Discussion and conclusion
The clinical manifestations of ECD range from isolated focal lesions to life-threatening multiple-organ failure and the radiological findings of ECD are specific. And a summary of the characteristic features and ophthalmologic findings of ECD is presented in Tables
1 and
2.
Table 1
Characteristic features of Erdheim-Chester disease
Bones | 95% | Osteosclerosis at the metadiaphysis of bones around the knee, axial skeleton, and small bones of the feet [ 4] |
Endocrine | 50–70% | Diabetes insipidus, anterior pituitary hormonal deficiencies, and hyperprolactinemia [ 5] |
Arterial | 50–80% | Periaortic infiltration “coated aorta”; infiltration of the supra-aortic trunk branches, visceral arteries, renal artery stenosis, and coronary arteries [ 6] |
Respiratory | 50% | Mediastinal infiltration; pleural, septal, and maxillary sinus thickening [ 6] |
Cardiac | 40–70% | Pericardial infiltration and effusion, right atrial pseudotumor, and atrioventricular sulcus [ 7] |
Retroperitoneum | 40–50% | Perinephric infiltration “hairy kidneys”; hydronephrosis and adrenal infiltration [ 4] |
Nervous system | 40% | Cognitive impairment, ataxia, and peripheral neuropath; brainstem/cerebellum masses; cerebral white matter enhancement; and dural and pituitary stalk thickening [ 6] |
Orbit | 30% | |
Dermatologic | 25% | Xanthelasma-like lesions around the eyes, face, neck, and inguinal folds [ 8] |
Testes | 3–5% | May occur as a hybrid/overlap disease with RDD [ 5] |
Table 2
Ophthalmologic findings of Erdheim-Chester disease
Palpebrae | Xanthelasmas | |
Orbit | Progressive bilateral proptosis [ 3] | Hypodensity on CT and isointensity to hypointensity on MRI with heterogeneous enhancement [ 10] |
Optic nerve | Decreased visual acuity [ 3] | Enhancement or compression of the optic nerve on MRI [ 11] |
Extraocular muscle | | Enhancement or enlargement of the muscle on MRI [ 11] |
Intraocular |
Anterior chamber | Uveitis (cells) | —— |
Vitreous | Vitritis | —— |
Retina | Recurrent Serous Retinal Detachment [ 12] | Drusen-like deposits of histiocytic material with progressive staining on fluorescein angiography [ 12] |
Optic disc | | —— |
RPE | Chronic pigmentary and atrophic changes along with pigment clumping [ 12] | —— |
Choroid | Quiescent choroidal neovascularization [ 13] | Disappearance of intermediate and large choroidal vessels and intact choriocapillaris in the lesion on EDI-OCT [ 14] |
The diagnosis of ECD relies on typical radiological findings combined with a site-specific histopathological examination, particularly for detecting
BRAF mutation or other MAPK pathway alterations [
15]. Ocular involvement occurs in approximately 30% of ECD cases [
4], and the ocular region offers a superficial and relatively accessible site for obtaining pathological specimens, making it optimal for diagnosis [
12]. Thus, surgical intervention to obtain tissue samples for definitive diagnosis is crucial.
The gross resection specimen of ECD is typically a greyish-yellow or greyish-white, tough mass that adheres closely to the tissue. The histological feature of ECD is mononuclear foam tissue cell infiltration, multinucleated giant cells or Touton cells are often seen, and fibrosis can be seen in most cases [
16]. Immunohistochemistry exhibits positive expression of CD68 and negative expression of CD1a and S-100 [
12].
BRAFV600E mutation testing (up to 54% of ECD patients have
BRAFV600E mutations) is crucial for diagnosis and effective treatment [
12]. This mutation is the most common mutation in cerebral, cardiac, and orbital ECD [
17]. But whether the diagnosis of ECD can be doubted usually depends on the pathologist’s experience. In our case 1, the pathological biopsy showed fibrous tissue hyperplasia with histiocyte reactions, no further immunohistochemistry and mutant gene detection were carried out, and the diagnosis of inflammatory pseudotumor was made. It was not until a year later, after the second biopsy, that a diagnosis of ECD was established. In contrast with the experience of case 1, the orbital biopsy in our second case revealed adipose tissue infiltrated by foamy CD68-positive histiocytes. This combined with clinical and imaging findings led quickly to the diagnosis of ECD.
However, it is difficult to distinguish these pseudotumoral lesions. The differential diagnosis of orbital ECD is centered on IgG4-related orbital inflammation, granulomatosis with polyangiitis (GPA), orbital lymphoma, and idiopathic orbital inflammatory disease [
18,
19]. These have many overlapping clinical manifestations (orbital masses, retroperitoneal infiltration, periaortitis, and so on) [
20] with ECD. Typical long bone lesions and xanthelasma-like lesions are unique clinical manifestations of ECD, but there are also many atypical cases. IgG4-positive plasma cells are always detected in the pathological tissue of ECD of the orbit [
21], making it more difficult to distinguish it from IgG4-related disease (IgG4-RD). In case 1, an affluent IgG4-positive plasma cell population was detected, but
BRAF showed a mutation in exon 15, confirming the diagnosis of ECD. Therefore, tissue biopsy by an experienced pathologist and identification of
BRAF and other MAPK pathway mutations in biopsies are key in diagnosing the disease [
6].
Treatment options for ECD include corticosteroids, biologic agents (IFN-α), chemotherapy, and BRAF inhibitors (BRAFIs) [
15]. Traditional approaches like IFN-α are recommended for patients with mild-to-moderate disease severity [
2]. And surgery is crucial for ECD-involved orbit, serving not only for diagnostic biopsy but also for relieving mass effect, minimizing further impairment of visual function. The mass exerts pressure on critical structures, such as blood vessels and nerves, resulting in irreversible visual impairment. And proptosis and exposure keratopathy can also occur due to the presence of an intraorbital mass, impacting visual function and causing discomfort. Due to the diffuse growth pattern observed in ECD, surgical excision presents significant challenges [
22] and only when the tumor reaches a considerable size will it begin to develop ocular symptoms such as proptosis and visual decline. Therefore, early screening and timely treatment of ocular involvement when patients present with symptoms involving other organs or systems can maximize the preservation of visual function.
In
BRAFV600E patients, BRAFIs are recommended as the first-line therapy [
2]. Vemurafenib, an FDA-approved BRAF inhibitor for ECD treatment [
23], shows rapid improvements in radiology, clinical outcomes, and laboratory markers within 4 weeks for refractory ECD patients [
24]. Just like in Case 2, the patient experienced significant improvement in symptoms within 2 weeks of medication use. The standard dose of Vemurafenib is 960 mg twice daily, but lower doses of 480 mg have shown good tolerability [
12]. Recent studies by Ruan and Saunders et al. also suggest that lower doses (25–50% of the FDA-approved dose) are both effective and well tolerated and are recommended as initial treatment [
25,
26]. In case 2, the patient received a starting dose of 240 mg/bid (25% of the FDA-approved dose) for 1 year and no recurrence of symptoms during follow-up. But the patient started experiencing bone and joint pain after taking the medication, which we speculate to be a side effect of Vemurafenib. This is consistent with the known side effects of Vemurafenib, which include arthralgias, pancreatitis, QT prolongation, and cutaneous manifestations such as squamous cell carcinoma and keratoacanthoma [
27]. Patient 1 had the
BRAFV600E mutation, but he rejected targeted therapy for financial reasons. The patient underwent surgery and local radiotherapy; he had no recurrence of orbital tumors within 1 year after treatment, but his polyserositis did not improve. Although complete remission could not be achieved, it seemed he made a good choice. ECD is not a radiosensitive disease, but radiotherapy is a good method for situations where immediate palliation of symptoms is needed (large tumors causing CNS, ocular, or internal organ compromise) [
2,
28].
The existence of both ECD and primary thrombocytosis in our case 2 is interesting. Histiocytic and dendritic cell neoplasms can be clonally related to leukemias [
29,
30]. Approximately 10.1% of patients with ECD have an overlapping myeloid neoplasm [
31] and hallmark driver mutations of myeloid neoplasms (such as
JAK2V617F and
CALR mutations) coexisting with that characteristic of histiocytosis (such as
BRAFV600E and
MAP2K1 mutation) were frequently detected by molecular analysis [
3,
15]. The
CALR mutation and the
BRAFV600E mutation were detected in our patient. This finding furthers our understanding of ECD etiology and disease classification and plays a vital role in guiding treatment [
3]. Papo et al. reported that there are different kinase mutations in histiocytosis and myeloid tumors, and the use of BRAFIs may promote the growth of malignant tumors driven by mutations other than
BRAFV600E [
3], but if they share the same kinase mutation, targeted therapeutics will result in beneficial responses across both conditions. Therefore, evaluation of a concomitant myeloid neoplasm will be critical before initiating targeted therapies for refractory ECD. The guidelines also point out that clinicians should continually monitor peripheral blood counts and strongly consider bone marrow evaluation with myeloid NGS to assess for abnormalities [
2,
31]. However, myeloid tumors can be diagnosed before, at the same time as, or after ECD, making these cases a diagnostic challenge for the practicing pathologist.
In conclusion, owing to the rarity and diverse clinical manifestations of ECD, misdiagnosis and missed diagnosis can easily occur. Surgical intervention to obtain tissue samples for definitive diagnosis is crucial, and identification of BRAF and other MAPK pathway mutations in biopsies has become extremely helpful in diagnosing the disease. Despite the surgical resection is not curative, its significance lies in biopsy to establish diagnosis and/or surgical debulking to relieve mass effect, minimizing further impairment of visual function. Targeted therapy is the most effective treatment for patients with a positive BRAF mutation. In addition, approximately 10.1% of patients with ECD have an overlapping myeloid neoplasm, and myeloid tumors can be diagnosed before, at the same time as, or after ECD. Because the two may share the same pathogenesis, coexisting ECD and myeloid neoplasm may promote or counteract the effect of targeted therapy. Therefore, evaluation of a concomitant myeloid neoplasm is also critical before initiating targeted therapies for refractory ECD.
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