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

Localised Langerhans cell histiocytosis of the hypothalamic-pituitary region: case report and literature review

INTRODUCTION

Langerhans cell histiocytosis (LCH) localised in the hypothalamic-pituitary region (HPR) is very rare, especially in adults. Diabetes insipidus (DI) is considered to be a hallmark of HPR LCH, while anterior pituitary abnormalities are usually seen as consequences of surgery, radiotherapy or chemotherapy.

CASE DESCRIPTION

We present a patient with localised HPR LCH with dominant anterior pituitary dysfunction and tumour mass effects but without DI. Seven years after surgery and local radiotherapy, she is stable. Control MRI shows no residual tumour growth and thorough physical examination is still without any signs of disease spread.

CONCLUSIONS

Anterior pituitary deficiency can appear without DI and not only as a consequence of LCH treatment. All patients with LCH should be screened for this endocrine abnormality so that appropriate substitution therapy may be provided.

29 year-old male with seizure and syncope. Intracerebral Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH), previously referred to as histiocytosis X, is a dendritic cell histiocytic tumor that demonstrates a variable spectrum of organ involvement. Clinical syndromes within this entity include eosinophilic granuloma, Hand-Schuller-Christian disease, Abt-Letterer-Siwe Disease, and Hashimoto-Pritzker disease. Currently, it is classified on the basis of extent, such as unifocal, multifocal, or disseminated disease. LCH typically occurs in childhood and adolescence as solitary osteolytic lesions. When involving the central nervous system, it is usually either a result of extra-axial extension from skull vault epicenters, or is restricted to the hypothalamic-pituitary axis. Discrete intraparenchymal, intra-axial CNS lesions are rare. This report presents a case of an intra-axial LCH in a 29 year-old male who, following this diagnosis, was found to have multiple pulmonary lesions on imaging, attributed to the same disease process.

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

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

Craniospinal Langerhans cell histiocytosis in children: 30 years' experience at a single institution

OBJECTIVES

The goal of this study was to review a large series of patients with Langerhans cell histiocytosis (LCH) who had craniospinal lesions to assess the long-term course, outcome, and efficacy of treatment of the disease.

METHODS

Forty-four patients with LCH who presented to a single pediatric neurosurgical department between 1976 and 2006 were retrospectively reviewed.

RESULTS

This series included 29 boys and 15 girls, ranging in age from 2 months to 13 years, with a mean follow-up duration of 4.5 years. Twenty-seven patients (61%) had unifocal bone lesions, 12 (27%) had multifocal bone disease, 2 (5%) had solitary hypothalamic-pituitary axis lesions, and 3 (7%) had multiple organ involvement at presentation. Five (19%) of the 27 patients with unifocal bone disease and 4 (33%) of the 12 patients with multifocal bone disease had delayed development of new bone lesions during the follow-up period. The time to development of new bone lesions ranged from 1 month to 1 year. Two of the 3 patients with multiple-organ LCH died. Patient age < or = 2 years at the time of initial presentation was a risk factor for both initial multifocality and eventual dissemination. In all patients with initial multifocal bone involvement or later dissemination of unifocal bone disease, LCH was controlled by chemotherapy, except for 2 who were treated by surgery alone. Three patients had histological evidence of spontaneous resolution of their lesions.

CONCLUSIONS

Patients with unifocal LCH can be effectively treated with surgery alone. Very young patients are more likely to have multifocal disease and disseminations, and will usually require chemotherapy to control their disease. Spontaneously regressing lesions need not be resected; however, a biopsy procedure can be performed for diagnostic purposes.

A case of isolated langerhans cell histiocytosis of the hypothalamus with remission and regrowth after surgery

We describe a new case of isolated Langerhans cell histiocytosis (LCH) of the hypothalamus. A 53-year-old female patient presented with polydipsia, headache, anorexia, and fatigue. Neurological imaging revealed a mass projecting from the hypothalamus into the third ventricle. Gross total removal of the tumor was performed. Light microscopy showed LCH, and immunohistochemical studies revealed S-100 and CD1a immunoreactivity in the Langerhans cells. Although the most common CNS site for LCH is the hypothalamus, isolated hypothalamic LCH, confirmed by biopsy, is very rare. The residual mass appeared to remit spontaneously 3.5 years after surgery, with regrowth 3 years later.

Microsurgical anatomic features of the lamina terminalis

OBJECTIVE

The lamina terminalis (LT) is a structure of considerable interest for microneurosurgery, and precise knowledge regarding its normal anatomic features and the variations thereof is required. The purpose of this study, which was based on microanatomic dissection of human cadaveric specimens, was to review the microsurgical anatomic features of the LT and its neurovascular relationships. The surgical implications of the morphometric data are discussed.

METHODS

The region of the LT was examined in 10 human cadaveric heads, obtained from 8 fresh adult cadavers and 2 formalin-fixed adult cadavers, and in 10 formalin-fixed, isolated, adult brains. An operating microscope was used for all dissections and measurements.

RESULTS

Assuming the LT to be a triangular structure, we performed measurements of the distance between the midportion of the upper edge of the chiasm and the lower edge of the anterior commissure (height), which averaged 8.25 mm. The distance between the medial edges of the optic tracts (base) averaged 12.81 mm. The area averaged 52.84 mm(2). A minimal amount of retraction was needed to fully expose the LT, and generally there was no need to mobilize the anterior cerebral artery-anterior communicating artery complex. Perforating branches to the hypothalamus and optic apparatus are laterally located and do not interfere with LT incision and/or fenestration.

CONCLUSION

The LT constitutes a clearly identifiable microsurgical target. The allowable extent of LT opening is sufficient to provide wide access into and free cerebrospinal fluid flow from the third ventricle. Fenestration of the LT is a safe procedure, provided that the relevant anatomic landmarks are identified and respected.

Langerhans cell histiocytosis limited to the pituitary-hypothalamic axis--two case reports

Langerhans cell histiocytosis rarely presents as a solitary lesion in the pituitary-hypothalamic region, and is indistinguishable from germinoma, which occurs much more frequently, especially in Japanese. A 14-year-old girl and a 9-year-old girl presented with polydipsia and polyuria as the initial symptoms. Magnetic resonance (MR) imaging demonstrated a round mass at the pituitary stalk appearing as isointense on T1-weighted imaging and hyperintense on T2-weighted imaging. Endocrinological examination revealed mild hypopituitarism with central diabetes insipidus. Both patients underwent open craniotomy. Histological examination revealed granulomatous tissue with eosinophil infiltration and frequent Langerhans histiocyte clustering, compatible with the diagnosis of Langerhans cell histiocytosis. Low-dose local irradiation of 20 Gy was administered. First patient was followed up for 8 years, and her hypopituitarism gradually improved to a minimal level with only amenorrhea as the residual symptom. Recent MR imaging showed no residual mass at the region. Second patient was followed up for 15 months, and her diabetes insipidus is stable. MR imaging performed 5 months after the treatment showed marked reduction of the mass. These cases reemphasize the importance of histological diagnosis for lesions with similar neuroimaging appearances. Biopsy and low-dose irradiation are an effective treatment for this rare and essentially benign lesion, as opposed to attempting total removal of the mass.