What is the role of chemotherapy in the treatment of Langerhans cell histiocytosis (LCH)?

Updated: Sep 16, 2020
  • Author: Cameron K Tebbi, MD; Chief Editor: Vikramjit S Kanwar, MBBS, MBA, MRCP(UK), FAAP  more...
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Most chemotherapy agents for the treatment of Langerhans cell histiocytosis are used in combination. The length of therapy is arbitrarily chosen. In some studies, patients were stratified by risk factor. [310] Use of a combination of cytarabine arabinoside (Ara-C), vincristine, and prednisolone to treat disseminated Langerhans cell histiocytosis with organ dysfunction has been reported.

In a study of 18 pediatric patients with Langerhans cell histiocytosis and multiorgan involvement, 8 had additional organ dysfunction; 8 of 10 patients with organ involvement achieved complete remission. [311] Five of 8 patients with additional dysfunction achieved complete remission. Four (22%) of 18 patients developed diabetes insipidus. Two with organ dysfunction died at the time of the report. The regimen was described as being mildly toxic and relatively well tolerated. In this regimen, cytarabine (100 mg/m2/d for 4 consecutive days), vincristine (1.5 mg/m2 on day 1), and prednisone (40 mg/m2/d for 4 wk followed by 20 mg/m2 for 20 d) were administered. The combination of vincristine and cytarabine was repeated every other week for 4 weeks. Thereafter, the interval was extended by 1 week until this combination was administered every 6 weeks, until complete remission was achieved (4-16 wk).

In a multicenter study in 1983-1988, Italian investigators assigned 70 patients with biopsy-proven Langerhans cell histiocytosis into good-prognosis or poor-prognosis groups, depending on their organ dysfunction. [312] Sixteen patients with limited disease were treated with surgery alone, 5 received immunotherapy with thymus extract then chemotherapy, and 49 patients received chemotherapy with vinblastine (5.5 mg/m2/wk for 3 mo).

Poor responders in this group were then treated with doxorubicin (20 mg/m2 intravenously for 2 d every 3 wk for 3 mo). Patients who did not improve with this regimen were administered etoposide (200 mg/m2 intravenously) for 3 consecutive days every 3 weeks for at least 3 months or until their disease progressed.

The poor-prognosis group (11 patients) received doxorubicin (20 mg/m2 on days 1 and 2), prednisone (40 mg/m2 by mouth on days 1-29), vincristine (1.5 mg/m2 intravenously once a week for 4 wk starting on day 8), and cyclophosphamide (400mg/m2 on days 15 and 29 for 9 courses).

Only 1 of 10 patients with good prognosis had a favorable response during therapy with thymus extract. Of 54 patients receiving chemotherapy (49 as first-line treatment), 34 achieved complete remission with vinblastine, and 8 had a recurrence after 4-22 months. Of 15 patients achieving remission with etoposide, 1 had a relapse 10 months after therapy. In 11 patients with poor prognoses, 7 had progressive disease, and 6 died within 9 months of diagnosis. Organ dysfunction appeared to significantly affect survival, with only 46% of patients surviving for 12 months. The main complication was diabetes insipidus, which occurred in 20% of patients. The overall incidence of disease-related disabilities was 48%.

In the Austrian and German DAL-HX 83/90 study, patients were stratified into 3 groups: those with multifocal bone disease (group A), those with soft-tissue involvement but without organ dysfunction (group B), and those with organ dysfunction (group C). [310] Induction therapy consisted of etoposide (60 mg/m2/d for 5 d on days 1-5, followed by weekly dosing of 150 mg/m2), prednisone (40 mg/m2 on days 1-28), and vinblastine (6 mg/m2 starting at week 3 of therapy). Maintenance therapy was risk related and consisted of vinblastine, 6-mercaptopurine, and prednisone in all patients, with etoposide added in group B and methotrexate and etoposide added in group C. Mortality rates for groups A, B, and C were 8%, 9%, and 38%, respectively.

An organized international approach to LCH has been successful. [45, 283, 313] Using the Histiocyte Society’s Langerhans cell histiocytosis I protocol, [314, 282] investigators prospectively and randomly assigned patients with multisystemic Langerhans cell histiocytosis who met criteria based on standard diagnostic evaluation. [62] Patients received vinblastine (6 mg/m2 intravenously weekly for 24 wk) or etoposide (150 mg/m2 intravenously on 3 consecutive days every 3 wk for 24 wk). All patients received methylprednisolone (30 mg/kg intravenously for 3 consecutive days [maximum daily dose of 1 g]). Of the 447 patients who were registered from various countries, 192 had multisystemic disease, and 136 were randomly assigned (72 to the vinblastine arm and 64 to the etoposide arm).

Patients were evaluated at predetermined intervals. Responses at 6 weeks appeared to differentiate responders from nonresponders, who had poor outcomes. Neither the patients’ ages nor the number, type, or dysfunction of the organs differentiated the groups. At 6 weeks, 51 (50%) of 103 patients achieved a complete response or substantial disease regression, whereas 32 (31%) had stable disease or partial or mixed responses. Disease progression was reported in 19 patients. At 26 months, the mortality rate was 18%. Among the patients who died, 4 had an initial response, 5 had intermediate responses, and 9 had initial nonresponses.

The protocol allowed nonresponders to switch to another treatment arm. Only 34% of patients who had switched had favorable results. Disease recurrence was observed in 11 patients who received vinblastine and in 8 who received etoposide. The 2 arms were statistically similar in terms of initial responses, recurrences, and mortality rates. The overall probability of diabetes insipidus was 42%.

The randomized Langerhans cell histiocytosis II study of the Histiocyte Society was performed to compare the effects of oral prednisone with vinblastine (with or without etoposide) in patients with multisystemic disease. Patients were divided into low- or high-risk groups. All patients received prednisone (40 mg/m2/d for 28 d with weekly reduction afterward) and vinblastine (6 mg/m2 intravenously weekly for 6 wk). The low-risk group received continuation therapy with vinblastine (6 mg/m2 during weeks 9, 12, 15, 18, 21, and 24), as well as 5-day pulses of prednisone during the same weeks. Patients in the low-risk group were excluded from randomization.

Patients in the high-risk group were randomly assigned to treatment A or B. Treatment consisted of an initial 6 weeks of therapy with prednisolone and weekly vinblastine and continuation therapy, pulses of vinblastine and/or oral prednisone as in the low-risk group, and daily doses of 6-mercaptopurine (50 mg/m2 during weeks 6-24). Treatment B was the same as treatment A, with the addition of etoposide (150 mg/m2 administered on day 1 of weeks 9, 12, 15, 18, 21, and 24). Results of this protocol have not yet been published.

The Langerhans cell histiocytosis III study of the Histiocyte Society indicated that in children with multi-system Langerhans cell histiocytosis, the use of intense, prolonged initial treatment can produce an overall 5-year survival rate of 84%. High-risk patients in the study underwent 12 months of treatment, receiving one or two 6-week courses of chemotherapy and a subsequent course of milder continuation therapy, with the first 12 weeks of treatment appearing to be critical to patient outcomes. [315]

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