Solitary Langerhans-cell histiocytosis of the clivus and sphenoid sinus with parasellar and petrous extensions: case report and a review of literature

Ophthalmologic Involvement in Adults with Histiocytic Disorders: Clinical Presentation and Treatment Outcomes

PURPOSE

To evaluate the clinical presentation, treatment, and outcomes in adult patients with histiocytic disorders with ocular, orbital, optic nerve, or cavernous sinus involvement.

DESIGN

Observational, retrospective chart review.

PARTICIPANTS

Adult patients (age ≥ 18 years) at Mayo Clinic from January 1, 1996, to July 1, 2021, with histiocytic disorders. Inclusion criteria were (1) histiocytic disorder by biopsy and appropriate clinical phenotype; (2) available medical records; and (3) ocular, orbital, optic nerve, or cavernous sinus involvement.

METHODS

Retrospective chart review.

MAIN OUTCOME MEASURES

Response to therapy, measured in clinical and radiographic impact.

RESULTS

Thirty-two patients were identified: 7 with Langerhans cell histiocytosis (LCH); 15 with Erdheim-Chester disease (ECD); 1 with mixed LCH/ECD phenotype; 8 with Rosai-Dorfman disease (RDD); and 1 with mixed RDD/ECD phenotype. Ophthalmologic involvement was part of the initial presentation in 69% of patients (22/32). Eyelid edema (13/32, 41%) and proptosis (12/32, 38%) were the most frequent presentations. Isolated orbital or cavernous sinus involvement was present in 3 of 7 patients with LCH and 1 of 8 patients with RDD. Optic nerve sheath involvement was present in 2 of 7 LCH patients, 14 of 15 ECD patients, and 1 RDD/ECD patient. Diffuse (> 75%) orbital involvement was seen in 12 of 15 ECD patients and 1 of 7 LCH patients. Ocular involvement was seen in 1 of 15 ECD patients, 6 of 8 RDD patients, and 1 of 1 mixed RDD/ECD patient. The cavernous sinuses were involved in 1 of 7 LCH patients, 5 of 15 ECD patients, and both mixed phenotype patients. Visual acuity was affected in 14 patients (14/24, 58%) with a median logarithm of the minimum angle of resolution visual acuity of 0.1 (range, -0.12 to 3). BRAF V600E mutations were found in 75% (3/4) of LCH patients and 91% (10/11) of ECD patients. Patients received a variety of treatment, and response was variable across disease types.

CONCLUSIONS

Orbital involvement was more commonly seen in LCH and ECD, whereas ocular involvement was more common in RDD. Visual acuity may be impacted from ocular involvement or compression of the optic nerve with diffuse orbital involvement.

Endonasal Endoscopic Removal of a Langerhans Cell Histiocytosis from Far Lateral Frontal Sinus

Introduction: Langerhans cell histiocytosis (LCH) is a rare disease in adults, and it is even uncommon in pediatric populations, affecting only 1-2 people per million. A LCH located in the frontal sinus is exceptionally unusual. We present a case of LCH located in the far lateral of the frontal sinus and discuss management as well as surgical techniques to control this far lateral frontal sinus lesion. Case Presentation: A 39 year old female, presented with a history of progressive headaches and purulent nasal discharge for three months. Computed tomography (CT) of the sinuses showed an approximately 15 × 10 mm soft tissue with osteolytic bony changes located in lateral wall of the frontal sinus on the left side. Total tumor removal was achieved by minimally invasive endonasal endoscopic surgery with a periorbital suspension technique. Histopathologic analysis revealed LCH and the patient was referred to a hematologist for further treatment. Conclusion: LCH is a rare hematological pathology. It should be diagnosed timely and treated with a multidisciplinary approach. To get a definitive diagnosis a biopsy is mandatory. Having LCH in the far lateral frontal sinus can be challenging for a biopsy even for experienced surgeons. Using curved instruments while performing an endonasal periorbital suspension technique makes it possible to access the lateral wall of the frontal sinus safely and provides an effective surgical route similar to traditional open approaches without causing any external scars.

Unusual sites of bone involvement in Langerhans cell histiocytosis: a systematic review of the literature

Background

Langerhans cell histiocytosis (LCH) is a rare disease that originates from the uncontrolled proliferation and accumulation of bone marrow-derived immature myeloid dendritic cells. Dendritic cells are a type of histiocyte that play an important role in the human immune system and are found in the bone, skin, stomach, eyes, intestines, and lungs.

Objective

This systematic review aimed to collect and report published case reports of rare bone disease caused by LCH to avoid misdiagnoses or delays in diagnosis.

Methods

We systematically searched Scopus, PubMed, Embase, and Web of Sciences from August 1, 2000 to December 31, 2019. Studies reporting cases of LCH with rare bone involvement were included.

Results

We identified 60 articles including 64 cases. Of the identified cases, 31 (48.4%) involved children, and 33 (51.6%) involved adults. Additionally, 46.9% (30 individuals) were from Asian countries. The mean age of the children was 7.6 ± 4.3 years and that of the adults was 36 ± 12 years. The findings indicated that unifocal bone involvements were the most prevalent form of the disease (68.7%), and, overall, the skull and chest wall were the most commonly affected bones in both adults and children. The spine and long bones were the second most commonly affected bones in children, and the spine and jaw were the second most commonly affected bones in adults. Pain and swelling were the most frequent presenting signs among the investigated cases, and loss of consciousness, myelopathy, nerve palsy, visual loss, torticollis and clicking sounds were rare signs. Osteolytic lesions were the most frequent radiologic feature (62.5%), and intracranial hemorrhage, fluid–fluid level, dura and intracranial extension and pathologic fractures were rare radiological features. Total excision, curettage and observation in the unifocal group of patients and systemic chemotherapy in the other groups (i.e., multifocal and multisystem) were the most frequent management approaches. The recovery rates of the unifocal and multifocal groups were 77.3% and 81.8%, respectively, while that of the multisystem group was 55.5%. The rates of recurrence and mortality in the multisystem group were 11% and were higher than those in the other groups.

Conclusions

LCH is a rare disease that can affect any organ in the human body. However, bone is the most commonly involved organ, and rare bone involvements may be the first or only symptom of the disease due to the rarity of such lesions; a lack of familiarity with them may result in misdiagnosis or delayed diagnosis.

Langerhans cell histiocytosis in the occipital condyle: a case study and a brief review of the literature

We present a case study of a 5-year-old patient, who presented with left-sided torticollis. Due to persistence of problems, a CT and an MRI were made showing a single osteolytic lesion centred on right occipital condyle. After an open biopsy, histology confirmed it to be Langerhans cell histiocytosis (LCH). Torticollis or restricted range of motion is a presenting feature in 76% of children with LCH with cervical involvement. There remains much debate on the best treatment strategy. The clinical and radiological outcomes of the case study presented on this article support the treatment of LCH with chemotherapy in cases with solitary involvement of the occipital condyle.

Isolated Sphenoid Sinus Lesions: Experience with a Few Rare Pathologies

INTRODUCTION

The sphenoid sinus is often neglected because of its difficult access. The deep position of the sphenoid sinus hinders early diagnosis of pathologies in that location. Delayed diagnosis can cause serious complications due to proximity to many important structures.

OBJECTIVES

The aim of this study is to demonstrate different pathologies which can affect the sphenoid sinus and elucidate the findings.

METHODS

Cases of isolated sphenoid sinus lesions encountered in the neurosurgical setting which had rare pathologies are discussed. Pathologies such as Langerhans cell histiocytosis, solitary plasmacytoma, chordoma, pituitary adenoma, leiomyosarcoma, fungal infection, and mucocele which appeared primarily in sphenoid sinus are discussed along with their imaging features and pathological findings.

CONCLUSION

Multitude of different pathologies can occur in sphenoid sinus. Detailed preoperative imaging is very helpful, but transnasal biopsy and histological study are required often for definitive diagnosis. The possible advantages of early diagnosis before spread of pathology for prognosis cannot be overemphasized.

Eosinophilic granuloma at the cerebellopontine angle in an adult; a rare case report and literature review

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a rare immunologic disorder, identified by immature proliferation of histiocytes which may present as systemic or focal lesions. Eosinophilic granuloma (EG) is localized from of LCH mainly involving bones such as skull, femur, spine, ribs, mandible and pelvis. Cerebello-pontine (CP) angle is a rare anatomic location for involvement by EG.

PRESENTATION OF CASE

A 32 year old man was being evaluated in our neuro-oncology clinic due to diplopia since 4 months ago. On physical examination he had left sided abducens paresis, hyposthesia over left half of his face and a decreased corneal reflex on left side. A magnetic resonance imaging (MRI) study revealed a lesion at left CP angle measuring 30×25×25mm in size which was isointense in T1, hypointense on T2 with homogenous enhancement in post-contrast study. A standard retrosigmoid approach was carried out for resection of this lesion. Pathology report of the frozen section depicted infiltration of eosinophils and large mono-nuclear cells. The infiltrative nature of the lesion encouraged us not to attempt further resection. Permanent pathology report was in favor of EG. Patient was referred to an oncology clinic for proceeding with the steroid therapy.

DISCUSSION

To the best of authors' knowledge, this is the first report of EG at CP angle in an adult, in the literature. Infiltration of eosinophils and positivity for CD1a and S-100 renders the diagnosis unmistakable.

CONCLUSION

When the diagnosis is suggestive of EG, incompletely excised lesions can be further managed by steroid therapy.

Solitary Langerhans cell histiocytosis of the occipital condyle: a case report and review of the literature

BACKGROUND

Despite the recent advent of various radiographic imaging techniques, it is still very difficult to correctly distinguish a pediatric osteolytic lesion in the occipital condyle, which makes it further complicated to decide on the necessity of and the adequate timing for radical resection and craniocervical fusions. To establish a legitimate therapeutic strategy for this deep-seated lesion, surgical biopsy is a reasonable choice for first-line intervention. The choice of surgical approach becomes very important because a sufficient amount of histological specimen must be obtained to confirm the diagnosis but, ideally, the residual bony structures and the muscular structures should be preserved so as not to increase craniocervical instability. In this report, we present our experience with a case of solitary Langerhans cell histiocytosis (LCH) involving the occipital condyle that was successfully treated with minimally invasive surgical biopsy with a far lateral condylar approach supported by preoperative 3D computer graphic simulation.

CASE REPORT

An 8-year-old girl presented with neck pain. Magnetic resonance imaging and computed tomography (CT) revealed an osteolytic lesion of the left occipital condyle. At surgery, the patient was placed in the prone position. A 3-cm skin incision was made in the posterior auricular region, and the sternocleidomastoid and splenius capitis muscles were dissected in the middle of the muscle bundle along the direction of the muscle fiber. Under a navigation system, we approached the occipital condyle through the space between the longissimus capitis muscle and the posterior belly of the digastric muscle and lateral to the superior oblique muscle, verifying each muscle at each depth of the surgical field and, finally, obtained sufficient surgical specimen. After the biopsy, her craniocervical instability had not worsened, and chemotherapy was performed. Twelve weeks after chemotherapy, her neck pain had gradually disappeared along with her torticollis, and CT showed remission of the lesion and marked regeneration of the left occipital condyle. Within our knowledge, this is the first reported case of LCH involving the occipital condyle. Although very rare, our case indicated that LCH can be an alternative in the differential diagnosis of osteolytic lesions in the craniocervical junction, in which early bone regeneration with sufficient cervical stability is expected after chemotherapy.

CONCLUSIONS

In cases of pediatric osteolytic lesions, when they initially presented with apparent cervical instability, craniocervical fusion may possibly become unnecessary after a series of treatments. Thus, the effort to maximally preserve the musculoskeletal structure should be made until its histological diagnosis is finally confirmed.

Isolated Langerhans Cell Histiocytosis Bone Lesion in Pediatric Patients: Systematic Review and Treatment Algorithm

OBJECTIVE

The present study reviewed all cases reported of isolated Langerhans cell histiocytosis bone lesions in the head and neck of pediatric patients. The objective was to create a treatment algorithm to facilitate the diagnosis and management of these lesions.

DATA SOURCES

Eligible articles were identified through a comprehensive search of the following electronic databases: PubMed, Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

Two authors independently reviewed the titles and abstracts retrieved by the electronic search concordant with the criteria for study eligibility. The lists of articles from each author were jointly reviewed and a common list created. All relevant articles were reviewed in hard copies and as full texts to justify inclusion.

RESULTS

A total of 201 patients (67% male, mean age: 8.1 ± 4.3 years) were included from 45 studies. Clinical presentations included swelling (64%), pain (9%), or both (18%). The skull (61%) and the orbit (24%) were the most common location for isolated bone lesions in the head and neck. The most frequently documented management option was resection, followed by observation, chemotherapy, and intralesional steroid injection.

CONCLUSIONS

Due to its rarity and variability in presentation and severity, treatment of these lesions has yet to be standardized. Based on the review, a diagnosis and treatment algorithm was created for head and neck surgeons when encountering these types of lesions.

Langerhans cell histiocytosis in the jugular foramen

Langerhans cell histiocytosis (LCH) is a rare disease of neoplastic proliferation of monocyte-macrophage system. Although LCH can affect almost any organ, solitary involvement of jugular foramen is extremely rare and can present a diagnostic dilemma because of its rarity at this location. Here, we present the case of an adult patient with LCH affecting the jugular foramen, and review the relevant literature.

Langerhans cell histiocytosis of the petrous bone with sudden sensorineural hearing loss. Case report

A 56-year-old woman with Langerhans cell histiocytosis of the petrous bone presented with sudden onset of sensorineural hearing loss and vertigo without other neurological impairment, mimicking idiopathic sudden sensorineural hearing loss. Differential diagnosis was difficult until neuroimaging demonstrated a lesion of the petrous bone. The patient eventually underwent removal of the lesion via the transpetrosal approach, and received postoperative chemotherapy consisting of vinblastine, methotrexate, 6-mercaptopurine, and prednisolone. Although her hearing did not recover, complete remission was achieved, and the patient is currently free from disease. Physicians need to be aware that patients with sudden onset of hearing loss may have an unexpected and hidden disease which requires neuroimaging and histological examinations for definitive diagnosis and appropriate treatment.

Spontaneous Resolution of Eosinophilic Granuloma in a Patient with a Psychotic Disorder

A 16-year-old female who manifested psychotic symptoms underwent CT and MRI for the evaluation of an incidentally discovered asymptomatic palpable mass of the right occipital region of the skull. The correlation between clinical and radiological data and biopsy data led to the diagnosis of eosinophilic granuloma. The radiological finding is discussed and reviewed in relation to clinical aspects and literature data.

Cerebrospinal fluid otorrhoea: a rare presentation of Langerhans' cell histiocytosis of the temporal bone

Objective:

To report a case of Langerhans cell histiocytosis of the temporal bone presenting with cerebrospinal fluid fistula.

Patient:

A Caucasian woman presented to a tertiary care centre in Quebec, Canada, with a new onset of cerebrospinal fluid fistula. She had a significant destructive lesion of the temporal bone, and was diagnosed with Langerhans cell histiocytosis on biopsy.

Interventions:

The patient underwent surgical resection with reconstruction of the posterior fossa and tegmen. She suffered a relapse less than one year after surgery, and was finally treated with chemotherapy.

Main outcome and results:

The patient was free of disease at three-year follow up. No recurrence of the cerebrospinal fluid leak was observed after treatment.

Conclusion:

Langerhans cell histiocytosis of the temporal bone with intra-cranial involvement is rare in adults, with only two cases previously reported. Eleven paediatric cases have been reported. To our knowledge, this patient represents the first report of cerebrospinal fluid fistula as the initial presentation of the disease.

Imaging lesions of the cavernous sinus

Our aim was to review the imaging findings of relatively common lesions involving the cavernous sinus (CS), such as neoplastic, inflammatory, and vascular ones. The most common are neurogenic tumors and cavernoma. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the CS as can perineural and hematogenous metastases. Inflammatory, infective, and granulomatous lesions show linear or nodular enhancement of the meninges of the CS but often have nonspecific MR imaging features. In many of these cases, involvement elsewhere suggests the diagnosis. MR imaging is sensitive for detecting vascular lesions such as carotid cavernous fistulas, aneurysms, and thromboses.