Malignant Histiocytosis X

Report of a Rapidly Fatal Case in an Elderly Man

COLIN WOOD, MD,’ GARY S. WOOD, MD,t DAVID G. DENEAU, MD,* ALLEN OSEROFF, MD, PHD,* JAY H. BECKSTEAD, MD,* AND JACOB MALIN, MDg

A 71-year-old white man developed an increasing number of 1-to-10 mm, erythematous nodules, many with central ulceration, most prominent on the head and trunk. Biopsy of a nodule showed infiltration of the dermis and epidermis by large cells with multilobulated nuclei and numerous mitoses. Electron microscopy showed that most tumor cells contained Langerhans’ cell granules. Immunohistochemical studies demonstrated a pattern of antigen expression similar to that of Langerhans’ cells including Ia and Leu-6 (T6) antigens. Chest x-ray showed diffuse pulmonary infiltration and similar tumor cells were present in the sputum and urine. He developed increasing dyspnea and jaundice despite chemotherapy, and died 6 months after the onset of the disease. Autopsy showed massive tumor infiltration of the lungs, liver, spleen, and lymph nodes, and focal involvement of the myocardium, skin and bladder. Clinical and cytologic features indicated this case to be a rare example of highly malignant histiocytosis X in an elderly man.

Cancer 54347-352, 1984.

ISTIOCYTOSIS x rarely presents in the elderly as a H disease involving multiple organs and tissues.’-6 We present the clinical, biopsy, cytologic, and autopsy

findings in a 7 1-year-old man who presented with multiple skin nodules and pulmonary infiltration by bizarre cells with ultrastructural and immunochemical features of Langerhans’ cells, resulting in death 6 months after the onset of the disease.

Materials and Methods Immunohistologic Staining

Representative portions of fresh skin biopsies were snap-frozen, cryostat-sectioned, and acetone-fixed as pre- viously described.’ A three-stage monoclonal antibody/ biotinylated goat anti-mouse IgG/avidin-horseradish per- oxidase immunohistochemical technique was used to characterize cellular antigen expression.’ Selected murine hybridoma anti-human monoclonal antibodies and bio- tinylated peanut agglutinin were employed as first-stage reagents (Table 1). Biotinylated purified goat anti-mouse IgG (heavy and light chains) (Tago, Inc., Burlingame, CA) was used as the second stage reagent, and avidin-

From Stanford University Medical Center, Stanford, California. * Department of Dermatology. t Department of Pathology. # Department of Pathology, University of California School of Med-

4 Department of Pathology, Washoe Medical Center, Reno, Nevada. Accepted for publication April 29, 1983.

icine.

horseradish-peroxidase conjugate (Vector Laboratories, Inc., Burlingame, CA) was used as the third-stage reagent. Localizations of the horseradish-peroxidase label was vi- sualized with 3,3-diaminobenzidine (DAB) as previously de~cribed.~ Sections were counterstained with methylene blue. Controls included staining with the first stage deleted and with irrelevant monoclonal antibodies of identical isotype.

Histochemistry

Tissue blocks were fixed at 4°C in phosphate-buffered 2% paraformaldehyde with 0.0 1 mol/l phosphate buffer with 3% sucrose, dehydrated in acetone, and embedded in glycol methacrylate as previously described.8 All of the enzyme histochemical reactions were performed directly on 2-micron sections of plastic embedded tissue. The results are presented in Table 2.

Fluorescence-Activated Cell Sorter Analysis

Fluorescence-activated cell sorter (FACS) analysis of peripheral blood mononuclear cells was performed as previously described.’ Briefly, a two-stage method was employed using monoclonal antibody followed by flu- oresceinated purified goat anti-mouse IgG (Tago, Inc., Burlingame, CA). The panel of antibodies included anti- Leu 1,2,3, and anti4 HLA-Dr (Becton Dickinson, Mountain View, CA), anti-OK-T6 (Ortho Pharmaceu- tical, Raritan, NJ).

347

348 CANCER July 15 1984 VOl. 54

times a day. Except for psoriasis limited to the elbows, knees, and scalp, which was present for approximately 6 years, his skin was normal until 2.5 months prior to admission. At that time symptoms resembling influenza were followed by an eruption that consisted of two to three blisters on the abdomen. This was diagnosed as herpes zoster, and treated with systemic steroids on two occasions. The dose given is not known. He remained about the same until 2 to 3 weeks later when he developed an increasing number of small papules on his trunk. After 2 months these had become 1 to 10 mm in diameter, skin-colored or erythematous nodules, many with rolled borders and central necrosis, most prominent on the trunk and head (Figs. 1 and 2), but involving the entire body. In the last few weeks he de- veloped increased shortnesss of breath and cough productive of whitish sputum, and pedal edema.

After the initial skin biopsy was reported as a poorly differ- entiated malignant neoplasm, the patient was admitted to the hospital for tests which included sigmoidoscopy, chest x-ray, lymphangiogram, bone marrow aspiration and biopsy, upper GI, barium enema, liver and spleen scan. All these tests were negative. The patient was then admitted to the Stanford Uni-

FIG. 1 . Multiple nodules on the trunk, neck, and shoulder of a 71- year-old man. Some of the nodules are centrally ulcerated.

Case Report

A 7 1-year-old white man, who was a retired bus driver, with a history of a total right hip prosthesis, was well except for emphysema with shortness of breath and hypertension, for which he received propranolol hydrochloride (Inderal) 10 mg four

FIG. 2. Ulcerated erythematous nodule on forehead.

RG. 3. Biopsy of a skin nodule showing diffuse infiltration of the upper dermis and lower epidermis by mononuclear cells, some with very large lobulated nuclei (Epon embedded, original magnification X240).

No. 2 MALIGNANT HISTIOCYTOSIS X . Wood et al. 349

versity Hospital Dermatology Service. He was afebrile, but had nausea and vomiting. Chest x-ray showed marked diffuse pul- monary infiltrates throughout both lungs with no evidence of hilar or mediastinal adenopathy. Intravenous pyelography showed no abnormality.

Skin biopsy of a nodule showed diffuse dermal infiltration by tumor cells which also extended as nests and scattered cells into the epidermis (Figs. 3 and 4). The tumor cells were large and round, with abundant pale eosinophilic cytoplasm. Nuclei were large and very pleomorphic with fine chromatin, and were multilobulated or highly folded. Mitotic figures were numerous, ranging from 9 to 17 per square mm. in sections of tumor tissue. Many eosinophils were also present.

Cytologic examination of sputum showed large numbers of malignant cells with folded nuclei identical to those seen in the skin biopsy, with many resemblances to true histiocytes (Fig. 5). A few degenerated abnormal cells identical to those in the sputum were present in the urine.

Electron microscopy of a skin biopsy showed that most tumor cells in the dermis and epidermis contained Langerhans’ cell granules (Fig. 6).

Immunohistochemical studies are summarized in Table 1, and they showed that almost all the cutaneous tumor cells dem- onstrated a pattern of antigen expression similar to that of Lan-

FIG. 5. Smear of sputum containing histiocytoid cells with large highly lobulated pale-staining nuclei (X 1900).

gerhans’ cells including HLA (A, B, C), leukocyte common antigen, la, Leu-6/T6 (Fig. 7) and Leu-3/T4. The first three of these are widely distributed among bone-marrow-derived cells, whereas Leu-6/T6 is restricted to a thymocyte subset and cells of Langerhans’ lineage. Leu-3/T4 antigens are primarily ex- pressed by helper T-cells, although they can also be detected in cells of monocyte/macrophage and Langerhans’ lineage.’ Other reagents specific for B-cells and T-cells were unreactive with the tumor cells.

Fluorescence-activated cell sorter analysis of peripheral blood did not reveal detectable levels of circulating OKT6+ cells. The fluorescence patterns were comparable to normal controls.

Enzyme histochemical studies are summarized in Table 2. Although the nonspecific esterases were negative, the pattern of staining with acid phosphatase and ATPase in conjunction with the negative reactions of the other enzymes is consistent with a Langerhans’ cell origin of the tumor cells.

The patient was transferred to the Oncology Service. At this time his blood pressure was 110/70 mm. He was obese, and in no acute distress. Skin lesions were as previously described, with diffuse scalp scaling in addition. No peripheral adenopathy was found. Breath sounds were decreased bilaterally, with increased expiratory phase. There was no pedal edema and no hepato- splenomegaly. tests gas on room air with a pH of 7.43, pC02 37, p02 52. There was an

FIG. 4. Infiltration of the upper dermis by large cells with large ir- regularly lobulated nuclei. Mitosis is seen in one of the cells infiltrating the epidermis (X470).

350 CANCER July 15 1984 VOl. 54

Discussion

Ultrastructural morphology, enzyme histochemistry, and immunophenotyping all demonstrate that the cu- taneous tumors in this patient are composed of cells with

FIG. 6. Electron micrograph of tumor cell in skin nodule, containing numerous cytoplasmic Langerhans’ cell granules (original magnification X60,OOO).

increase in residual volume and in residual volume to total lung capacity ratio. Helium time was prolonged, and all flows were severely decreased with some improvement after bronchodi- lators. The a:A gradient was 54. The impression was of severe obstructive lung disease. The patient’s propranol hydrochloride was stopped, and he was discharged home on aminophylline 200 mg four times a day to receive chemotherapy, consisting of methotrexate, vincristine, prednisone, and tamoxifen.

Despite chemotherapy he developed increasing dyspnea, jaundice, and ascites, and died 2 months later. Autopsy showed massive tumor infiltration of the lungs, liver, spleen, and lymph nodes, and focal involvement of myocardium, skin, kidney, and bladder. Tumor cells were identical to those in the earlier skin biopsies, many showing extremely large multilobulated nuclei- like bunches of grapes (Fig. 8). Numerous mitoses were seen, and scanty eosinophils were present. Tumor cells invaded bladder epithelium in a pagetoid pattern and lined and filled pulmonary alveoli, thus correlating with prior positive sputum and urine cytologies. Occasional clusters of tumor cells entrapped within abdominal aortic atherosclerotic plaque and renal glomerular capillary tufts constituted evidence of hematogenous tumor dis- semination, at least terminally. Only a few scattered tumor cells were found in sections of bone marrow. No tumor was found in the stomach, duodenum, intestines, pancreas, or seminal vesicles.

TABLE I . Tumor Reactivity With Selected Monoclonal Antibodies and Plant Lectins in Cryostat Sections

Reagent/(antigen Tumor recognized)* Leukocyte distribution reactivity

W6/32t (HLA) L3B1 2$/(common

leukocyte antigen)

L203$(Ia)

Peanut agglutinin4

SK9 11 /(Leu-6)

OKT67l/(T6)

SK3/(Leu-3a) (1

OKT4T/( T4) CCT4#/(T4)

61D3** 63D3**

163-4211/(kappa) I- 155-2 Il/(lambda) 1D12$/(mu) H299#/(B1)

LI 7Fl2 [//(Leu- 1)

ATM 1. I II/(Leu-5)

4H9$

SK4 II/(Leu-3B)

SK7 II/(Leu-4)

3Alt t

SKI II/(Leu-Za)

L 12E7$

HNK-1 II/(Leu-7)

JS#/(calla)

Pan-leukocyte

B-cells, macrophages Langerhans’ cells, activated

Germinal center, cells,

T-cells

macrophages, cortical thymocytes

Thymocytes, Langerhans’ cells

Helper T-cells, thymocytes Macrophages, some

langerhans’ cells

Macrophages

B-cells

T-cells, thymocytes

Cytotoxic/suppressor T-cells, some helper T-cells, thymocytes

thymocytes Cytotoxic/suppressor Tsells,

Cortical thymocytes

Natural killer cells

Common acute lymphoblastic leukemia, pre-B-cells

* The equivalencies between the anti-Leu and anti-T series of anti- bodies are as follows: Leu-I (TI), Leu-2 (T8), Leu-3 (T4), Leu-4 (T3), Leu-5 (TI I), Leu-6 (T6).

Reagents were obtained from the following sources:

$ Ronald Levy, Stanford University, Stanford, California. 4 Vector Laboratories, Inc., Burlingame, California 11 Becton Dickinson, Mountain View, California.

Ortho Pharmaceuticals, Raritan, New Jersey. # Coulter Electronics, Inc., Hialeah, Florida. ** J. Donald Capra, University of Texas Health Science Center, Dallas,

tt Barton Haynes, Duke University, Durham, North Carolina.

Pel-Freez Biological, Rogers, Arkansas.

Texas.

No. 2 MALIGNANT HISTIOCYTOSIS X - Wood et al. 35 1

TABLE 2. Tumor Histochemistry in Plastic Sections

Enzyme Comment

Acid Phosphatase

ATPase

+ Paranuclear (Golgi) distribution

+ Membrane staining

Alpha-naphthyl butyrate esterase -

5' nucleotidase -

Peroxidase

Beta glucuronidase Aldaline uhosuhatase -

neous tumors) is another unusual feature in this case. Mitotic figures have been noted in the skin in histiocytosis X, but they are usually few in number."*" In one patient with Hand-%huller-Christian disease only a single mitotic figure was recognized in a tumor cell, in all the sections studied of multiple biopsies of skin lesions,'* although about 25% of the cells were synthesizing DNA. Rarely has conspicuous mitotic activity been reported in histio-

FIG. 7. Biopsy of a skin nodule showing staining of all the tumor cells for T6 antigen in frozen section, using immunoperoxidase technique (X470).

features of Langerhans' cells, as in histiocytosis X. How- ever, the bizarre nuclear configurations, abundant mitoses, and rapidly fatal dissemination in an elderly patient are unique features in this case. Tumor cells were identified in sputum after pulmonary infiltration was recognized in x-rays. Cells with cytoplasmic Langerhans' cell granules have been previously reported in bronchoalveolar washes of four patients with pulmonary histiocytosis X.9 The current case appears to be the first in which cells of his- tiocytosis X have been reported in sputum and urine.

In most cases of histiocytosis X, the nuclei are large and pale staining, often crescent-shaped and occasionally circling a central area of cytoplasm like a wreath. In the seven elderly patients with disseminated histiocytosis de- scribed by Vollum,' the main impression was of the his- tiocytes having a uniform appearance, although some- times binucleate or small giant cell forms were seen with some variation in cell size." In this case many nuclei were extremely large and highly lobulated, with the clus- ters of pale-staining lobules resembling a bunch of grapes.

high mitotic counts (9- 17 per mm2 in sections Of Cut& This appearance was most distinctive (Figs' and 8)' The FIG. 8. Lymph node from autopsy showing infiltration by tumor cells

with large nuclei, some of which resemble a bunch of grapes (x470).

352 CANCER July 15 1984 Vol. 54

cytosis X, although two such cases were reported as ma- lignant histiocytosis rather than histiocytosis X despite clinicopathologic features resembling histiocytosis X and demonstration of Langerhans cell granules in a few too many tumor cells.13J4

The cells in histiocytosis X have so much in common with Langerhans’ cells that it is useful to consider histio- cytosis X as a Langerhans’ cell proliferative di~0rder.l~ Even in disseminated forms of histiocytosis X in elderly patients, the histiocytes rarely show cytologic features characteristic of malignancy. lo In contradistinction, the tumor cells in the current case show cytologic features characteristic both of Langerhans’ cells and of malignant neoplasia. Thus, this case appears to represent the ag- gressive end of a clinicopathologic spectrum of Langer- hans’ cell proliferative disorders, counterbalanced at the other extreme by relatively indolent lesions such as solitary eosinophilic granuloma. The cause of histiocytosis X is unknown. Herpes zoster has been reported to occur in association with the onset of lymphoma in elderly patients. The diagnosis of herpes was not proven in this case, and although the dose of corticosteroids given to treat it is not known, it seems likely that the patient was not im- munosuppressed by this treatment at the onset of his disease.

In summary, this is a fatal case of malignant Langer- hans’ cell tumor in an elderly man, with death resulting from pulmonary tumor infiltration despite chemotherapy, within a few months of the onset of nodular skin lesions.

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