Unicentric Castleman Disease

Castleman disease coexisting with papillary thyroid carcinoma: A case report

Castleman disease (CD) is a rare lymphoproliferative disorder of unknown etiology characterized by lymph node enlargement. CD cannot be confirmed by preoperative puncture cytology, and definitive diagnosis depends on postoperative histopathology. Due to the lack of characteristic clinical manifestations and imaging features, in clinical practice, CD is often easily missed or misdiagnosed, and it is frequently mistaken for lymphoma or autoimmune diseases. Cases of CD that coexist with papillary thyroid carcinoma (PTC) are particularly rare and are often misdiagnosed as PTC with lymph node metastasis. The present study discusses the diagnosis, treatment process and prognosis of a case involving PTC that is complicated with unilateral, single-center CD. This patient was diagnosed with a right lobe nodal gland of the thyroid gland combined with a mass in the left supraclavicular fossa. The postoperative pathological examination revealed a right lobe papillary carcinoma of the thyroid gland with metastasis of the right cervical lymph node combined with CD in the left supraclavicular fossa. The immunohistochemical results of the right cervical lymph node were thyroglobulin (+), thyroid transcription factor-1(+). Immunohistochemical results of left supraclavicular fossa mass: Bcl-2 (low expression in the germinal center, high expression outside), Bcl-6 (germinal center +), Cyclin D1 (-), cluster of differentiation 38 (focally+). In future clinical practice, when encountering PTC with mediastinal masses, clinicians should consider not only common lymph node metastases but also the possibility of CD. Overall, this study aims to provide valuable insights and experience for clinicians regarding CD and PTC.

Castleman disease of stomach treated by endoscopic submucosal dissection: a case report and literature review

Background

Castleman disease (CD) is a relatively rare benign lymphoproliferative disorder of the lymphoid tissue. According to clinical manifestations, it is classified into two types: unicentric CD (UCD) and multicentric CD (MCD). Pathological subtypes include hyaline-vascular (HV), plasma cell (PC), and mixed (MV). Gastrointestinal CD is extremely rare, and limited information is available regarding its clinical presentation and management.

Case Summary

We report a case of a patient who presented with paroxysmal epigastric pain for 4 years. Laboratory tests showed no remarkable abnormalities, whereas CT revealed endogenous occupancy on the side of the greater curvature of the stomach. Ultrasonographic endoscopy demonstrated hypoechoic, well-defined foci. The lesion initially suspected to be an inflammatory fibroma was subsequently pathologically confirmed as HV-UCD following endoscopic submucosal dissection. The lesion was completely resected, and the patient showed no signs of recurrence during 7 months of follow-up.

Conclusion

Gastrointestinal CD is rare and should be differentiated from other occupying lesions. Its definitive diagnosis relies on histopathology.

Pelvic unicentric Castleman's disease mimicking accessory spleen: A rare presentation of Castleman's disease, a case report and literature report

INTRODUCTION AND IMPORTANCE

Castleman disease, a rare, mostly benign lymphoproliferative disorder, is classified as unicentric or multicentric Castleman disease, with HHV-8 association affecting the latter. Unicentric Castleman disease typically presents as a single enlarged lymph node, most often mediastinal, while multicenter Castleman disease involves multiple lymph nodes. Treatment depends on the type and severity, ranging from surgical resection for unicentric Castleman disease to chemotherapy for multicentric Castleman disease.

CASE PRESENTATION

A 28-year-old Ethiopian man presented with three months of pelvic pain, altered bowel habits, and urinary frequency. The physical examination was unremarkable. Investigations revealed a retroperitoneal pelvic mass, initially suspected to be an accessory spleen. Surgery revealed a 10 × 8 × 4 cm mass. Histopathology showed features consistent with unicentric Castleman disease, confirmed by characteristic "onion skin" and "lollipop" appearances, CD20 positivity, and negative HHV-8 and Bcl-2. The patient recovered well after surgical resection.

CASE DISCUSSION

Pelvic unicentric Castleman disease is a rare presentation of this uncommon disorder, typically affecting the mediastinum. While its pathogenesis is unclear, it's not associated with HHV-8, IL-6 overproduction, or human immunodeficiency virus in all cases (as in this patient). Unicentric Castleman disease is characterized by localized symptoms or may be asymptomatic, unlike multicentric Castleman disease which presents with systemic manifestations. Imaging (ultrasound and CT in this case) guides diagnosis, with histopathology confirming the characteristic "onion skin" and "lollipop" appearances. Surgical excision is the treatment of choice for unicentric Castleman disease, offering excellent outcomes (as seen in the patient). Multicentric Castleman disease requires more extensive treatment, with a less favorable prognosis. Long-term follow-up is crucial due to the risk of malignant transformation.

CONCLUSION

Unicentric pelvic Castleman disease, a rare condition sometimes confused with accessory spleen, requires histopathological diagnosis. While often linked to HIV/AIDS or HHV-8, it can occur without risk factors and usually responds well to surgical excision.

Rare Unicentric Intrapulmonary Castleman Disease: A Systematic Review and Report of a Case

Objectives

Castleman disease (CD) is a very rare B-cell lymphoproliferative disorder marked by the abnormal enlargement of lymph node tissue. It can present as either unicentric (UCD) or multicentric, with the former often appearing in intrathoracic regions, although its presence within the lungs is uncommon.

Methods

We report the case of a 42-year-old woman who underwent resection of an 11 cm intrapulmonary UCD. Additionally, we conducted a systematic review of the demographics, clinical presentation, diagnosis, and treatment approaches for intrapulmonary UCD.

Results

Our review identified 35 documented cases of intrapulmonary UCD, including our case. The average age was 34 years, with a female predominance of 57.7%. Tumor sizes ranged from 1.5 to 11 cm, with our case being the largest. Of the 24 cases with reported anamnesis, 58.3% were asymptomatic, while 41.7% had nonspecific symptoms such as cough, chest pain, or fever (as in our case). Histological analysis was available for 24 cases, with 83.3% identified as the hyaline vascular type. Biopsies through small needle aspiration or fresh-frozen samples failed in all attempts, requiring resection for diagnosis and treatment. Due to high vascularity, delicate location, and lack of diagnosis, lobectomy or pneumonectomy was performed in 45.7% of cases. Among the 11 cases with reported follow-up, no disease recurrence was observed over an average of 3 years.

Conclusion

Our systematic review highlights the rarity of UCD in the lungs. The demographics of intrapulmonary UCD align with the general disease profile. Surgical removal is crucial for both diagnosis and treatment. The significant vascularity and pulmonary location of these tumors present challenges, requiring pre-operative awareness and precautions.

Unicentric Castleman Disease: Updates and Novel Insights Into Spindle Cell Proliferations and Aggressive Forms of a Localized Disease

Castleman Disease (CD) is a rare lymphoproliferative disorder that can be separated into two primary forms: Unicentric Castleman disease (UCD) and multicentric Castleman disease (MCD). UCD is localized, while MCD is systemic. Though UCD generally has a favorable prognosis following surgical resection, more aggressive forms of this disease have been identified, including cases associated with dendritic and spindle cell proliferation. Genetic analysis has deepened our understanding of UCD. Despite advancements in better understanding the pathophysiology of UCD, challenges persist in the diagnosis, management, and treatment due to its rarity and heterogeneity. Here, we review current knowledge on UCD, highlighting the epidemiology, clinical presentation, diagnostic criteria, and treatment options while emphasizing the need for further research and innovation in therapeutic strategies.

Mediastinal Castleman disease presenting as a paraspinal mass causing back pain and shortness of breath in a young adult

This case report details a rare presentation of unicentric Castleman disease (UCD), hyaline vascular type in a 22-year-old woman. The patient presented with a large, well-circumscribed mass in the paravertebral region causing back pain and shortness of breath. Diagnostic imaging and biopsy confirmed the diagnosis, and surgical excision led to a favorable outcome. This case underscores the critical need to include Castleman disease in the differential diagnosis for young adults presenting with mediastinal masses. Early recognition and surgical intervention are essential for a favorable prognosis in UCD cases.

A rare perspective: fine-needle aspiration cytologic features of hyaline vascular type of Castleman disease: A case report

RATIONALE

Castleman disease, also known as Castleman syndrome, is a rare, nonmalignant lymphoproliferative disorder. The localized subtype of this disease is primarily the hyaline vascular type of Castleman disease (HVCD). Although this disease is a benign lesion, the histologic features are similar to those of some malignant lymphomas, so an accurate diagnosis of the disease is required. Lymph node hyperplasia lesions are usually diagnosed mainly by relying on biopsy histopathology, but the surgical process is time-consuming and expensive, and a part of patients usually refuse to undergo this examination method. Fine-needle aspiration cytology (FNAC) is a convenient, rapid, minimally invasive test for surface masses, and patients often receive cytopathology results in as little as a few minutes. Currently, there are few reports on the pathological features of FNAC in HVCD, so our cytopathological experience of using FNAC for rapid diagnosis of HVCD and other diseases that need to be differentiated are described in detail to give some meaningful references to the pathologists in recognizing HVCD from a rare cytological point of view.

PATIENT CONCERNS

A late 50s female patient presented to the hospital with a single subcutaneous enlarged nodule in the right side of the neck, which had been present for >6 months. The nodule exhibited a relatively clear border, and the patient presented with no signs of pain, no skin damage, and no other notable symptoms, but was concerned about the benignity or malignancy of the enlarged nodule.

DIAGNOSES

To determine the exact diagnosis of the neck nodule, the patient first underwent FNAC, followed by surgical excision of the neck nodule for histopathologic examination.

INTERVENTIONS

Since HVCD is a benign lesion and the superficial neck nodes were removed by minimally invasive surgery, the patient did not receive any other interventions.

OUTCOMES

We successfully and accurately diagnosed the rare HVCD using FNAC. Histologically similar lesion features of HVCD were successfully observed in cytology. The cytologic pattern of HVCD is distinctly different from that of other benign lymphoid tissue proliferative lesions or metastatic carcinomas.

LESSONS

This case shows important cytologic features for the diagnosis of HVCD using FNAC. The FNAC results showed abundant follicular dendritic cells and transparent blood vessels, and these cytologic features recapitulate the histopathologic alterations that were seen in HVCD. So by observing these cytologic features can help us to make an accurate diagnosis of HVCD using FNAC.

The Enigma of Idiopathic Multicentric Castleman Disease: An Elusive Diagnosis

Castleman disease (CD) is a rare lymphoproliferative disorder encompassing a spectrum of conditions with distinct histopathological findings and varied clinical presentations. Diagnostic challenges are often encountered due to overlapping features with other malignancies, infections, and autoimmune disorders. Idiopathic multicentric Castleman disease (iMCD) is a subtype of CD, characterized by generalized lymphadenopathy, polyclonal lymphoproliferation, systemic inflammation, and a cytokine storm that can be life-threatening. Here, we present a case of iMCD in a 70-year-old male with constitutional symptoms, dyspnea, and pancytopenia. Imaging demonstrated multifocal lymphadenopathy. Histopathological examination of a cervical lymph node revealed Castleman-like features, meeting the major criteria for a diagnosis of iMCD. Elevated interleukin-6 (IL-6) levels further supported the diagnosis. Treatment with siltuximab was planned but was preempted by the patient's demise following acute heart failure exacerbation. Diagnosing CD necessitates a thorough evaluation to differentiate it from other diseases. Treatment strategies, particularly IL-6 blockade, play a crucial role in the management of iMCD and improve patient outcomes.

Clinicopathological characteristics of unicentric Castleman disease: A single-center experience of 12 patients

BACKGROUND

Castleman disease (CD) is an uncommon lymphoproliferative disorder with distinct pathological characteristics. Unicentric Castleman disease (UCD) presents as a single lymph node enlargement, often without significant symptoms. Complete surgical resection is the standard treatment for UCD. This study aimed to explore the clinicopathological features of UCD in a Taiwanese population.

METHODS

We retrospectively identified 12 patients with UCD who had undergone surgical treatment between January 1, 2006 and June 30, 2022 at the National Taiwan University Hospital. Clinical and radiological findings were retrieved from medical records. All available pathological slides were reviewed.

RESULTS

The patients' mean age was 38.1 years (range, 17 to 69); five (41.7%) were male, and seven (58.3%) were female. Nearly all cases of UCD were in the mediastinum, except for one case in the neck. Most patients were asymptomatic and without abnormal laboratory test results. Computed tomography revealed well-defined tumor borders, contrast enhancement, and occasional calcification. Ten patients underwent en bloc tumor resection, while the remaining two underwent partial resection. Among them, seven (58.3%) underwent video-assisted thoracoscopic surgery (VATS), and four (33.3%) underwent thoracotomy. The mean follow-up duration was 92 months. The patients who underwent total resection had no recurrence.

CONCLUSION

Detailed clinicopathological information on UCD in the Taiwanese population is present in our article. Both complete and partial surgery are effective for treatment. VATS may be preferred over thoracotomy due to less operative time and bleeding.

Multicentric Castleman Disease: A Case Report of an Arab Female

We report the case of a 74-year-old female, who presented with a two-month history of fever, night sweats, and lymphadenopathy. She was thoroughly investigated, with high clinical suspicion for lymphoma. However, lymph node biopsy results revealed histopathological features of a hyaline vascular variant of Castleman disease. Owing to the involvement of multiple lymph node regions and the presence of systemic symptoms, the patient was diagnosed with multicentric Castleman disease and was started on steroid therapy, as well as anti-interleukin-6 (anti-IL-6) therapy, namely, tocilizumab, for the management of this condition. The patient responded well to the treatment and was discharged home in stable condition.

Castleman's Disease Presenting as an Unusual Pelvic Retroperitoneal Mass

Castleman's disease (CD) is characterised by benign lymphoepithelial proliferation and is a peculiar form of angiofollicular lymph node hyperplasia rather than a neoplasm or a hamartoma. CD is broadly classified as unicentric CD (UCD) and multicentric CD. In the unicentric variant, patients have localised disease affecting only a single lymph node or a group of adjacent nodes in a single region, which clinically presents as an enlarging mass without any other significant symptoms. The mediastinum and thoracic lymph nodes are commonly involved. However, it is uncommon for CD to occur in the pelvic presacral region of the retroperitoneum. A 31-year-old male presented with progressive, dull aching, intermittent lower abdomen pain for three months with no aggravating or relieving factors or any associated symptoms. He was haemodynamically stable, and his general physical examination was normal. An abdominal examination elicited mild tenderness in the left iliac region of the abdomen. Contrast-enhanced computed tomography of the abdomen and pelvis revealed an encapsulated nodal mass with intralesional calcification displacing the bladder to the right side, and fine needle aspiration cytology showed atypical cells. An exploratory laparotomy was performed with an in toto excision biopsy of the pelvic retroperitoneal mass, and it was diagnosed as a hyaline-vascular variant of UCD. Immunohistochemistry revealed angiofollicular hyperplasia and atretic germinal centres that are crossed by sclerotic vessels and hyalinisation, confirming the diagnosis. The patient is currently asymptomatic and is leading a routine life. The hyaline-vascular variant is the most common variant seen in UCD. Compared to the multicentric type, the unicentric type seldom exhibits systemic involvement. Surgical resection is typically curative. Although it is asymptomatic, it is essential to achieve complete surgical resection to prevent the neoplastic potentialities of CD. In the presence of an uncertain solitary solid pelvic retroperitoneal mass, the diagnosis of UCD should be considered, as surgical resection can achieve a favourable outcome.

Immunology and targeted therapy in Castleman disease

INTRODUCTION

Castleman disease (CD) is a benign lymphoproliferative disease causing severe systemic inflammation. Interleukin-6 (IL-6) is a major pathogenesis of multicentric CD (MCD), but only 30-60% of patients respond to IL-6 inhibitors. Novel agents for IL-6 inhibitor-refractory cases are needed. Clinical data and samples are being collected on a large scale and the clinical, pathological, and pathogenetic aspects are being elucidated.

AREAS COVERED

The pathological and clinical classification of CD is outlined. Focusing on idiopathic MCD (iMCD), this review identifies therapeutic targets and summarizes currently recommended drugs and promising therapeutic candidates.

EXPERT OPINION

The pathogenesis of MCD has been implicated in the activation of the Janus kinase (JAK)-transcriptional signaling activator (STAT) 3 pathway and the phosphatidylinositol 3-kinase (PI3K)/Akt/mechanical target of rapamycin (mTOR) signaling pathway. iMCD-TAFRO (thrombocytopenia, anasarca, fever/elevated CRP, reticulin myelofibrosis/renal dysfunction, organ enlargement) is resistant to IL-6 inhibitors, and cyclosporine and mTOR inhibitors are sometimes effective. JAK inhibitors and mTOR inhibitors may be therapeutic agents for iMCD. Recently, we have shown that peripheral helper T (Tph) cell abnormalities are at the core of iMCD pathogenesis. Therapies targeting chemokine (C-X-C motif) ligand 13 (CXCL13) produced by Tph cells and blocking the Tph-CXCL13-B cell pathway may satisfy unmet need in refractory cases.

A case of adrenal Castleman disease combined with liver cirrhosis and splenomegaly

To describe a rare case of left adrenal Castleman disease (CD), splenomegaly, and cirrhosis. An examination revealed a left adrenal mass for more than three months, the patient, 44, was well-prepared for surgery after her left adrenal tumor was removed laparoscopically using a retroperitoneal approach, her postoperative pathology suggested that she had Castleman disease of the adrenal glands, and there had been no metastasis or recurrence during the six-month follow-up period. We have evaluated linked literature reports in this article, reporting relevant clinical knowledge regarding the disease and synthesizing previous research, in an effort to increase our understanding of it.

A rare presentation of unicentric Castleman's disease in the thigh: A case report and review of literature

BACKGROUND

Castleman's disease (CD) is a rare lymphoproliferative, emulating both benign and malignant diseases. The diagnosis of CD is formulated upon the combination of clinical and laboratory criteria and ultimately confirmed by histopathological assessment. Due to its rarity, CD presents a challenge in treatment selection, with available options encompassing surgery, chemotherapy, and autologous stem cell transplantation. However, studies suggest that surgical resection of the lesion is the most effective treatment modality, especially for unicentric CD (UCD).

CASE SUMMARY

Here, we describe the case of a 25-year-old woman who presented with painless left thigh swelling for 10 wk. She had been following a low-fat diet to lose weight and had normal laboratory results. Magnetic resonance imaging revealed a well-circumscribed, demarcated cystic lesion located in the left inguinal region with eccentrically positioned signal void vascular structures, measuring 4.3 cm × 3 cm × 3.2 cm, likely of lymphoid origin. The patient underwent surgical resection, and the final histopathology showed a vascular proliferation and hyalinization of the vessel walls, along with atretic germinal centers traversed by penetrating vessels, consistent with CD. The patient was discharged home one day after the procedure in good condition, with a follow-up appointment scheduled in our outpatient clinic.

CONCLUSION

Although surgical resection is the mainstay for UCD, a multidisciplinary approach is needed due the lack of specific diagnostic features and treatments.

Stroma-Rich Hyaline Vascular Type of Castleman Disease: A Case Report and Literature Review

Castleman disease (CD) is a rare lymphoproliferative disorder characterized by abnormal lymph node enlargement. We present the first documented case of a stroma-rich variant of hyaline vascular Castleman disease in Saudi Arabia. A 24-year-old Saudi female known to have acetylcholine receptor antibody-positive myasthenia gravis (MG) presented with shortness of breath, oral thrush, and an acute myasthenia gravis exacerbation, necessitating intensive care unit (ICU) admission. During her hospitalization, she was found to have a large pelvic mass. The mass was surgically excised. The diagnosis of stroma-rich hyaline vascular Castleman disease was rendered after histopathological examination. The patient's symptoms improved after the surgery. This case underscores the importance of considering Castleman disease in complex clinical presentations, especially in the context of autoimmune and paraneoplastic diseases. Recognition and timely intervention are crucial for patient management. Additionally, the report adds to the global literature on Castleman disease, emphasizing the need for further research into its clinical manifestations and associations.

Radiological Imaging Findings of Adrenal Abnormalities in TAFRO Syndrome: A Systematic Review

This systematic review article aims to investigate the clinical and radiological imaging characteristics of adrenal abnormalities in patients with thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome. We searched the literature in PubMed, the Cochrane Library, and the Web of Science Core Collection. Ultimately, we analyzed 11 studies with 22 patients plus our 1 patient, totaling 23 patients. The mean age was 47.0 ± 12.6 years. There were 20 male and 3 female patients, respectively. The histopathological analysis of lymph nodes was conducted in 15 patients (65.2%), and the diagnosis was consistent with TAFRO syndrome in all 15 patients. Among the 23 patients, 11 patients (18 adrenal glands) showed adrenal ischemia/infarction, 9 patients (13 adrenal glands) showed adrenal hemorrhage, and 4 patients (7 adrenal glands) showed adrenomegaly without evidence of concurrent ischemia/infarction or hemorrhage. One patient demonstrated unilateral adrenal hemorrhage and contralateral adrenomegaly. In patients with adrenal ischemia/infarction, the adrenal glands displayed poor enhancement through contrast-enhanced computed tomography (CT). In patients with adrenal hemorrhage, the adrenal glands revealed high attenuation through non-enhanced CT and hematoma through magnetic resonance imaging. Adrenomegaly, with or without adrenal ischemia/infarction or hemorrhage, was observed in all patients (23/23, 100%). The subsequent calcification of the affected adrenal glands was frequently observed (9/14, 64.3%) when a follow-up CT was performed. Abdominal pain was frequent (15/23, 65.2%), all of which occurred after the disease's onset, suggesting the importance of considering TAFRO syndrome as a cause of acute abdomen. Given the absence of evidence of adrenal abnormalities in non-TAFRO-idiopathic multicentric Castleman disease (iMCD), they may serve as diagnostic clues for differentiating TAFRO syndrome from non-TAFRO-iMCD.

Primary hepatic Castleman disease

Castleman disease (CD) is a rare, benign lymphoproliferative disorder with characteristic histopathological features, but variable aetiology, presentation, treatment and prognosis. It is broadly classified based on its location and histopathological features, with unicentric hyaline vascular disease presenting most commonly. We present a case of primary, unicentric hepatic CD that was incidentally found on imaging and managed with laparoscopic resection.

Unmet Clinical Needs in the Management of Idiopathic Multicentric Castleman Disease: A Consensus-based Position Paper From an ad hoc Expert Panel

Castleman disease describes a group of heterogeneous clinicopathological disorders now included in the tumor-like lesions with B-cell predominance of the World Health Organization classification. Managing idiopathic multicentric Castleman disease (iMCD) is challenging, because few systematic studies or comparative randomized clinical trials have been conducted. International, consensus evidence-based guidelines for iMCD were published in 2018, but gaps in the therapeutic options for difficult-to-treat patients, who do not respond to siltuximab and other conventional therapies, still exist. This article presents the results of group discussion among an ad hoc constituted Panel of Italian experts to identify and address unmet clinical needs (UCNs) in managing iMCD. Recommendations on the appropriateness of clinical decisions and proposals for new research concerning the identified UCNs were issued through formalized multiple-step procedures after a comprehensive analysis of the scientific literature. The following key UCNs were addressed: strengthening the diagnostic certainty in iMCD patients before planning first-line therapy; management of siltuximab therapy; choice and management of immune-modulating, or chemotherapy agents in patients resistant/intolerant to siltuximab therapy. While most of the conclusions reached by the Panel are consistent with the existing guidelines, some alternative therapeutic options were stressed, and the discussion contributed to bringing forth the issues that need further investigation. Hopefully, this comprehensive overview will improve the practice of iMCD and inform the design and implementation of new studies in the field.

Analysis of characteristics of four patients with adrenal unicentric Castleman disease

Background

Castleman Disease (CD) is a group of diseases with characteristic lymph node histopathology, characterized by marked enlargement of deep or superficial lymph nodes. Adrenal CD is rarely reported, and an accurate preoperative diagnosis of adrenal CD is difficult.

Method

We report four cases of CD in the adrenal gland confirmed by pathology and review the characteristics of this rare disease, highlighting the necessity of diagnostic evaluation and follow-up of the patients.

Results

All of the patients sought medical advice because of adrenal incidentalomas. No significant abnormalities were presented in the biochemistry or endocrine systems. The imaging suggested a moderate-to-large mass with uneven moderate contrast enhancement of the adrenal region, similar to a pheochromocytoma. All cases were misdiagnosed as pheochromocytomas before operation and finally confirmed by histopathology. Three cases were pathologically diagnosed as hyaline vascular CD, and one case was diagnosed as plasma cell CD. All the patients are alive without recurrence after a median follow-up of 8 years.

Conclusion

The adrenal CD should be considered after excluding pheochromocytoma and malignancy in the adrenal region. The long-term prognosis of patients with complete resection of the mass is excellent.

Unicentric form of Castleman´s disease, pitfalls of diagnosis and surgical treatment

Background

Castleman´s disease is an extremely rare heterogenous lymphoproliferative pathology with a mostly benign behavior. It is a localized or generalized lymph node enlargement of an unknown aetiology. Unicentric form is typically a slow-growing solitary mass occurring mostly in the mediastinum, abdominal cavity, retroperitoneum, pelvis and neck. Aetiology and pathogenesis of CD is probably diverse, varying in different types of this heterogeneous disease.

Materials and Methods

Authors present a review of this issue based on their extensive experience. The aim is to summarize the crucial factors in the management of diagnostics and a surgical treatment of the unicentric form of Castleman´s disease. One of the key issues in the unicentric form is precise preoperative diagnostics and thus choosing the right surgical treatment strategy. Authors highlight pitfalls of the diagnosis and surgical treatment.

Results

All histological types such as a hyaline vascular type, plasmacytic type and a mixed type are presented as well as options of surgical and conservative treatment. Differential diagnosis and malignant potential is discussed.

Conclusion

Patients with Castleman´s disease should be treated in the high- volume centers, with a great experience in major surgical procedures as well as with preoperative imaging diagnostic techniques. Specialized pathologists and oncologists focusing on this issue are also absolutely necessary to avoid misdiagnosis. Only this complex approach can lead to excellent outcomes in patients with UCD.

CT of Castleman disease in the mediastinum

Castleman disease is a rare lymphoproliferative disease commonly occurring as a benign localized mass of lymph nodes in the mediastinum. Given that Castleman disease presents as asymptomatic or through non-specific thoracic symptoms, detection is considered complex. Ultimately, surgical resection is the preferred course of action with a greater than 90% relapse-free survival and no malignant transformation reported. In this article, we describe the case of a 34-year-old male with an unclear smoking history who was diagnosed with hyaline-vascular Castleman disease. We focus on optimizing diagnosis and management through the application of radiological imaging modalities, including computed tomography scans.

Colonic Castleman Disease on FDG PET/CT

ABSTRACT

Colonic Castleman disease is very rare. We report FDG PET/CT findings of colonic Castleman disease in a 72-year-old man. On FDG PET/CT, it presented as a colonic soft tissue mass with intense FDG uptake. The final pathology supported a diagnosis of Castleman disease, plasma cell variant. This case hints us, although rare, Castleman disease should be considered as a differential diagnosis when we notice a hypermetabolic colon mass on PET/CT.

Castleman Disease Mimicking Pancreatic Neuroendocrine Tumour: Interpretation of Positron Emission Tomography in Pancreatic Incidentaloma

We report a rare case of an incidental pancreatic lesion that proved to be Castleman disease in a peripancreatic lymph node, which mimicked a high-grade pancreatic neuroendocrine tumour (PNET) based on findings on positron emission tomography (PET). The disease was discovered as an incidental finding on CT imaging of the abdomen and was investigated and managed as PNET. Surgical resection was performed with distal pancreatectomy and splenectomy, however, histology revealed the lesion was a lymph node affected by Castleman disease. Often termed the great mimic, Castleman disease is a rare lymphoproliferative disorder that is often mistaken for other primary lesions of the organ due to its location and should be considered a differential of fluorodeoxyglucose (FDG)-avid PET lesions on imaging.

Long-term treatment outcome of Castleman’s disease: A real-world experience

Background

Castleman disease (CD), classified as unicentric CD (UCD) or multicentric CD (MCD), is a rare non-neoplastic lymphoproliferative disorder of unknown origin. Owing to its rarity, the clinical characteristics, therapeutic modalities, treatment outcomes, and prognostic factors related to UCD or MCD are not well defined.

Method

We retrospectively analyzed 88 patients with CD, including those with hyaline-vascular, plasma-cell, mixed type, hypervascular, and plasmablastic subtypes, for presenting symptoms, physical, laboratory, and radiologic findings, and treatment response in the Korean population.

Results

The median patient age was 44 years (range: 18–84 years) with slight predominance of women (53.4%). UCD and MCD accounted for 38.6% (n=34) and 61.4% (n=54) of cases, respectively. Histopathologically, UCD patients were classified as 88.2% (n=30) hyaline-vascular and 11.8% (n=4) plasma cell types, whereas MCD patients were classified as 27.8% (n=15) hypervascular, 61.1% (n=33) plasma cell, 7.4% (n=4) mixed, and 3.7% (n=2) plasmablastic types. Twelve (13.6%) patients exhibited a poor performance status with an Eastern Cooperative Oncology Group score of 2. The most common presenting symptom was sustained fever, followed by fatigue, anorexia, peripheral edema, and weight loss. Furthermore, splenomegaly, pleural effusion, and ascites were observed to be associated with CD. Surgical resection and siltuximab were the preferred treatment modalities for UCD and MCD, respectively, with favorable symptomatic, laboratory, and radiologic outcomes and safety profiles. The overall survival was 90.2%, with no significant difference between the UCD and MCD groups (p=0.073), but progression-free survival was significantly poorer in the MCD group (p=0.001). Age ≥60 years and splenomegaly significantly affected the overall and progression-free survival rates.

Conclusion

Patients with UCD had favorable outcomes with surgical resection of a solitary mass, whereas in patients with MCD, old age and splenomegaly were identified as independent prognostic factors. Further well-designed prospective studies under advancing knowledge of the pathophysiology of MCD are warranted to establish suitable guidelines for the discontinuation or prolonging infusion intervals of siltuximab and treatment modalities for HHV-8 positive MCD patients or patients with siltuximab failure.

Historical and pathological overview of Castleman disease

Castleman disease consists of several lymphoproliferative subtypes that share some histological features in the lymph nodes. On the other hand, numerous clinical findings and etiologies make the disease challenging to understand. The origin of the disease is the hyaline vascular-type unicentric Castleman disease (UCD), first reported by Benjamin Castleman et al. in 1954. Although UCD is characterized by localized lesions and lack of symptoms, multicentric Castleman disease (MCD) with multiple lesions and systemic symptoms was reported by Frizzera in 1983. MCD is further divided according to KSHV/HHV8 infection status. In KSHV/HHV8-related MCD, viral infection signals lead to excessive cytokine production, and cause clinical and pathologic abnormalities. Some cases of plasma cell-type KSHV/HHV8-negative MCD can be found in association with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-proteins, and skin changes), which is a paraneoplastic syndrome. The others are idiopathic MCD, which are currently considered a heterogeneous group of diseases with overlapping pathological and clinical features. In this article, we summarize the historical evolution of Castleman disease to help understand the disease concept. We also review the latest ideas and definitions of the subtypes within the MCD spectrum and summarize the histopathological findings.

Comprehensive analysis of 65 patients with Castleman disease in a single center in China

This study aimed to investigate the epidemiologic, clinical, pathological characteristics, and treatment of patients with Castleman disease (CD) in a single center in China. We retrospectively analyzed the data of 65 Chinese CD patients, divided into unicentric CD (UCD) and multicentric CD (MCD) groups, and also microscopic subtypes as hypervascular (HV), plasmacytic (PC) and Mixed. Based on whether HHV-8 infection existed, MCD was subdivided into HHV-8-associated MCD and idiopathic Castleman disease (iMCD). Detailed epidemiologic, clinicopathological, and treatment data were analyzed and discussed. Of total 65 patients (UCD 33, MCD 32), HV (81.8%) accounted for the most of UCD and total. More females in UCD (60.6%) and more males in MCD (65.6%) were observed. CD occurred in all age groups, most commonly in 40-49 years. The mean age of onset of total was 38.5 years with PC higher than HV (45.5 vs. 35.1 years, P = 0.0413). The median diagnosis delay of MCD was longer than that of UCD (3.00 vs. 1.25 months, P = 0.0436). Abdomen (39.4%) and neck (30.3%) were the most-seen locations of lymphadenopathy in UCD, with neck (65.6%) being predominant in MCD. Mean major diameter of specimens of UCD was greater than MCD (6.4 vs. 3.1 cm, P < 0.0001). These results provided the featured and detailed profile of Castleman disease in Henan province in China with a considerable number of cases, which presented distinct evidence with other studies.

The disease course of Castleman disease patients with fatal outcomes in the ACCELERATE registry

Castleman disease (CD) describes a group of rare, potentially fatal lymphoproliferative disorders. To determine factors associated with mortality in CD, we analysed data from deceased patients in the ACCELERATE registry and compared them with matched controls. We analysed demographic, treatment and laboratory data from all deceased CD patients, matched controls and a subgroup of idiopathic multicentric Castleman disease (iMCD) patients. Of the 140 patients in ACCELERATE with a confirmed CD diagnosis, 10 had died. There were 72 patients with confirmed iMCD; six were deceased. The deceased CD cohort had more hospitalisations per year, higher overall hospitalisations and more days hospitalised per month, and received more treatment regimens per year than the matched‐control group. Analysis of laboratory values showed a significantly decreased absolute lymphocyte count at months 3 and 6 in the deceased cohort compared with controls. Among iMCD patients, there was a higher proportion of iMCD‐TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction and organomegaly) cases in the deceased group. The deceased iMCD group had significantly lower immunoglobulin M, international normalised ratio and platelet count. These data demonstrate that there may be differences between patients who have fatal and non‐fatal outcomes, and provide preliminary suggestions for parameters to evaluate further.

Castleman Disease: A Multicenter Case Series from Turkey

Objective:

Castleman disease (CD) is a rare disease also known as angiofollicular lymph node hyperplasia. The two main histological subtypes are the hyaline vascular and plasma cell variants. It is further classified as unicentric CD (UCD) or multicentric CD (MCD) according to the anatomical distribution of the disease and the number of lymph nodes involved. The aim of this multicenter study was to evaluate all cases of CD identified to date in Turkey to set up a national registry to improve the early recognition, treatment, and follow-up of CD.

Materials and Methods:

Both adult (n=130) and pediatric (n=10) patients with lymph node or involved field biopsy results reported as CD were included in the study. Patients’ demographic information, clinical and laboratory characteristics, imaging study results, treatment strategies, and clinical outcomes were evaluated retrospectively.

Results:

A total of 140 patients (69 male and 71 female) with a diagnosis of UCD (n=73) or MCD (n=67) were included. The mean age was 39 years in the UCD group and 47 years in the MCD group. Female patients were more common in the UCD group. The most common histological subtype was hyaline vascular for both UCD and MCD patients. Asymptomatic patients were more common in the UCD group. Anemia, elevations of acute phase reactants, and hypoalbuminemia were more common in the MCD group. The most commonly used treatment strategies for UCD were surgical excision, rituximab, and radiotherapy, respectively. All UCD patients were alive at a median of 19.5 months of follow-up. The most commonly used treatment strategies for MCD were methyl prednisolone, R-CHOP, R-CVP, and rituximab. Thirteen MCD patients had died at a median of 34 months of follow-up.

Conclusion:

This study is important in presenting the patient characteristics and treatment strategies for CD from Turkey, with the potential of increasing awareness about CD. Treatment data may help in making decisions, particularly in countries that do not have access to siltuximab. However, larger prospective studies are needed to make definitive conclusions.

Mediastinal tumours and pseudo-tumours: a comprehensive review with emphasis on multidisciplinary approach

The diagnosis of a mediastinal mass may be challenging for clinicians, since lesions arising within the mediastinum include a variety of disease entities, frequently requiring a multidisciplinary approach. Age and sex represent important information, which need to be integrated with imaging and laboratory findings. In addition, the location of the mediastinal lesion is fundamental; indeed, we propose to illustrate mediastinal diseases based on the compartment of origin. We consider that this structured approach may serve as hint to the diagnostic modalities and management of mediastinal diseases. In this review, we present primary mediastinal tumours in the evolving context of new diagnostic and therapeutic tools, with recently described entities, based on our own experience with >900 cases encountered in the past 10 years.

Given the mediastinal anatomical heterogeneity, the correct positioning of mediastinal lesions becomes primal, in order to first establish a clinical suspicion and then to assist in planning biopsy and surgical procedurehttps://bit.ly/3p0gsk3

An unusual cause of ascites: Castleman disease

Background

Castleman disease (CD) is a group of rare lymphoproliferative diseases with common lymph node histological features that can easily be misdiagnosed as infections, multiple autoimmune diseases, and malignant tumors.

Case presentation

Here we report a rare case of a Chinese male with refractory ascites for two years and was eventually diagnosed as CD.

Conclusions

The challenges in diagnosis of CD arise from the large differential, clinical heterogeneity and our limited understanding of pathology. In case of rare ascites, CD needs to be considered.

Bilateral lung transplantation for Castleman disease with end-stage bronchiolitis obliterans

Bronchiolitis obliterans (BO) is a severe complication of Castleman disease (CD), a rare lymphoproliferative disease with unclear pathogenesis. Currently, there are no reports on the safety or outcomes of bilateral lung transplantation in patients with BO due to CD. This study aimed to characterize the clinical manifestations and features of BO and CD. We retrospectively analyzed the medical records of six consecutive patients with BO and CD who underwent bilateral lung transplantation between December 2012 and December 2020. The average age of patients at lung transplantation was 33 ± 15 years, and the age range of patients at diagnosis of CD was about 9-56 years. The body mass index was 15.2 ± 1.9 kg/m² . The average time from diagnosis to lung transplantation was 4.1 ± 2.7 years. All the patients had unicentric CD (UCD); five had concomitant paraneoplastic pemphigus, and four received extracorporeal membrane oxygenation during surgery. The average hospital stay was 51 ± 53 days. Infection was the most common postoperative complication. CD did not recur in any of the patients. Thus, bilateral lung transplantation is a viable and safe treatment for selected patients with CD and BO, which can improve the quality of life and prolong survival.

Combinatorial treatment for unresectable unicentric Castleman disease

Unresectable, symptomatic unicentric Castleman disease (UCD) can represent a formidable therapeutic challenge. UCD masses are often highly vascularized offering the opportunity for therapeutic embolization. Herein, we report on 6 patients in which therapeutic embolization was combined with other medical interventions including surgery (n = 3), rituximab (n = 6), cryoablation (n = 2), and chemotherapy (n = 3). Five patients had significant tumor volume reductions (median: 83.2%; range: 76.7-100). All five responding patients had resolution of symptomatology. There were no serious complications in the patients who received embolization and proceeded to surgery. In conclusion, effective disease and symptom control can be obtained in patients with symptomatic, unresectable UCD by combining different therapeutic interventions.

Hypermetabolic Unicentric Castleman Disease of Kidney on FDG PET/CT

ABSTRACT

A 62-year-old man presented with a huge lesion of left kidney on ultrasound in a health examination 1 month ago. The mass showed hypervascularity on enhanced CT and intense FDG uptake on FDG PET/CT in the lower pole of kidney, which suggested renal malignancy. The histopathological result after surgical resection of the mass confirmed the diagnosis of Castleman disease, the hyaline vascular variant.

International evidence-based consensus diagnostic and treatment guidelines for unicentric Castleman disease

Castleman disease (CD) includes a group of rare and heterogeneous disorders with characteristic lymph node histopathological abnormalities. CD can occur in a single lymph node station, which is referred to as unicentric CD (UCD). CD can also involve multicentric lymphadenopathy and inflammatory symptoms (multicentric CD [MCD]). MCD includes human herpesvirus-8 (HHV-8)-associated MCD, POEMS-associated MCD, and HHV-8-/idiopathic MCD (iMCD). The first-ever diagnostic and treatment guidelines were recently developed for iMCD by an international expert consortium convened by the Castleman Disease Collaborative Network (CDCN). The focus of this report is to establish similar guidelines for the management of UCD. To this purpose, an international working group of 42 experts from 10 countries was convened to establish consensus recommendations based on review of treatment in published cases of UCD, the CDCN ACCELERATE registry, and expert opinion. Complete surgical resection is often curative and is therefore the preferred first-line therapy, if possible. The management of unresectable UCD is more challenging. Existing evidence supports that asymptomatic unresectable UCD may be observed. The anti-interleukin-6 monoclonal antibody siltuximab should be considered for unresectable UCD patients with an inflammatory syndrome. Unresectable UCD that is symptomatic as a result of compression of vital neighboring structures may be rendered amenable to resection by medical therapy (eg, rituximab, steroids), radiotherapy, or embolization. Further research is needed in UCD patients with persisting constitutional symptoms despite complete excision and normal laboratory markers. We hope that these guidelines will improve outcomes in UCD and help treating physicians decide the best therapeutic approach for their patients.

A 10-year observational single-center study of retroperitoneal unicentric Castleman disease

Diagnosis of unicentric Castleman disease (UCD) is not easy before the resection and obtainment of pathological result. We retrospectively summarized 10-year experience of clinical evaluation and management for retroperitoneal UCD in Peking Union Medical College Hospital (PUMCH) between December 1, 2009 and December 31, 2019. Seventy two UCD patients with pathological diagnosis after resection were screened out. Among them 25 patients had retroperitoneal UCD. The average age of the 25 patients was 43.80 ± 12.79, and 52.00% were male. No patients had systemic symptoms, and 1 patient got preoperative treatment. The average size of masses was 5.59 ± 2.86 cm. The UCD sites included kidney, adrenal area, perinephric area, pancreas, peripancreatic area, area of descending part of duodenum, periaortic area or beside iliac artery, and others. The masses presented different degree of enhancement on CT scans and hypoecho or isoecho on ultrasound. Increased metabolism could be found on 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT). Some patients had positive results on somatostatin receptor imaging, but none had positive results on 131I-metaiiodo-benzylguanidine (131I-MIBG). Some patients presented the elevated level of interleukin-6 (IL-6), 24hour-urinary catecholamine and tumor markers. All the patients received complete resection of masses and 96.00% had hyaline-vascular type pathology except 1 patient (plasma cell-type). Ninety two percent patients received a long-term follow-up with an average follow-up time of 35.48 ± 33.90 months. No patients died or experienced relapse during follow-up. Differential diagnosis of retroperitoneal UCD may be difficult according to imaging and laboratorial examinations. Differential diagnosis with pheochromocytomas/paragangliomas should be taken into special consideration. Different imaging examinations, such as CT/MRI, 18F-PET/CT, somatostatin receptor imaging and 131I-MIBG, can be combined for differential analysis. Complete resection is the best treatment and could provide a final pathological diagnosis.

Surgical resection for pelvic retroperitoneal Castleman's disease: A case report and review literature

Castleman's disease (CD) is a rare atypical lymphoproliferation disorder first reported in 1954. Clinically, CD is classified as unicentric or multicentric CD based on anatomical distribution. Unicentric CD primarily affects the mediastinum, and rarely affects the retroperitoneal location. The standard treatment for unicentric CD is complete surgical resection; however, this can be complicated by a high degree of attachment with other organs or hypervascularity. Preoperative angiography and embolization of the arteries that feed the problematic mass can reduce intraoperative bleeding in cases of CD with hypervascularity. In the present case report, a 44-year-old man who was found to have a pelvic retroperitoneal mass with calcification based on abdominal imaging results is discussed. Due to the hypervascularity of the mass, preoperative embolization was performed. The mass was completely resected without any complications. Additionally, a review of the literature on pelvic CD and preoperative embolization of CD was performed to provide an up-to-date reference on the management and outcomes of patients with CD.

Abdominal Mass Caused Failure to Thrive in a Young Boy: Mixed-Type Localized Retroperitoneal Castleman Disease

Castleman disease is a rare cause of retroperitoneal mass in children. Clinical presentation and laboratory findings are usually nonspecific. Imaging shows features of a hypervascular or soft tissue mass. We present a 12-year-old boy who complained of frequent colds, fatigue, and failure to gain weight for the past 4 years who was referred to our hospital. Anemia and hypergammaglobulinemia were revealed in laboratory tests. Imaging showed a well-delineated retroperitoneal soft tissue mass with intense homogenous enhancement at the midline below the aortic bifurcation. The histopathological features were consistent with mixed type unicentric Castleman disease. Surgical removal was curative. Our patient's hematological abnormalities resolved, and he gained 10 kg in the next 4 weeks after the operation and reached the 25–50th percentile for his age.

Castleman disease. Interaction with dermatopathy: Case report

INTRODUCTION

Castleman disease (CD) is a lymphoproliferative disorder with lymph node hypertrophy. In the unicentric form (UCD), it affects one lymph node or chain of lymph nodes. In the multicentric form (DCM), there is hypertrophy of several lymph node chains with the formation of tumor masses, causing compressive symptoms. This case report showed a case of CD in a different location(inguinal region) associated to a multiple skin lesions.

PRESENTATION OF THE CASE

We reported a UCD in a 43-year-old female patient with no previous comorbidities. Since January 2016, this patient developed erysipelas lesions of the left leg (LL) from the thigh root to the foot. Concomitantly, a tumor mass appeared in the inguinal region. In 2019 we performed a biopsy that revealed changes characteristic of CD. Due to extremely poor trophic conditions, the skin area with erysipelas was resected, and the raw surface was grafted.

DISCUSSION

As an inference, the erysipelas may have been responsible for the subsequent lymphangitis, lymphedema and lymph node hypertrophy.

CONCLUSION

Resection of the diseased skin and lymph node excision constitute the treatment of UCD and result in improvement of the clinical picture. Nevertheless, further study of the inflammatory reaction and of markers such as interleukin-6 and the presence of skin disorders in DC is needed.

Castleman's disease in two patients with spondyloarthritis treated by Tumor Necrosis Factor-alpha antagonists

Castleman's disease is a rare lymphoproliferative syndrome involving several anatomical and clinical entities. We report two cases of Castleman's disease in patients with spondyloarthritis (with and without psoriasis) treated with Tumor Necrosis Factor-alpha blockers. During follow-up, imaging examinations, carried out for disease assessment, fortuitously revealed a pelvic mass close to the psoas or an atypical cervical adenopathy. Both lesions were in moderate hypermetabolism on Positron emission tomography-computed tomography. After surgical excision and histological analysis, Castleman's disease was diagnosed without signs of malignancy. To the best of our knowledge, these are the first cases of Castleman's disease diagnosed in a context of spondyloarthritis treated with Tumor Necrosis Factor-alpha blockers. The relationship between these two pathologies and the link with Tumor Necrosis Factor-alpha blockers agents has not been explored in the literature until now.

Histologic and Laboratory Characteristics of Symptomatic and Asymptomatic Castleman Disease in the Pediatric Population

OBJECTIVES

Compare the morphologic, laboratory, and clinical features of asymptomatic and symptomatic Castleman disease in the pediatric population.

METHODS

We reviewed clinical records and histopathology of patients with Castleman disease from 2 pediatric institutions.

RESULTS

Of 39 patients with pediatric Castleman disease, 37 had unicentric disease, all classified with the hyaline vascular variant of Castleman disease, 8 of which were clinically symptomatic. These 8 patients demonstrated abnormal laboratory findings, including microcytic anemia, elevated erythrocyte sedimentation rate and C-reactive protein, and hypoalbuminemia. In addition, histopathologic evaluation showed that the 8 symptomatic cases had more hyperplastic germinal centers, fewer atrophic or regressed germinal centers, fewer mantle zones containing multiple germinal centers, reduced "onion skinning" of mantle zones, and fewer "lollipop" formations compared with the asymptomatic cases.

CONCLUSIONS

This series of pediatric Castleman disease showed that lymph nodes from asymptomatic patients generally demonstrated the more classic hyaline vascular histology, whereas those with symptoms could lack or have only focal classic findings. As such, reactive lymph nodes with subtle Castleman-like features should prompt clinical correlation to ensure proper diagnosis.

Clinical features and treatment of 7 Chinese TAFRO syndromes from 96 de novo Castleman diseases: a 10-year retrospective study

Background

Castleman disease (CD) is a rare polyclonal lymphoproliferative disorder with unknown etiology. TAFRO syndrome is now regarded as a specific subtype of CD, and is still a huge challenge for clinicians.

Methods

To clarify the clinical features and management of TAFRO syndrome in China, we retrospectively analyzed 96 patients with HIV-negative CD (52 with unicentric CD and 44 with multicentric CD), who were diagnosed and treated at our center between 2008 and 2017. Specially, we systematically reviewed the 7 TAFRO syndrome cases based on the 2015 criteria proposed by Masaki.

Results

Among the 7 cases, there were 3 men and 4 women, and the median age was 53 years. The main symptoms included thrombocytopenia (7/7), anasarca (7/7), fever (4/7), renal dysfunction (7/7), and organomegaly (6/7). One patient was treated with corticosteroid monotherapy, one received RD (Rituximab, dexamethasone), and 5 received CHOP/COP like chemotherapy as first-line treatment, 2 of the 5 combined with Rituximab. Four patients needed hemodialysis or CRRT because of progressive renal failure. The outcome for TAFRO syndrome was significantly worse compared to other types of CD. Although 3 patients improved after early treatment, 4 patients died due to disease progression, and only one patient achieved complete resolution of all the symptoms after changing to lenalidomide based regimen.

Conclusions

This study reveals that TAFRO syndrome is more severe and has more systemic symptoms than other iMCD, most cases need active treatment, and their prognoses are poor. Lenalidomide based regimen may be as a promising new therapy for TAFRO syndrome.

Exfoliative Erythroderma: An Unusual Presentation of Paraneoplastic Pemphigus Associated with Castleman's Disease

We report a 23-year-old woman who presented with generalized scaly erythematous rash predominately on the upper trunk and hemorrhagic stomatitis. The histopathologic and immunopathologic findings were consistent with the diagnosis of paraneoplastic pemphigus. Castleman's tumor was diagnosed with computed tomography and exploratory laparotomy. A partial clinical improvement was observed after complete tumor removal and intravenous immunoglobulin administration. However, the patient died as a result of septicemia.

Clinicopathological comparison and therapeutic approach to Castleman disease-a case-based review

Castleman disease (CD) is a rare, B-cell lymphoproliferative disorder affecting lymph nodes and extranodal anatomical locations. Four types of clinical presentations can be distinguished after exclusion of mimics. The first division is into unicentric CD (UCD) and multicentric CD (MCD). MCD is classified further as HHV-8-negative (idiopathic), MCD associated with HHV-8 infection, and POEMS associated MCD. From the histological standpoint, UCD and MCD can be classified as hyaline-vascular (HV), plasma cell (PC), or mixed cellularity (MC) type, with a spectrum of histopathological manifestations. We present clinical and histopathological features and grading of 25 cases of CD classified according to CDCN histological criteria and according to this clinical algorithm, along with outcomes. Here we provide a fine-resolution description of the histological features of CD. We review and discuss the current diagnostic algorithm, grading system, and recently recommended treatment options. In the presented group of 25 patients with CD there were 14 women and 11 men in the age range 15-79 years. UCD was identified in 15 patients and it was most often located in mediastinum. MCD most frequently occurred as generalized lymphadenopathy. The most common type of CD was HV. All patients with UCD underwent complete surgical resection with a positive outcome. Patients with MCD had diagnostic partial surgical excision of the lesions, later followed by different types of treatment (corticosteroids, chemotherapy, radiotherapy, immunomodulatory agents) or 'watch and wait'. In four cases CD was associated with other malignancies (laryngeal cancer, small lymphocytic lymphoma, gallbladder cancer with hepatic metastases, primary squamous cell lung cancer). The accuracy of histopathological examination is essential and re-evaluation has to be performed in case of relapse or unexpected course of CD. Treatment tailored to fit the disease type and severity should follow the novel recommendations, including anti-IL-6 treatment in the case of MCD.