Craniofacial and skull base findings in Langerhans cell histiocytosis in pediatric patients

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1 Peditrís Originl rtile Crniofil nd skull se findings in Lngerhns ell histioytosis in peditri ptients Dniel Forlino (1), Ptriio Mnzone (2), Mtilde Cristin Gomel (2), Mrí Betriz Nioli (2), Cesy Pedrini (3) Resumen L histioitosis de éluls de Lngerhns (HCL) es un entidd poo freuente, on un inideni nul de 2,6 5,4 por millón de niños en l polión generl. Tiene mnifestiones óses (lesiones osteolítis solitris o múltiples en huesos plnos, lrgos e irregulres) o multisistémis. Se desrien los hllzgos imgenológios de un serie retrospetiv de 17 pientes pediátrios, de 1 12 ños de edd, on histioitosis de éluls de Lngerhns en el mizo fil y l se del ráneo. Ls mnifestiones inluyeron lesiones osteolítis y ms de prtes lnds, que oupn ls viddes dyentes, omo l órit, los senos prnsles, l j timpáni y l mstoides. En el mxilr inferior puede provor resorión del reorde lveolr on prieni de dientes flotntes. L omplejidd ntómi del áre de estudio requiere su vlorión medinte tomogrfí omputd (TC) y resonni mgnéti (RM) on ontrste. L histioitosis de éluls de Lngerhns dee onsiderrse dentro de los dignóstios difereniles de ls lesiones del mizo fil y l se del ráneo, espeilmente en pientes pediátrios. Plrs lve. Histioitosis. Peditrí. Mizo fil. Bse del ráneo. Astrt Crniofil nd skull se findings in Lngerhns ell histioytosis in peditri ptients. Lngerhns ell histioytosis (CLH) is n unommon entity, of unknown etiology, with n inidene of 2.6 t 5.4 per 1,000,000 hildren/yer in the generl popultion. It my hve one mnifesttions (solitry or multiple osteolyti lesions in flt, long nd irregulr ones) or multiorgn mnifesttions. We report the rdiologil findings in retrospetive series of 17 peditri ptients ged 1 to 12 yers old, with CLH in rniofil nd skull se. Rdiologil findings inluded osteolyti nd soft tissue lesions oupying the orit, sinuses, tympni vity nd mstoid. In the mndile, resorption of the lveolr ridge with the pperne of floting teeth ws oserved. The ntomil omplexity of the re studied required evlution y CT nd MRI with ontrst. LCH disese should e onsidered in the differentil dignoses of rniofil nd skull se lesions, espeilly in peditri ptients. Keywords. Histioytosis. Peditri. Crniofil. Skull se. INTRODUCTION Lngerhns ells histioytosis (LCH), formerly known s Histioytosis X, is rre disorder of unknown etiology with n nnul inidene of 2.6 to 5.4 ses per hildren in the generl popultion, with pek inidene ourring in hildren etween 1 nd 3 yers old. It my our t ny ge with slight mle predominne (1-8). Ptients my present with solitry or multiple one lesions, or with multisystem involvement. Solitry lesions hve good prognosis nd my even resolve spontneously. The presene of multiple or multisystem lesions my hve severe nd even lethl ourse. Fvr et l. proposed new lssifition, sed on the origin of histioyti disorders nd their iologil ehvior (9) (Chrt 1). LCH ffets the fil ones nd se of the skull in 6% to 27% of ptients (7-14). In review of one histioytosis performed in 480 ptients, the skull nd mxilofil ones were ffeted in 7.5% of ses, exept for the jw, whih hd n inidene of 0.2% (7). In ddition, in review performed t the Myo Clini in 263 ptients (inluding hildren nd dults), the rte of involvement ws 15% for the jw, 6.8% for the orit, 6% for the mxill nd 27% for the skull, without differentiting etween the lvri nd the skull se (8). In n dditionl review of 100 ptients with rnil nd intrrnil mnifesttions of LCH, lesions ourred in the mndile in 15% of ses, in the skull se (temporl nd sphenoid one) in 13% of ses nd in the mxill in 8% (10). Our im hs een to retrospetively review the lotion nd hrteristis of the lesions used y LCH (1) Dignóstio por Resonni Mgnéti S.A (1) Cátedr de Dignóstio por Imágenes, Fultd de Mediin, UNNE. (2) Hospitl Pediátrio Avelino Cstelán, Resisteni, Cho. (3) Hospitl Pediátrio Jun Plo II, Corrientes, Corrientes. Correspondeni: Dr. Dniel Forlino - dnielforlino@gmil.om Reiido: oture 2011; eptdo: oture 2012 Reeived: otoer 2011; epted: otoer 2012 SAR doi: /rrv77n107 RAR - Volumen 77 - Número Págin 1

2 Lngerhns ell histioytosis in peditri ptients in mxillofil ones, skull se, nd lvri, to inlude this ondition into differentil dignoses in peditri ptients. MATERIALS AND METHODS We performed retrospetive review of imging studies otined in 17 peditri ptients (11 oys nd 6 girls) with histopthology dignosis of LCH nd rniofil nd skull se lesions. The men ge ws 3.3 yers (rnge: 1-12 yers) nd ll ptients were evluted y plin rdiogrph (x-ry) nd ontrst-enhned omputed tomogrphy (CT) with helil snner. In 4 ses, volume rendering reonstrutions were performed nd in hlf of these ses findings ould e orrelted with those of one sns. Eight ptients of the series were lso evluted y ontrst-enhned mgneti resonne imging (MRI) using 1.5 T MRI snner. RESULTS Lotions of lesions in our series of ptients re shown in Tle 1. The most ommon ssoition ws the se of the petrous temporl one nd the greter wing of the sphenoid one in 5 ptients (29.4%). Of the totl numer of ptients with rniofil nd skull se involvement, 2 hd solitry one lesions nd 15 hd multiple one lesions; 9 (52%) hd multisystem involvement. Rdiologilly, lesions were osteolyti. In the ute phse, mrgins were smooth, poorly defined, nonsleroti nd of eveled pperne, nd in the hroni phse (or fter tretment) mrgins were sleroti nd quired geogrphi pperne. We rrely oserved smll one isolted frgments within the re of osteolysis, mimiking res of one sequestr s in osteomyelitis. Only mndiulr lesions were ssoited with lminr periostel retion. CT llowed etter visuliztion of one involvement in ntomilly omplex strutures, suh s the fil ones nd the skull se (espeilly the petrous temporl one). The soft tissue omponent of the tumor ppered homogeneous, isodense to musle in ontrst- nd non-ontrst enhned imges. The methylene diphosphonte one sn showed high rdiotrer uptke in the fil ones nd the skull se in ll ptients of our series. However, it ws possile to identify onomitnt lesions in the lvri s photon negtive res. In the MRI, the soft tissue omponent ppered s n heterogeneous nd vrile pttern (hypo-, iso- or hyperintense) on T1-weighted imges, while on T2- weighted imges nd STIR, it ws hyperintense, heterogeneous nd with high uptke of the ontrst gent. Enhnement of neighoring strutures, suh s the dur mter, fsie nd musles ws lso oserved. Diffusion imging, performed in one ptient in the Chrt 1: Histioyti diseses (9). Histioyti diseses Dendriti ell-relted Mrophge-relted Lngerhns ell histioytosis Seondry dendriti ell proesses Juvenile xnthogrnulom nd relted disorders Solitry histioytoms of vrious dendriti ell phenotypes Hemophgoyti syndromes - Primry hemophgoyti lymphohistioytosis - Seondry hemophgoyti syndrome * Infetion-ssoited * Mlignny-ssoited * Rheumti disese-ssoited * Others Rosi-Dorfmn disese (sinus histioytosis with mssive lymphdenopthy) Solitry histioytom with mrophge phenotype Mlignnt disorders Monoyte-relted Leukemis * Monoyti leukemi M5A nd B * Aute myelomonoyti leukemis M4 * Chroni myelomonoyti leukemi Extrmedullry monoyti tumor or srom. Dendriti ell-relted histioyti srom Mrophge-relted histioyti srom Págin 2 RAR - Volumen 77 - Número

3 Dniel Forlino et l. Chrt 2: Usefulness of dignosti imging methods in LCH with rniofil nd skull se involvement. RX CT Identifition of osteolyti lesions. High resolution nd sensitivity for identifition of osteolyti lesions in omplex ntomil res. Identifition of intrrnil nd extrrnil soft tissue tumor omponent. NM Rdiotrer uptke in tive disese (flse negtives: 16-35%). MRI PET/CT Mrked enhnement of soft tissue tumor omponent nd one mrrow infiltrtion fter the intrvenous injetion of gdolinium Assessment of the pituitry stlk, meninges nd rin prenhym Monitoring of tive disese nd response to tretment. Tle 1: Lotion of the LCH lesions in the seventeen ptients evluted. Pt. Nº Age nd Petrous Orits Mndile Mxill Other Multisystem gender temporl nd skull one involvement one se lesions 1 F 2 yers 2 month x M 1 yers 7 month x x Clvri - 3 F 4 yers x Clvri - 4 M 8 yers 2 month x - Lymph nodes 5 F 2 yers x x x x Clvri, spine Lymph nodes, lung, nd long nd liver, spleen nd CNS flt ones 6 M 2 yers x Clvri nd Lymph nodes, liver, spine spleen nd CNS 7 F 2 yers 4 month x x Clvri Lung nd CNS 8 M 2 4 month x Clvri Liver, spleen nd skin 9 M 1 yer x x Clvri, spine Lymph nodes, liver, nd flt ones spleen nd skin 10 M 1 yer x - Lymph nodes, lung nd skin 11 F 1 yer 6 month x x Spine Lymph nodes, lung, liver, spleen, skin nd CNS 12 M 5 yers x x Clvri nd - long ones 13 M 1 yer 9 month x Clvri - 14 F 1 yer x Clvri, spine Lymph nodes nd nd flt ones lung 15 M 2 yers 6 month x x Clvri - 16 M 12 yers x Clvri - 17 M 3 yers x - - RAR - Volumen 77 - Número Págin 3

4 Lngerhns ell histioytosis in peditri ptients series, showed slightly heterogeneous ehvior, with smll restrited diffusion res. The extent of one mrrow involvement, without osteolysis, ws etter doumented with STIR tehniques. Chrt 2 shows the usefulness of dignosti imging methods for rniofil nd skull se LCH. DISCUSSION Monolonl growth of one mrrow-derived Lngerhns ells rpidly progresses from the entrl portion of the one nd expnds nd produes osteolysis of the ortil one or tles of ompt one, oupying neighoring spes nd vities. The higher rte of lesions in the petrous temporl one, sphenoid one nd orits in ptients with multisystem LCH oserved in our series is onsistent with findings from multienter studies reported in the literture (14, 15). The lesions found in the studied popultion re summrized elow, sed on their lotion: Temporl one In greement with our series, temporl one involvement hs een reported in 15-61% of ll peditri ptients with histioytosis during the ourse of multisystem forms (16-18). The most ommon symptom ws otorrhe, with no response to medil tretment. Presenting symptoms lso inlude djent soft-tissue mss or lesions in the externl uditory nl (ezem or rsh), whih my e misleding euse these findings re similr to those of otomstoiditis or otitis of the externl uditory metus, or the middle er, nd therefore dignoses my e delyed. Ptients with lrge lesions hd onduting defness used y uditory ossile hin erosion. None of the ptients hd vertigo, fil nerve prlysis or neurosensoril defness, lthough these symptoms hve een reported in the literture (10). The predominnt imging finding is involvement of the petrous one se with osteolysis of the squm of the temporl one, mstoid, tympni vity, externl uditory nl nd, less frequently, uditory ossile hin erosion. This is ssoited with soft tissue msses, showing homogeneous/heterogeneous pttern on CT nd MRI (Figs. 1 nd 2). This finding hs een oserved in 8 ptients (2 of them with ilterl involvement). Differentil dignosis should inlude otomstoiditis with sess, primry tumor (suh s rhdomyosrom) nd metstsis. Orits nd skull se Ten ptients hd lesions in oritl wlls nd/or the skull se, ut only one orresponded to eosinophili grnulom. All others hd oritl involvement in the ontext of multisystem LCH. Oritl involvement y LCH ounts for 1-2% of ll oritl tumors nd ommonly mnifests s eosinophili grnulom (19, 20). Oritl involvement ours y osteolyti lesions in oritl wlls, espeilly in the roof nd posterolterl wll, with involvement of the greter wing of the sphenoid one. The soft tissue omponent of the tumor extends into the orit with predomi- Fig. 1: One-yer old oy with multiorgn LCH nd msses in the ilterl mstoid region of 2 months durtion. Non-ontrst enhned xil () nd oronl () CT sn otined with one window t the level of the petrous temporl one. Extensive soft tissue msses with mrked osteolysis of the mstoid, middle er nd externl er, with ossile hin erosion nd extension to the temporl squm in oth petrous portions (*). () CT follow-up two yers fter the initition of tretment, with mrked redution of lesions. Págin 4 RAR - Volumen 77 - Número

5 Dniel Forlino et l. d Fig. 2: Sme ptient of figure 1. MRI imges: () T1-weighted xil view, () T2-weighted oronl view. Enlrged lymph nodes in the nek ( ). (í). ()Diffusion, (d) T1-weighted oronl view with ontrst t the level of the petrous temporl one. (*) Heterogeneous soft tissue msses t the se of oth petrous ones, isointense with rin prenhym on T1-, T2- nd diffusion-weighted imges surrounding the rtilginous portion of the externl uditory nl (orse rrow).deformtion of the skin ontour nd displement of the urile.(d) Mrked ontrst-enhnement nd thikening of ilterl durl til in the middle rnil foss ( ). nntly extronl lotion (Figs. 3 nd 4), nd it my invde the extrinsi eye musles nd the lriml glnd, using ompression nd displement of the eyell. It rrely uses infiltrtion of the intronlretroulr spe, surrounding the opti nerve, nd infiltrtes the Inferior oritl fissure nd the infrtemporl foss (15). Osteolysis of the greter wing of the sphenoid one quires "punhed out" eveled pperne on CT. The soft tissue omponent of the tumor grows towrds the middle rnil foss, with durl nd extrdurl lotion, nd durl til. The pperne of lesions on one sn is vrile, depending on osteolsti tivity (Fig. 5). LCH my lso involve the pituitry stlk, with the onsequent syndrome of dietes insipidus in 5% to 50% of ptients (8-15). MRI findings re hrterized y the loss of the spontneous hyperintense signl of the posterior pituitry nd thikening of the pituitry stlk on T1-weighted imges 10, 11, 15). Less frequently, infiltrtion of the rin nd ereellum ours. In our series, 30% of ptients hd dietes insipidus nd none of them hd involvement of the rin prenhym. RAR - Volumen 77 - Número Págin 5

6 Lngerhns ell histioytosis in peditri ptients Fig. 3: Boy ged 8 yers nd 2 months with mss in the outer nd upper mrgin of the left orit, proptosis nd ervil lymphdenopthy. CT imges: () Coronl CT soft-tissue window imge of the orits, without ontrst; () nd () Axil CT one window imge of the oritl roof. (*) Osteolyti lesion of the roof nd lterl wll of left orit, with soft tissue mss isodense to rin prenhym, ompressing nd displing the eyell. Fig. 4: Sme ptient s in Figure 3. Coronl MRI: () T1-weighted imges, () STIR nd () Contrst-enhned, ft-sturted, T1-weighted imges. (*) Heterogeneous nd hyperintense mss on T1- nd T2-weighted imges on the roof nd lterl wll of left orit. The mss enhnes fter ontrst dministrtion, with extrdurl intrrnil lotion. Clinilly, ptients exhiit mss in the oritl mrgin nd upper eyelid with proptosis nd swelling in the temporl region (19-21). Involvement of the ody of the sphenoid nd formen mgnum with osteolysis of the oipitl one is very rre (10) (Figs. 6 nd 7). In this series, it ourred in 3 ptients. The most importnt differentil dignoses re oritl ellulitis with sess, rhdomyosrom, metstti disese from neurolstom, leukemi infiltrtion/lymphom (21-23). Jw nd mxill Jw involvement hs silly two forms: one is the fol osteolyti lesion in the vertil tuulr portions of the mndile, nd in the horizontl portion with resorption of the lveolr ridge, produing the rdiologil pperne of floting teeth (6, 7, 24) (Figs. 8 nd 9). Gingivl leeding nd inflmmtion is one form of linil evidenes. In our series, 3 ptients hd fol Págin 6 RAR - Volumen 77 - Número

7 Dniel Forlino et l. d Fig. 5: Multiorgn LCH. () nd () Child ge 1 yer nd 7 months: () Axil CT one window imge of the orit. Osteolysis of the greter wing of the right sphenoid one of eveled pperne (thin rrows); () Contrst-enhned xil CT of the orit. Thikening nd durl til in the sphenoid one (orse rrows). () nd (d) Another 5-yer-old ptient: () ontrst-enhned CT. Simultneous involvement of the right orit nd left temporl one (*). The ltter shows extrdurl intrrnil extension with no signifint osteolysis ( ). (d) Bone sn: view from the vertex with photon positive res in fil ones ( ) nd photon negtive res in the lvri (*). lesions of the vertil portion nd one ptient showed lveolr ridge resorption (with torpid progress nd loss of lmost ll teeth). Four ptients hd mxillry involvement with ouption of the mxillry sinuses y soft tissue tumor nd wll osteolysis. Lesions my lso invde the nsl vity, zygomti one nd mxillry lveolr ridge (see Fig. 6). Differentil dignoses inlude sinusl or dentl infetions, with osteomyelitis, firodysplsi, hyperprthyroidism, Ewing's srom, metstsis nd leukemi infiltrtion/lymphoms (6). Follow-up of ptients ws performed y CT nd MRI. Bone sn is srely useful euse photon positive res persist fter heling (14, 25, 26). Other imging methods used nd reported in the literture inlude somtostin reeptor sintigrphy using 111In-DTPA-D-Phe1-otreotide, whih depits the tive sites of disese nd thus n help in monitoring the response to tretment (27). Whole-ody mgneti resonne imging is dignosti lterntive for ssessing the extent of skeletl nd extrskeletl lesions of LCH in ptients with multisystem involvement (exept for pulmonry lesions) (26). Positron emission tomogrphy (PET-CT) with fluoro- RAR - Volumen 77 - Número Págin 7

8 Lngerhns ell histioytosis in peditri ptients d Fig. 6: Girl ged 1 yer nd 6 months with multisystem LCH. () Skull profile x-ry, () Axil CT one window imge of the skull se. Extensive osteolyti lesion of the sphenoid one, involving the ody nd right greter nd lesser wings ( ). () Axil CT sn t the level of the mxill. Centrl osteolyti lesion of the right zygomti one (*) nd of the left mxill, with the nsl vity nd sinus eing oupied y soft tissue mss surrounding tooth germs (white rrows). (d) Anterior view of the skull on one sn. Intense uptke of the trer in oth mxille, skull se nd wlls of the right orit ( ). deoxygluose (18 FDG) n detet metolilly tive lesions with uptke vlues (SUV) greter thn 2. It is urrently used for monitoring the response to tretment (11, 23, 25). CONCLUSION Dignosis of LCH should e onsidered in the presene of rniofil nd skull se osteolyti lesions with soft tissue omponents in peditri ptients, ruling out the vrious differentil dignoses ording to topogrphy. Referenes 1. Shmidt S, Eih G, Geoffry A, et l. Extrosseous Lngerhns ell histioytosis in hildren. Rdiogrphis 2008; 28: Lieermn PH, Jones CR, Steinmn RM, et l. Lngerhns ell (eosinophili) grnulomtosis. A liniopthologi study enompssing 50 yers. Am J Surg Pthol 1996; 20: Bhti S, Nesit ME Jr., Egeler RM, Bukley JD, Mertens A, Roison LL. Epidemiologi study of Lngerhns ell histioytosis in hildren. J Peditr 1997; 130: Alston RD, Ttevossin RG, MNlly RJ, Kelsey A, Birh JM, Eden TO. Inidene nd survivl of hildhood Lngerhns ell histioytosis in Northwest Englnd from 1954 to Págin 8 RAR - Volumen 77 - Número

9 Dniel Forlino et l. Fig. 7: One-yer-old girl with multisystem LCH. () CT with 3D reonstrution, posterior view: osteolyti lesion in the oipitl one, involving the posterior mrgin of the formen mgnum (*). () T1-weighted sgittl imge: Hypointense heterogeneous mss in the oipitl one, without intrrnil involvement (*). Fig. 8: Twelve-yer-old oy with multisystem LCH. () nd () Front nd lterl x-ry views of fil ones. Extensive osteolyti mndiulr lesion involving the lveolr ridge with floting teeth pperne ( ). Involvement of mxille is lso oserved. Peditr Blood Cner 2007; 48: Cmpos MK, Vin MB, de Oliveir BM, Rieiro DD, Silv CM. Lngerhns ell histioytosis: 16-yer experiene. J Peditr (Rio J) 2007; 83: Kirks D. Prtil Peditri Imging. Dignosti Rdiology of Infnts nd Children. Phildelphi:Lippinott-Rven; 1998: Stull MA, Krnsdorf MJ, Devney KO. Lngerhns ell histioytosis of one. Rdiogrphis 1992; 12: Kilptrik SE, Wenger DE, Gilhrist GS, Shives TC, Wolln PC, Unni KK. Lngerhns' ell histioytosis (histioytosis X) of one. A liniopthologi nlysis of 263 peditri nd dult ses. Cner 1995; 76: Fvr BE, Feller AC, Puli M, et l. Comtemporry lssifition of histioyti disorders. The WHO Committee On Histioyti/Retiulum Cell Prolifertions. Relssifition Working Group of the Histioyte Soiety.Med Peditr Onol 1997; 29: D'Amrosio N, Soohoo S, Wrshll C, Johnson A, Krimi S. Crniofil nd Intrrnil Mnifesttions of Lngerhns Cell Histioytosis: Report of Findings in 100 Ptients. AJR Am J Roentgenol 2008; 191: Hoover KB, Rosenthl DI, Mnkin H. Lngerhns ell histioytosis. Skeletl Rdiol : RAR - Volumen 77 - Número Págin 9

10 Lngerhns ell histioytosis in peditri ptients Fig. 9: Six-yer-old oy with mndiulr eosinophili grnulom: () Coronl CT one window imge t the level of the vertil portion of the mndile; () CT with 3D reonstrution of fil ones, right lterl view. (*) Osteolyti lesion of the right vertil portion of the mndile, with soft tissue mss, extending towrds the msseter musle with lminr periostel retion ( ). 12. Howrth DM. Gilhrist GS, Mulln BP, Wisemn GA, Edmonson JH, Shomerg PJ. Lngerhns ell histioytosi: dignosis, nturl history, mngement, nd outome. Cner 1999; 85: Wng J, Wu X, Xi ZJ. Lngerhns ell histioytosis of one in hildren: A liniopthologi study of 108 ses. World J Peditr 2010; 6: Imshuku S, Kinugw N, Mtsuzki A, et l. Lngerhns ell histioytosis whit multifol one lesions: omprtive linil fetures etween single nd multi-systems. Int J Hemtol 2009; 90: Demerel P, Vn Gool S. Peditri neurordiologil spets of Lngerhns ell histioytosis. Neurordiology 2008; 50: Fernández-Ltorre F, Menor-Serrno F, Alonso-Chrterin S, Aren-Jiménez J. Lngerhns s ell histioytosis of the temporl one in peditri ptients. Imging nd follow-up. AJR Am J Roentgenol 2000; 174: MCffrey TV, MDonld TJ. Histioytosis X of the er nd temporl one: review of 22 ses. Lryngosope 1979; 89: Goldsmith AJ, Myssiorek D, Vlderrm E, Ptel M. Unifol Lngerhns' ell histioytosis (eosinophili grnulom) of the petrous pex. Arh Otolryngol Hed Nek Surg 1993; 119: Iuresi AC, Rendo J, Luengo Gimeno F, Mnzitti J. Mnifestiones oulres de l histioitosis de éluls de Lngerhns: Revisión de 40 sos. Oftlmol Clin Exp 2007; 1: Krmer TR, Noeker RJ, Miller JM, Clrk LC. Lngerhns ell histioytosis with oritl involvement. Am J Ophthlmol 1997; 124: Khnn G, Sto Y, Smith RJ, Bumn NM, Nerd J. Cuses of fil swelling in peditri ptients: orreltion of linil nd rdiologi findings. Rdiogrphis 2006; 26: Chung EM, Smirniotopoulos JG, Speht CS, Shroeder JW, Cue R. From the rhives of the AFIP: Peditri orit tumors nd tumorlike lesions: nonosseous lesions of the extroulr orit. Rdiogrphis 2007; 27: Chung EM, Murphey MD, Speht CS, Cue R, Smirniotopoulos JG. Peditri orit tumors nd tumorlike lesions: osseous lesions of the orit. Rdiogrphis 2008; 28: Meyer JS, Hrty MP, Mhouhi S, et l. Lngerhns ell histioytosis: presenttion nd evolution of rdiologi findings whit linil orreltion. Rdiogrphis 1995; 15: Kste SC, Rodriguez-Glindo C, M Crville ME, Shulkin BL. PET-CT in peditri Lngerhns ell histioytosis. Peditr Rdiol 2007; 37: Goo HW, Yng DH, R YS, et l. Whole-ody MRI of Lngerhns ell histioytosis: omprison with rdiogrphy nd one sintigrphy. Peditr Rdiol 2006; 36: Lstori S, Montell L, Ctlno L, Rotoli B, Muto P, Plmieri G. Funtionl imging of Lngerhns ell histioytosis y (111) In-DTPA-D-Phe(1)-otreotide sintigrphy. Cner 2002; 94: The uthors delre no onflits of interest. Págin 10 RAR - Volumen 77 - Número