Follow Up for Childhood Langerhans Cell Histiocytosis Survivors

The reported overall incidence of long-term consequences of Langerhans cell histiocytosis (LCH) has ranged from 20% to 70%. The reason for this wide variation is due to case definition, sample size, therapy used, method of data collection, and follow-up duration. Of note, in one study of the quality of life of long-term survivors of skeletal LCH, the quality of life scores were not significantly different from healthy control children and adults.[1] In addition, the quality of life scores were very similar between those with and without permanent sequelae.

Children with low-risk organ involvement (skin, bones, lymph nodes or pituitary gland) have an approximately 20% chance of developing long-term sequelae.[2] Those with diabetes insipidus (DI) are at risk for panhypopituitarism and should be monitored carefully for adequacy of growth and development. In a retrospective review of 141 patients with LCH and DI, 43% developed growth hormone (GH) deficiency. [3-5] The 5- and 10- year risks of GH deficiency among children with LCH and DI were 35% and 54%, respectively. There was no increased reactivation of LCH in patients who received GH compared with those who did not.[3]

Growth and development problems are more frequent because of the young age at presentation, and the more toxic effects of long-term prednisone therapy in the very young child. Patients with multisystem involvement have a 71% incidence of long-term problems.[2-5]

Hearing loss has been found in 13% of children treated for LCH.[5]

Neurologic symptoms secondary to vertebral compression of cervical lesions have been reported in 3 of 26 LCH patients with spinal lesions.[5] Central nervous system (CNS) LCH occurs most often in children with LCH of the pituitary or CNS-risk skull bones (mastoid, orbit, or temporal bone.). Significant cognitive defects and magnetic resonance imaging abnormalities may develop in some long-term survivors with CNS-risk skull lesions.[6] Some patients have markedly abnormal cerebellar function and behavior abnormalities, while others have subtle deficits in short-term memory and brain stem-evoked potentials.[7]

Orthopedic problems from lesions of the spine, femur, tibia, or humerus may be seen in 20% of patients. These problems include vetebral collapse or instability of the spine that may lead to scoliosis, and facial or limb asymmetry.

Diffuse pulmonary disease may result in poor lung function with higher risk for infections and decreased exercise tolerance. These patients should be followed with pulmonary function testing, including the diffusing capacity of carbon monoxide and ratio of residual volume to total lung capacity.[8]

Liver disease may lead to sclerosing cholangitis, which rarely responds to any treatment other than liver transplant.[9]

Dental problems characterized by loss of teeth have been significant for some patients, usually related to overly aggressive dental surgery.

Bone marrow failure secondary to LCH or from therapy is rare and is associated with a higher risk of malignancy. Patients with LCH have a higher-than-normal risk of developing secondary cancers.[10,11] Leukemia (usually acute myeloid) occurs after treatment, as does lymphoblastic lymphoma. Concurrent LCH/malignancy has been reported in a few patients, and some patients have had their malignancy first, followed by development of LCH. Three patients with T-cell acute lymphoblastic leukemia (T-ALL) and aggressive LCH, for which the two disorders had shared markers of clonality, have been reported.[12,13] One study reported two cases in which clonality with the same T-cell receptor gamma genotype was found.[12] The authors of this study emphasized the plasticity of lymphocytes developing into Langerhans cells. In the second study, one patient with LCH after T-ALL who had the same T-cell receptor gene rearrangements and activating mutations of the NOTCH1 gene was described.[13]

An association between solid tumors and LCH has also been reported. Solid tumors associated with LCH include retinoblastoma, brain tumors, hepatocellular carcinoma, and Ewing sarcoma.

Specific long-term follow-up guidelines after treatment of childhood cancer or in those who have received chemotherapy have been published by the Children's Oncology Group, and are available on their Curesearch Website.

References

1. Lau LM, Stuurman K, Weitzman S: Skeletal Langerhans cell histiocytosis in children: permanent consequences and health-related quality of life in long-term survivors. Pediatr Blood Cancer 50 (3): 607-12, 2008.  [PUBMED Abstract]
   
   
2. Haupt R, Nanduri V, Calevo MG, et al.: Permanent consequences in Langerhans cell histiocytosis patients: a pilot study from the Histiocyte Society-Late Effects Study Group. Pediatr Blood Cancer 42 (5): 438-44, 2004.  [PUBMED Abstract]
   
   
3. Donadieu J, Rolon MA, Pion I, et al.: Incidence of growth hormone deficiency in pediatric-onset Langerhans cell histiocytosis: efficacy and safety of growth hormone treatment. J Clin Endocrinol Metab 89 (2): 604-9, 2004.  [PUBMED Abstract]
   
   
4. Komp DM: Long-term sequelae of histiocytosis X. Am J Pediatr Hematol Oncol 3 (2): 163-8, 1981.  [PUBMED Abstract]
   
   
5. Willis B, Ablin A, Weinberg V, et al.: Disease course and late sequelae of Langerhans' cell histiocytosis: 25-year experience at the University of California, San Francisco. J Clin Oncol 14 (7): 2073-82, 1996.  [PUBMED Abstract]
   
   
6. Nanduri VR, Lillywhite L, Chapman C, et al.: Cognitive outcome of long-term survivors of multisystem langerhans cell histiocytosis: a single-institution, cross-sectional study. J Clin Oncol 21 (15): 2961-7, 2003.  [PUBMED Abstract]
   
   
7. Mittheisz E, Seidl R, Prayer D, et al.: Central nervous system-related permanent consequences in patients with Langerhans cell histiocytosis. Pediatr Blood Cancer 48 (1): 50-6, 2007.  [PUBMED Abstract]
   
   
8. Bernstrand C, Cederlund K, Henter JI: Pulmonary function testing and pulmonary Langerhans cell histiocytosis. Pediatr Blood Cancer 49 (3): 323-8, 2007.  [PUBMED Abstract]
   
   
9. Braier J, Ciocca M, Latella A, et al.: Cholestasis, sclerosing cholangitis, and liver transplantation in Langerhans cell Histiocytosis. Med Pediatr Oncol 38 (3): 178-82, 2002.  [PUBMED Abstract]
   
   
10. Egeler RM, Neglia JP, Puccetti DM, et al.: Association of Langerhans cell histiocytosis with malignant neoplasms. Cancer 71 (3): 865-73, 1993.  [PUBMED Abstract]
    
    
11. Egeler RM, Neglia JP, Aricò M, et al.: The relation of Langerhans cell histiocytosis to acute leukemia, lymphomas, and other solid tumors. The LCH-Malignancy Study Group of the Histiocyte Society. Hematol Oncol Clin North Am 12 (2): 369-78, 1998.  [PUBMED Abstract]
    
    
12. Feldman AL, Berthold F, Arceci RJ, et al.: Clonal relationship between precursor T-lymphoblastic leukaemia/lymphoma and Langerhans-cell histiocytosis. Lancet Oncol 6 (6): 435-7, 2005.  [PUBMED Abstract]
    
    
13. Rodig SJ, Payne EG, Degar BA, et al.: Aggressive Langerhans cell histiocytosis following T-ALL: clonally related neoplasms with persistent expression of constitutively active NOTCH1. Am J Hematol 83 (2): 116-21, 2008.  [PUBMED Abstract]
    
    

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