Adult Orbital Xanthogranulomatous Disease

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1 Adult Orbital Xanthogranulomatous Disease Evening Specialty Conference: Ophthalmic Pathology Sunday, March 22, 2015 Lynn Schoenfield Associate Professor, Ohio State University Wexner Medical Center

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3 No financial disclosures

4 Goals Be familiar with the rare entity of Adult orbital xanthogranulomatous disease (AOXGD) Know the 4 subtypes List the differential diagnosis Know what clinical and histopathologic/immunohistochemical features are important in the diagnosis

5 Case 46 year old male with 9 year history of diplopia, proptosis, and papilledema Orbit MRIs: diffuse intraconal masses with encasement of optic nerves bilaterally, L>R Brain MRI: non-specific lesions, particularly involving the brain stem PMH: Malignant melanoma of right shoulder 2 years prior (in 2011) with previous dysplastic nevi in various locations Pericardial effusion Renal function deteriorating Denies bone pain

6 Case - PMH Dyslipidemia Hypertension Obesity

7 Laboratory findings HgB = 10.4 g/dl Serum protein = 6.1 g/dl BUN = 39 mg/dl, Creatinine = 1.97 mg/dl, Estimated GFR decreased Calcium = 9.9 mg/dl ALT = 8 U/L Cholesterol = 212 mg/dl, Triglycerides = 479 mg/dl Normal immunoglobin levels; specifically normal IgG4 No paraproteinemia

8 Histopathology

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11 Histopathology Pertinent Immunohistochemical Stains Negative for S-100 CD1a MelanA AE1/3 CD3 and CD20 (kappa and lambda light chains showed polyclonal population) Only occasional IgG4 positive plasma cells

12 Histiocytic Disorders (Histiocyte Society Writing Group 1987) Class I: Langerhans cell histiocytosis histiocytosis X spectrum Class II: Histiocytoses of mononuclear phagocytes other than Langerhans cells Class III: Malignant histiocytic disorders

13 Adult orbital xanthogranulomatous disease (AOXGD) Type II - Non-Langerhans type of histiocytosis Rare and poorly understood heterogeneous group of syndromes

14 AOXGD Age range: (usually middle age) No sex preference, except for Erdheim Chester disease (male>female, 3:1) Clinically: Bilateral firm, indurated, rubbery, yellow masses: subcutaneous, subconjunctival, or periocular CT scan demonstrating preseptal anterior or diffuse intraconal orbital infiltration

15 ECD

16 AOXGD: 4 Subtypes Adult onset xanthogranuloma (AOX) Adult onset asthma and periocular xanthogranuloma (AAPOX) Necrobiotic xanthogranuloma (NBX) Erdheim-Chester disease (ECD)

17 Histopathology Sheets of foamy histiocytes (xanthoma cells) Fibrosis Touton giant cells Dispersed aggregates of lymphocytes Necrobiosis of collagen (in necrobiotic xanthogranuloma)

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21 Histopathology Xanthoma cells: cytoplasm positive for lipid stains (Oil red-o or adipophilin Lack atypia and high mitotic rate (or Ki- 67) Positive by IHC for CD68, CD163, XIIIa Negative for CD1a and usually S-100 Negative for IHC markers for melanoma, carcinoma, etc.

22 Adult onset xanthogranuloma (AOX) Solitary lesion Adult onset juvenile xanthogranuloma (JXG) of the orbit No systemic findings

23 Adult onset asthma and periocular xanthogranuloma (AAPOX) Syndrome described by Jakobiec et al in 1993 based on small number of cases In addition to asthma, patients may have lymphadenopathy and increased IgG levels (polyclonal)

24 Necrobiotic xanthogranuloma (NBX) Subcutaneous skin lesions in eyelids and anterior orbit (and sometimes throughout body or internally) Skin lesions have strong propensity to ulcerate and then become fibrotic Frequent systemic findings: Paraproteinemia and multiple myeloma

25 NBX

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27 Erdheim Chester disease (ECD) Most devastating subtype Dense, progressive fibrosclerosis of orbit and internal organs Bone involvement common Mediastinum, pericardium, pleura, retroperitoneum, and perinephric region

28 Erdheim-Chester Disease Frequency of clinical and radiologic features: Bone pain (50%) Periaortic infiltration (60%) Pericardial involvement (45%) Exophthalmos (27%) Diabetes insipidus (27%) Xanthelasma (19%) Hairy kidney appearance on CT CNS involvement (15-25%) Pulmonary involvement (22%) Death (60%)

29 Orbital involvement in AOXGD Anterior orbit/adnexal: AOX AAPOX NBX Diffuse or intraconal orbit: ECD

30 Differential Diagnosis Adult xanthogranulomatous disease Langerhans histiocytosis Extranodal Rosai-Dorfman disease Inflammatory pseudotumors including inflammatory myofibroblastic tumor and IgG4 related sclerosing disease Juvenile xanthogranuloma (JXG) Lymphoma RA Sarcoid Infection Melanoma Metastatic carcinoma

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45 Diagnosis May not be apparent until the disease process evolves Sometimes overlap of subtypes as well as syndromes (ECD with LCH or ECD with Rosai-Dorfman disease)

46 Erdheim-Chester Disease Treatment: Interferon α Cyclophosphamide Vemurafenib (BRAF inhibitor) in severe multisystem disease when BRAF V600E mutation exists Steroids

47 Recent update on patient s condition Treated with cyclophosphamide and prednisone FDG PET/CT: soft tissue prominence around origin of great vessels and pericardium, as well as around kidneys; also increased FDG uptake of long bones Stroke/Carotid artery stenosis

48 Summary AOXGD is a non-langerhans type of xanthogranulomatous disease (type II), typically affecting middle age adults May or may not be part of systemic disease Several disease entities should first be ruled out (metastasis, melanoma, inflammatory processes, etc.) Histopathologic findings alone cannot be used alone to subclassify the 4 subtypes (except perhaps if necrobiosis is present) Clinical correlation required because of the nonspecific findings

49 References 1. Guo J and Wang J. Adult orbital xanthogranulomatous disease. Arch Pathol Lab Med. 2009;133: Sivak-Callcott JA, Rootman J, Rasmussen SL, et al. Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review. Br J Ophthalmol. 2006;90: Haroche J, Arnaud L, Cohen-Aubart F, Hervier B, Charlotte F, Emile JF, Amoura Z. erdheim-chester disease. Curr Rheumatol Rep. 2014;16: Dalia S, Jaglal M, chervenick P, Cualing H, Sokol L. Clinicopathologic characteristics and outcomes of histiocytic and dendritic cell neoplasms: The Moffitt Cancer Center experience over the last twenty five years. Cancers 2014;6: Jakobiec FA, Mills MD, Hidayat AA, et al. Periocular xanthogranulomas associated with severe adult-onset asthma. Trans Am Ophthalmol Soc. 1993;91: Chapman PB, Hauschild A, Robert C, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. 2011;364: Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy. A newly recognized benign clinicopathological entity. Arch Pathol. 1969;87: Vemuganti GK, Naik MN, Honavar SG. Rosai Dorfman disease of the orbit. Journal of Hematology and Oncology. 2008; Yalan B, Huo Z, Meng Y, Wu H, Yan J, Zhou Y, Liu X, Song L. Extranodal Rosai-Dorfman disease involving the right atrium in a 60 year old male. Diagnostic Pathology 2014;9: Foucar E, Rosai J, Dorfman RF. The ophthalmologic manifestations of sinus histiocytosis with massive lymphadenopathy. Am J Ophthalmol. 1979;87: Sanchez R, Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy. An analysis of 113 cases with special emphasis on its extranodal manifestations. Lab Invest. 1977;36: Foucar E, Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): Review of the entity. Semin Diagn Pathol 1990;7: Yamamoto H, Yamaguchi H, Aishima S, Oda Y, Kohashi K, Oshiro Y, Tsuneyoshi M. Inflammatory myofibroblastic tumor versus IgG4-related sclerosing disease and inflammatory pseudotumor. A comparative clinicopathologic study. Am J Surg Pathol. 2009;9:

50 Thank you?

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