title: Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review.
abstract: OBJECTIVE
  Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.
  
  
  METHODS
  22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.
  
  
  RESULTS
  137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.
  
  
  CONCLUSIONS
  Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.
authors.affiliation: Department of Ophthalmology, West Virginia University Eye Institute, Morgantown, 26505, USA. jsivak@hsc.wvu.edu
authors.forename: J A
authors.initials: JA
authors.lastname: Sivak-Callcott
authors.forename: J
authors.initials: J
authors.lastname: Rootman
authors.forename: S L
authors.initials: SL
authors.lastname: Rasmussen
authors.forename: R A
authors.initials: RA
authors.lastname: Nugent
authors.forename: V A
authors.initials: VA
authors.lastname: White
authors.forename: D
authors.initials: D
authors.lastname: Paridaens
authors.forename: Z
authors.initials: Z
authors.lastname: Currie
authors.forename: G
authors.initials: G
authors.lastname: Rose
authors.forename: B
authors.initials: B
authors.lastname: Clark
authors.forename: A A
authors.initials: AA
authors.lastname: McNab
authors.forename: F V
authors.initials: FV
authors.lastname: Buffam
authors.forename: J M
authors.initials: JM
authors.lastname: Neigel
authors.forename: M
authors.initials: M
authors.lastname: Kazim
mesh_terms: D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D000368:Aged; D000369:Aged, 80 and over; D001249:Asthma / Q000150:complications / Q000378:metabolism; D005128:Eye Diseases / Q000175:diagnosis* / Q000378:metabolism; D005260:Female; D006099:Granuloma / Q000175:diagnosis* / Q000378:metabolism; D006801:Humans; D007150:Immunohistochemistry / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D009916:Orbital Diseases / Q000175:diagnosis* / Q000378:metabolism; D014057:Tomography, X-Ray Computed; D014973:Xanthomatosis / Q000175:diagnosis* / Q000378:metabolism