Langerhans Cell Histiocytosis

____________________________________________ BACKGROUND Langerhans cell histiocytosis (LCH) is a group of idiopathic disorders characterized by the presence of cells with characteristics similar to bone marrow derived Langerhans cells juxtaposed against a backdrop of hematopoietic cells, including T-cells, macrophages, and eosinophils. In 1868, Paul Langerhans discovered the epidermal dendritic cells that now bear his name. The ultrastructural hallmark of the Langerhans cell, the Birbeck granule, was described a century later. The term Langerhans cell histiocytosis is generally preferred to the older term, histiocytosis X. This newer name emphasizes the histogenesis of the condition by specifying the type of lesional cell and removes the connotation of the unknown ("X") because its cellular basis has now been clarified. Although the epidermal Langerhans cell has been presumed to be the cell of origin in LCH, recent studies have called this belief into question. Specifically, a variety of other cellular populations have been identified that possess phenotypic characteristics similar to Langerhans cells, including expression of CD207 and Birbeck granules. Therefore, in addition to epidermal Langerhans cells, other potential cellular origins for LCH include dermal langerin+ dendritic cells, lymphoid tissue-resident langerin+ dendritic cells, and monocytes that can be induced by local environmental stimuli to acquire a Langerhans cell phenotype. Notably, LCH cells have been found to express markers of both resting epidermal Langerhans cells (CD1a, intracellular major histocompatibility complex II [MHCII], Birbeck granules) and activated Langerhans cells (including CD54 and CD58). As a result, the pathologic cells of LCH have been hypothesized to represent Langerhans cells in a state of arrested maturation.[3] Taken together, these findings have led some to speculate that LCH is not a specific disease of epidermal Langerhans cells, but rather one of mononuclear phagocyte dysregulation. The working group of the Histiocyte Society has divided histocytic disorders into 3 groups: (1) dendritic cell histiocytosis, (2) macrophage-related disorders, and (3) malignant histiocytosis. LCH belongs in group 1 and encompasses a number of diseases. On one end, the clinical spectrum includes an acute, fulminant,

disseminated disease called Letterer-Siwe disease, and, on the other end, solitary or few, indolent and chronic lesions of bone or other organs called eosinophilic granulomas. The intermediate clinical form called HandSchller-Christian disease is characterized by multifocal, chronic involvement and classically presents as the triad of diabetes insipidus, proptosis, and lytic bone lesions. A congenital, self-healing form called Hashimoto-Pritzker disease has also been described. ____________________________________________ PATHOPHYSIOLOGY The pathogenesis of Langerhans cell histiocytosis (LCH) is unknown. An ongoing debate exists over whether LCH is a reactive or neoplastic process. Arguments supporting the reactive nature of LCH include the occurrence of spontaneous remissions, the extensive elaboration of multiple cytokines by dendritic cells and T-cells (the so-called cytokine storm) in LCH lesions, and the good survival rate in patients without organ dysfunction. Furthermore, a rigorous investigation of potential chromosomal aberrations in LCH via analysis of ploidy, karyotype, single-nucleotide polymorphism arrays, and array-based comparative genomic hybridization did not reveal genetic abnormalities; these findings strongly support the idea of LCH as a reactive process. On the other hand, the infiltration of organs by a monoclonal population of aberrant cells, the possibility of lethal evolution, and the cancer-based modalities of successful treatment are all consistent with a neoplastic process. In addition, the demonstration, by use of X chromosome linked DNA probes, of LCH as a monoclonal proliferation supports a neoplastic origin for this proliferation; however, the presence of this finding in distinct subtypes with different evolutions demands further investigations to elucidate its significance. A 2010 study comparing gene expression of cells expressing CD207 (a marker of Langerhans cells) in LCH lesions with epidermal CD207+ control cells identified differential expression of more than 2000 genes between these 2 subsets. These differences were found in genes involved in cell cycle regulation, apoptosis, cell signaling, metastasis, and myeloid differentiation. Interestingly, this analysis found no differences in expression of proliferation markers between these subsets of CD207+ cells, consistent with the hypothesis that LCH may be a disease of abnormal cellular accumulation.

The extensive variability in gene expression between these 2 cellular populations has prompted speculation that LCH cells may develop from a population of cells distinct from epidermal Langerhans cells. Specifically, it is hypothesized that "misguided" blood-derived myeloid dendritic cells are recruited to specific anatomic sites and their subsequent stimulation of T-cell trafficking and local immunomodulation is responsible for the characteristic lesions of LCH. Notably, this hypothesis is consistent with either an oncogenic or reactive etiology for LCH, because what stimulates these misguided cells remains unclear. Evidence suggests a role for immune dysfunction in the pathogenesis of LCH, through the creation of a permissive immunosurveillance system. Specifically, findings from immunohistochemical and immunofluorescence analyses of LCH biopsy specimens have led to the hypothesis that semimature LCH cells stimulate the expansion of a polyclonal population of regulatory T cells. These regulatory T cells may, in turn, inhibit the immune system (in part via the elaboration of interleukin (IL) 10 and prevent it from effectively resolving LCH lesions. Detection of high serum levels of the proinflammatory cytokine IL-17A in patients with LCH has given rise to speculation that IL-17A is also involved in the pathogenesis of the disease. Further investigation into this phenomenon has led to the proposal that IL-17A induces dendritic cell/Langerhans cell fusion into multinucleated giant cells that in turn recruit other inflammatory cells and cause local tissue destruction, creating the characteristic lesions of LCH. However, these findings have not been independently reproduced, and the role of IL-17A in the pathogenesis of LCH remains controversial. Some studies have also indicated that expression of vascular endothelial growth factor (VEGF); Bcl-2 family proteins; and FADD, FLICE, and FLIP proteins in the Fas signaling pathway may be involved in the pathogenesis of LCH. The E-cadherin-beta-catenin-Wnt signaling pathway has also been implicated in LCH, and downregulation of E-cadherin may be associated with disease dissemination.[3, 16]

____________________________________________ EPIDEMIOLOGY Mortality/Morbidity More than half the patients younger than 2 years with disseminated Langerhans cell histiocytosis (LCH) and organ dysfunction die of the disease, whereas unifocal LCH and most cases of congenital self-healing histiocytosis are self-limited. Multifocal chronic LCH is self-limited in most cases, but increased mortality has been observed among infants with pulmonary involvement. Race The prevalence of Langerhans cell histiocytosis (LCH) seems to be higher among whites than in persons of other races. Sex The frequency of Langerhans cell histiocytosis (LCH) is greater in males than in females, with a male-to-female ratio of 2:1. Age Langerhans cell histiocytosis (LCH) affects patients from the neonatal period to adulthood, although it appears to be more common in children aged 0-15 years (reportedly approximately 4 cases per million population).[17] The age at onset varies according to the variant of LCH, as follows[3] : Letterer-Siwe disease occurs predominantly in children younger than 2 years. The chronic multifocal form, including Hand-SchllerChristian syndrome, has a peak of onset in children aged 2-10 years. Localized eosinophilic granuloma occurs frequently in children aged 5-15 years. mostly

Pulmonary LCH is more common during the third and fourth decades of life.[3] ____________________________________________ HISTORY The clinical presentation of Langerhans cell histiocytosis (LCH) depends on the extent of dissemination. Unifocal bony LCH is characterized by the development of solitary osseous lesions at any site. Unifocal bony LCH is least common in the hands and the feet. These

lesions are often asymptomatic and are detected incidentally during investigation for unrelated disorders. Patients with multisystem disease may have a protean history depending on the location of osteolytic lesions and the degree of organ dysfunction. Patients with Hand-Schller-Christian syndrome (which occurs in 25% of patients with multifocal LCH) often present with recurrent episodes of otitis media and mastoiditis or with polyuria and polydipsia. Letterer-Siwe disease presents with symptoms suggestive of a systemic infection or malignancy, including a generalized skin eruption, anemia, and hepatosplenomegaly. The congenital form of LCH manifests as skin lesions at birth or during the early postnatal period. Cutaneous nodules and ulceration have onset early in life. Rarely, patients with purpuric lesions present with a blueberrymuffin appearance.[18] Symptoms of organ involvement may also occur. ____________________________________________ PHYSICAL Signs of Langerhans cell histiocytosis (LCH) depend on the localization and the extent of the disease. The clinical spectrum is broad, and an individual case may differ markedly from the prototypes described. Solitary cutaneous disease presents with noduloulcerative lesions in the oral, perineal, perivulvar, or retroauricular regions.[19] Rarely, solitary cerebral lesions may occur. In adults with LCH, the pulmonary system is the most frequently involved organ system, and solitary pulmonary lesions may be the only manifestation. Chronic cough, dyspnea, chest pain, and recurrent pneumothoraces are typical signs and symptoms of pulmonary disease.[20] Because of its protean nature, LCH must be considered in more unusual presentations, including protein-losing enteropathy in infants and combined pulmonarythyroid involvement in adults.[21, 22] Chronic unifocal LCH Chronic unifocal LCH (eosinophilic granuloma of bone) classically presents as a solitary calvarial lesion in young adults; other frequent sites of involvement include vertebra, rib, mandible, femur, ilium, and scapula.

Lesions are usually asymptomatic, but bone pain and a soft tissue mass may occur. When calvarial lesions extend into the nervous system, a variety of neurologic manifestations may be seen. Bony lesions may cause otitis media by destruction of the temporal and mastoid bones, proptosis secondary to orbital masses, loose teeth from infiltration of the mandibles, or pituitary dysfunction due to involvement of the sella turcica. Spontaneous fractures can result from osteolytic lesions of the long bones; vertebral collapse with spinal cord compression has been described. Mono-ostotic lesions of LCH may also appear in less common sites, such as the scapula.[23] Classic multifocal LCH (Hand-Schller-Christian disease) The classic multifocal form of LCH (Hand-SchllerChristian disease) includes diabetes insipidus, exophthalmos, and bony defects, particularly of the cranium. Lesions may affect a variety of systems, including liver (20%), spleen (30%), and lymph nodes (50%). Pulmonary involvement may occur. Osteolytic lesions of the long bones can lead to spontaneous fractures. One third of patients have mucocutaneous lesions, most frequently infiltrated nodules and ulcerated plaques, especially in the mouth, axillae, and anogenital region. Other cutaneous manifestations include extensive coalescing, scaling, or crusted papules. Acute disseminated LCH Patients with acute disseminated LCH (multiorgan involvement) present with fever, anemia, thrombocytopenia, pulmonary infiltrates, skin lesions, and enlargement of lymph nodes, spleen, and liver. Cutaneous abnormalities are present in almost 80% of patients, frequently as the first sign. The eruption may be extensive, involving the scalp, face, trunk, buttocks, and intertriginous areas. Lesions consist of closely set petechiae and yellow-brown papules topped with scale and crust. The papules may coalesce to form an erythematous, weeping or crusted eruption mimicking seborrheic dermatitis. Intertriginous lesions are often exudative, and secondary infection and ulceration may occur. Osteolytic lesions are not common in the disseminated form of LCH, but the mastoid can be affected, resulting in a clinical picture of otitis media, which may be the presenting complaint. Aural discharge, conductive hearing loss, and postauricular swelling have been described.[24]

As described above, patients with pulmonary involvement present with chest pain, hemoptysis, dyspnea, failure to thrive, cystic changes, and pneumothorax; if lung disease is extensive, oxygen diffusion and lung capacity may be reduced.[25, 26] Neurologic involvement may produce seizures, vertigo, headache, ataxia, and cognitive defects. Congenital self-healing histiocytosis Congenital self-healing histiocytosis presents at birth or during the early neonatal period with firm, red-brown, painless papulonodules (1-10 mm in diameter) or vesicles and crusts scattered over the scalp, face, and, to a lesser extent, trunk and the extremities. Lesions may ulcerate. Lesions may be solitary. Lesions may be followed by residual hypopigmented or hyperpigmented macules. ____________________________________________ CAUSES The etiology of Langerhans cell histiocytosis (LCH) remains unknown. Langerhans cell proliferation may be induced by a viral infection, a defect in intercellular communication (T cell macrophage interaction), and/or a cytokine-driven process mediated by tumor necrosis factor, IL-11, and leukemia inhibitory factor.[27, 28, 29] Specifically, human herpesvirus 6 (HHV-6) has been proposed to contribute to the initiation and/or modulation of persistent LCH. However, other studies have not shown a correlation between HHV-6 and LCH, and their reported associations may represent coincidental findings.[30, 31] Cigarette smoking may play a role as a chronic irritant in the development of eosinophilic granuloma of the lung. ____________________________________________ DIFFERENTIALS y y y y y y y y Acrodermatitis Enteropathica Acropustulosis of Infancy Eosinophilic Pustular Folliculitis Erythema Toxicum Neonatorum Incontinentia Pigmenti Mastocytosis Seborrheic Dermatitis Wiskott-Aldrich Syndrome

____________________________________________ LAB STUDIES Blood testing Recommended baseline diagnostic evaluations for Langerhans cell histiocytosis (LCH) include CBC count with differential, reticulocyte count, erythrocyte sedimentation rate, direct and indirect Coombs test, and immunoglobulin levels.[33] In case of anemia, leukopenia, or thrombocytopenia, a bone marrow aspirate is indicated. Coagulation studies may be indicated. Liver function tests These can include tests measuring total protein, albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gammaglutamyltransferase values. If liver function test results are abnormal, a liver biopsy should be considered to differentiate LCH from cirrhosis. Urinalysis Urine specific gravity and osmolality are measured after overnight water deprivation to screen for diabetes insipidus. _____________________________________ IMAGING STUDIES Chest radiography (posteroanterior and lateral) Langerhans cell histiocytosis (LCH) can present as a micronodular and interstitial infiltrate in the mid zone and base of the lungs, with sparing of the costophrenic angles. Older lesions show a honeycomb appearance. High-resolution CT scanning may be required if lung involvement is suspected based on radiography findings of pulmonary infiltrates or a cystic appearance.[17] Patients with radiographically demonstrated pulmonary involvement, in whom chemotherapy is being considered, require a biopsy of the lung preceded by bronchoalveolar lavage (BAL) to exclude opportunistic infections. If the BAL findings are diagnostic, the biopsy of the lung can be obviated. Skeletal radiograph survey Unifocal LCH presents as a single osteolytic lesion, usually affecting long or flat bones (in children, the calvaria and femurs; in adults, the ribs).

Multifocal LCH shows osteolytic lesions involving the calvaria, sella turcica, mandible, vertebrae, and/or long bones of the upper extremities. Note the image below. On a plain skull radiograph, lesions are typically lytic, with sharp borders and a punched out appearance. Although radionuclide bone scanning is suggested for establishing the extent of osseous involvement, the latter is not as sensitive as the skeletal radiograph survey in most patients. MRI of the head and spine is also useful to identify craniofacial or vertebral bone lesions. CT scanning or MRI CT scanning or MRI of the hypothalamic-pituitary region may reveal abnormalities of these organs. In particular, magnetic resonance spectroscopy may be valuable in the early detection and evaluation of the neurodegenerative component.[34] Fluorodeoxyglucose positron-emission tomography scanning Fluorodeoxyglucose (FDG) positron-emission tomography (PET) scanning may also be used when evaluating patients for LCH. In one study, FDG-PET scanning found 35% more sites of active disease than radiography, CT scanning, MRI, and bone scanning and was particularly effective at identifying bony lesions. FDG-PET scanning has therefore been suggested as a superior alternative to bone scanning in the early evaluation of patients with LCH.[35] Notably, FDG-PET scanning has poor sensitivity for spinal lesions. FDG-PET scanning is able to identify LCH in tissues, including lymph nodes, spleen, and lung. FDG-PET scanning may also be useful in measuring response to treatment, particularly in patients with only bony involvement who may not require periodic CT scanning or MRI evaluation.[35, 36] ____________________________________________ OTHER TESTS Other testing in Langerhans cell histiocytosis (LCH) patients may involve the following: Pulmonary function testing may help identify otherwise asymptomatic pulmonary involvement.[17]

A small bowel series and biopsy are indicated in cases of unexplained diarrhea, failure to thrive, and malabsorption.[21] Hormonal studies of the hypothalamic-pituitary axis may reveal abnormalities. Visual and neurologic testing may be required. Consultation with an otolaryngologist for auditory testing may also be considered as needed.[4, 37] The results of a small Swedish study evaluating LCH patients with known neurodegeneration on MRI suggest that serial monitoring of cerebrospinal fluid biomarkers (including neurofilament light chain [NF-L], Tau, and glial fibrillary acidic protein [GFAp]) may help evaluate disease onset, severity, and response to therapy in patients with neural involvement.[38] However, more robust studies must be performed to evaluate this claim before such tests become common practice. ____________________________________________ PROCEDURES A biopsy of the is extremely helpful in establishing the diagnosis. skin

____________________________________________ HISTOLOGIC FINDINGS The histologic picture unifies the varied presentations of Langerhans cell histiocytosis (LCH), which are influenced by the location and age of the lesions. Although lesions typically appear granulomatous, with a reactive background of macrophages, eosinophils, multinucleated giant cells, and T-cells, the key to diagnosis is to identify the pathologic Langerhans cells.[39, 40] The latter cell resembles the normal Langerhans cell of the skin, except that it is not dendritic. It consists of a large, ovoid, mononuclear cell that is 1525 m in diameter, with a folded nucleus, a discrete nucleolus, and a moderate amount of slightly eosinophilic homogeneous cytoplasm. When the indentation of the nucleus affects its center, it acquires a reniform pattern; however, if it is peripheral, the nucleus has a coffee-bean shape. Special studies are useful for definitive identification of normal and pathologic Langerhans cells. The Birbeck granule is their distinctive ultrastructural hallmark. It

consists of an intracytoplasmic membranous body that is 33 nm wide and 190-360 nm long, possessing a short, rodlike shape with a dotted line down the midline of the space between the membranes (resembling a zipper) and a terminal expansion in the form of a vesicle, giving a racquet appearance. Although these granules are resistant to destruction by formalin fixation and paraffin embedding, the sensitivity of detection in such specimens is slightly decreased. Birbeck granules are rarely detected in lesions of the liver, the gastrointestinal tract, and the spleen. Langerhans cells also contain laminated substructures of lysosomes, tuboreticular structures, and trilaminar membranous loops.
High-power views. Marked epidermotropism is noted (left). The lesional cells are large, with abundant pink cytoplasm and reniform nuclei. An admixture of inflammatory cells, including occasional eosinophils, is present (right).

Electron microscopy. Tennis racquet form of Birbeck granules with a small terminal expansion.

Ultrastructural methods and enzyme histochemical studies (alpha-D-mannosidase and adenosine triphosphatase [ATPase]) have largely been replaced by immunohistochemical techniques. S-100 protein is strongly expressed in a cytoplasmic pattern, while peanut agglutinin (PNA) has a characteristic cell surface and paranuclear dot expression. LCH cells are positive for major histocompatibility (MHC) class II and CD1a. Expression of langerin (CD207), a Langerhans cell restricted protein that induces the formation of Birbeck granules and is constitutively associated with them, is a highly specific marker of Langerhans cells.[41] The pathologic Langerhans cell expresses phenotypic markers of an activated normal Langerhans cell in its early stages. Fine-needle aspiration combined with immunohistochemistry of the cell preparation plays an important role in documenting organ involvement by LCH.

High-power views. Diffuse immunoreactivity for S-100 protein (right). Langerhans cells and lymphocytes (left, hematoxylin and eosin).

Widespread positivity for CD1a. Note the presence of epidermotropism (right). Langerhans cells and lymphocytes are present in the epidermis and the papillary dermis (left, hematoxylin and eosin).

The Writing Group of the Histiocyte Society (1987) has proposed 3 levels of certainty in the diagnosis of LCH, based on clinical features, histopathology, and immunohistochemical techniques. A presumptive diagnosis is based on a typical clinical presentation and light microscopic findings. A designated diagnosis includes light microscopy in combination with positive S-100 and PNA staining studies. To make a definitive diagnosis, identification of Birbeck granules and CD1a antigens is required. In the future, identification of CD207 via immunohistochemistry or immunofluorescence may be formally used to diagnose the disease. ____________________________________________ STAGING The Histiocyte Society stratifies patients with Langerhans cell histiocytosis (LCH) into single-system LCH (SS-LCH) or multisystem LCH (MS-LCH). SS-LCH includes involvement of one of the following systems (either unifocal or multifocal involvement): y Bone y Skin y Lymph Node y Lungs y Central nervous system y Other (eg, thyroid, thymus) MS-LCH is defined as involvement of 2 or more organs or organ systems, irrespective of involvement of "risk organs." The following organ systems are classified as risk organs, and their involvement indicates a worse prognosis: y Spleen y Liver y Hematopoietic system y Lung