Eosinophilic granuloma occurring in a patient with Hodgkin disease

Pulmonary Langerhans Cell Histiocytosis Post-Hodgkin Lymphoma Completely Resolved With Vinblastine in a Heavy Smoker: Coincidence or Causation?

The association among Langerhans cell histiocytosis, hematolymphoid malignancies, and heavy smoking has been addressed in medical literature to identify a possible potential link. Such occurrence can pose diagnostic challenges, as well as important clinical implications for disease progression and treatment approaches. We present pulmonary Langerhans cell histiocytosis instance in a 35-year-old male patient, with a 34-pack-year smoking history and nodular sclerosing Hodgkin lymphoma stage IIB who developed multiple bilateral lung nodules. The patient completed 6 cycles of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine chemotherapy and radiotherapy 2 years earlier. CT chest scans revealed numerous micronodules scattered randomly throughout the upper and lower left lung lobes. Subsequent wedge resection exhibited cellular proliferation with grooved nuclei, eosinophilic cytoplasm, and surrounding inflammatory components. Immunohistochemical staining showed positive staining for S100 and CD1a confirming a diagnosis of pulmonary Langerhans cell histiocytosis. The patient responded to a 6-week treatment with vinblastine and prednisolone. A subsequent CT scan of the lungs revealed complete resolution after 3 years. This report underscores the importance of identifying pulmonary Langerhans cell histiocytosis in heavy smokers with Hodgkin lymphoma presenting with multiple nodular pulmonary lesions. For patients with Hodgkin lymphoma and a possible genetic predisposition, smoking may contribute to the overt development of pulmonary Langerhans cell histiocytosis. Therefore, smoking cessation and careful follow-up examinations are required. Further research is recommended to elucidate the underlying mechanisms of this intriguing association.

A case of Langerhans' cell histiocytosis following Hodgkin's disease

Langerhans' cell histiocytosis (LCH) is a group of disorders in various tissues characterized by the proliferation of Langerhans cells. It is rarely observed in adults. Langerhans cells are dendritic cells that express cluster of differentiation 1a (CD1a) and S100 protein, and contain Birbeck granules. Its etiopathogenesis remains to be elucidated. One possible etiological cause is a reactive proliferation of Langerhans cells following chemotherapy or radiotherapy for Hodgkin's disease (HD). A number of cases of LCH associated with malignant lymphoma have been reported previously. It may follow after the malignant lymphoma, or occur with it. However, fewer cases have been reported where the LCH followed after HD. In the present case report, a patient was diagnosed with HD following chemotherapy for LCH. As LCH was diagnosed, the patient was treated with a combination of various chemotherapeutic agents in two cycles of cyclophosphamide, vincristine, and prednisolone (COP), and eight cycles of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP). The patient went into a successful clinical remission. One year later, computed tomographic (CT) scans of the thorax and abdomen revealed augmentation of the tumor mass in the mediastinum. An excisional biopsy of the right inguinal lymph node was performed. The patient was diagnosed with nodular sclerosing Hodgkin's disease. Following four cycles of doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy, a whole-body positron emission tomographic CT scan revealed a decrease in tumor mass in the mediastinum. At present, the patient remains in treatment, and the prognosis has yet to be fully determined.

Synchronously diagnosed eosinophilic granuloma and Hodgkin's disease in a 12-year-old boy: a case report

Introduction

Synchronous composite tumors are uncommon. Simultaneous, rather than metachronous or consecutive, occurrences of eosinophilic granuloma and Hodgkin's lymphoma in children are very rare. This is the first report of this kind in the medical literature.

Case presentation

We report the case of a 12-year-old Iranian boy with eosinophilic granuloma localized in his leg around the knee and Hodgkin's lymphoma in a cervical lymph node. The two tumours occurred synchronously before the patient had received any treatment.

Conclusion

Several cases of an association between eosinophilic granuloma and lymphoproliferative disorder have been reported. Some of these cases involve Hodgkin's lymphoma and Langerhans cell histiocytosis occurring in the same patient. Genetic or environmental etiologies have been postulated for eosinophilic granulomas which occur following Hodgkin's lymphomas, but have as yet not been proven. To our knowledge, synchronous occurrence of these two malignant processes in a patient who has not received any prior treatment is rare in children.

Simultaneous occurrence of Hodgkin's lymphoma and eosinophilic granuloma: a potential pitfall in positron emission tomography imaging

Positron emission tomography (PET) with [18F]fluorodeoxyglucose [18F]FDG has evolved as a method of increasingly clinical importance in the management of patients with malignant lymphoma. However, inflammatory lesions also accumulate [18F]FDG and may cause difficulties with interpretation. This report deals with 2 patients with simultaneous occurrence of Hodgkin's lymphoma and eosinophilic granuloma, a rare but known coincidence of diseases. In the first case, Hodgkin's disease could not be differentiated from eosinophilic granuloma. Positron emission tomography showed increased [18F]FDG uptake both in lymphoma manifestations and in the granuloma. In the second case with proven Hodgkin's disease, post-treatment examination showed a positive PET lesion in the mediastinal residual mass, which was interpreted as viable lymphoma. However, histologic examination revealed that it was an eosinophilic granuloma.

Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years

We summarize our experience with 238 cases of Langerhans cell granulomatosis (LCG), 198 of whom were followed for a median period of 10.5 years. Our patients did well unless overtreated, and no deaths were attributed to the disorder itself. The disease may appear in unifocal or multifocal form, and treatment is based on this fact. Virtually all patients recovered completely except for occasional residual orthopedic problems or residual diabetes insipidus. Several of the patients underwent subsequent pregnancies without difficulty. The granulomas primarily occur in bone, but lung, skin, and lymph nodal involvement is not uncommon. Involvement of thyroid, thymus, and other sites is rare. The hallmark of the disease is the accumulation of Langerhans cells (LCs). We review the pathology of LCG by histology, electron microscopy, and immunolabeling. LCs originally were identified in squamous epithelium, but these cells are part of the widespread system of dendritic cells. The latter cells, which arise from CD34+ progenitors, are specialized and efficient antigen-presenting cells for T-cell-mediated immunity. In LCG, however, the major associated cells are not T cells, but mature eosinophils: hence the original name eosinophilic granuloma. Confusion about terminology has been based upon the scanty and rather crude pathology reports in the original literature. The term histiocytosis X was meant to cover a spectrum of three diseases--eosinophilic granuloma, Hand-Schüller-Christian disease (HSC), and Letterer-Siwe disease (LS)--but HSC and LS have no basis in pathology and hence the terms are meaningless. The term HSC has become a synonym for multifocal eosinophilic granuloma (LCG). The term LS has been used in reporting a number of benign, malignant, or unknown conditions. We prefer the term LCG to avoid confusion with the term histiocytosis X because there is evidence that the LC is not a member of the mononuclear phagocyte system and hence not a tissue macrophage, and because the use of the term "histiocyte" has become a convenience in much of the literature when reporting incompletely understood diseases.

Association of Langerhans cell histiocytosis with malignant neoplasms

BACKGROUND

The association of Langerhans cell histiocytosis (LCH) with a malignant neoplasm is rare and generally has been the subject of isolated case reports.

METHODS

A recent case of LCH seen at the University of Minnesota in combination with acute lymphoblastic leukemia led the authors to review their own charts from 1960 onward, in addition to the literature for other reported associations of LCH and malignant neoplasms.

RESULTS

In addition to the presented case and 3 cases from the files of the authors, the literature contained 87 reported cases. Of the 91 patients, 39 had LCH with malignant lymphoma (ML); 25 of these cases were Hodgkin disease. In 11 of these 39 patients, the LCH was diagnosed from 12 months to 33 years after the ML was diagnosed. In 62% of the patients with LCH-ML (24 patients), the diagnosis was made concurrently and the Langerhans cells were found in the same lymph nodes. In the remaining four patients, the diagnosis of LCH preceded that of ML by 6-24 months. In 22 patients, including 2 patients in the files of the authors, LCH was reported in association with leukemia; 16 (73%) of these cases were associated with acute nonlymphoblastic leukemia. In two cases the leukemia preceded the LCH. In 6 patients both diagnoses were made concurrently, and in 14 patients (64%) the diagnosis of LCH preceded the diagnosis of leukemia by 8 months to 17 years. In the remaining 30 patients, LCH was associated with a variety of solid tumors, including a lung carcinoma in 12 patients. In all of these 12 cases the LCH was confined to the lung, and in 75% (9 of 12) of patients the diagnoses were made concurrently. In the 16 patients in whom the LCH preceded the solid tumor, the malignant diseases in 69% (11 of 16) developed within the radiation field used for the treatment of the LCH.

CONCLUSIONS

The intimate and simultaneous association of LCH with ML and lung carcinomas suggests strongly that the process that leads to the association is a reactive one. However, in the patients with leukemia and the other solid tumors, the latency of the malignant neoplasm after the diagnosis of LCH is suggestive of a therapy-related process.

Histiocytosis X arising in Hodgkin's disease: immunophenotypic characterization with a panel of monoclonal antibodies

This report describes the antigenic profile of the proliferating cells of pulmonary histiocytosis X (HX) in a patient treated with chemotherapy for Hodgkin's lymphoma; the association of pulmonary HX and Hodgkin's disease has rarely been described in the literature. The histopathological diagnosis of HX was confirmed with the aid of monoclonal antibodies (mAbs) to CD4, CD1a, and polyclonal serum anti S-100 protein. The phenotype of HX cells has been analysed using a panel of mAbs against HLA class I A, B, C monomorphic determinants, locus A and B, beta 2-microglobulin, HLA class II distinct monomorphic determinants, DP, DQ, DR, intercellular adhesion molecule-1 (ICAM-1) and vitronectin receptors. Our results indicate that HX cells express HLA class I and II, including locus A, locus B and DP, DQ, DR, like their normal counterpart (represented by Langerhans cells) and detectable levels of ICAM-1 but not vitronectin receptors. We would like to stress the possibility of the association of HX and Hodgkin's lymphoma extending the immunophenotypic profile of HX cells.

Unusual bony lesions of histiocytosis X in a patient previously treated for Hodgkin's disease

We present an unusual case of multifocal Histiocytosis X in a 78-year-old man treated for Hodgkin's Disease 33 and 24 years previously. The Hodgkin's Disease at first involved cervical nodes and 9 years later axillary and inguinal nodes and was treated by radiotherapy. Chronic destructive lesions developed in the femora and pelvis and bone biopsies showed a curious mixture of fibroblastic tissue and foamy macrophages. These lesions eventually resulted in pathological fractures of the femoral necks, and bilateral hip replacements were required seven years after initial detection of the bony lesions. There was a focal infiltrate of S-100 protein positive histiocytic cells containing Birbeck granules in the femoral heads. There was radioisotopic and radiological evidence of other skeletal lesions. The association between Histiocytosis X and Hodgkin's Disease is recognised but rare and its significance is discussed.

Histiocytosis X mimicking recurrent malignant disease: a report of two cases

Two cases of histiocytosis X initially thought to be recurrent malignant disease are described. Previously reported cases associated with malignant disease are reviewed and the importance of biopsy confirmation of recurrence is emphasised.

The coexistence of Langerhans' cell granulomatosis and malignant lymphoma may take different forms: report of seven cases with a review of the literature

Several reports in the literature have documented an association of Langerhans' cell granulomatosis (LCG) with malignant lymphoma (ML). Seven additional patients are described, and different aspects of such an association are demonstrated. The diagnosis of LCG, made on the basis of routinely stained biopsy material, was supported by S-100 protein immunoperoxidase reactivity and/or the presence of Birbeck granules on electron microscopy. In six patients (cases 1 to 6) the LCG consisted of localized foci in nodes involved by ML. However, in one of these patients (case 1) focal LCG was again associated with ML in a later lymph node biopsy specimen from a different site, and in another patient (case 6) LCG subsequently developed in the skin and lungs. In the remaining case (case 7) pulmonary LCG developed one year after the diagnosis of Hodgkin's disease. Localized LCG in a lymph node involved by ML could represent an immune response to ML (cases 1 to 6 in the present study and 16 literature cases). The findings in case 6 indicate that such a response has the potential to become disseminated. Cases in which LCG and ML are found at different sites (case 7 in the present study and five literature cases) probably represent the coincidental association of two unrelated disorders. Finally, it has been postulated that, in rare instances, the development of Hodgkin's disease or malignant histiocytosis in a patient with LCG might represent malignant evolution of this hyperplastic process.

Solitary Langerhans' cell granulomatosis of the stomach associated with gastric carcinoma

A case of Langerhans' cell granulomatosis associated with gastric adenocarcinoma is reported. A review of the literature demonstrate an association of this entity with Hodgkin or non-Hodgkin lymphomas alone. The discussion is centred on differential diagnosis from the pseudo-sarcoid granulomatous reaction. Further reports may assist in classifying the granulomatous reaction to tumours into two types, epithelioid and Langerhans.

Histiocytosis: nosology and pathobiology

The histiocytoses represent a heterogeneous group of conditions. Their common denominator is the proliferation and the activation of the mononuclear phagocyte system (MPS). On the basis of recent advances in the knowledge of the distribution, biology, and behavior of the MPS, the following classification is proposed. Reactive and secondary histiocytoses related either to a chronic parasitic intracellular infection or to a patent or latent immunodeficiency state. Some well-established conditions belong to this category--i.e., familial lympho-histiocytosis, cytophagic sinus histiocytosis, Omenn's reticulosis. The dystrophic histiocytoses associated with the storage of either exogenous or endogenous material. It is prudent to separate the storages of homogeneous and chemically defined lipid material (such as cerebroside, sphingomyelin, etc.) from those of heterogeneous lipid material. Proliferative histiocytoses: it is crucial to distinguish the malignant histiocytosis from the histiocytosis X, which seems to be associated with a nonmalignant proliferation of a subpopulation of the MPS, the Langerhans cell system.