Origins of cancer in the neonate

Xanthoma disseminatum: a case report and literature review

This case report describes the neuro-opthalmologic and respiratory manifestations of xanthoma disseminatum, a rare histiocytosis syndrome characterized by disseminated lesions in a young male adult. Multimodality management of this disease, including the role of local radiotherapy, is discussed accompanied by a review of the literature.

Cholestasis, sclerosing cholangitis, and liver transplantation in Langerhans cell Histiocytosis

OBJECTIVE

To analyze features and outcomes of cholestasis, sclerosing cholangitis (SC), and liver transplantation (LTx) in patients with Langerhans cell Histiocytosis (LCH) between October 1987 and June 1999.

STUDY DESIGN

Of 182 cases with LCH, 36 had hepatic involvement and 12 of those presented with cholestasis. These 12 were the focus of our study. Their median age was 23 months (range: 3-36). Hepatomegaly or hepatosplenomegaly was found in 11 of the 12; elevations of alkaline phosphatase, transaminases, gamma glutamyl transpeptidase (GGT), and less frequently direct bilirubin were detected. Sonography, liver biopsy, and cholangiography were consistent with the diagnosis of SC in 11 patients. None of the biopsies revealed Langerhans cells (LC). Frequently associated lesions of skin, bone, and ear were noted. Early patients were treated with Vinblastine/prednisone for 8 weeks, later patients with the LCH I and LCH II protocols of the Histiocyte Society (HS).

RESULTS

Median follow-up was 28 months (range: 10-86). Three patients improved and remained without signs of progressive SC at 27, 32, and 86 months. Nine had progressive liver sequelae resistant to chemotherapy. Of these nine, five received LTx, three died before LTx with progressive SC, and one awaits LTx. Three LTx patients survive without disease reactivation 14, 25, and 37 months post-transplant. Two patients died less than one month after LTx, due to renal failure and sepsis in the first patient and bowel volvulus with perforation followed by sepsis in the second one.

CONCLUSIONS

SC is a frequent and usually progressive sequela of multisystem LCH in our institution. LTx has become the treatment of choice for the majority of patients and should be considered early in cases with severe hepatic involvement.

Langerhans cell histiocytosis associated with partial DiGeorge syndrome in a newborn

PURPOSE

We report the unrecognized association of Langerhans cell histiocytosis (LCH) with partial DiGeorge syndrome.

PATIENT AND METHODS

A 7-week-old infant with endocrine and immunologic characteristics of DiGeorge syndrome displayed multisystem involvement of Letterer-Siwe disease at birth.

RESULTS

Despite vigorous medical support and chemotherapy, she died at 9 months of age with multisystem failure.

CONCLUSIONS

This case supports the role of the thymus n the pathogenesis of LCH.

Langerhans cell histiocytosis in children under 2 years of age

This is a retrospective study of 55 children under the age of 2 years diagnosed with Langerhans cell histiocytosis (LCH). They were classified according to age and organ function and dysfunction following Lahey's criteria. The studied population was divided into four groups by age of diagnosis (0-6, 7-12, 13-18, and 19-24 months). Statistical analysis showed no significant difference in outcome between age groups, although the population under 6 months had a 81.3% fatality rate. The presence of organ dysfunction was a major cause of death in all age groups, being statistically significant in outcome (P > 0.005) compared with patients without organ dysfunction. The presence of thrombocytopenia and/or respiratory dysfunction was also highly associated with a fatal outcome. In the surviving population, no second malignancies have been reported. The late secondary effects of therapy include endocrine, orofacial, and osseous pathologies.

Morphological and quantitative analyses of normal epidermal Langerhans cells using confocal scanning laser microscopy

Confocal scanning laser microscopy (CSLM), when used in conjunction with computerized image processing systems, provides a powerful tool for morphological and quantitative analyses of biological tissues. In this study, normal human epidermal sheets were stained by an indirect immunofluorescence method using anti-CD1a monoclonal antibody. Positively stained epidermal Langerhans cells (LCs) were visualized using the Bio-Rad MRC-600 Confocal Imaging System. Images obtained from the confocal microscope were volumetrically rendered and quantitatively analysed using ANALYZE (Version 4.0) running on a Sun SPARC 2 Workstation. Normal epidermal LCs were shown to be large disc-like structures with five to nine long dendritic processes per cell, orientated with their flat surfaces parallel to the skin surface. LCs form a monolayer network of cells distributed evenly throughout the suprabasal layers of the epidermis, with no direct physical contact between dendritic processes. Mean LC density was estimated to be 582 per mm2 (95% confidence intervals, CI = 233-940), and mean cell volume was 612 microns3 (95% CI = 257-1020). LCs in sun-exposed sites were significantly lower in mean cell density, but larger in mean cell volume, than in covered sites. Mean surface area projected by LCs was estimated to be 26.8% (95% CI = 18.9-34.2), and this value did not show significant regional or individual variation. Our data support the notion that epidermal LCs are organized in such a way as to maximize their surface area for efficient trapping of antigens, and a reduction in LC density per unit area in sun-exposed sites is compensated for by an increase in the mean cell volume.

Langerhans cell histiocytosis: lack of a viral etiology

Langerhans cell histiocytosis (LCH) is an enigmatic histiocytic proliferative disorder of unknown etiology that affects children primarily. We have investigated the possibility that viruses are etiological or that they have a "triggering effect" in LCH. Sensitive in situ hybridization and polymerase chain reaction (PCR) techniques were used in 56 cases of LCH. We sought and failed to find evidence of genomes for adenovirus, cytomegalovirus, Epstein-Barr virus, herpes simplex virus, human herpesvirus type 6, human immunodeficiency virus, human T-cell leukemia virus types I and II, and parvovirus. Although some probes hybridized to tissues from several cases, PCR failed to confirm the presence of viral genome in any. We conclude that there is no evidence that these viruses are associated with LCH.

Digestive tract involvement with exudative enteropathy in Langerhans cell histiocytosis

Protein-losing enteropathy was observed in two children with Langerhans' cell histiocytosis (LCH). One patient was an infant with congenital cutaneous lesions; the second child had sigmoid and lymph node infiltration. Electron microscopy and immunohistochemistry confirmed, in both, infiltration of duodenum, skin, and liver by LCH. Gastrointestinal involvement by LCH seldom produces prominent clinical manifestations but indicates widespread multisystem disease. Immunohistochemical and/or ultrastructural features allow definitive diagnosis from mucosal biopsy specimens. Review of the literature of gastrointestinal infiltration by LCH emphasizes its poor prognosis, especially when associated with organ dysfunction.

Malignant histiocytosis X. A distinct clinicopathologic entity

Histiocytosis X (HX) is characterized morphologically by a proliferation of Langerhans' cells (LC), and most often has an indolent, chronic course. To determine whether a distinct clinicopathologic entity of malignant histiocytosis X exists, the authors examined tissues from 31 patients with HX and divided them into four categories. Group A (19 patients) was characterized morphologically by benign-appearing LC and had an indolent course. The male:female (M:F) ratio was 10:9, and the mean age was 21 years (range, 2 months to 60 years). The immunophenotype of this group was S-100+, vimentin+, LN-2+, LN-3+, lysozyme-, LCA-, Leu-M1-. Group B (three patients) had benign-appearing LC, yet had an aggressive clinical course. All patients were male, with a mean age of 47 years (range, 3 years to 72 years). Organs involved included the liver, spleen, heart, thymus, lung, kidney, and pancreas. The immunophenotype was the same as for Group A. Group C (two patients) had atypical and malignant appearing LC, yet a relatively benign clinical course. The ages were four and 65 years, with one female and one male patient. In both patients, the cells were S-100+, vimentin+, LN-2+, LN-3+, and LCA-. Group D (seven patients) was characterized by atypical and malignant-appearing LC and an aggressive clinical course. The mean age was 25 years (range, congenital to 54 years) with one female and six male patients. Organs involved were the thymus, lungs, spleen, liver, kidney, brain, heart, pancreas, stomach, and muscle. Birbeck granules were found in two patients, and the one patient on which fresh tissue was available was CD1+. The typical immunophenotype was S-100+, vimentin+, LN-2+, LN-3+, Leu-M1-, lysozyme-. The results of our study indicate that (1) a distinct clinical entity of malignant HX, characterized morphologically by malignant-appearing LC and clinically by male predominance, atypical organ involvement, and an aggressive clinical course, does exist; and (2) the morphologic appearance of the LC is an imperfect predictor of the clinical severity of HX.

Can prenatal irradiation protect the embryo from tumor development?

Although the processes of cell proliferation and differentiation are--without comparison--most pronounced during early embryonic life, this period, before and during organogenesis, appears to be highly resistant to carcinogenesis. One possible explanation for this paradox could be that cancer is controlled by the regulators influencing development, regulators that are most active during early embryonic life. In addition, it seems that under certain conditions, as shown by experiments on rat brain, prenatal irradiation can decrease rather than increase the subsequent carcinogenic effect of a chemical carcinogen. The possible reasons for this are discussed.

Pretreatment liver biopsy in 20 children with histiocytosis X: a clinicopathologic correlation

Liver biopsies were done on 20 patients with histiocytosis X (HX) as part of pretreatment evaluation prior to entry on two Childrens Cancer Study Group protocols. Seventeen patients had hepatomegaly, and seven had one or more abnormal laboratory parameters using Lahey's criteria for liver dysfunction. Nineteen of 20 specimens showed various abnormalities of the portal triads. A single biopsy revealed normal liver. Among the changes were triaditis, bile duct proliferation, variable fibrosis with histiocytic infiltrates, and cirrhosis. One patient had typical granulomas of HX within the liver parenchyma in addition to portal triaditis. Patients with larger livers and dysfunction tended to show more marked histologic abnormalities in the portal triads. However, correlations among liver size, function, and pathology showed considerable overlap. Early death among these patients was more likely to be associated with progressive HX in other sites and/or infection. Death from cirrhosis and liver failure per se occurred in one patient 4 years after initial biopsy, but five other children had evidence of cirrhosis on biopsy or at autopsy. The majority of patients with triaditis initially did not have clinical evidence of progressive liver disease although four expired with other manifestations of HX or infection. Conversely, patients showing fibrohistiocytic changes or cirrhosis initially were likely to have continuing or progressive liver disease. Although the liver histology was not diagnostic of HX, the types of portal changes usually predicted the subsequent course of liver disease.

Radiation therapy in the management of Langerhans cell histiocytosis

Twenty-two patients with Langerhans cell histiocytosis (LCH) were managed in the UCLA Department of Radiation Oncology from 1974 to 1987. Their median age was 17 years (range 1-42 years) and median followup 4.5 years (range 1-13 years). Fourteen patients had disease localized to a bone (13) or a soft tissue (one). Eight patients had LCH involving multiple bones (3) or soft tissues plus bones (5). Nine of 10 patients less than 19 years old had disease confined to bone(s) compared to 7 of 12 older patients. Fifty-six sites of LCH (40 bone, 16 soft tissue) were irradiated. Pediatric patients received therapy to 15 sites (14 bone, 1 soft tissue) and adults 41 sites (26 bone, 15 soft tissue). Median dose for bone lesions was 900 cGy (range 600-1,500) and for soft tissue 1,500 cGy (range 600-2,600). Local control was achieved in 46 of 56 sites (82%). Control rates for bone and soft tissue lesions were 35 of 40 (88%) and 11 of 16 (69%), respectively. Fifteen of 15 sites in pediatric patients were controlled compared to 29 of 41 (72%) in adults. Ten sites (18%) recurred 10 months to 4 years after irradiation. Recurrences were in-field and noted only in adults with involvement of multiple soft tissues plus bones. All recurrent soft tissue lesions had been treated with orthovoltage. Five patients developed new foci of LCH subsequent to irradiation. Four of these patients had disease involving soft tissues and bones. One patient with progressive LCH initially presented with a single bone lesion. The acute and chronic effects of radiation therapy were minimal. One patient suffered transient enlargement of adenopathy. An elevated serum TSH level was detected 9 years after irradiation of a cervical vertebra in another patient.

Langerhans' cell histiocytosis (histiocytosis X): experience at the Children's Hospital of Philadelphia, 1970-1984

Sixty-four patients with biopsy-proven Langerhans' cell histiocytosis (LCH, formerly designated as histiocytosis X) were managed at the Children's Hospital of Philadelphia from 1970 through 1984. Their median age was 3 yr (range, 0.1-22 yr). Thirty-three patients had localized lesions affecting a bone (27) or soft-tissue region (6). Twenty-two patients had multifocal disease affecting bones (17) or soft, nonosseous tissues (5). None of these patients had evidence of dysfunction of liver or lungs, and none had abnormal peripheral blood cell counts. The remaining nine patients had multifocal LCH plus dysfunction of liver or lungs (6) or abnormal blood counts (3). Treatment consisted primarily of surgical excision for patients with localized lesions and of drug therapy with or without irradiation and surgery for those with multifocal disease. Recurrence was infrequent (7%) in those with localized LCH, and all survived. Recurrence was frequent (74%) in those with multifocal LCH but without organ dysfunction or abnormal blood counts, but 21 of the 22 survived. By contrast, only three of the nine patients with organ dysfunction or abnormal blood counts survived. Thus organ dysfunction and abnormal blood counts at diagnosis emerged as the major adverse prognostic factors in children with LCH.

Dermal Langerhans' cell tumor in chronic myelomonocytic leukemia

Disseminated dermal tumors in a 71-year-old male represented the first clinical manifestation of a chronic myelomonocytic leukemia. The dermal infiltrate in one of the nodules consisted predominantly of closely packed pleomorphic Langerhans' cells (LC) with typical Birbeck granules and a strong reactivity for S-100 protein. The simultaneous presence of immature myeloid cells led to the suspicion of an underlying myeloproliferative disorder. The diagnosis of chronic myelomonocytic leukemia was subsequently confirmed by bone marrow histology and blood picture. Although some peritrabecular foci of histiocytic cells were detected in bone marrow, no LC could be identified by electron microscopy and histochemical methods. Tumorous aggregates of LC in myeloproliferative disorders have not been described in the literature. Histiocytosis X and related diseases could be definitely excluded in the present case. This case obviously suggests an interrelation between the myeloproliferative disease and the focal accumulation of LC in the dermis. In animal studies by Katz et al. LC have been shown to originate in the bone marrow, whereas the origin of LC in man is still a matter of discussion. The present case supports the hypothesis that LC in man are also of myeloid origin. The neoplastic blood monocytes could be the precursors of the dermal LC. This differentiation did not take place in the bone marrow but only in the dermis where LC occur under nonneoplastic conditions ("homing").

Radionuclide imaging in histiocytosis X

Radionuclide imaging (99mTc bone scans, 99mTc S colloid scans, 99mTc brain scans and 67gallium scans) and bone radiographs were done in 54 children with histiocytosis X. The results are discussed, compared with the literature and indications for the different nuclear medicine studies are given.

Chromosome abnormalities in familial hemophagocytic lymphohistiocytosis

Familial hemophagocytic lymphohistiocytosis (FHLH) is an uncommon disorder characterized by multiorgan infiltration with phagocytic histiocytes/macrophages. It may be inherited as an autosomal recessive trait, but specific associated cytogenetic abnormalities have not been documented. The authors describe a 10-week-old white female without prior family history of FHLH, who fulfilled the histologic and clinical criteria for the diagnosis. In addition, cytogenetic abnormalities, including the presence of double minute chromosomes and occasional loss of chromosomes 7 and 12, were documented in unstimulated peripheral blood cells. These karyotypic findings are usually associated with dyserythropoietic and leukemic states, and have not been described previously in the context of FHLH. It may be useful to do chromosome analyses on unstimulated peripheral blood cultures from FHLH patients before treatment to examine the karyotype of proliferating cells, which may represent the infiltrative histiocytes seen in the disorder.

S-100 protein immunohistochemistry and electron microscopy in the diagnosis of Langerhans cell proliferative disorders: a comparative assessment

To better define the roles of S-100 protein immunohistochemistry and electron microscopy in the diagnosis of Langerhans cell proliferative disorders, a comparative assessment of the two techniques was performed using material from 39 cases of histiocytosis X and 2 cases of infantile self-healing reticulohistiocytoma. Both techniques proved highly reliable, but neither alone enabled diagnostic confirmation in all instances. The two techniques proved complementary and used together did enable identification of Langerhans-type histiocytes in all cases studied. Neither was judged clearly superior and both offered certain advantages. Electron microscopy was found overall to be a slightly less sensitive technique, but more specific and less subject to misinterpretation. The S-100 stain was found to be particularly useful in situations where sampling problems were likely to be encountered or where the available specimen was otherwise suboptimal for electron microscopic examination. Because the S-100 stain is the more cost-effective to employ, we now recommend it for the purpose of providing routine diagnostic confirmation. In an investigative setting, however, we continue to recommend electron microscopy as the primary technique.

Familial hemophagocytic lymphohistiocytosis: report of four cases in two families and review of the literature

Four cases of familial hemophagocytic lymphohistiocytosis (FHL) from two families with first cousins affected in family and siblings in another are presented. The pathological findings, including neuropathology, transmission (TEM), and scanning electron microscopy (SEM), are discussed. This is the first study of this condition to include TEM and SEM. One hundred and fifty-nine cases from the literature, including the author's four cases, are reviewed. The familial occurrence in 116 instances in sibships and consanguinity in 13 of the 73 families support autosomal-recessive inheritance. In five families there were affected first cousins--an observation not readily explained by autosomal-recessive transmission. We suggest that the genetic aspects of FHL be more fully explored and that in future cases parents and other relatives be included in the hematologic, immunologic, and genetic evaluation.

The familial histiocytoses

Several rare disorders characterized by histiocytic hyperplasia are inherited as single-gene Mendelian traits. These familial forms of histiocytosis are heterogeneous and can be clearly distinguished from each other by clinical and genetic criteria. The genetic nature of these disorders can lead to familial recurrence and thus necessitates their distinction from the classical reticuloendothelioses. The clinical manifestations and modes of inheritance of the various familial histiocytoses are reviewed.

Benign isolated histiocytosis mimicking chicken pox in a neonate: report of two cases with ultrastructural study

Two cases of benign isolated cutaneous histiocytosis X in newborn infants are reported. Clinically, the lesions mimicked chicken pox, and the histologic findings in skin biopsies were indistinguishable from those described in infantile Letterer-Siwe disease. Electron microscopy showed Langerhans' cells with the classical trilaminar, racket-shaped granules. Our cases a well as 10 of the 21 previously reported cases showed spontaneous resolution of the skin lesions. Since this is a benign spontaneous resolving histiocytosis, we recommend that no therapy be given provided that no other signs of systemic involvement are found.

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.

Langerhans' cells and macrophages in eosinophilic granuloma. An enzyme-histochemical, enzyme-cytochemical, and ultrastructural study

Biopsy material of six patients with eosinophilic granuloma (EG) was investigated by electron microscopic and enzyme-histochemical methods for acid phosphatase (AcP), leucyl-beta-naphthylamidase (LA), adenosine triphosphatase, and alpha-naphthyl-acetate esterase (NE). Paraplast sections were used for demonstration of lysozyme with an immunoperoxidase method. Results of staining for these different enzymes suggested the existence of two separate sets of histiocytic cells: one type with "dot-like" AcP staining and negative for NE and lysozyme; and the other with diffuse AcP staining, positive for NE and lysozyme, and often showing signs of phagocytosis. The first type presumably represented Langerhans' cells and also often showed positive staining for LA. Macrophages were generally negative for LA. Electron microscopic study confirmed the impression gained from enzyme-histochemical studies. No intermediate cell types between Langerhans' cells and genuine macrophages were seen. From these results it is concluded that in EG no transformation exists between Langerhans' cells and macrophages. The latter are presumably of reactive nature.

The pathogenesis, diagnosis, and treatment of histiocytosis syndromes

The histiocytosis syndromes previously known, and often still referred to, as histiocytosis-X were originally categorized by many as malignant neoplasms. They have been treated as such with aggressive chemotherapy and radiation therapy. Although these modalities are still used, there are significant differences between the histiocytosis syndromes and the true malignant disease that suggest conservative management for many patients. The clinical course of malignant neoplasia is relentlessly progressive with virtually no survival in untreated patients. The histiocytosis syndromes are characterized by frequent spontaneous remissions and exacerbations, with varying morbidity and survival in untreated patients, depending on the extent of the disease. Pathologically, the lesions of histiocytosis appear as reactive infiltrates, possessing little of the cellular atypicality and homogeneity characteristic of malignancy. Although the etiology of these phenomena is unknown, histiocytosis syndromes appear to represents a reactive autoimmune disorder triggered by unknown stimuli.

Histiocytosis X in children: patterns of disease and results of treatment

The pathologic materials and clinical courses of 36 children aged 1 month-22 years, with histiocytosis X (H-X) seen at the Philadelphia Children's Cancer Research Center from 1970 to 1979 were reviewed. The pathologic subtype of H-X was favorable (type II) in 31 patients, unfavorable (type I) in one patient, and unclassified in four patients whose specimens were limited to a skin biopsy. Sixteen patients had localized H-X involving bone (14 patients), soft tissue (1 patient), or skin only (1 patient); all are alive and well after treatment with surgery alone (12 patients), radiation therapy (RT) (3 patients), or observation (1 patient); only 1 of the 16 developed recurrent H-X. The other 20 patients presented with multifocal H-X involving the skeleton alone (3 patients); the skeleton and soft tissues other than liver (7 patients); soft tissue exclusive of the liver (3 patients); soft tissue including the liver (4 patients); or soft tissues, skeleton, and liver (3 patients). These 20 patients were treated with surgery alone (1 patient), RT (4 patients), or multiple drugs +/- RT (15 patients). Seven of the 20 patients are alive and well without recurrence at a median of 4 years after diagnosis. Nine of the 20 patients, including 3 with liver dysfunction, responded completely to initial therapy but developed recurrence; each was retreated with drugs and is alive and well at a median of 4 years. The remaining 4 patients had widespread disease with dysfunction of the liver and/or hematopoietic system at diagnosis, failed to respond, and died. We conclude that (1) patients with multiple bony lesions with or without associated soft tissue disease or skin involvement have a favorable outlook and do not require systemic chemotherapy; (2) systemic treatment also is unnecessary for patients with localized H-X since recurrence is rare; (3) drugs can benefit patients with multifocal H-X, although the optimal duration of therapy is unclear; and (4) favorable response to treatment indicates high probability of disease-free survival. However, organ dysfunction at diagnosis is ominous: four of seven patients with liver dysfunction are dead, as are all three patients who presented with peripheral blood count depression.

Electron microscopy in histiocytosis X

In an ultrastructural study of 24 cases of histiocytosis X, we were able to demonstrate Langerhans cell granules in all of 18 cases from which tissues had been submitted primarily for electron microscopy and in 4 of 6 cases from which only tissue retrieved from paraffin blocks was available for examination. In a subsequent correlative study we were able to demonstrate Langerhans cell granules in deparaffinized material from 11 of 14 cases (79%) in which they were known to exist. The incidence of histiocytes displaying Langerhans cell granules (in a single plane of section) fell from a median of 48% in samples processed primarily for electron microscopy to 14% in those retrieved from paraffin blocks. Our data suggest that electron microscopy, even when applied to the study of suboptimally preserved material, is a highly sensitive technique for confirming a diagnosis of histiocytosis X.