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

Hematolymphoid neoplasm mimicking endodontic lesions: case series and review of the literature

Hematolymphoid neoplasms originating in the periapical region of a tooth are rare occurrences. Their signs, symptoms, and radiographic findings can also mimic lesions of endodontic origin. History-taking and clinical examination provide clues to determine the possibility of a non-endodontic lesion, although the definitive diagnosis can only be rendered based on histologic examination. In our case series, we present four cases of hematolymphoid neoplasms that radiographically mimicked endodontic lesions. All the cases initially underwent endodontic treatment, but the lesions failed to resolve. In one case, the clinician suspected a diagnosis of lymphoma based on the patient's history. In the other cases, the clinicians' impression was that the lesions originated from endodontic issues. We present two cases of diffuse large B-cell lymphoma, a case of a plasma cell neoplasm, and a case of Langerhans cell histiocytosis, along with a literature review of three entities when found in the oral cavity as well as review of hematolymphoid neoplasm mimicking endodontic lesion previously reported in literature.

Does Fractal Analysis Have a Role in Diagnosis of Langerhans Cell Histiocytosis?

PURPOSE

Langerhans cell histiocytosis (LCH) of the jaws is a rare disease and is often diagnosed at an advanced stage. This study aims to assess the trabecular pattern of jaws via fractal analysis (FA) on initial panoramic radiographs (OPG) of the patients with LCH to facilitate interpretation of the radiographic changes.

METHODS

A case-control study investigated LCH cases with jaw involvement retrieved from the databases of Istanbul and Kocaeli Universities between 2010 and 2021. Initial OPGs of LCH cases and OPGs of healthy sex- and age-matched controls were investigated with FA. All images were assessed using ImageJ software. On each OPG, a total of 6 regions of interest (ROIs) located on the mandible were investigated bilaterally. The independent variables were the trabecular patterns of jaws of LCH cases and their control matches. The outcome variables were the fractal dimension (FD) values obtained from the ROIs on OPGs. Data were analyzed using the Mann-Whitney U test and Student's t test.

RESULTS

Fifteen LCH-control pairs were investigated. In one ROI located in the supracortical area above the left mandibular angle, FD values of LCH cases (1.273 ± 112.8) were significantly lower than controls (1.308 ± 85.3; P < .05). Lower FD values were also calculated for some of the remaining ROIs, but there was no significant difference between groups (P > .05).

CONCLUSIONS

Regarding our results, FA was not a useful parameter to discern radiographical trabecular changes between LCH cases and controls. Multicenter studies with larger populations are needed to investigate the potential of FA in the identification of this rare disease.

Diagnostic Challenge in Rapidly Growing Langerhans Cell Histiocytosis with Aneurysmal Bone Cyst in the Maxilla: A Case Report

Langerhans cell histiocytosis (LCH) is a rare neoplastic disorder characterized by the clonal proliferation of CD1a +/CD 207 + dendritic cells, whose features are similar to those of epidermal Langerhans cells. LCH is more common in children than in adults. Localized osteolytic lesions in the craniofacial bones are the most common manifestations of LCH. However, LCH can also present as a multifocal and multisystem disease with poor prognosis. Locally aggressive LCH needs to be differentiated from various diseases such as osteomyelitis, malignant bone tumors, and soft tissue sarcomas. However, it is difficult to diagnose, since the imaging findings are nonspecific. We report a case of a highly aggressive LCH in the maxilla accompanied by a fluid-fluid level.

A case of langerhans cell histiocytosis of the mandible that spontaneously regressed after biopsy in a child

In younger patients of LCH, we should consider that the effectiveness of follow-up without aggressive treatment for SS-type LCH in the oral and maxillofacial bone. However, there are very rare case in which an SS-type LCH recurred after showing a healing tendency. Regular follow-up must be performed even after healing.

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.

Primary oral manifestation of Langerhans cell histiocytosis refractory to conventional therapy but susceptible to BRAF-specific treatment: a case report and review of the literature

Langerhans cell histiocytosis (LCH) is a diagnostic and therapeutic challenge. We report on a rare case of its primary oral manifestation that was treated successfully with the BRAF-specific agent, vemurafenib, after insufficient standard LCH treatment. This case underlines the importance of proper diagnosis and the evaluation of targeted therapy as a valuable tool in LCH treatment. Furthermore, the close collaboration of surgeons, oncologists, and dentists is mandatory to ensure adequate treatment, restore the stomatognathic system in debilitating post-treatment situations, improve quality of life, and ensure effective disease control in infants and young patients.

High Prevalence of BRAF V600E Mutations in Langerhans Cell Histiocytosis of Head and Neck in Chinese Patients

Langerhans cell histiocytosis (LCH) is characterized by clonal proliferation of Langerhans cells and has been classified as a hematolymphoid tumor. BRAF V600E mutation was found to be frequent in LCH; however, it has also been reported that Asia patients with LCH tend to show a lower rate of BRAF V600E mutation. In this study, we found LCH from the head and neck region often involved bone especially the posterior of the mandible and presented a high prevalence of BRAF V600E mutation in Chinese patients. Our findings also showed immunohistochemical detection correlated very well to DNA sequencing of BRAF alterations, which may be useful in the diagnosis of LCH, especially in cases with a low proportion of Langerhans cells, and BRAF inhibitors might be a treatment option for patients with LCH harboring BRAF V600E mutation.

Langerhans' Cell Histiocytosis Mimicking a Pott Puffy Tumor

Langherans' cell histiocytosis (LCH) is a rare disease mostly affecting children in the first decade of life. As clinical presentation is extremely heterogenous, a prompt diagnosis may be challenging, sometimes leading to a diagnostic delay, especially when the disease involves a single site. Herein, we report a case of a child with an unusual presentation of (LCH) mimicking a Pott puffy tumor with extracranial and epidural abscesses, surgically treated. Through this unique case we summarize possible manifestations of LCH with bone involvement and we underline the importance of considering possible complications due to bone erosions such as infection, to avoid a misdiagnosis.

Clinicopathological and Immunohistochemical Study of Head and Neck Langerhans Cell Histiocytosis from Latin America

Langerhans cell histiocytosis (LCH) is an inflammatory myeloid neoplastic proliferation with variable clinical behavior caused by the accumulation of CD1a⁺/CD207⁺ histiocytes, associated with a variable number of eosinophils, lymphocytes, plasma cells and multinucleated giant cells, most commonly observed in male children. LCH is uncommon in the head and neck region, occurring as ulcerated and reddened plaques or nodules that cause destruction of adjacent soft tissues and bone. The exact etiology of LCH is still unknown and controversial, with possible etiologic role of viruses, including Epstein-Barr virus (EBV). The aim of this study was to describe the clinicopathologic and immunohistochemical features of patients with LCH of the head and neck region. Clinical data from 19 patients with LCH were obtained from the archives of the Federal University of Rio de Janeiro and the Clinical Head and Neck Center of Guatemala. All cases were submitted to morphological, immunohistochemical analysis with CD1a, CD207, CD3, CD20, CD68, S-100 and Ki-67 and in situ hybridization for EBV. Ten cases were female and 9 male, with mean age of 11.5 years. Fourteen cases were located in the oral cavity, three cases in lymph nodes, and two cases in the scalp. In regard to the oral lesions, 13 cases were intra-osseous with six cases in anterior mandible, five cases in posterior mandible, and two cases in posterior maxilla while one case was located exclusively in the gingiva. The inflammatory pattern showed variation in the number of plasma cells, eosinophils and lymphocytes, while tumor cells were positive for CD1a, S-100 and CD68 in all cases, and positive for CD207 in 18 cases. In situ hybridization for EBV were negative in all cases.

Cholesteatoma as a complication of Langerhans Cell Histiocytosis of the temporal bone: A nationwide cross-sectional analysis

OBJECTIVE

To determine if patients with Langerhans Cell Histiocytosis (LCH) of the temporal bone have a higher risk of developing cholesteatoma.

METHODS

Review of literature and cross-sectional weighted analysis of patients under 19 with a diagnosis of LCH from the National Inpatient Sample (NIS) and Kids' Inpatient Database (KID) from 2000 to 2013. ICD-9 codes and demographics were analyzed; pairwise comparisons and multivariate analyses were performed.

RESULTS

Only seven cases of cholesteatoma after the treatment for LCH of the temporal bone have been documented in the literature. No significant association between cholesteatoma and LCH was seen (OR 0.747 [0.149-3.751]). Patients with LCH did have a higher incidence of chronic otitis media, chronic otitis externa, chronic sinusitis, hearing loss, and otitis media with effusion.

CONCLUSION

Our results show that patients with Langerhans Cell Histiocytosis do not appear to have a higher risk of developing cholesteatoma. However they are more likely to be diagnosed with chronic otitis externa which should be differentiated from cholesteatoma or recurrence of LCH.

Atlanto-axial langerhans cell histiocytosis in a child presented as torticollis

Langerhans cell histiocytosis (LCH) is a rare condition mostly seen in children and adolescents. Eosinophilic granuloma (EG) is one of its three clinical entities and is considered as a benign osteolytic lesion. Many reports of patients with spine histiocytosis are well documented in the literature but it is not the case of atlantoaxial localization. We report here a new observation of atlantoaxial LCH in a 4-year-old boy revealed by persistent torticollis. He was successfully treated with systemic chemotherapy and surgery. Inter-body fusion packed by autologous iliac bone was performed with resolution of his symptoms. It is known that conservative treatment is usually sufficient and surgery should be reserved for major neurologic defects in spine EG. In atlantoaxial lesion, surgical treatment should be frequently considered.

Management of eosinophilic granuloma in pediatric patients: surgical intervention and surgery combined with postoperative radiotherapy and/or chemotherapy

BACKGROUND

Eosinophilic granuloma (EG) of spine in pediatric patients presents kinds of clinical manifestation and a difficult management scenario. The choice of treatment, issues of surgical intervention versus conservative treatment, combination therapy or single treatment, all these factors, including neurological deficits, spinal stability, long-term complications, and continued skeletal growth, must be considered.

METHODS

From 2008 to the 2015, 31 pediatric patients of spinal EG were retrospectively reviewed. They were 17 males and 14 females, with a mean age 8.89 ± 2.84 years old (range, 3.5-14 years old). All the cases were divided into two groups. Twenty-three cases (Group S) accepted surgical interventions and surgery combined with local low-dose radiotherapy and/or chemotherapy. Eight patients (Group C) accepted radiotherapy and/or chemotherapy. All the patients had imaging studies of the lesion including standard radiography, three-dimensional computed tomography (CT) scan, and magnetic resonance imaging (MRI) prior to and after treatment. Cases in group S underwent surgery-related treatment, which include six patients accepted surgery only, nine patients accepted postoperative low-dose radiotherapy, four patients accepted additional chemotherapy, and four patients accepted both. Cases in group C accepted radiotherapy and/or chemotherapy, which include five patients accepted radiotherapy, one patient accepted chemotherapy, and two patients accepted both radiotherapy and chemotherapy. Clinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and/or complications were recorded and analyzed.

RESULTS

All the 31 patients had pain relief (both in group S and group C) but the patients in group S obtained more prompt pain relief. All the patients in group S obtained local kyphosis correction, reconstruction of stability of spine, and recovery of neurological deficit after treatment. They have no surgery-related complications after treatment and in follow-up. Seventeen patients who received additional postoperative radiotherapy and/or chemotherapy also had good outcomes. There were no severe radiation and chemotherapy complications in procedure. The patients (group C) who accepted non-surgical treatment also have no severe complications, and a new femur lesion was found in one patient in follow-up.

CONCLUSION

Surgical intervention, including anterior and/or posterior approach with bone graft or surgery combined with postoperative low-dose radiotherapy and/or chemotherapy is a safe and effective way for treatment of the spinal EG. Compared with radiotherapy and/or chemotherapy, more prompt pain relief can be achieved via surgical intervention or surgery combined radiotherapy and/or chemotherapy.

Clinical Characteristics of Benign Pediatric Cranial Vault Tumors: Surgical Considerations Based on 100 Cases

BACKGROUND/AIMS

Tumors of the cranial vault occur at every age of childhood. Although they are mostly benign lesions, their symptomatology is variable and requires extended diagnostics. The choice of therapeutic strategy strongly depends on histopathological diagnosis, and therefore surgical excision is the elective treatment in such cases. Despite several published papers, the literature still lacks reliable clinical characteristics regarding this heterogeneous group of lesions in pediatric patients.

METHODS

We present a series of 100 children (55 male, 45 female) with scalp and cranial vault masses (average age: 3.6 years; range: 1 month to 17 years). Eighty-three (83%) patients underwent surgical excision. Demographic data, clinical presentation, diagnostic studies, choice of therapy, and the results of treatment were evaluated.

RESULTS

All removed tumors were benign pathologies: pilar cysts (30%), epidermoid/dermoid cysts (21%), vascular malformations (11%), inflammatory tumors (5%), and dysraphic remnants (2%). However, underlying bone destruction was observed in 61% of cases. Cranial extension occurred in 34%. Recurrence was noted in 1 case.

CONCLUSIONS

Cranial vault tumors are characterized by constant growth and may penetrate the cranial cavity. Delayed surgery increases the risk of intracranial complications. Surgical problems include inappropriate planning, higher risk of intraoperative bleeding, and the need for subsequent cranioplasty.

Eosinophilic Granuloma of the Mandible: Is a Conservative Treatment Sufficient for Local Disease Control?

Eosinophilic granuloma is the most benign and common form of the Langerhans cell histiocytosis, a rare proliferative disease that can affect single or multiple organs. In the quite common head and neck manifestation these lesions can be confused in the beginning, with other bone diseases such as odontogenic cysts, periodontal disease, or malignancies. Treatment varies depending on the size, number, localization of the lesions, and patient's general conditions. The authors describe here a patient of a single lesion of eosinophilic granuloma localized in the posterior mandible region treated with a very conservative surgical approach in a patient with poor socio-economic conditions. The authors performed teeth extractions, an excisional biopsy and open curettage and after a follow-up of 24 months without partial mandible resection and reconstruction time the lesion had healed. The clinical situation confirmed that, in carefully selective patients, a conservative approach could be a useful therapeutic opportunity.