Langerhans' cell histiocytosis: head and neck manifestations in children

Primary Oro-Facial Manifestations of Langerhans Cell Histiocytosis in Pediatric Age: A Bi-Institutional Retrospective Study on 45 Cases

Aims: Langerhans Cell Histiocytosis is a rare hematologic disorder usually affecting children and most commonly involving the head and neck region. Primary oro-facial manifestations are rare, and their diagnosis is often challenging as they are numerous and often resemble common pathologies, refractory to conventional medical and/or instrumental treatments. For such reasons, the diagnosis is frequently delayed, as is the following staging and therapy onset. We retrospectively studied 45 pediatric patients affected by Langerhans Cell Histiocytosis with onset in the head and neck, to examine their clinical and radiological features at the early stage. Materials and Methods: The study was a retrospective bi-institutional analysis (Department of Pediatric Dentistry and Pediatric Oncology of “Sapienza” University of Rome, Department of Interdisciplinary Medicine of the University of Bari “Aldo Moro”), which enrolled 45 patients (age range 0–18 year-old) affected by Langerhans Cell Histiocytosis with oro-facial onset. Data regarding clinical appearance, number, site, synchronous or metachronous occurrence, involved tissues/organs, radiographic features and clinical outcomes were collected, listed and overall differentiated by two age ranges (0–10-year-olds and 10–18-year-olds). Results: Patients were 26 males and 19 females, with an average age at the time of diagnosis of 4.8 ± 3.8 years (median = 3.9 years). The most common findings were inflamed, hyperplastic, painful and often ulcerated gingival lesions (22 cases), associated with deciduous tooth mobility and/or dislocation with bone loss in 18 cases, followed by nine single eosinophilic granulomas of the mandible and two of the maxilla. Lesions of the palatal mucosa were observed in six patients; nine patients showed on radiograms the characteristic “floating teeth” appearance in the mandible with synchronous lesions of the maxilla in six. Paresthesia was relatively un-frequent (three cases) and the pathological fracture of the mandible occurred in six. Head/neck lymph nodes involvement was associated with oral lesions in 12 cases and skull lesions in 14. Otitis (media or externa) was detected in four instances, exophthalmia in two, cutaneous rush in nine, contextual presence or subsequent onset of insipidus diabetes in eight. As for therapy, single or multiple small jaw lesions were all surgically removed; chemotherapy with vinblastine alone or associated with corticosteroids was the principal treatment in almost the 80% of cases; more than 50% of patients received corticosteroids, while only three patients received adjunctive radiotherapy. The overall mortality account for less than 9% (four of 45 cases) and recurrence observed in eight patients after therapy. Conclusions: Langerhans Cell Histiocytosis may mimic several oro-facial inflammatory and neoplastic diseases. Considering the potential disabling sequela following head and neck localization of Langerhans Cell Histiocytosis in children, especially at the periodontal tissues with teeth and alveolar bone loss, lesion recognition along with the histological examination of suspicious tissues is mandatory to achieve an early diagnosis and to prevent further organ involvement.

A rare case of extensive cranial Langerhans cell histiocytosis, synchronously presenting as otitis externa and giant cell arteritis

Langerhans cell histiocytosis (LCH) is a rare histiocytic disorder of unpredictable clinical course and varied modes of presentation. The spectrum of presentation is wide, ranging from isolated eosinophilic granulomas to multiple lesions and diffuse systemic involvement. We present the case of a 52-year-old man, who presented with an 8-week history of worsening otalgia and superficial temporal tenderness attributed to otitis externa within the community and subsequently giant cell arteritis. Computed tomography and magnetic resonance imaging were undertaken due to atypical features, which demonstrated bony destruction within the right greater wing of the sphenoid, squamous part of temporal and mastoid bone, with middle cranial fossa communication. Intra-orbital extension was noted with abutment of the lateral rectus muscle. Mastoid biopsies demonstrated a mixture of lymphocytes, eosinophils and monomorphic epithelial cells with pale cytoplasm and focal areas of granulation tissue/necrosis. The features were consistent with a diagnosis of LCH, and the patient was subsequently transferred to a tertiary centre for definitive treatment.

Primary head and neck Langerhans cell histiocytosis in children

Objective

To evaluate the experience of a tertiary care children's hospital in the diagnosis, treatment, and long-term outcomes of patients with primary head and neck Langerhans' cell histiocytosis.

Study Design and Setting

A retrospective study of patients who presented with Langerhans' cell histiocytosis that primarily affected head and neck sites between January 1, 1986, and December 31, 2004, at Children's Mercy Hospital.

Results

Twenty-two patients were diagnosed and treated for LCH at our hospital during this time period. Seventeen patients had head and neck involvement; 14 of these patients had primary head and neck LCH. Lesions of the head and neck are complicated and involve multiple structures including the calvarium and skull base. Overall outcomes were good with 10 of 14 patients without disease at time of last follow-up. Recurrence is common and involved 50% of our patients.

Conclusions

Langerhans' cell histiocytosis commonly affects the head and neck. These lesions are complex and require prudent evaluation and treatment. Due to the complex nature of head and neck lesions, primary chemotherapy is the treatment of choice.

Significance

Because of the frequent head and neck involvement of this disease, otolaryngologists need to be familiar with its presentation, work-up, and treatment. EBM rating: C-4

Langerhans cell histiocytosis: Current concepts in dentistry and case report

Langerhans cell histiocytosis (LCH), which is a rare granulomatous pediatric disease of unknown etiology, is characterized by the idiopathic proliferation and accumulation of abnormal and clonal Langerhans cells or their marrow precursors, resulting in localized, solitary or multiple destructive lesions. These lesions are most commonly eosinophilic granuloma, which are found in craniofacial bone structures such as the skull and mandible, skin and other organs. In children, the disease has a variable initial presentation, and the clinical course, prognosis and survival are unpredictable. The aims of this report were to present an LCH case in a girl aged 2 years, 8 months and her clinicopathological features, to describe the bucodental management provided, and to discuss special dental considerations of this disease.

Key words:Children, dental management, histiocytosis, Langerhans cells.

Head and neck manifestations of langerhan's cell histiocytosis in children: a 46-year experience

OBJECTIVE

Langerhan's cell histiocytosis (LCH) is an uncommon disease characterized by abnormal proliferation of polyclonal Langerhan's cells, most commonly presenting with head and neck manifestations. This is a report of a series of patients with LCH at St. Jude Children's Research Hospital over a 46-year period. The purpose was to examine the head and neck presentations of LCH, their treatments and outcomes, and to compare with other previously reported series.

METHODS

This was a retrospective study of all patients with a diagnosis of LCH who presented to St. Jude Children's Research Hospital, Memphis, TN between 1962 and 2008. Patients who presented with an initial diagnosis of LCH but were later determined to not fit the diagnostic criteria were excluded from the study. IRB approval was obtained and a chart review was conducted to collect data regarding demographics, tumor site(s) and manifestations, pathology, treatment, surgical procedures, and outcomes. This data was compiled and compared to previously published results.

RESULTS

Eighty-eight cases of LCH with at least one head and neck manifestation were diagnosed during the period studied. There were 54 males and 34 females, with an average age of onset of 4.1 years. The most common lesions were those involving the skull (44.3%) and cervical lymph nodes (40.9%). The most common treatment was chemotherapy (80%) and corticosteroids (64%), with vinblastine being the most common chemotherapeutic agent. Surgical intervention occurred in 39% of cases. Total mortality due to LCH was 9.1%. The results were found to generally concur with other previously published studies.

CONCLUSION

This study represents the largest series of head and neck manifestations of LCH reported to date. Although LCH is a rare disease, it often mimics other common head and neck pathologies and therefore requires a high index of suspicion. Biopsy is required for definitive diagnosis and the mainstay of treatment is chemotherapy.

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.

High incidence of hearing loss in long-term survivors of multisystem Langerhans cell histiocytosis

BACKGROUND

Ear involvement in the acute phase of Langerhans cell histiocytosis (LCH) is commonly seen and well documented, but the long-term sequelae are less well described, particularly in relation to hearing loss.

METHODS

We investigated 40 patients with biopsy-proven multisystem LCH >5 years from the end of treatment, using detailed audiological assessment and CT/MRI imaging of the petrous temporal bones.

RESULTS

The incidence of ear involvement in the acute phase of disease was 70%. Fifteen of the 39 patients tested (38%) had residual permanent hearing loss at long-term follow-up.

CONCLUSIONS

The incidence of hearing loss is much higher than has previously been reported in LCH, and may reflect a referral bias of young (<2 years) and more complex patients to our tertiary centre. However, the hearing loss appears to be highly specific to this patient group when compared to other long-term survivors of childhood cancers, probably due to the propensity of LCH to involve the ears. We therefore recommend audiology testing as an important part of long-term follow-up for patients with multisystem LCH.

Successful outcome of Langerhans cell histiocytosis complicated by therapy-related myelodysplasia and acute myeloid leukemia: a case report

BACKGROUND

Various therapeutic options are available for the management of Langerhans cell histiocytosis. However, treatment administered to control this disease may be complicated by acute leukemia.

CASE PRESENTATION

A 34 years old male was diagnosed to have Langerhans cell histiocytosis in March 1999. Unfortunately, the cytotoxic chemotherapy and radiotherapy given to control the repeated relapses and exacerbations of the primary disease predisposed him to therapy-induced myelodysplastic syndrome which transformed into acute myeloid leukemia. After achieving complete remission of his leukemia, the patient received an allogeneic hematopoietic stem cell transplant. The allograft was complicated by chronic graft versus host disease that was controlled by various immunosuppressive agents and extracorporal photophoresis.

CONCLUSION

Management of complicated cases of histiocytosis requires various therapeutic modalities and a multidisciplinary approach. Having complications of therapy eg myelodysplasia or acute leukemia make the outcome more dismal and the management options limited to aggressive forms of treatment. High dose chemotherapy followed by an allograft may be a curative option not only for therapy-related myelodysplasia/acute leukemia, but also for frequently relapsing and poorly controlled Langerhans cell histiocytosis.

Langerhans' cell histiocytosis of the temporal bone in children

OBJECTIVE

Langerhans' cell histiocytosis (LCH) is a rare pathology that implies an abnormal proliferation of these kinds of cells associated with a granular infiltration that affects different structures of the human body, including the temporal bone. The authors present their series of LCH of the temporal bone in children at the Sainte-Justine university hospital. The twofold objective of this study is to illustrate the clinical presentation, management and prognosis of this disease, and to compare these results with previously reported series.

METHODS

A retrospective study was conducted between 1984 and 2007 with patients diagnosed and treated for a LCH of the temporal bone at the Sainte-Justine university hospital, a paediatric tertiary care center. A chart review was performed to obtain demographic, clinical, paraclinical, and therapeutic data. They were analysed and compared to other published series. Through a MEDLINE query, we found that since 1966, 50 articles dealing with a LCH of the temporal bone have been published.

RESULTS

Fifty-nine cases of LCH were diagnosed and among them, 10 children had temporal bone involvement. They were four females and six males with a mean age of 3.28 years. The two most frequent clinical manifestations were the presence of a mass in the temporal region (70%) and otitis (60%). Two of our patients had a unifocal lesion of the temporal bone implicated. Eight patients had a multisystem involvement among which, two showed evidence of organ dysfunction. In 80% of cases, the diagnosis was made by immunohistochemical findings of the S-100 protein and/or the CD1 antigen. The common radiological finding on a skull CT scan is a lytic lesion in the temporal bone. Seven patients were treated by chemotherapy, two were treated by radiotherapy as a primary treatment, and one received radiotherapy for a recurrence on the pituitary gland. Finally, one patient was treated with local steroid injections. Two patients had a recurrence. All our patients were in total remission on a mean average of 1.6 years after the diagnosis. Our results concord with other studies in which the prognosis of unifocal bone disease is excellent and children with a multifocal disease have a survival rate of 65-100%.

CONCLUSION

LCH is a rare disease. A high-index suspicion should be raised in the context of a temporal mass, chronic otitis, and otorrhea. A biopsy is recommended in the presence of a temporal bone lytic lesion. Chemotherapy is the preferred therapeutic modality.

Langerhans' cell histiocytosis: report of a case with temporal localization

The authors report a case of Langerhans' cell histiocytosis (LCH) with temporal localization and rapidly evolving initial clinical presentation in a 12-year-old boy. This disease of currently unknown etiology is actually considered a proliferative entity of cells with phenotypic characteristics of normal Langerhans' cells. An immunoregulation defect leading to abnormal maturation and migration of Langerhans' cells might be the basis for LCH. According to the Hystiocyte Society diagnostic criteria, ATPase, S 100 and D-mannoxidase positivity in addition to typical hystopathologic findings are sufficient for diagnosis of LCH. Head and neck localization of LCH occurs in about 70% of cases; males are more frequently affected than females, age at presentation varies from a few months to 15 years. Presenting features, initial diagnostic evaluation, differential diagnosis and treatment protocol of a unifocal monosystemic temporal bone localization of LCH are presented.

Ear involvement in childhood Langerhans' cell histiocytosis

BACKGROUND

Ear involvement (EI) in Langerhans' cell histiocytosis (LCH) occurs quite often. We reviewed the Italian pediatric population of 251 children with LCH diagnosed between 1982 and 1995, focusing on EI, to highlight the prevalence, the clinical presentation, the outcome during follow-up, and the prognostic impact of otologic LCH.

METHODS

EI was defined by chronic otorrhea and/or mastoid infiltration, external auditory meatus lesions, and middle/internal EI. The age at diagnosis, sex, system involved, organ dysfunction, treatment, disease control, and outcome were recorded.

RESULTS

EI was noted at presentation in 34 children (13. 5%). They had a younger age at diagnosis (p=.0013) and near totality of multisystem disease (93.8% of patients with EI). Among patients with multisystem disease, children with EI seemed to have a higher risk of poor response and a higher percentage of second line treatment (p=.003).

CONCLUSIONS

EI seems to identify patients with a particular disease behavior, which requires a more accurate evaluation at diagnosis, staging and treatment, and a strict follow-up, considering the possibility of an unfavorable outcome.

Langerhans' cells histiocytosis

Langerhans cell histiocytosis (LCH) is a rare disorder of unknown cause, characterized by the proliferation of histiocytic cells in various tissues and organs. The role of the otolaryngologist is important in the early and accurate evaluation, staging and diagnosis of LCH, because it may mimic more common diseases such as otitis externa and acute mastoiditis. We discuss a case report of bilateral mastoid involvement in a child with a history of otalgia unresponsive to medical therapy.

Presentation and diagnosis of unilateral maxillary swelling in children

Facial asymmetry secondary to pathologic processes involving the maxillary sinus and its surrounding structures presents a challenge for the clinician. An organized approach to evaluate these patients is essential in order to differentiate inflammatory sinus pathology from disease processes primarily involving the surrounding maxilla, parotid gland, orbital contents, and dental structures. In addition to a thorough history and physical examination, appropriate imaging studies must be obtained to localize the pathologic processes and develop a meaningful differential diagnosis. Once this is accomplished, specific treatment modalities can be developed. Representative cases will be presented to illustrate this organized approach to unilateral maxillary swelling, including soft tissue and osseous masses, fibro-osseous lesions, osseous cysts and inflammatory lesions.

Labyrinthine involvement in Langerhans' cell histiocytosis

BACKGROUND

Langerhans' cell histiocytosis, a rare condition caused by the proliferation of abnormal Langerhans' cells ('LCH cells') and an accompanying granulomatous infiltrate, can affect several organs including the ear. External and middle ear involvement are common with a reported incidence as high as 61%. The bony labyrinth is resistant to erosion by the granulation tissue, thereby protecting the cochlea and vestibular structures. Probably for this reason, involvement of the inner ear is rare, with few case reports in the literature.

PATIENTS

We report two girls, one with bilateral and the other with unilateral mastoid involvement, in whom there was invasion of the labyrinth. The first girl had 'single system' LCH affecting only bone and developed an acute hearing loss due to invasion of the cochlea, while the second had both bone and skin involvement and labyrinthine involvement was diagnosed on imaging prior to the onset of labyrinthine symptoms.

CONCLUSION

Inner ear involvement can lead to permanent deafness, which may be prevented by early institution of treatment. Threatened inner ear involvement requires urgent systemic medical therapy with steroids, possibly combined with chemotherapy.

Head and neck Langerhans cell histiocytosis

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