex, body mass index, BRAF V600E status, high sensitivity C-reactive protein level, sellar imaging, and pituitary hormonal dysfunction. RESULTS A total of 61 patients with ECD (46 [75%] men; mean [SD] age, 54.3 [10.9] years) were evaluated. Seventeen patients (28%) had hypothyroidism requiring levothyroxine therapy. The prevalence of both central and primary hypothyroidism were higher than community estimates (central hypothyroidism: 9.8% vs 0.1%; odds ratio, 109.0; 95% CI, 37.4-260.6; P < .001; primary hypothyroidism: 18.0% vs 4.7%; OR, 4.4; 95% CI, 2.1-8.7; P < .001). Patients with hypothyroidism (both primary and central), compared with patients with euthyroidism, had higher body mass index (median [interquartile range] 31.4 [28.3-38.3] vs 26.7 [24.4-31.9]; P = .004) and a higher prevalence of panhypopituitarism (7 [47%] vs 3 [7%]; P < .001). Among patients with hypothyroidism, those with central hypothyroidism, compared with patients with primary hypothyroidism, had a lower mean (SD) body mass index (28.3 [2.6] vs 36.3 [5.9]; P = .007) and higher frequencies of abnormal sellar imaging (5 [83%] vs 3 [27%]; P = .050) and panhypopituitarism (5 [83%] vs 3 [27%]; P = .050). CONCLUSIONS AND RELEVANCE In this cohort study, a higher prevalence of central and primary hypothyroidism was identified in patients with ECD compared with the community. There should be a low threshold for testing for hypothyroidism in patients with ECD, and treatment should follow standard guidelines.
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Affiliation(s)
- Skand Shekhar
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Ninet Sinaii
- Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jorge A. Irizarry-Caro
- Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Rahul Dave
- Inova Fairfax-Virginia Commonwealth University College of Medicine, Falls Church
| | - Georgios Z. Papadakis
- Department of Radiology, Medical School, University of Crete, Heraklion, Greece
- Foundation for Research and Technology Hellas, Computational Biomedicine Laboratory, Heraklion, Greece
| | - Amit Tirosh
- Neuroendocrine Tumor Service, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Brent S. Abel
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Joanna Klubo-Gwiezdzinska
- Thyroid Tumors and Functional Thyroid Disorders Section, Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Monica C. Skarulis
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Bernadette R. Gochuico
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Kevin O’Brien
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Fady Hannah-Shmouni
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Dasdelen S, Büschek F. Erdheim-Chester-Erkrankung – eine histiozytäre Multisystemerkrankung mit ungewöhnlicher Nierenbeteiligung. Internist (Berl) 2020; 61:969-979. [DOI: 10.1007/s00108-020-00849-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Association of BRAF V600E with Hypothalamic-Pituitary-Adrenal Axis Involvement in Erdheim-Chester Disease. ENDOCRINE AND METABOLIC SCIENCE 2020. [DOI: 10.1016/j.endmts.2020.100051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Erdheim–Chester disease: a rapidly evolving disease model. Leukemia 2020; 34:2840-2857. [DOI: 10.1038/s41375-020-0944-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 01/19/2023]
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Abstract
Erdheim-Chester disease (ECD) is a rare but increasingly recognized multi-system disorder. Its diagnosis and treatment require integration of clinical information, imaging studies, and pathology studies. Of note, ECD can now be defined as a clonal myeloid disorder due to mutations which activate mitogen-activated protein kinase (MAPK) pathways and where an inflammatory milieu is important in the pathogenesis and clinical manifestations of the disease. Biopsy demonstrating characteristic histopathologic features in addition to clinical and radiographic features, most often sclerosing long bone involvement, is required to establish a diagnosis. Detection of somatic MAPK pathway mutations can also assist in the differential diagnosis of ECD and related histiocytic neoplasms. Also, genetic analysis establishing BRAF and RAS mutational status is critical in all ECD patients, as these features will impact therapy with MAPK inhibition. Therapy is recommended at diagnosis in all patients, except for those patients with minimally symptomatic disease. Prospective therapeutic trials are essential to furthering therapeutic progress in ECD.
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Affiliation(s)
- Gordon Starkebaum
- University of Washington, Division of Rheumatology, 1959 NE Pacific St., Box 356428, Seattle, WA, 98195-6428, USA.
| | - Paul Hendrie
- Division of Hematology, University of Washington, 1959 NE Pacific St., Box 358081, Seattle, WA, 98195-6428, USA.
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Angelousi A, Alexandraki K, Tsoli M, Kaltsas G, Kassi E. Hypophysitis (Including IgG4 and Immunotherapy). Neuroendocrinology 2020; 110:822-835. [PMID: 32126548 DOI: 10.1159/000506903] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Hypophysitis is characterized by inflammation of the pituitary gland that can be primary (PH) or secondary (SH) to other diseases or following drug administration. It may also be classified according to anatomical and histopathological criteria, leading to variable degrees of hypopituitarism and/or compressive symptoms to nearby structures. There has recently been an increase in the number of hypophysitis cases, raising the interest on the spectrum of its pathogenesis, clinical, biochemical/endocrinological, and imaging features. However, the use of conventional biomarkers, including currently utilized pituitary autoantibodies, has relatively limited diagnostic accuracy. Lymphocytic hypophysitis (LH) is the commonest cause of PH, whereas IgG4-related hypophysitis is increasingly being recognized. Histiocytosis and granulomatous diseases are the most frequent causes of SH, although infections and lymphoma have also been reported. The increasing use of immune checkpoint inhibitors in oncology is associated with a high incidence of hypophysitis, providing further understanding of its pathogenesis. Hypophysitis can occur silently and be easily missed, potentially leading to substantial morbidity or mortality due to adrenal insufficiency, requiring a high index of clinical suspicion and timely initiation of appropriate treatment. In most cases of LH or drug-induced hypophysitis, active surveillance along with replacement of established hormonal deficiencies is needed. In the presence of compressive and/or evolving symptoms, treatment with glucocorticoids either alone or in combination with other immunosuppressive agents can be used. Surgical decompression is reserved for nonresponsive cases with threatened vital structures. Timely diagnosis and intervention are important to minimize disease-related morbidity and mortality. We aimed to review current concepts and recent developments in the pathogenesis, diagnosis, and management of hypophysitis.
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Affiliation(s)
- Anna Angelousi
- First Department of Internal Medicine, Laiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece,
| | - Krystallenia Alexandraki
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Tsoli
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Papo M, Emile JF, Maciel TT, Bay P, Baber A, Hermine O, Amoura Z, Haroche J. Erdheim-Chester Disease: a Concise Review. Curr Rheumatol Rep 2019; 21:66. [DOI: 10.1007/s11926-019-0865-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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31
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Goyal G, Young JR, Koster MJ, Tobin WO, Vassallo R, Ryu JH, Davidge-Pitts CJ, Hurtado MD, Ravindran A, Sartori Valinotti JC, Bennani NN, Shah MV, Rech KL, Go RS. The Mayo Clinic Histiocytosis Working Group Consensus Statement for the Diagnosis and Evaluation of Adult Patients With Histiocytic Neoplasms: Erdheim-Chester Disease, Langerhans Cell Histiocytosis, and Rosai-Dorfman Disease. Mayo Clin Proc 2019; 94:2054-2071. [PMID: 31472931 DOI: 10.1016/j.mayocp.2019.02.023] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/14/2019] [Accepted: 02/22/2019] [Indexed: 12/25/2022]
Abstract
Histiocytic neoplasms, a rare and heterogeneous group of disorders, primarily include Erdheim-Chester disease, Langerhans cell histiocytosis, and Rosai-Dorfman disease. Due to their diverse clinical manifestations, the greatest challenge posed by these neoplasms is the establishment of a diagnosis, which often leads to a delay in institution of appropriate therapy. Recent insights into their genomic architecture demonstrating mitogen-activated protein kinase/extracellular signal-regulated kinase pathway mutations have now enabled potential treatment with targeted therapies in most patients. This consensus statement represents a joint document from a multidisciplinary group of physicians at Mayo Clinic who specialize in the management of adult histiocytic neoplasms. It consists of evidence- and consensus-based recommendations on when to suspect these neoplasms and what tests to order for the diagnosis and initial evaluation. In addition, it also describes the histopathologic and individual organ manifestations of these neoplasms to help the clinicians in identifying their key features. With uniform guidelines that aid in identifying these neoplasms, we hope to improve the awareness that may lead to their timely and correct diagnosis.
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Affiliation(s)
- Gaurav Goyal
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Maria D Hurtado
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Karen L Rech
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN.
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Clinical characterization of men with long QT syndrome and torsades de pointes associated with hypogonadism: A review and pharmacovigilance study. Arch Cardiovasc Dis 2019; 112:699-712. [PMID: 31477476 DOI: 10.1016/j.acvd.2019.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Long QT syndrome (LQTS) can cause the potentially fatal ventricular tachycardia torsades de pointes (TdP). QT interval corrected for heart rate (QTc) is shorter in men than in women, with testosterone contributing to shorten QTc. We recently described male hypogonadism as a reversible risk factor for acquired LQTS and TdP, but the clinical characteristics of such patients have not been characterized. AIMS To describe the clinical characteristics of men with acquired LQTS or TdP associated with hypogonadism caused by endocrine conditions or androgen deprivation therapy (ADT), and to evaluate the relationship between testosterone concentrations and electrocardiographic changes. METHODS We searched MEDLINE (to 04 January 2019) and the French pharmacovigilance database (to 09 August 2018) to identify male cases of acquired LQTS and TdP associated with endocrine hypogonadism or ADT; their narratives were gathered from reporting collaborators. RESULTS We identified seven cases of TdP (one fatal) with endocrine hypogonadism, abnormally long QTc and morphologically abnormal T-wave notches. After reversion of low testosterone concentrations in the surviving patients (N=6), QTc shortened, T-wave morphology normalized and there was no TdP recurrence. Among these cases, none had mutation in the LQTS genes, three men required testosterone and three had reversible hypogonadism after resolution of a concurrent acute severe illness. We found an additional 27 reports of men with LQTS (N=6), TdP (N=9; 2/9 fatal) or sudden death (N=12; 10/12 fatal) suspected to be induced or favoured by ADT (24/27 for prostate cancer). Generally, after ADT withdrawal, QTc shortened and no TdP recurred. CONCLUSION We propose seeking for hypogonadism caused by endocrine conditions or ADT in men presenting with TdP. Caution is warranted when ADT is used in situations at risk of TdP. Testosterone may be useful to treat or prevent TdP.
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Weber J, Hammond N, Yaghmai V, Nikolaidis P, Miller F, Horowitz J. Imaging features of immune-mediated genitourinary disease. Abdom Radiol (NY) 2019; 44:2217-2232. [PMID: 30915493 DOI: 10.1007/s00261-019-01946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis. METHODS In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis. RESULTS Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease. CONCLUSION Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.
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Affiliation(s)
- Jonathon Weber
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA.
| | - Nancy Hammond
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Vahid Yaghmai
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Paul Nikolaidis
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Frank Miller
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Jeanne Horowitz
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
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Abstract
Hypophysitis is a rare entity characterized by inflammation of the pituitary gland and its stalk that can cause hypopituitarism and/or mass effect. Etiology can be categorized as primary or secondary to systemic disease, but may also be classified according to anatomical and hispathological criteria. Newly recognized causes of hypophysits have been described, mainly secondary to immunomodulatory medications and IgG4-related disease. Diagnosis is based on clinical, laboratory and imaging data, whereas pituitary biopsy, though rarely indicated, may provide a definitive histological diagnosis. For the clinician, obtaining a broad clinical and drug history, and performing a thorough physical examination is essential. Management of hypophysitis includes hormone replacement therapy if hypopituitarism is present and control of the consequences of the inflammatory pituitary mass (e.g. compression of the optic chiasm) using high-dose glucocorticoids, whereas pituitary surgery is reserved for those unresponsive to medical therapy and/or have progressive disease. However, there remains an unmet need for controlled studies to inform clinical practice.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona, United States.
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Peter J Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Monmany J, Granell E, López L, Domingo P. Resolved heart tamponade and controlled exophthalmos, facial pain and diabetes insipidus due to Erdheim-Chester disease. BMJ Case Rep 2018; 2018:bcr-2018-225224. [PMID: 30337283 PMCID: PMC6254461 DOI: 10.1136/bcr-2018-225224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
A 69-year-old woman suffering from exophthalmos and facial pain came to us referred for aetiological diagnosis of exophthalmos. Orbital MRI showed thinned extrinsic ocular musculature, intraconal fat infiltration, retro-ocular compression and thickening of maxillary and sphenoid sinus walls. She had been suffering from diabetes insipidus for the last 7 years. During our diagnosis process, she presented signs of cardiac tamponade. Transthoracic heart ultrasound revealed large pericardial effusion and a heterogeneous mass that compressed the right ventricle. No osteosclerotic lesions on appendicular bones were present. Pericardiocentesis temporarily controlled tamponade and corticoid therapy temporarily abated exophthalmos. Pericardiectomy definitively resolved tamponade. Histological examination of pericardial tissue was conclusive of Erdheim-Chester disease. Exophthalmos responded to pegylated interferon-alpha-2a. Facial bone pain disappeared after zoledronic acid and interferon treatment. During interferon therapy, the patient suffered from a severe generalised desquamative exanthema that slowly resolved after discontinuing interferon. Diabetes insipidus remains controlled with desmopressin.
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Affiliation(s)
- Jaume Monmany
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Esther Granell
- Diagnòstic per la Imatge, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laura López
- Anatomia Patològica, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pere Domingo
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Haroutunian SG, O'Brien KJ, Estrada-Veras JI, Yao J, Boyd LC, Mathur K, Gahl WA, Mirmomen SM, Malayeri AA, Kleiner DE, Jaffe ES, Gochuico BR. Clinical and Histopathologic Features of Interstitial Lung Disease in Erdheim⁻Chester Disease. J Clin Med 2018; 7:jcm7090243. [PMID: 30154360 PMCID: PMC6162862 DOI: 10.3390/jcm7090243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 11/16/2022] Open
Abstract
Limited information is available regarding interstitial lung disease (ILD) in Erdheim⁻Chester disease (ECD), a rare multisystemic non-Langerhans cell histiocytosis. Sixty-two biopsy-confirmed ECD patients were divided into those with no ILD (19.5%), minimal ILD (32%), mild ILD (29%), and moderate/severe ILD (19.5%), based on computed tomography (CT) findings. Dyspnea affected at least half of the patients with mild or moderate/severe ILD. Diffusion capacity was significantly reduced in ECD patients with minimal ILD. Disease severity was inversely correlated with pulmonary function measurements; no correlation with BRAF V600E mutation status was seen. Reticulations and ground-glass opacities were the predominant findings on CT images. Automated CT scores were significantly higher in patients with moderate/severe ILD, compared to those in other groups. Immunostaining of lung biopsies was consistent with ECD. Histopathology findings included subpleural and septal fibrosis, with areas of interspersed normal lung, diffuse interstitial fibrosis, histiocytes with foamy cytoplasm embedded in fibrosis, lymphoid aggregates, and focal type II alveolar cell hyperplasia. In conclusion, ILD of varying severity may affect a high proportion of ECD patients. Histopathology features of ILD in ECD can mimic interstitial fibrosis patterns observed in idiopathic ILD.
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Affiliation(s)
- Sara G Haroutunian
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Kevin J O'Brien
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Juvianee I Estrada-Veras
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jianhua Yao
- Radiology and Imaging Sciences, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Louisa C Boyd
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Kavya Mathur
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - William A Gahl
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - S Mojdeh Mirmomen
- Laboratory of Diagnostic Radiology Research, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Ashkan A Malayeri
- Laboratory of Diagnostic Radiology Research, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA.
| | - David E Kleiner
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Elaine S Jaffe
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Bernadette R Gochuico
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Abstract
The hematolymphoid infiltrations are challenging lesions in endocrine organs and tissues. The fourth edition of WHO classification of tumors of endocrine organs and the fourth edition of WHO classification of tumors of hematopoietic and lymphoid tissues are recently published. The updates in both fields include some new disease descriptions and prognostic markers. Our aim in this review article is to give practical diagnostic information about the most frequently seen hematolymphoid involvements of the pituitary gland, thyroid, and adrenal tissue. We designed the text in the order of organs and the contents according to the disease frequency. The pituitary gland and cellar region are the most frequently involved with Langerhans cell histiocytosis. Although it is very rare, Erdheim-Chester disease has recently been included in the classification and still needs more clear diagnostic definitions. Lymphoproliferative thyroid lesions and presentations create diagnostic problems for the pathologists. IGG4-related disease and its relation with thyroiditis is a new concept. There are many unknowns on pathobiology of the disease spectrum and discussion on defined diagnostic criteria of the IGG4-related thyroid diseases. The overlapping features of thyroiditis and primary thyroid lymphomas also create diagnostic difficulties. The frequently recognized primary hematolymphoid lesions of the endocrine organs may not be difficult to diagnose since they are expected lesions. The secondary involvement of hematolymphoid neoplasia may be more difficult to diagnose for an endocrine pathologist. In this review article, we aim to give brief description of the diseases and practical diagnostic approach by using optimum markers guided by the latest WHO classifications.
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Affiliation(s)
- Isinsu Kuzu
- Department of Medical Pathology, Ankara University School of Medicine, Ahmet Adnan Saygun Cad. No:35. Morphology Building, Sihhiye, 06100, Ankara, Turkey.
| | - Ahmet Dogan
- Hematopathology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
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Pan Z, Kleinschmidt-DeMasters BK. CNS Erdheim-Chester Disease: A Challenge to Diagnose. J Neuropathol Exp Neurol 2017; 76:986-996. [PMID: 29096034 DOI: 10.1093/jnen/nlx095] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 01/18/2023] Open
Abstract
Erdheim-Chester disease (ECD) is a rare nonLangerhans cell histiocytosis. Although approximately 50% of cases eventually involve the central nervous system (CNS), the CNS has seldom been reported as the initial biopsy site. The diagnosis of CNS ECD can be challenging due to morphologic overlap with reactive histiocytic proliferation, Langerhans cell histiocytosis (LCH), and extranodal Rosai-Dorfman disease (RDD). We present 3 cases from our files that illustrate the protean manifestations of ECD. Case 1 was a 47-year-old man with ataxia, dysarthria, and intermittent ophthalmoplegia whose cerebellar biopsy had shown only profuse, nonspecific Rosenthal fiber-rich piloid gliosis; ECD was diagnosed only at autopsy. The gliosis and marked variations in histiocyte morphology in different anatomical sites added to the diagnostic challenge. Case 2 was a 67-year-old female with chronic progressive symptoms and a pontine lesion that had been considered to be CLIPPERS by neuroimaging. Identification of a BRAFV600E mutation allowed an ECD diagnosis and treatment with the specific BRAFV600E inhibitor vemurafenib, which resulted in a marked sustained clinical response. Case 3 was diagnosed as ECD after positive bone biopsy with typical foamy histiocytes. Six years later, there was massive dural involvement that showed RDD-like, BRAF-mutation-negative histiocytosis. These cases highlight the clinical and histologic overlap that can occur among these disorders.
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Affiliation(s)
- Zenggang Pan
- Department of Pathology; Department of Neurology; and Department of Neurosurgery, University of Colorado Denver, Aurora, Colorado
| | - Bette K Kleinschmidt-DeMasters
- Department of Pathology; Department of Neurology; and Department of Neurosurgery, University of Colorado Denver, Aurora, Colorado
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Pekic S, Popovic V. DIAGNOSIS OF ENDOCRINE DISEASE: Expanding the cause of hypopituitarism. Eur J Endocrinol 2017; 176:R269-R282. [PMID: 28258131 DOI: 10.1530/eje-16-1065] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/17/2017] [Accepted: 03/02/2017] [Indexed: 12/14/2022]
Abstract
Hypopituitarism is defined as one or more pituitary hormone deficits due to a lesion in the hypothalamic-pituitary region. By far, the most common cause of hypopituitarism associated with a sellar mass is a pituitary adenoma. A high index of suspicion is required for diagnosing hypopituitarism in several other conditions such as other massess in the sellar and parasellar region, brain damage caused by radiation and by traumatic brain injury, vascular lesions, infiltrative/immunological/inflammatory diseases (lymphocytic hypophysitis, sarcoidosis and hemochromatosis), infectious diseases and genetic disorders. Hypopituitarism may be permanent and progressive with sequential pattern of hormone deficiencies (radiation-induced hypopituitarism) or transient after traumatic brain injury with possible recovery occurring years from the initial event. In recent years, there is increased reporting of less common and less reported causes of hypopituitarism with its delayed diagnosis. The aim of this review is to summarize the published data and to allow earlier identification of populations at risk of hypopituitarism as optimal hormonal replacement may significantly improve their quality of life and life expectancy.
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Affiliation(s)
- Sandra Pekic
- School of MedicineUniversity of Belgrade, Belgrade, Serbia
- Clinic of EndocrinologyDiabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia
| | - Vera Popovic
- School of MedicineUniversity of Belgrade, Belgrade, Serbia
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Tan AC, Yzer S, Atebara N, Marr BP, Verdijk RM, Dalm VA, Freund KB, Yannuzzi L, Missotten T. Three Cases of Erdheim-Chester Disease With Intraocular Manifestations: Imaging and Histopathology Findings of a Rare Entity. Am J Ophthalmol 2017; 176:141-147. [PMID: 28153505 DOI: 10.1016/j.ajo.2017.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To report intraocular manifestations of Erdheim-Chester Disease (ECD) with multimodal imaging. DESIGN A retrospective observational case series. METHODS This was a multicenter case series of 3 patients with confirmed tissue diagnosis of ECD that showed intraocular manifestations and were imaged at baseline and follow-up visits. RESULTS Intraocular manifestations are rarely observed in association with ECD. Intraocular manifestations of ECD seen on multimodal imaging include histiocytic choroidal infiltration causing choroidal lesions, complicated by recurrent serous retinal detachment (SRD). Short-term resolution of SRD was observed with ocular therapies including intravitreal injections of anti-vascular endothelial growth factor or verteporfin photodynamic therapy in combination with systemic chemotherapy therapies and oral corticosteroids; however, recurrences were common. Chorioretinal biopsy confirmed the diagnosis of ECD in 1 case, with the presence of histiocytic infiltration, fibrosis, and characteristic immunohistologic staining. In another case, with a novel ARAF positive mutation, treatment with sorafenib showed regression of the choroidal lesions and resolution of the SRD on multimodal imaging. These lesions were previously resistant to other forms of therapy. CONCLUSIONS Rare intraocular manifestations of ECD confirmed on histopathology can be imaged with multimodal imaging. We report 3 cases, including 1 case diagnosed through histology from chorioretinal biopsy and another case associated with a novel ARAF mutation responsive to targeted therapy with sorafenib. The identification of novel somatic mutation associated with ECD enabled treatment with a new-targeted systemic agent. Multimodal imaging in these cases can also be used to monitor response to therapy.
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Cavalli G, De Luca G, Dagna L. Advances in potential targeted therapies for Erdheim-Chester disease. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1285226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Librizzi MS, Arroyave L, García E, Serraclara A, Maíz M, Díaz-Guerra GM, Hawkins F. Erdheim-Chester Disease: Case Report With Multisystemic Involvement, Including Diabetes Insipidus And Hypogonadism. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161298.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Erdheim–Chester disease is a rare non-Langerhans cell histiocytic disorder. It is primarily a disease of the long bones. Pulmonary involvement in systemic disease is detected in about half the reported cases. Isolated lung involvement is extremely rare with no clear recommendations for treatment. A 52-year-old caucasian male was evaluated for 1.9 cm × 1.6 cm spiculated nodule in the right upper lobe. Pulmonary function testing and bronchoscopy with endobronchial ultrasound, transbronchial biopsy, and microbiology were inconclusive. Positron emission tomography–computed tomography (PET-CT) was significant for the avidity in same lung nodule along with mediastinal and hilar adenopathy but no bone involvement. Wedge resection with histopathology and immunohistochemistry reported a fibrohistiocytic infiltrate in bronchovascular distribution which was positive for CD68 and negative for CD1A, S100, and BRAF V600E mutation. Magnetic resonance imaging brain ruled out central nervous system involvement. The rarity of the condition along with the complex pathology makes it difficult to diagnose and hence intervene appropriately.
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Affiliation(s)
- Enambir Singh Josan
- Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Jason W Green
- Department of Pulmonary Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Syed Imran M Zaidi
- Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Jayantilal B Mehta
- Department of Pulmonary Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
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Rice CM, Hall CA, McCoubrie P, Renowden SA, Cohen N, Scolding NJ. Erdheim-Chester disease: 25-year history with early CNS involvement. BMJ Case Rep 2016; 2016:bcr-2016-216747. [PMID: 27702933 DOI: 10.1136/bcr-2016-216747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We report a case of Erdheim-Chester disease (ECD) with a 25-year history following initial presentation with diabetes insipidus and brainstem involvement. The exceptionally long history is particularly notable, given that ECD is a life-threatening disorder and there is a recognised association between central nervous system involvement and poor outcome. The case is a timely reminder of the presenting features of the condition, given the emergence of potential new treatment options.
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Affiliation(s)
- C M Rice
- Department of Clinical Neuroscience, University of Bristol, Bristol, UK
| | - C A Hall
- North Bristol NHS Trust, Bristol, UK
| | | | | | - N Cohen
- North Bristol NHS Trust, Bristol, UK
| | - N J Scolding
- Department of Clinical Neuroscience, University of Bristol, Bristol, UK North Bristol NHS Trust, Bristol, UK
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