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PubMed2003

Preoperative evaluation of lymph node metastasis in esophageal cancer.

Lymph node metastasis (LMN) in esophageal cancer occurs from the superficial cancer and spreads wildly from the neck to the abdomen. Hence precise determination of LMN is essential when adequate treatments are employed. There are several reports about ultrasonic features of malignant lymph nodes (LNs), and in summary, reports of endoscopic ultrasonography (EUS) findings of malignant LNs showed they were more than 5-10 mm in diameter, with a distinct border, hypoechoic internal echo and round shape. Sensitivity, specificity and accuracies for the diagnosis of malignant LNs by EUS were 49-99%, 33-99% and 71-96%. The rates widely varied, because the accuracy of EUS's ability to determine malignancy were based on the evaluation of various echo features of LNs, and were dependent on the judgement of subjective observers. Therefore histological analysis is necessary for adequate treatments. Endoscopic ultrasonography guided fine-needle aspiration cytology (EUS-FNA) has been performed for the diagnosis of malignant LNs since 10 years. Results of those reports were sensitivity 81-97%, specificity 83-100% and accuracy 83-97%. EUS-FNA staging was better than EUS staging. Also clinically obvious complications by EUS-FNA have not been reported. Therefore published evidence showed that EUS-FNA is safe and useful for confirmation of malignant LNs.

Biopsy, Needle↗

PubMed2004

The value of sentinel lymph node biopsy in elderly breast cancer patients.

BACKGROUND: Although sentinel lymph node biopsy has been accepted as a useful procedure for certain breast cancer patients, the value of this procedure in the elderly remains unknown. We undertook this study to evaluate changes in adjuvant treatment attributable to sentinel lymph node biopsy. METHODS: A total of 104 patients > or =65 years underwent sentinel lymph node biopsy plus lumpectomy or mastectomy for the treatment of clinically node-negative invasive breast cancer. Demographic, pathologic, and treatment data were evaluated using an SAS software package (SAS, Cary, North Carolina). RESULTS: Twenty-nine of 104 patients (28%) had metastatic disease in > or =1 sentinel lymph node. Nonsurgical treatment was modified in 38% of patients because of sentinel lymph node biopsy results. Changes included adjuvant chemotherapy and/or hormonal therapy, adjuvant axillary radiotherapy, and decisions against adjuvant therapy. CONCLUSIONS: These data suggest that sentinel lymph node biopsy in elderly breast cancer patients is beneficial.

Aged↗

PubMed1995

Management of lymph node metastases in breast cancer and gastric cancer.

The management of regional lymph node metastases in breast cancer and gastric cancer is reviewed. Regional lymph node metastasis is a critical prognostic factor in these diseases, but there is an apparent discrepancy in the efficacy of regional lymph node dissection between them. A number of prospective randomized clinical trials have demonstrated that regional lymph node dissection improves the regional control of breast cancer, but does not improve the survival. On the other hand, only retrospective or prospective comparative studies have shown that extended lymph node dissection significantly improves the survival in gastric cancer. Although the discrepancy in the regional lymph node dissection between breast and gastric cancers has been explained by differences in their biological behaviors, caution must still be exercised in drawing conclusions from these norandomized studies.

Breast Neoplasms↗

PubMedDate not supplied

[Lymph node evaluation in colorectal cancer].

BACKGROUND: In Brazil, colorectal carcinoma is the third cause of death by malignant tumors among women, and the fifth among men. Lymph node involvement is one of the most relevant prognostic maker in these tumors. AIM: To study lymph node involvement in colorectal carcinoma in relationship to biological behavior and tumor location. PATIENTS AND METHODS: One hundred and eight five colorectal carcinoma cases were studied. Lymph node involvement was analyzed according to tumor location, diameter, vessel invasion, and TNM staging. RESULTS: Three thousand nine hundred and six lymph nodes were harvested in 185 patients (21.1 lymph nodes/patient). Metastasis were detected in 399/2,573 peritumoral lymph nodes (15.5%) and in 72/1,333 non-peritumoral lymph nodes (5.4%). Eighty-six patients presented metastasis; in these patients 471/1942 lymph nodes were compromised. In 26 patients peritumoral and non-peritumoral lymph nodes were involved; in 57 cases metastasis were detected only in peritumoral lymph nodes and in 3, only non-peritumoral lymph nodes were involved. The number of lymph node was higher among cecal tumors and smaller in the rectum and sigmoid. There was a positive correlation between the number of metastatic lymph node and pT, tumor diameter and lymphatic and venous invasion; there was a negative correlation between lymph node involvement and lymphocytic response; pN was significantly associated with pT. CONCLUSIONS: Colorectal carcinoma involves preferentially peritumoral lymph node, but in 29 patients (15,7%) non-peritumoral lymph nodes were affected, which is important for tumor staging and prognosis. pN and the number of metastatic lymph nodes were associated with other behaviour markers.

Colorectal Neoplasms↗

PubMedDate not supplied

The role of sentinel lymph node biopsy with blue dye alone in breast cancer patients with excisional biopsy.

PURPOSE: Sentinel lymph node biopsy (SLNB) appears to offer an excellent alternative method to routine axillary lymph node dissection for staging patients with breast cancer. The aim of this study is to evaluate the effect of excisional biopsy on identification and false negative rate of sentinel lymph node biopsy with blue dye alone in breast cancer patients with clinically negative axilla. MATERIAL AND METHODS: From March 1998 to March 2003, 266 consecutive sentinel lymph node biopsies (SLNB) were performed using isosulfan blue dye alone. Patients were divided into two groups. One hundred and four patients (39.1%) had previously undergone an excisional biopsy (Group I); in 162 patients (60.9%), pre-operative diagnosis was obtained by either fine-needle aspiration biopsy (FNAB) or core biopsy (Group II). Following sentinel lymph node biopsy, all patients had axillary lymph node dissection (ALND). Data concerning patients, sentinel lymph nodes and the status of the axilla were collected and compared using Fisher's exact test. A p value of less than 0.05 was considered statistically significant. RESULTS: The sentinel lymph node was successfully identified by blue dye in 94.3% (251/266) of patients. Mean lymph nodes removed from the axilla was 19 (range 11-36) and the mean number of sentinel nodes was 2 (range 1-5). The identification and false negative rate were unrelated to size, type or location of the tumour, or a previous surgical biopsy. CONCLUSIONS: SLNB with blue dye for evaluation of the axilla is a rapid and accurate technique that provides increased efficacy in the detection of lymphatic metastasis when careful pathologic evaluation with serial sections is performed. The risk-benefit analysis of lymphatic mapping with blue dye provides improvement in staging, with reduced morbidity and hospital stay, and the elimination of general anaesthesia. The technique may also be used safely and accurately in breast cancer patients with excisional biopsy.

Biopsy, Needle↗

PubMed1983

[Early ultrastructural findings on lymph node sinuses].

Submandibular and mesenteric lymph nodes of Chiroptera (Rinolophus f.e. and Pipistrellus p.) display a marginal sinus, located between the capsule and the cortical parenchima. There are also trabecular sinuses, which deepen in both the cortical and paracortical zones and medullary sinuses in the zona medullary. All the above mentioned sinuses are made up of a distinct endothelial cell wall lying on a variably thick layer of amorphous substance and collagen fibers. Moreover, the endothelial subcapsular wall of the marginal sinus and the endothelium lying the connective tissue septa form a continuous layer, whereas the endothelium adjacent to the parenchima in the marginal, trabecular and medullary sinuses exhibits and interrupted course, so as to allow a free to and from passage of cells between the parenchimal and sinus compartments. The Authors also compare the ultrastructural features of the lymph node sinuses in Chiroptera with those of other mammals including man.

Animals↗

PubMed2000

Lymphatic mapping and sentinel lymph node biopsies.

Once melanoma cells leave the skin and travel to the lymph nodes, they have metastasized, thereby reducing chances for the patient's long-term, disease-free survival. Methods for tracing and removing lymph nodes include elective lymph node dissection, lymphoscintigraphy, and sentinel lymph node biopsy. This article reviews the concepts, procedures, and effectiveness of these techniques.

Disease-Free Survival↗

PubMed2000

Morphometric analysis of regional lymph nodes with and without metastasis from early gastric carcinoma.

BACKGROUND: To the authors' knowledge detailed morphometric changes in lymph nodes with and without metastasis in patients with early gastric carcinoma remain undocumented. METHODS: Histologic slides of 1847 lymph nodes dissected from 115 consecutive patients who underwent gastrectomy for early gastric carcinoma were examined histologically and measured using computer morphometry with the public domain National Institutes of Health Image program. Quantitative data were analyzed in relation to preoperative and intraoperative clinical assessments and postoperative pathologic diagnosis. RESULTS: Metastasis was found in 11 lymph nodes (0.6%) from 8 patients (7.0%). Metastatic lymph nodes showed a mean maximum dimension of 4.8 mm, a mean area of 14.4 mm(2), and a mean ratio of maximum/minimum dimension of 1.36; the corresponding values for nonmetastatic lymph nodes were 4.7 mm (P = 0.45), 13.2 mm(2) (P = 0. 13), and 1.66 (P = 0.10), respectively. The lymph node with a metastasis was not necessarily the largest of the dissected lymph nodes from each patient, and histologically each lymph node with a metastasis showed pericancerous fibrosis in > 10% of its area. The sensitivities of preoperative computed tomography, abdominal ultrasonography (US), endoscopic US, and intraoperative assessments to diagnose metastasis were 0%, 13%, 0%, and 13%, respectively, and the sensitivities of these modalities to detect lymph nodes > 10 mm in dimension were 18%, 10%, 3%, and 10%, respectively. CONCLUSIONS: Digital quantitative analysis is useful and widely applicable to clinicopathologic evaluation. The diagnostic sensitivity of lymph node metastasis in patients with early gastric carcinoma in the current study was very low with preoperative and intraoperative assessments because lymph node metastases were small and showed subtle histologic changes of pericancerous fibrosis.

Adult↗

PubMed1996

Bony landmarks are not an adequate substitute for lymphangiography in defining pelvic lymph node location for the treatment of cervical cancer with radiotherapy.

PURPOSE: Curative radiotherapy (RT) for carcinoma of the cervix requires adequate irradiation of regional lymph node groups. The best nonsurgical method of defining lymph node anatomy in the pelvis remains the lymphangiogram (LAG). This study was designed to determine if bony landmarks could accurately substitute for LAG as a means of determining lymph node position for the purpose of pelvic RT treatment planning. METHODS AND MATERIALS: The post-LAG simulation films of 22 patients treated at the Fox Chase Cancer Center for cervical cancer were examined. On anterior/posterior (A/P) simulation films, the distance of lymph nodes was determined from the top, middle, and bottom of the sacroiliac joint, and at the pelvic rim, 1 and 2 cm above the acetabulum. On lateral (LAT) simulation films, lymph node position was measured at points 0, 4, and 8 cm along a line from the bottom of L5 to the anterior aspect of the pubic symphysis. Positive values represent lateral and anterior distances relative to the reference point on A/P and LAT films, respectively. Negative values represent distances in the opposite direction. The adequacy of standard pelvic fields as defined by the Gynecologic Oncology Group (GOG) (A/P: 1.5 cm margin on the pelvic rim; LAT field edge is a vertical line anterior to the pubic symphysis) was also examined. Data are expressed as the mean +/- two standard deviations, (i.e. 95% confidence level). RESULTS: On A/P simulation films, the distance of visualized lymph nodes had mean values of -1.6 +/- 1.7 cm (range -4.1 to -0.4 cm), -1.3 +/- 1.5 cm (range -3.4 to 0.0 cm), and 1.2 +/- 1.8 cm (range -1.0 to 2.6 cm) from the sacro-iliac (SI) joint at the superior, middle, and inferior points, respectively. The mean distance of the nodes from the pelvic rim at points 1 and 2 cm above the acetabulum was 0.3 +/- 1.2 cm (range -0.6 to 1.8 cm) and 0.2 +/- 1.8 cm (range -1.6 to 2.1 cm), respectively. On LAT simulation films, the distance of lymph nodes from points 0, 4, and 8 cm from the previously described reference line had mean values of 2.0 +/- 1.0 cm (range 1.3 to 3.0 cm), 0.9 +/- 3.9 cm (range -1.9 to 5.1 cm), and 1.8 +/- 2.1 cm (range -0.8 to 3.5 cm), respectively. Ten of 22 (45%) patients would have had inadequate nodal irradiation if their fields had been designed according to standard GOG parameters. In all cases, these incompletely irradiated lymph nodes were from the lowest of the lateral external iliac group. CONCLUSION: Great variability in pelvic lymph node location is demonstrated when LAG is used to directly visualize their location. Bony structures are inaccurate landmarks for pelvic lymph node position. The GOG standard pelvic fields are not consistently adequate to cover all lateral external iliac lymph nodes, although the clinical significance of this subgroup of lymph nodes is not known. At this time, LAG remains the ideal radiographic modality to define anatomic location of regional lymph nodes for pelvic RT treatment planning. The clinical importance of the most lateral group of external iliac lymph nodes in various stages of cervical cancer represents a potential area of future research.

Acetabulum↗

PubMed1985

What constitutes adequate study of axillary lymph nodes in breast cancer?

This study was undertaken to determine the value of the clearing technique and multilevel sectioning of lymph nodes to aid in optimally examining axillary dissections for lymph node metastases. One hundred consecutive mastectomy specimens with axillary dissections were initially examined by our routine technique: examination of fat for lymph nodes by inspection and palpation and examination of one microsection from each lymph node. The remaining axillary tissue was then cleared using the technique of Durkin and Haagensen and each of the originally examined lymph nodes was resectioned at two additional deeper levels. In our routine examination, 2203 lymph nodes were found with 211 lymph nodes containing metastatic tumor. Clearing disclosed 412 additional lymph nodes, of which 17 contained metastatic tumor. The two additional microsections of lymph nodes revealed tumor in only two lymph nodes which were initially free of tumor. The extended study of the axilla did not add significantly to our routine examination.

Axilla↗

PubMed1977

Electron microscopy of lymph nodes of hamsters experimentally infected with Treponema pertenue.

The morphology of lymph node tissue from normal hamsters and from hamsters experimentally infected with Treponema pertenue Gauthier was compared by means of light and electron microscopy. The capsules of the lymph nodes from infected hamsters showed an increased thickness in comparison with those of the non-infected animals. The infected lymph nodes differed from normal lymph nodes by small accumulations of neutrophilic leucocytes in the cortical areas. In addition, the amount of intercellular collagenous matrix present between large elongated cells was greatly increased in lymph nodes from infected animals. Electron microscopy of thin sections of infected lymph nodes showed intercellularly located treponemes in the leucocyte infiltration areas. These regions also showed the increased amounts of the collagenous matrix. Treponemes were occasionally found intracellularly in macrophages. These treponemes did not show their typically helical shape, but were present as spherical forms or cysts.

Animals↗

PubMed2002

Lymphatic mapping and sentinel lymph node biopsy in squamous cell carcinoma of the lower lip.

AIMS: The risk of metastases to the submandibular and submental lymph nodes in squamous cell carcinoma (SCC) of the lower lip is closely related to the primary tumour size and the differentiation of the tumour. In order to determine the feasibility of the technique and the possible metastatic lymph nodes in SCC of the lower lip, intraoperative lymphatic mapping and sentinel lymph node biopsy was performed in patients with tumour size greater than 2 cm (T2) and clinically non-palpable regional lymph nodes (N0). METHODS: Intraoperative lymphatic mapping with patent blue dye was performed in 20 patients with SCC of the lower lip. The stained lymph node (sentinel) was identified in each patient and sent for frozen section analysis in order to verify tumour metastasis. All patients had undergone bilateral suprahyoid neck dissection at the same stage. RESULTS: Three of the patients were female and 17 were male. The median age was 66. Sentinel lymph nodes were identified in 18 of the patients (90%). Intraoperative or post-operative histopathologic examination of the sentinel lymph node showed tumour metastasis in three of the patients (16.6%). The histopathologic examination of the remaining 15 patients whose sentinel lymph nodes were free of metastasis, showed no metastasis in the non-sentinel lymph nodes. In two of the three patients with metastatic sentinel lymph nodes, non-sentinel lymph nodes were free of metastases. There were no false negative results and no local or systemic complications of the technique were seen among the patients. CONCLUSIONS: Intraoperative lymphatic mapping and sentinel lymph node biopsy is feasible in patients with SCC of the lower lip who have large tumour size and non-palpable regional lymph nodes. The technique may help to avoid neck dissection when the patient has negative sentinel lymph node and when positive provides useful information for more effective radical treatment.

Adult↗

PubMed1998

Value of laparoscopic evaluation of paraaortic and pelvic lymph nodes for treatment of cervical cancer.

OBJECTIVE: Laparoscopy was used to identify and localize suspicious lymph nodes in patients with cervical cancer. STUDY DESIGN: Eighty-four patients with cervical cancer International Federation of Gynecology and Obstetrics stage IA2 to IV were staged by laparoscopic paraaortic and pelvic lymphadenectomy. The accuracy of laparoscopic assessment of lymph node status was compared with the histologic result. Positive lymph nodes were localized topographically by use of laparoscopy. RESULTS: Sensitivity and specificity of laparoscopic evaluation for identifying positive paraaortic and pelvic lymph nodes was 92.3%. Combination of laparoscopic evaluation and frozen section helped to diagnose all patients with involved lymph nodes correctly. In 13 of 84 (15.4%) patients the result of lymph node assessment by laparoscopic evaluation and frozen section changed primary therapy. In two of these patients one positive lymph node was located in the lateral part of the cardinal ligament, and the hysterectomy was extended to be a more radical procedure. CONCLUSIONS: Laparoscopic evaluation identified the lymph node status in patients with cervical cancer with high accuracy. Topographic localization showed that the lateral part of the cardinal ligament is involved early in lymph node spread.

Aorta↗

PubMed1982

[Arterial vascular bed of the human mesenteric lymph nodes].

The anatomy of the blood vessels has been studied in 394 mesenteric lymph nodes macro- and microscopically. Morphometrical measurements of the size and diameter of the nodes have been performed in the intraorganic arteries of all orders of branching. Correlative connections existing between the size of the nodes and the number of the arteries supplying them with blood, between the size of the nodes and the diameter of the arteries feeding them, between the number of the hiluses and the number of the arteries supplying the lymph node with blood have been determined. As the results of the investigation demonstrate, the mesenteric lymph nodes having various localization differ in their size and form. The number and diameters of the arteries getting into the nodes via the hilus and the capsule vary within a wide range. There are two (often) or three (seldom) hiluses. One - three arteries get into one hilus. The structure of the intraorganic arterial vessels in the mesenteric lymph nodes is complex and variable, depended on the form of the nodes, number and position of the hiluses, on the type of blood supply and on the branching of the arteries getting into the nodes via the hiluses. In most of the mesenteric lymph nodes there are four orders of branching of the intraorganic arteries, each of them having a specific type of division into branches. All the intraorganic arteries either are situated within the trabecular connective tissue or are surrounded with elastic and collagenous fibres. The arteries of various order are differently connected with the structural-tissue elements of the lymph nodes. There are various variants in blood supply of the lymph node folliculi. The arterial vessels of the human mesenteric lymph nodes have a twisty course.

Adult↗

PubMed1987

Innervation of mouse lymph nodes: nerve endings on muscular vessels and reticular cells.

Lymph node nerve endings have been studied in 1- to 48-day-old mice. Serial sections of Epon-embedded lymph nodes were observed under the electron microscope to find the nerve endings. Most lymph node nerve fibers finally reach the smooth muscle cells of arterioles and muscular venules. Both kinds of vascular endings are similar, although endings are less numerous on venules. Nerve endings consist of one or more nerve processes surrounded by a usually incomplete Schwann cell sheath; frequently, axons show wide areas directly facing the muscle cells. The distance between such a naked axon and a myocyte ranges from 100 to 800 nm. Small granulated and clear vesicles are especially abundant in varicosities of nerve processes that are located very close to muscle cells. Nerve endings of lymph node vasculature probably correspond to vasomotor sympathetic adrenergic endings, regulating the degree of contraction of vessels which have a muscular layer. Other kinds of nerve endings also exist in lymph nodes: some axons appear free in the stroma and contact the surfaces of reticular cells; the latter also extend delicate cytoplasmic processes that surround the axons. The functional significance of nerve cell-reticular cell contacts is unknown.

Animals↗

PubMed2004

[Effect of injecting activated carbon ultramicroparticles around the gastric tumor on staining lymph node].

OBJECTIVE: To observe the effect of injecting activated carbon ultramicroparticles around the gastric tumor before or during operation on staining lymph nodes and guiding the lymphadenectomy of gastric cancer. METHODS: Forty-three cases of gastric cancer received activated carbon (AC) ultramicroparticles around the tumor by submucosal endoscopic injection 1 approximately 6 days before the operation and/or intraoperative subserosal injection (AC group), whereas 82 cases of gastric cancer without the injection were used as control group. The number of dissected lymph nodes, number of black-stained lymph nodes and its relation to the injection time, metastasis of lymph nodes, and the side effect of the procedure were analyzed. RESULTS: The average numbers of resected lymph nodes were 34 +/- 13 in the AC group, significantly higher than that in the control group (16 +/- 9, P < 0.05). The dissected N(2) lymph nodes in the AC group was 25 +/- 9, significantly higher than that in the control group (8 +/- 4, P < 0.05). The total ratio of black-stained lymph node was 60.3% in general, 71.3% for the N1 lymph nodes and 56.3% for the N(2) lymph nodes in the AC group. Satisfactory effect of black staining of lymph nodes could be seen 2 days after local gastric tissue injection of activated carbon ultramicroparticles. The metastasis rate was 67.4% in the AC group, not significantly different from that in the control group (63.4%, P > 0.05). In the patients of AC group the metastasis rate of black-stained lymph node was 26.8%, significantly higher than that of the unstained lymph nodes (3.3%) and higher than that of the control group (18.4%). No serious side effect happened after the activated carbon ultramicroparticles injection in local gastric tissue. CONCLUSION: Local injection of activated carbon ultramicroparticles around the tumor is an effective, easy and safe procedure to guide gastric cancer lymphadenectomy.

Adult↗

PubMed2001

Comparison of intraoperative frozen section analysis of sentinel node with preoperative positron emission tomography in the diagnosis of axillary lymph node status in breast cancer patients.

BACKGROUND: Although axillary lymph node status is an important prognostic factor and axillary dissection is regarded as the gold standard for staging, it requires radical surgery which is accompanied by considerable postoperative problems such as lymphedema. This study was carried out to evaluate the diagnostic accuracy of preoperative positron emission tomography (PET) and intraoperative frozen biopsy of sentinel lymphadenectomy (SLND) in detecting axillary lymph node metastasis. METHODS: We studied 18 patients who had preoperative PET and SLND for breast cancer in the Department of Surgery at Samsung Medical Center. They all had preoperative PET with a radiolabeled glucose analogue ([18F]FDG) to visualize primary tumors and metastatic nodes. Isosulphan blue dye was used for intraoperative SLND. Frozen and permanent biopsies were then compared after full axillary dissection. RESULTS: In 18 cases, six had positive metastatic nodes in the permanent biopsy of full axillary dissection but were negative in three cases by preoperative PET. There was one false negative result by frozen biopsy of SLND which was later shown to be positive by permanent biopsy. The sensitivity and specificity of SLND and PET for detecting axillary node metastasis were 83, 100% and 50, 100%, respectively. CONCLUSION: Although both methods are good for axillary nodal status, the intraoperative frozen biopsy result of SLND was superior to preoperative PET in our preliminary study.

Adult↗

PubMed1988

Pathology of the lymph node and spleen in systemic mast cell disease.

The spleen and lymph node are two of the most common organs involved in systemic mast cell disease (SMCD). However, SMCD infiltrates in the spleen and lymph node have a broad spectrum of morphological patterns which can make it difficult to recognize the diagnosis, especially when specimens are examined from patients in whom SMCD is not suspected. We reviewed the pathological features of 16 spleen and 23 lymph node specimens from 19 patients which represented all available material from a series of 58 Mayo Clinic patients with SMCD. The purpose of this study was to investigate the pathological manifestations of SMCD involvement in the spleen and lymph node and to address difficulties in differential diagnosis. All compartments of the spleen and lymph node were found to be affected by SMCD. SMCD lesions in the spleen were found in a paratrabecular (92%), parafollicular (69%), follicular (15%), and a diffuse red pulp (8%) distribution. In the lymph node, mast cell infiltrates affected the paracortex (88%), the parafollicular region (50%), the follicles (25%), the medullary cords (13%), and the sinuses (6%). Mast cells were frequently found in a perivascular location, and associated eosinophilia was common. Because of the broad spectrum of histological manifestations of SMCD in the spleen and lymph node, a wide range of differential diagnoses is discussed including follicular lymphoma, T-cell lymphoma, monocytoid B-cell hyperplasia and lymphoma, Kaposi's sarcoma, and Langerhans' cell granulomatosis.

Diagnosis, Differential↗