Chemotherapy of reticuloendotheliosis. Comparison of methotrexate plus prednisone vs. vincristine plus prednisone

Clinical characteristics and treatment outcome of Langerhans cell histiocytosis: 22 years' experience of 154 patients at a single center

Langerhans cell histiocytosis (LCH) is a rare disease of unknown etiology. Large studies by single institutions have been infrequent because of the rarity of the disease and the diversity of clinical manifestations. In this study, the clinical characteristics, prognostic factors, and treatment outcomes were analyzed. Medical records were analyzed retrospectively for the 154 patients diagnosed and treated with LCH at Seoul National University Children's Hospital from January 1986 to December 2007. A total of 154 patients were evaluated. One hundred and six patients (68.8%) had single system disease, 48 patients (31.2%) had multisystem disease. Twenty-nine patients (18.8%) had risk organ involvement. Twenty-nine patients (18.8%) relapsed and the overall survival (OS) of the total study population was 97.1% with a median follow-up period of 7.0 years. Patients less than 4 years old, with involvement more than 2 organs and with risk organ involvement showed lower progression free survival (PFS) (P = .001, <.001, and <.001, respectively). Estimated 10-year PFS of patients with and without risk organ involvement were 52.6% and 83.8%, respectively. Patients with single system LCH had excellent prognosis showing 89.6% of PFS and 100% of OS. Patients with multisystem LCH also had a high survival rate, although the incidences of relapse remain to be solved. A new strategy to decrease the incidence of relapse is needed.

Multisystem Langerhans cell histiocytosis in children: current treatment and future directions

Langerhans cell histiocytosis (LCH) is a rare (about 3-5 cases per million children aged 0-14 years), non-malignant disease characterized by proliferation and accumulation of clonal dendritic cells, extreme clinical heterogeneity, and an unpredictable course. Three large-scale, international, prospective therapeutic studies (LCH-I to III) for multisystem LCH (MS-LCH) have been conducted by the Histiocyte Society since 1991. The cumulative lessons from these studies are summarized in this review. Patients with MS-LCH represent a heterogeneous group with respect to disease severity and outcome, therefore treatment stratification and risk-tailored treatment are mandatory. The risk for mortality can be predicted based on involvement of 'risk organs' (e.g. hematopoietic system, liver, and/or spleen) at diagnosis and on response to initial therapy (assessed after 6-12 weeks of treatment). Thus, patients without involvement of risk organs (low-risk group) are not at risk for mortality but need systemic therapy in order to control the disease activity and avoid reactivations and permanent consequences. Patients with risk organ involvement (risk group) are at risk for mortality, and lack of therapy response defines a subgroup with a particularly dismal prognosis (high-risk group). Those patients in the risk group who respond to therapy and survive are at risk for reactivations and permanent consequences. The LCH-I study compared the efficacy of vinblastine and etoposide, and concluded that they are equivalent single-agent treatments for children with MS-LCH. However, the results of this trial were inferior with respect to response rate at week 6, disease reactivation rate, and sequelae, when compared with historical trials using more intensive regimens. The combination of prednisolone and vinblastine was established as a standard first-line treatment through the LCH-II and LCH-III studies. The regimen consists of one to two 6-week courses (continuous oral corticosteroids 40 mg/m2/day for 4 weeks, tapered over 2 weeks plus weekly vinblastine intravenous push) of initial therapy, followed by a continuation phase (three weekly pulses of oral prednisolone 40 mg/m2/day for 5 days plus a vinblastine injection). The addition of a third drug to the standard combination (etoposide in LCH-II and methotrexate in LCH-III) failed to significantly improve survival in the risk group. The remaining mortality in the risk group is about 20%, and up to 40% in the high-risk group. Concerning low-risk MS-LCH, comparison of results of the LCH-II study with historical data suggested that the remaining reactivation rate of about 50% (and possibly permanent consequences) could be reduced by prolongation of the total treatment duration. To study this hypothesis, in the low-risk group of the LCH-III study standard maintenance therapy was randomly given for a total treatment duration of 6 and 12 months. Unpublished preliminary data from this recently closed trial suggested that prolongation of the treatment duration may significantly improve reactivation-free survival. In summary, several studies have shown that systemic therapy is indicated for all patients with MS-LCH. A standard two-drug regimen consisting of an initial 'intensive' phase for 6-12 weeks, followed by a less intensive 'maintenance phase' for a total treatment duration of at least 12 months is recommended for patients treated outside of clinical trials. Non-responders, particularly those with progressive disease in risk organs, are eligible for experimental salvage approaches. Remaining questions will be addressed in the upcoming LCH-IV trial, which is in the process of intensive preparation.

Maxillofacial manifestations of Langerhans cell histiocytosis: a clinical and therapeutic analysis of 10 patients

The definition of Langerhans cell histiocytosis (formerly known as histiocytosis X) includes the clinical syndromes Hand-Schueller-Christian syndrome, Abt-Letterer-Siwe syndrome, and eosinophilic granuloma. The paper gives an overview of current diagnostic and treatment strategies of LCH. Furthermore, records and clinical data of 10 patients with LCH were evaluated retrospectively. Patients' age ranged from 13 years to 42 years. The mandible was more frequently involved than the maxilla. Three patients (30%) had systemic manifestations of LCH in addition to their oral lesions. The longest follow-up period was 12 years. During follow-up six patients (60%) developed recurrent LCH and received adjuvant chemo- or radiation therapy. For solitary bone lesions, surgical curettage is the recommended treatment. Those patients with multi-organ involvement or recurrent LCH should be included into clinical trials initiated by the Histiocyte Society.

Disseminated Langerhans cell histocytosis in children: treatment outcome

Langerhans cell histiocytosis is an interesting disorder with a variety of presentations and variable outcomes. This study evaluates response to treatment, recurrence, and survival in disseminated Langerhans cell histiocytosis treated at Regional Cancer Centre, Trivandrum, India from 1983 through 1994. Thirty-five patients with disseminated Langerhans cell histiocytosis were seen. Six had group A disease, 21 had group B disease, and eight had group C disease. In group A, five of six patients are disease free at a median follow-up of 48 months. Two had recurrence after initial treatment, which was salvaged. In group B, 13 of 15 patients had complete response after chemotherapy, nine of whom experienced recurrence later. Three of five patients who received irradiation alone experienced recurrence. One died of progressive disease. Two patients were lost to follow-up. Seventeen of 20 are alive with median follow-up of 67 months. In group C, one of eight patients are alive after multiple recurrences. Of the surviving patients, 29% had significant sequelae. In summary, group A and B patients do well with treatment, and most of the recurrences can be salvaged. A significant proportion of patients have sequelae. Newer aggressive protocols must be developed for treating group C patients. Measures to prevent sequelae must also be developed.

Etoposide in Langerhans cell histiocytosis in children: a preliminary experience

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

Oral methotrexate and alternate-day prednisone for low-risk Langerhans cell histiocytosis

Many treatments for low-risk Langerhans cell histiocytosis (LCH) involve unpleasant side-effects or risks of late effects. To provide treatment with minimal toxicity and no known risk of late effects, we have used oral alternate-day prednisone (PDN, 40 mg/sq.m./day) and weekly methotrexate (MTX, 20 mg/sq.m. once weekly) in a series of 13 children with 17 episodes of LCH. Patients were monitored with monthly physical examinations, blood counts and chemistry panels, and radiographs and scans obtained at the treating physician's discretion. Patients who responded had the prednisone tapered and MTX discontinued after three months of treatment. Recurrences while treatment was being tapered, or after its discontinuation, were managed with resumption of MTX and PDN. Treatment was successful in 16 of the 17 episodes, meaning that symptoms resolved and abnormal physical or radiographic findings improved. Symptomatic relief occurred in two weeks or less in 14 of 17 episodes; objective improvement generally occurred within one month, and in all cases by three months. The median duration of treatment was 5 months. Toxicity was limited to slight, transient elevations in hepatic enzymes in three patients. We conclude that oral chemotherapy with alternate-day PDN and weekly MTX is effective and non-toxic in patients with low-risk LCH.

Treatment strategy for disseminated Langerhans cell histiocytosis. DAL HX-83 Study Group

Treatment of Langerhans cell histiocytosis (LCH) remains problematic. To test the hypothesis that rapid initiation and long-term continuation of chemotherapy can improve survival and reduce recurrence and late consequences of disseminated LCH, we have completed a prospective clinical trial (DAL HX-83). One hundred six newly diagnosed patients were stratified into three risk groups (A: multifocal bone disease [n = 28]; B: soft tissue involvement without organ dysfunction [n = 57]; C: organ dysfunction [n = 21]). All patients received an identical initial 6-week treatment (etoposide [VP-16], prednisone, and vinblastine), and continuation treatment for 1 year, slightly adapted according to stratification at diagnosis. It included oral 6-mercaptopurine and eight pulses of vinblastine and prednisone for all patients, plus VP-16 in group B and VP-16 and methotrexate in group C. Eighty-nine percent and 91% of patients in groups A and B and 67% of the most severely affected group C, achieved complete resolution of disease. The speed of resolution was rapid (median 4 months) and independent of disease severity. The frequency of recurrence after initial resolution was low (12%, 23%, and 42% in groups A, B and C); overall fully 77% of patients have remained free of recurrence. Permanent consequences developed after diagnosis in 20% of the patients. Diabetes insipidus after initiation of treatment occurred in only 10% of patients. Mortality (9%) was limited to patients of groups B (two patients) and C (eight patients). Finally, among the 106 patients treated by DAL HX-83 none have developed a malignancy (median follow-up 6 years, 9 months). The shorter duration of active disease, low rate of recurrence and permanent consequences, and improved survival among patients with poor prognosis support the strategy of rapid initiation of a predefined prolonged treatment upon the diagnosis of disseminated LCH.

Cytosine-arabinoside, vincristine, and prednisolone in the treatment of children with disseminated Langerhans cell histiocytosis with organ dysfunction: experience at a single institution

Fifty-two pediatric patients with Langerhans cell histiocytosis (LCH) were diagnosed at the Emma Kinderziekenhuis (EKZ) in Amsterdam over a 20-year period. Eight patients with multiorgan involvement with organ dysfunction and ten patients with multi-organ involvement without organ dysfunction received chemotherapy containing cytosine-arabinoside, vincristine, and prednisolone as part of their treatment. Five of the 8 patients (63%) with organ dysfunction and eight of the 10 (80%) without the organ dysfunction who needed chemotherapy because of the deteriorating of symptoms despite conventional therapy are presently in complete clinical remission. Two of those with organ dysfunction have died. Four of the total 18 patients developed diabetes insipidus either as an initial symptom or during the course of the disease. These results in both groups compare satisfactorily with other chemotherapeutic regimens, and since this combination is only mildly toxic, it has been well tolerated. Therefore we would recommend wider experience using this regimen in patients with widespread LCH with organ dysfunction as well as in patients with disseminated LCH in which chemotherapy proved to be necessary.

Histiocytosis X: successful treatment with recombinant interferon-alpha A

Two patients with disseminated histiocytosis X were treated with intramuscular injections of recombinant interferon alpha A. The bone, skin and visceral lesions of these patients diminished rapidly. Significant sclerosis and recalcification of bone were observed. From our limited but positive experience, it would be justified to consider the use of interferon in patients with disseminated histiocytosis X.

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

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

Langerhans cell histiocytosis: clinical experience with 124 patients

We cared for 124 pediatric patients with a histologic diagnosis of Langerhans' cell histiocytosis (histiocytosis X) over a period of 14 years. Clinical, laboratory, and radiographic findings were analyzed. The most frequent manifestations were bone lesions, lymph node involvement, and skin infiltration. Liver disease was noted in 50% of patients and lung disease in 23%; hematologic changes were also frequent. Dysfunction and involvement of these three organ systems, plus age of onset, distinguished the group of patients with the highest mortality. All patients with generalized disease or organ dysfunction were treated with systemic chemotherapy. The actuarial survival curve at 10 years was 63%.

Natural history of histiocytosis X: a Pediatric Oncology Group Study

The best therapy for patients with histiocytosis X with disease involvement other than isolated bone lesions but without organ dysfunction is unclear. This retrospective study was undertaken to define the natural history of this group of patients. In 25 of the 92 studied patients, there was no progression of the disease after diagnosis. In 53 surviving patients, the disease either continuously progressed (40) or recurred intermittently (13). The onset of last disease activity was 24 months or less for 55% of these children. A fatal outcome occurred in 14 children. All of these children developed organ dysfunction and 11/14 died during or before the second year of disease. These three different outcomes could not be predicted from the parameters evaluated; however, the disease that never abated but was continuously active was associated with a suboptimal outcome, and the development of organ dysfunction was a grave prognostic sign.

The pathogenesis, diagnosis, and treatment of histiocytosis syndromes

The histiocytosis syndromes previously known, and often still referred to, as histiocytosis-X were originally categorized by many as malignant neoplasms. They have been treated as such with aggressive chemotherapy and radiation therapy. Although these modalities are still used, there are significant differences between the histiocytosis syndromes and the true malignant disease that suggest conservative management for many patients. The clinical course of malignant neoplasia is relentlessly progressive with virtually no survival in untreated patients. The histiocytosis syndromes are characterized by frequent spontaneous remissions and exacerbations, with varying morbidity and survival in untreated patients, depending on the extent of the disease. Pathologically, the lesions of histiocytosis appear as reactive infiltrates, possessing little of the cellular atypicality and homogeneity characteristic of malignancy. Although the etiology of these phenomena is unknown, histiocytosis syndromes appear to represents a reactive autoimmune disorder triggered by unknown stimuli.

Histiocytosis-X in gynecology

(1) Histiocytosis-X can manifest itself in virtually every organ, but in gynecology it is an absolute curiosity. (2) Differential diagnosis must exclude specific and nonspecific ulcerations and granulations such as syphilis, tuberculosis, Boeck's disease, and also neoplastic processes like lymphomas, sarcomas, carcinomas, and malignant diseases of the hemopoietic system. (3) The diagnosis by light microscopy alone, as in our case, may be insufficient; therefore, electron microscopy should be used. As soon as the diagnosis is confirmed histologically, an extensive examination of all organs is necessary in order to establish an exact prognosis and an optimal plan of therapy. (4) Because of the unknown etiology of histiocytosis-X, a causal treatment is not yet possible. In spite of this, with a symptomatic, individualized therapy by means of excision, low-dose irradiation and cytotoxic agents a 5-year survival of 90% was obtained for the patients. (5) Because of its rarity and multidisciplinary character, histiocytosis-X is a challenge to interdisciplinary and interregional cooperation. Though not being a malignoma in the strict sense, diagnosis, therapy, and in part prognosis are not essentially different from a malignant disease.

Histiocytosis X in children: patterns of disease and results of treatment

The pathologic materials and clinical courses of 36 children aged 1 month-22 years, with histiocytosis X (H-X) seen at the Philadelphia Children's Cancer Research Center from 1970 to 1979 were reviewed. The pathologic subtype of H-X was favorable (type II) in 31 patients, unfavorable (type I) in one patient, and unclassified in four patients whose specimens were limited to a skin biopsy. Sixteen patients had localized H-X involving bone (14 patients), soft tissue (1 patient), or skin only (1 patient); all are alive and well after treatment with surgery alone (12 patients), radiation therapy (RT) (3 patients), or observation (1 patient); only 1 of the 16 developed recurrent H-X. The other 20 patients presented with multifocal H-X involving the skeleton alone (3 patients); the skeleton and soft tissues other than liver (7 patients); soft tissue exclusive of the liver (3 patients); soft tissue including the liver (4 patients); or soft tissues, skeleton, and liver (3 patients). These 20 patients were treated with surgery alone (1 patient), RT (4 patients), or multiple drugs +/- RT (15 patients). Seven of the 20 patients are alive and well without recurrence at a median of 4 years after diagnosis. Nine of the 20 patients, including 3 with liver dysfunction, responded completely to initial therapy but developed recurrence; each was retreated with drugs and is alive and well at a median of 4 years. The remaining 4 patients had widespread disease with dysfunction of the liver and/or hematopoietic system at diagnosis, failed to respond, and died. We conclude that (1) patients with multiple bony lesions with or without associated soft tissue disease or skin involvement have a favorable outlook and do not require systemic chemotherapy; (2) systemic treatment also is unnecessary for patients with localized H-X since recurrence is rare; (3) drugs can benefit patients with multifocal H-X, although the optimal duration of therapy is unclear; and (4) favorable response to treatment indicates high probability of disease-free survival. However, organ dysfunction at diagnosis is ominous: four of seven patients with liver dysfunction are dead, as are all three patients who presented with peripheral blood count depression.

Pulmonary histiocytosis X in adult patients

Clinical findings and course of the disease are described in 6 patients suffering from pulmonary histiocytosis X. Diagnosis was suspected when a reticulo-nodular pattern was detected by conventional X-ray or by computerized tomography of the lungs. Laboratory tests were non-specifically altered, lung function was impaired. Signs of the disease improved spontaneously in one patient and when cytostatics were given in two of five patients. To judge the course of the disease, repeated controls of lung function parameters -- besides roentgenographic methods -- were of particular value.

Histiocytosis-X

Twelve of 17 patients with histiocytosis-X were immunologically abnormal, as shown by the presence of circulating lymphocytes spontaneously cytotoxic to cultured human fibroblasts or of antibody to autologous erythrocytes. The patients also had a notable lack of histamine H2 surface receptors on their T lymphocytes, suggesting a suppressor-cell deficiency. The lymphocyte abnormalities were reversed in vitro after incubation in a crude extract of calf thymus gland, and therefore all 17 patients were treated with daily intramuscular injections of this extract. With this therapy, 10 patients entered complete remission -- a response at least as good as that observed in historical controls treated with chemotherapy. A positive clinical response was associated with an increase in the number of T-cell histamine H2 receptors to normal levels and with correction of the other immunologic abnormalities. The results of this preliminary study justify a larger prospective clinical trial of thymic extract and further investigation of the immunoregulatory mechanisms in histiocytosis-X.

Atypical lymphadenopathies of the head and neck

Atypical lymphadenopathies fail to achieve the morphologic criteria of a malignant neoplasm, but exceed the usual concepts of follicular, lymphoid, or sinus histiocytic hyperplasias. Rich cellular proliferations usually composed of prominent histiocytes, or immunoblasts, or both with or without a vascular scaffolding obscure the nodal architecture. Toxoplasmosis, infectious mononucleosis, zoster, and vaccination-induced lymphadenopathies are caused by infectious agents, dermatopathic lymphadenitis is associated with cutaneous disease, anticonvulsant pseudolymphoma occurs in individuals hypersensitive to anticonvulsants (usually phenytoin), and Chediak-Higashi syndrome is an inherited abnormality of lysosomal microtubule function; the causes of sinus histiocytosis with massive lymphadenopathy, giant lymph node hyperplasia, angioimmunoblastic lymphadenopathy, mucocutaneous lymph node syndrome, and this histiocytoses remain unknown. The clinical course of these abnormalities varies from self-limited acute diseases (viral lymphadenopathies, toxoplasmosis, dermatopathic lymphadenitis, and usually anticonvulsive lymphadenopathy) to protracted, but benign abnormalities (sinus histiocytes with massive lymphadenopathy, giant lymph node hyperplasia, and multifocal eosinophilic granuloma). The diagnosis of angioimmunoblastic lymphadenopathy, Chediak-Higashi syndrome, and mucocutaneous lymph node syndrome necessitates a guarded prognosis, for death or the advent of a malignant lymphoma may interrupt their clinical course. Acute disseminated histiocytosis, even though the proliferated cell lacks the cytologic criteria of malignancy, should be regarded and treated as a malignant neoplasm.

Therapy in pulmonary histiocytosis X

Clinical findings and course of the disease are described in six patients suffering from pulmonary histiocytosis X. Diagnosis was suspected when a reticulonodular pattern was detected by conventional X-ray or by computerized tomography of the lungs. Laboratory tests were altered nonspecifically, and lung function was impaired. Signs of the disease improved spontaneously in one patient and when cytostatics were given in two of five patients. To judge the course of the disease, repeated controls of lung function parameters - besides roentgenographic methods - were of particular value.

Eosinophilic granuloma with involvement of the female genitalia

Four cases of eosinophilic granuloma involving the female genital tract are reviewed. The disease may remain localized, but more often involves other organs. Of particular interest was the association of the disease with diabetes insipidus in three patients. One of the patients with diabetes insipidus was successfully treated with radiotherapy to the hypothalamic area as soon as the symptoms of the disease appeared. Genital lesions may respond to radiotherapy. Chemotherapy is to be used for disseminated disease. Treatment of this condition requires studying the extent of the disease and establishing early treatment, as with any malignant lesion.

Quality of survival in histiocytosis X: a Southwest Oncology Group study

Sixty children survived for five years after the diagnosis of histiocytosis X. Serious disabilities were seen in 50% of children whose disease involved soft tissue and bone. Late deaths from pulmonary failure were associated with opportunistic infections in two cases. Future treatment approaches must weigh the risks of therapy-related complications against the probability of significant disability if the disease continues for many years.

Disseminated histiocytosis X: analysis of prognostic factors based on a retrospective study of 50 cases

This work is a retrospective study of 50 cases of DHX, collected over a period of 27 years. 24 children died, 26 are still alive. The prognosis for DHX was neither dependent on age (usually occurring in children under 2 years) nor on histological findings but on the extent of the lesions. It was possible to establish a clinical staging system distinguishing 2 groups. One, where the disease was severe and almost always fatal, often included the combined symptoms of thrombocytopenia, spontaneous anemia, jaundice, hepatosplenomegaly, respiratory insufficiency and absence of osteolytic lesions. The other, with a favorable prognosis, was characterized by skin lesions, diabetes insipidus, exclusively radiological pulmonary involvement and multiple bone lesions. In cases where death did not occur, DHX was often chronic, frequently persisting for 2 years or more and leading to serious sequelae such as diabetes insipidus, growth stunting, intellectual retardation, blindness or deafness.

Improved prognosis in disseminated histiocytosis

The prognosis for children with disseminated histiocytosis, previously considered poor, has improved dramatically with the application of modern principles of chemotherapy. Fourteen children with histiocytosis were staged clinically as follows: those without organ dysfunction, stage I; those with organ dysfunction, stage II; and histologically (B, benign and M, malignant). They were treated with either oral chlorambucil or combination chemotherapy with vinblastine and other agents. Clinical staging was of value in predicting response to treatment and prognosis, while histologic staging was of less value. Thirteen of the 14 children responded to treatment and are alive 4 to 67 months (median 12 months) after diagnosis. Two of these relapsed on treatment, and they have responded to a change in therapy. Two children relapsed after stopping treatment and were reinduced with reintroduction of similar therapy. Initial response to treatment suggests a favourable outcome, for children who initially responded to treatment but relapsed subsequently responded to either reintroduction of the same treatment or a change in treatment.

Histiocytosis X--comparison of three treatment regimens

The three treatment regimens evaluated in this study (vinblastine alone versus prednisone and vinblastine versus prednisone and 6-mercaptopurine) proved to be about equally efficacious in children with histiocytosis x. Inasmuch as many physicians regard this disorder as one with a high mortality rate, it is worth emphasizing that 59 of the 83 patients (71% are living).