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The presence of circulating cells with the mutation conferred a twofold increased risk of relapse.

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LCH cells, known for many years to be caused by a clonal proliferation, have now been shown to likely derive from a myeloid precursor whose proliferation is uniformly associated with activation of the MAPK/ERK signaling pathway.[4,5] However, the somatic mutation leading to the activation varies and is unknown in 10% to 20% of cases.[6] In the original breakthrough description of the V600E mutation occurring in approximately 60% of LCH biopsy specimens, the authors also described activation of the RAS-RAF-MEK-ERK pathway in almost all cases, regardless of stage and organ involvement.[7,8] Since then, activating mutations in several other genes in the pathway have been identified in a significant percentage of .[9-11] In accordance with these findings, the pathologic histiocyte or LCH cell has a gene expression profile closely resembling that of a myeloid dendritic cell.Studies have also demonstrated that the V600E mutation can be identified in mononuclear cells in peripheral blood and cell-free DNA, usually in patients with disseminated disease.[3,12,13] This shows that multisystem LCH arises from a somatic mutation within a marrow or circulating precursor cell, while localized disease arises from the mutation occurring in a precursor cell at the local site.[3] The above findings have led all clinicians to agree that LCH is a myeloid neoplasm; however, discussion remains about whether it is a malignant neoplasm with varying clinical behavior.(Refer to the Cytogenetic and Genomic Studies and Cytokine Analysis by Immunohistochemical Staining and Gene Expression Array Studies sections of this summary for more information.) LCH may involve a single organ (single-system LCH), which may be a single site (unifocal) or involve multiple sites (multifocal); or LCH may involve multiple organs (multisystem LCH), which may involve a limited number of organs or be disseminated.Involvement of specific organs such as the liver, spleen, and hematopoietic system separates multisystem LCH into a high-risk group and a low-risk group, where risk indicates the risk of death from disease.LCH cells stain positively with antibodies to S100, CD1a, and/or anti-Langerin (CD207).

Staining with CD1a or Langerin confirm the diagnosis of LCH, but care should be taken to correlate with clinical presentation in organs in which normal LC cells occur.[9] Because LCH cells activate other immunologic cells, LCH lesions also contain other histiocytes, lymphocytes, macrophages, neutrophils, eosinophils, and fibroblasts, and may contain multinucleated giant cells.

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Modern classification of the histiocytic diseases subdivides them into dendritic cell–related, monocyte/macrophage-related, or true malignancies.

Langerhans cell histiocytosis (LCH) is a dendritic cell disease.[1,2] Comprehensive gene expression array data analysis on LCH cells is consistent with the concept that the skin Langerhans cell (LC) is not the cell of origin for LCH.[3] Rather, it is likely to be a hematopoietic progenitor cell before being a committed myeloid dendritic cell, which expresses the same antigens (CD1a and CD207) as the skin LC.[4,5] This concept was further supported by reports that the transcription profile of LCH cells was distinct from myeloid and plasmacytoid dendritic cells, as well as epidermal LCs.[3,4,6,7] The Langerhans histiocytosis cells in LCH lesions (LCH cells) are immature dendritic cells making up fewer than 10% of the cells present in the lesion.[7,8] These cells are classically large oval cells with abundant pink cytoplasm and a bean-shaped nucleus on hematoxylin and eosin stain.

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