Dermatology

Necrobiotic Xanthogranuloma

Necrobiotic Xanthogranuloma

Are You Confident of the Diagnosis?

Necrobiotic xanthogranuloma (NXG) is chronic, progressive, granulomatous disorder with the potential to affect multiple organs, with a notable strong association with paraproteinemias and/or lymphoproliferative disease that demands lifelong monitoring and vigilance.

Characteristic findings on physical examination

On physical examination, there are yellowish to red-orange papules and nodules that coalesce into indurated plaques, typically 0.5 to 2 cm (Figure 1). Lesions often have overlying telangiectasias; scarring and ulceration occur in 40-50% of patients.

Figure 1.

Patient with periorbital necrobiotic xanthogranuloma, associated with an underlying IgG kappa paraprotenemia. (Courtesy of Bryan E. Anderson, MD)

Ocular lesions are found in 80-85% of all patients and are considered the classic cutaneous location, but these are not required for the diagnosis. The extent of periorbital involvement can be severe, and can contribute to ocular symptoms and complications. Many skin lesions initially start on the trunk or extremities (60-70% of cases) and subsequently involve the periorbital area. Oral mucosal erosions are occasionally present.

Most cases are asymptomatic, although burning and pain may occur. Periorbital lesions may lead to pain and blurred vision depending on the location and size.

Extracutaneous sites can be involved including the lung, myocardium, larynx, pharynx, skeletal muscle, kidney, intestine, and ovary. Hepatomegaly and/or splenomegaly can occur in 20% of patients. Most importantly, patients with NXG frequently display a paraproteinemia and have a high risk for developing a lymphoproliferative disease.

Expected results of diagnostic studies

Histopathologically, NXG is characterized by a granulomatous inflammation in the dermis extending into the subcutaneous fat. There are large zones of necrobiosis (altered collagen with sheets of histiocytes and inflammatory cells) surrounded by granulomas composed of macrophages with some foreign body-type and Touton giant cells (Figure 2). A moderate lymphocytic infiltrate and plasma cells can be seen. Degenerated collagen is common, and mucin deposition can occur. Cholesterol clefts within the necrobiosis are characteristic of NXG (Figure 3, Figure 4).

Figure 2.

Diffuse infiltration of the dermis and subcutis with altered collagen and granulomas (H&E, X4).

Figure 3.

Cholesterol clefts within necrobiotic collagen surrounded by mixed inflammatory infiltrate with giant cells (H&E, X20).

Figure 4.

Close-up view of the characteristic cholesterol clefts within the granulomatous inflammation (H&E, X60).

Laboratory studies should include the following: completew blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complement levels, cryoglobulins, and serum protein electrophoresis (SPEP). If SPEP is negative, then immunofixation may be considered, as it is a much more sensitive test for detection of specific monoclonal proteins compared with screening serum protein electrophoresis.

These tests are evaluating for anemia, leukopenia, hypocomplementemia, glucose intolerance and other organ involvement and underlying hematologic/ lymphoproliferative malignancies and paraproteinemia. Paraproteinemia is found in 80-90% of cases, with IgG kappa monoclonal gammopathy being the most common.

Patients require lifelong monitoring for the development of paraproteinemia and lymphoproliferative disease, and studies may need to be repeated regularly. No clear guidelines exist for frequency of monitoring, although annual monitoring is appropriate. If new symptoms or laboratory abnormalities develop, then more frequent monitoring may be necessary in some patients.

Imaging studies may include magnetic resonance or axial computed tomography of the orbit, which may demonstrate soft tissue densities within the orbit, extraocular muscle involvement, or diffuse orbital inflammation. Baseline echocardiography and dynamic cardiac imaging should be considered in all patients to evaluate for NXG involvement of the heart.

Referral to an oncologist for bone marrow biopsy should be considered in all patients with monoclonal gammopathy given the association with multiple myeloma and potential for myeloproliferative/lymphoproliferative disorders.

Diagnosis confirmation

The clinical differential diagnosis includes necrobiosis lipoidica, granuloma annulare, xanthelasma, and sarcoidosis; however, NXG often can be differentiated based upon the characteristic yellow-orange plaque morphology, clinical distribution pattern, and associated paraproteinemia, which is not present in other entities.

The most common entities to differentiate against include: necrobiosis lipoidica (pretibial location), xanthelasma (periorbital but less infiltrating plaques), sarcoidosis (less typically yellow/orange in color), and granuloma annulare (flesh and pink/red in color with more annular appearance, rarely periorbital). Normolipemic plane xanthoma also can be difficult to distinguish because it also can have a yellowish hue, normal serum lipids, and an upper body distribution pattern, but it typically lacks induration and never ulcerates.

A rare entity, adult-onset asthma with periocular xanthogranuloma (AAPOX) also is in the differential diagnosis and clinically presents with periocular infiltrative nodules. Although AAPOX has Touton giant cells and lipid-laden histiocytes, it characteristically has large lyphoid aggregates with germinal centers on histopathologic examination, which distinguishes it from NXG.

Histopathologic examination also can help differentiate between entities, but diagnosis may be difficult based on pathologic features alone. The histopathologic differential diagnosis includes necrobiosis lipoidica, granuloma annulare, juvenile xanthogranuloma, erythema induratum, foreign body granuloma, atypical sarcoidosis, and other xanthomatous disorders.

Who is at Risk for Developing this Disease?

NXG is an uncommon disease with approximately 100 cases reported in the literature since 1980, when it was first described.

A review of 48 cases found the age range to be 17 to 85 years with a mean age of onset in the sixth decade. Men and women are affected equally. The periorbital area is the most frequently involved site.

NXG typically follows a chronic and progressive but indolent course with a generally good prognosis. Prognosis is highly dependent on the extent of extracutaneous involvement and the presence of visceral malignancies. One study followed patients with NXG and multiple myeloma where there was 100% patient survival at 10 years and 90% at 15 years.

What is the Cause of the Disease?

Etiology

Pathophysiology

The pathogenesis of NXG is poorly understood. The role of the paraprotein has been investigated, and some hypothesize it functions as a lipoprotein, which allows it to bind to lipoprotein receptors of monocytes and cause xanthoma formation. Another theory is that the activation of monocytes in vivo may contribute to an intracellular accumulation of lipoprotein derived lipids in the skin.

Overall, the deposition of paraprotein and immune complexes is generally thought to elicit a granulomatous response, and hypoxia/ischemia induces necrobiosis. More recently, rare spirochetal organisms were identified in Germany, suggesting a potential role for an infectious etiology. Further investigation is required to determine the underlying etiology and pathophysiology.

Systemic Implications and Complications

In the skin, NXG can ulcerate and scar, either spontaneously or as a result of iatrogenic intervention, leading to disfigurement. NXG can have multiple systemic associations, leading to extracutaneous complications:

Ophthalmologic complications: Ophthalmologic symptoms include burning, itching, or painful eyes. Less commonly, diplopia has been reported. Reported findings include blepharitis, keratitis, conjunctivitis, restricted ocular motility and proptosis with some complication occurs in 50-80% of patients. These patients should be co-managed with ophthalmology to evaluate and manage these complications. Regular, life-long follow-up is recommended.

Lymphoproliferative/hematologic diseases: Serum monoclonal gammopathy, usually IgG-kappa, is found in 80% of patients, but only 10% of these will develop multiple myeloma. Due to the high frequency of monoclonal gammopathy, bone marrow biopsies are often performed to evaluate for evaluate for multiple myeloma.

Reported associations include multiple myeloma, chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and nonspecific myeloproliferative or lymphoproliferative diagnoses. These disorders may occur before or after the onset of skin lesions (8 years prior to onset to at least 11 years after). Patients with NXG require lifelong follow-up care and regular laboratory monitoring.

Heart involvement: Giant-cell myocardial disease can occur in these patients. Because of this, baseline routine echocardiography and dynamic cardiac imaging are recommended in all patients. If abnormalities are noted, then aggressive, systemic therapy should be considered. If cardiac symptoms at any point, then repeat imaging should be considered on an individual basis.

Other systemic involvement: Multiple extracutaneous sites have been reported with NXG. These include lung, liver, spleen (up to 20% with hepatosplenic involvement in one report), myocardium (above), larynx, pharynx, skeletal muscle, kidney, intestine, and ovary. Regular, long-term follow-up is recommended with these patients to evaluate for any systemic involvement.

Treatment Options

NXG is a rare disease and there is no treatment algorithm or accepted therapeutic ladder. Most of the treatments discussed are limited to case reports and small retrospective cases series. Due to the rarity of this disease, large-scale studies are lacking.

The treatment is varied and often times unsuccessful, although limited reports for some therapies have been reported to be successful. However, when lesions improve, the length of remission often is not reported. The treatment approach depends on whether the physician is treating NXG alone, or NXG in association with multiple myeloma, or NXG with extensive visceral/systemic involvement.

Treatment options are summarized in Table I.

Table I.

Treatment options for n ecrobiotic xanthogranuloma
Systemic Therapy Targeted/Local therapy
NXG and Multiple Myeloma:      Alkylating agents (chlorambucil, melphalan, cyclophosphamide) + systemic steroids Radiation therapyPhototherapy (psoralen + UVA)Intralesional steroid injections
NXG alone:     Alkylating agents:        Chlorambucil +/- systemic corticosteroids        Melphalan (usually low dose) +/- systemic corticosteroids        Cyclophosphamide +/- systemic corticosteroids     Other systemic agents:        Intravenous Immunoglobulin (IVIg)        Methotrexate        Thalidomide/Lenolidomide
        Interferon alpha-2b        Azathioprine        Plasmapheresis
        Systemic corticosteroids
        Autologous stem cell transplant
     Antibiotics:        Dapsone        Tetracycline class antibiotics        Clofazamaine    
Potent topical steroidsTopical chemotherapy (nitrogen mustard)Laser (Nd:YAG, CO2)Surgical excision

Optimal Therapeutic Approach for this Disease

NXG with Multiple Myeloma

It is recommended that these patients be managed in coordination with an oncologist. Chemotherapy with alkylating agents (chlorambucil, cyclophosphamide, melphalan) and systemic steroids are considered first-line therapy for these patients. Improvement in paraproteinemia has been reported with variable improvement in skin lesions; additional therapy may be required to address the cutaneous lesions.

NXG Alone

Systemic therapies

Chemotherapy is the most commonly reported treatment, with chlorambucil and low dose melphalan being the most frequently reported used options. The addition of systemic steroids may be considered. With these therapies, remission of skin lesions and paraproteinemia has been reported, but notably some patients treated did evolve to multiple myeloma, and not all patients who receive either of these therapies respond to treatment.

With other therapies, variable success has been reported. Half of the patients treated with cyclophosphamide have been reported to improve, half did not. Interferon-alpha 2b has been used infrequently with inconsistent results, but the trend is towards overall improvement.

Recently, intravenous immunoglobulin (IVIg) was used to successfully treat 2 patients refractory to multiple previous therapies who had widespread cutaneous NXG with resolution of cutaneous lesions after 4-6 cycles of IVIg. Long-term follow-up was not available. While expensive, IVIg is relatively well-tolerated and the results in these refractory, extensive patients were impressive. There are limited reports noting an improvement with plasmapheresis.

The unknown etiopathogenesis of NXG, along with the high prevalence of the paraproteinemia associated coupled with these results, lead the authors to suggest further study in this area and consideration for IVIg as a potential option in appropriate patients.

Various other single case reports using azathioprine, methotrexate, dapsone, clofazamine, thalidomide, ciprofloxacin and tetracyclines, have been reported with variable results.

Targeted/Local Therapy

For patients with residual disease, limited localized disease, symptomatic, or refractory disease may benefit from consideration of skin directed therapy.

Skin-directed radiotherapy may be considered in combination with chemotherapy, and has been reported with mixed results in the literature. Psoralen + UVA (PUVA) photochemotherapy has been tried in limited cases with variable success. Laser therapy with CO2 laser was reported as helpful in one patient, while the Nd:YAG laser was tried unsuccessfully in another patient.

For single and small lesions, surgical excision has been utilized with resolution of lesions. Often times, the extent of the disease does not allow for this to be a feasible option. Once again, there are reports of surgery inducing ulceration, and of disease relapse or flare after surgical debulking.

Limited to no benefit has been described with topical steroids, although several patients have been reported to respond to intralesional and systemic steroids. Conversely, there are rare reports of injections leading to disease progression and ulceration.

While there are no published reports of topical chemotherapy, there are experienced physicians who suggest anectodal response to topical nitrogen mustard in limited disease.

Patient Management

All patients should undergo initial and serial follow-up for systemic involvement. Most essential is education and monitoring for the development of lymphoproliferative disorders. Should patients develop new CBC abnormalities or a change in their paraproteinemia, further investigation is warranted with a low threshold to refer to a hematologist for consideration of a bone marrow biopsy.

As NXG can affect the internal organs, any systemic complaints warrant appropriate evaluation, particularly cardiac symptoms. Due to the periorbital predominance, many patients develop ocular symptoms; new or worsening symptoms should be evaluated appropriately, which may require ophthalmology consultation and/or radiographic imaging of the orbit.

When counseling patients it is essential to explain the diagnosis of NXG and the potential for development of ophthalmologic complications, systemic involvement, and the risk of developing lymphoproliferative or hematologic disorders throughout the course of the disease.

There is no cure for this disease, and many of the therapeutic choices are used based upon case reports because of the rarity of the disease. Often, trial and error in treatment of this disease is necessary, weighing toxic side effects of medications against potential benefit.

Unusual Clinical Scenarios to Consider in Patient Management

NXG itself constitutes an unusual clinical scenario; due to the chronic, often nonresponsive nature of this disease, there are no clear triggers to prompt clinicians for when to consider other entities. There are a variety of periocular granulomatous diseases; in atypical presentations or rapidly progressing patients, physicians may consider Erdheim-Chester disease in their differential diagnosis.

The evaluation of paraproteinemia is important in all patients when NXG is considered in the differential diagnosis. It is also important to follow these patients regularly for life because complications can occur at any time.

What is the Evidence?

Chave, TA, Chowdhury, MM, Holt, PJA. "Recalcitrant necrobiotic xanthogranuloma responding to pulsed high-dose oral dexamethasone plus maintenance therapy with oral prednisolone". Br J Dermatol. vol. 144. 2001. pp. 158-161.

(This report of difficult to treat NXG describes the use of oral steroids to treat and control the disease.)

Fernandez-Herrera, J, Pedraz, J. "Necrobiotic xanthogranuloma". Semin Cutan Med Surg. vol. 26. 2007. pp. 108-13.

(This reviews discusses the clinical manifestations, histopathology, differential diagnosis, prognosis, and treatment of NXG in clear language and highlights the important details that are important in these patients.)

Goede, JS, Misselwitz, B, Taverna, C. "Necrobiotic xanthogranuloma successfully treated with autologous stem cell transplantation". Ann Hematol. vol. 86. 2007. pp. 303.

(This is the first report of autologous stem cell transplantation in a patient with NXG in a setting where conventional myeloma therapy failed. It reviews that there is no consensus on a single best strategy for treatment.)

Hallerman, C, Tittelbach, J, Norgauer, J, Ziermer, M. "Successful treatment of necrobiotic xanthogranuloma with intravenous immunoglobulin". Arch Dermatol. vol. 146. 2010. pp. 957-60.

(This report reviews the concept that no first line therapy has been established for NXG, and reports impressive resolution of NXG with the use of intravenous immunoglobulin.)

Machado, S, Alves, R, Lima, M. "Cutaneous necrobiotic xanthogranuloma - successfully treated with low dose chlorambucil". Eur J Dermatol. vol. 11. 2001. pp. 458.

(This is another report highlighting successful treatment of NXG with chlorambucil.)

Matsura, F, Yamashita, S, Hirano, K. "Activation of monocytes in vivo causes intracellular accumulation of lipoprotein-derived lipids and marked hypocholesterolaemia: a possible pathogenesis of necrobiotic xanthogranuloma". Atherosclerosis. vol. 142. 1999. pp. 355.

(This study analyzed the function of serum monocytes in a patient with NXG and hypothesized that activated monocytes accumulate lipids, and are then deposited in the skin, leading to giant cell inflammatory reaction; this is one of few reports studying underlying pathogenesis with proposed mechanism of action.)

Silapount, S, Chon, SY. "Generalized necrobiotic xanthogranuloma successfully treated with lenalidomide". J Drugs Dermatol. vol. 9. 2010. pp. 273.

(This brief report discusses the limited treatment options for NXG and provides an example of successful treatment with resolution of paraproteinemia and NXG.)

Spicknall, KE, Mehregan, DA. "Necrobiotic xanthogranuloma". Int J Dermatol. vol. 48. 2009. pp. 1-10.

(This review provides an excellent summary of NXG, highlighting systemic involvement and treatment modalities in a table-formation, and providing a framework for pathogenesis. The review also discusses clinical and pathologic findings.)

Winkelmann, RK, Litzow, MR, Umbert, UJ. "Giant cell granulomatous pulmonary and myocardial lesions in necrobiotic xanthogranuloma with paraproteinemia". Mayo Clin Proc. vol. 72. 1997. pp. 1028.

(A case report of a patient that had pulmonary and cardiac involvement with necrobiotic xanthogranuloma.)

Wood, AJ, Wagner, VU, Abbot, JJ, Gibson, LE. "Necrobiotic xanthogranuloma: a review of 17 cases with emphasis on clinical and pathologic correlation". Arch Dermatol. vol. 145. 2009. pp. 279-84.

(This case series discusses the correlation between clinical presentation, histopathologic findings, and disease course in patients with NXG and further documents the association between NXG and paraproteinemia.)
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