Primary Cutaneous T-cell Lymphoma With Aberrant CD-20 Expression

IMPORTANCE

Primary cutaneous T-cell lymphoma with aberrant expression of cluster of differentiation (CD) 20 is an exceedingly rare manifestation of cutaneous T-cell lymphoma that is easily misdiagnosed as B-cell lymphoma. The significance and prognostic implications of T-cell neoplasms demonstrating the classic CD20 B-cell marker have yet to be elucidated.

OBSERVATIONS

We present a case of primary cutaneous T-cell lymphoma with aberrant CD20 expression in a 97-year-old male who presented with a 2-year history of pruritic plaques and nodules covering his body. Nodule biopsy demonstrated a dense, atypical dermal T-lymphocytic infiltrate consisting of predominantly large cells exhibiting classic T-cell markers (CD4 and CD3) along with aberrant expression of the B-cell marker CD20 (expressed in late pro-B to mature B cells).

CONCLUSIONS

The patient was tentatively diagnosed with primary cutaneous CD30-negative large T-cell lymphoma with aberrant CD20 co-expression, pending workup to exclude systemic lymphoma with cutaneous involvement. He unfortunately passed away 4 days after the initial dermatologic presentation.

RELEVANCE

The prognostic implications of CD20-positive T-cell lymphoma require further exploration, along with the potential role of CD20 antibody in treatment of this rare malignancy.

Marginal vitiligo: an unusual depigmenting disorder

BACKGROUND

Marginal vitiligo, or inflammatory vitiligo with raised borders is a unique subset of vitiligo vulgaris presenting with scattered depigmented, pruritic patches surrounded by a raised, erythematous border. Alternative diagnoses include discoid lupus erythematosus and cutaneous T-cell lymphoma.

PURPOSE

To properly guide treatment, it is important to exclude other conditions that present with a similar pattern of depigmentation. This requires the ability to identify specific cutaneous and histologic clues that support this diagnosis.

MATERIAL AND METHODS

A 22 year-old man presented with a history of depigmented, pruritic patches and surrounding raised, erythematous borders. Several areas of depigmentation on the scalp were associated with alopecia. Punch biopsy of the rim of a patch was performed and sent for routine hematoxylin and eosin staining and direct immunofluorescence.

RESULTS AND CONCLUSION

Histopathology revealed a spongiotic dermatitis with superficial dermal lymphocytic infiltrate and eosinophils; DIF demonstrated no immunoreactants. A diagnosis of inflammatory vitiligo with raised borders was thus made based on consistent clinical and histopathologic features. The symptoms improved with topical clobetasol 0.05% cream twice daily.

Primary cutaneous lymphomas: single center experience of dermatology and hematology clinics

PURPOSE

To present the clinical characteristics, treatments performed, response to treatment, and follow up of 40 patients diagnosed with primary cutaneous lymphoma.

METHODS

In this retrospective study included were 23 males and 17 females from our center with confirmed diagnosis of primary cutaneous lymphoma over an 8-year period. Data were retrieved from the patient medical records.

RESULTS

The median patient age at diagnosis was 59.5 years (range 33-86). Skin biopsies showed that 31 patients (77.5%) had mycosis fungoides (MF), 2 (5%) had anaplastic large cell lymphoma, 3 (7.5%) had diffuse large B cell lymphoma, 3 (7.5%) had poikilodermic mycosis fungoides, and 1 (2.5%) had non-classified non-Hodgkin lymphoma (NHL). In patients with T cell lymphoma clinical stage IA prevailed (42.5%). The 3 patients with B cell lymphoma had stage IE and 2 of them had B symptoms. Sezary cells were detectable in the peripheral blood of 3 patients. Twenty-three patients (57.5%) used only topical corticosteroids, 2 (5%) were treated with PUVA (psoralen ultraviolet A), 1 (2.5%) was treated with PUVA and chemotherapy, 8 (20%) received combination chemotherapy, 1 patient (2.5%) received PUVA+ interferon+topical nitrogen mustard, and 1 (2.5%) received chemotherapy+topical nitrogen mustard+interferon. Among 16 patients with the valuable response to treatment 5 (33%) showed complete remission (CR) and 9 (60%) partial remission (PR). The median follow up time for all patients was 1.5 months (range 1-135). While mean overall survival (OS) time was 123 months (95% CI 100.6-145.3), the estimated median OS was not reached.

CONCLUSION

Early diagnosis of MF is rather favorable in terms of high and long-term response rates to topical treatments.

Subcutaneous panniculitis-like T-cell lymphoma

Subcutaneous panniculitis like T-cell lymphoma derived from α/β T-cells (SPTCL-AB) belongs to the group of primary cutaneous T-cell lymphoma, and it represents less than the 1% of all primary cutaneous T-cell lymphomas. It affects patients in the 4th decade of life (median age of 36 years) with a female preference (male/female ratio 0.5) with 19% of patients being 20 years or younger. It can be sometime complicated by a hemophagocytic syndrome, and patients without hemophagocytic syndrome had a significantly better survival (5-year OS: 91% vs. 46%). Histopathologically, SPTCL-AB is characterized by a lobular lymphocytic panniculitis. Tumor cells distribute between individual adipose lobules, proliferating and forming "rim" and "capping" images, conferring a lace-like appearance at scanning magnification. This is not an entirely disease-specific feature, and can also be seen in other lobular lymphocytic panniculitis, either of inflammatory and neoplastic origin. Tumor cells are phenotypically CD45RO+, βF1+ (a monoclonal antibody able to identify the alpha/beta chain of TCR), CD3+, CD4-, CD8+, and express cytotoxic granules (TIA-1, granzyme and perforin), whereas they show variable deletion of T-cell restricted antigens like CD2, CD5 and CD7. The majority of cases show a monoclonal rearrangement for TCR beta and gamma genes and do not show genomic integration of EBV. The present review will focus on histopathologic, immunophenotypical and molecolare data useful to overcome to a specific diagnosis of SPTCL-AB and to differentiate SPTCL-AB from other lymphomas of T-cell or NK/T cell origin and with benign panniculitidis sharing with SPTCL-AB a predominant lobular lymphocytic pattern of involvement of subcutaneous tissue.

Erythrodermic CTCL: updated clues to diagnosis and treatment

Erythroderma is a rare but severe cutaneous condition characterized from a clinical point of view by a complete involvement (as per definition more than 80% body surface) of the skin surface. Pre-existing dermatoses account for about 70% of erythroderma cases, drug reactions are responsible for erythroderma in about 20%, whilst primary cutaneous T-cell lymphoma (CTCL) constitute less than 10% of and are represented by erythrodermic mycosis fungoides and Sézary syndrome. The challenge in these patients is represented by the identification of the etiological agents or conditions, which is clearly of overwhelming relevance in the clinical management and treatment strategies. In recent years, the development of multiparameter flow-cytometry, which allows to identify specific antigens expressed or not expressed on the surface of atypical lymphoid T-cells, and T-cell molecular biology techniques, which are aimed to identify the presence of a clonal T-cell population in the skin and blood on the basis of the finding of rearrangement of the T-cell receptor, have represented relevant useful tool in the differential diagnosis between benign and lymphomatous erythroderma. Moreover, a better understanding of the immunological and molecular pathways in CTCL disease evolution provided the identification of specific therapeutical targets, as well as the constant improvement in the laboratory techniques lead to the development of new and promising agents in CTCL.

Various faces of Hansen's disease

Leprosy is a chronic granulomatous disease caused by Mycobacterium leproe. Leprosy once considered a taboo is still misdiagnosed and underdiagnosed. In many cases leprosy is treated as common disorders like psoriasis, pyoderma, angioedema, pre vitiligo. Leprosy can present in many diverse ways which can be confused with many treatable and non treatable, infectious and non infectious forms. Leprosy is considered on the verge of elimination. But Leprosy cases are being newly diagnosed day by day. Here we are presenting 4 atypical cases of leprosy which did not seem to have classical presentation but were diagnosed as leprosy when investigated.

Primary cutaneous aggressive epidermotropic CD8+ T cell lymphoma with a chronic and indolent course. Is this different from peripheral T cell lymphoma?

Cutaneous T cell lymphomas most commonly have a CD4+ memory T cell phenotype and exhibit a relatively indolent course, but may in rare cases present with a CD8+ cytotoxic phenotype with a strikingly more aggressive clinical behavior. Primary cutaneous aggressive epidermotropic CD8+ T cell lymphoma is an extremely rare entity with distinct clinicopatological features. The clinical features and prognosis of the recently-described CD8+ peripheral lymphoma are very different from cytotoxic CD8+ epidermotropic lymphoma, but the histological and phenotypic characteristics are very similar. We report a new case of CD8+ epidermotropic lymphoma with a chronic course and suggest the possibility of an overlap between these two types of lymphoma.

Consistency and distribution of reflectance confocal microscopy features for diagnosis of cutaneous T cell lymphoma

Reflectance confocal microscopy (RCM) represents a noninvasive imaging technique that has previously been used for characterization of mycosis fungoides (MF) in a pilot study. We aimed to test the applicability of RCM for diagnosis and differential diagnosis of MF in a clinical study. A total of 39 test sites of 15 patients with a biopsy-proven diagnosis of either MF, parapsoriasis, Sézary syndrome, or lymphomatoid papulosis were analyzed for presence and absence of RCM features of MF. Cochran and Chi(2) analysis were applied to test the concordance between investigators and the distribution of RCM features, respectively. For selected parameters, the Cochran analysis showed good concordance between investigators. Inter-observer reproducibility was highest for junctional atypical lymphocytes, architectural disarray, and spongiosis. Similarly, Chi(2) analysis demonstrated that selected features were present at particularly high frequency in individual skin diseases, with values ranging from 73% to 100% of all examined cases.

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma: a retrospective case series and review of the provisional cutaneous lymphoma category

BACKGROUND AND OBJECTIVE

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma (PCSM-TCL) is a rare and provisional subcategory of cutaneous T-cell lymphoma, associated with a favorable prognosis. We present five cases of PCSM-TCL and review the literature to address questions surrounding its diagnosis and treatment.

METHODS

A retrospective review was conducted of 353 patients with non-mycosis fungoides cutaneous lymphomas evaluated at the M.D. Anderson Cancer Center Cutaneous Lymphoma Clinic over 10 years. A retrospective search of the English literature using PubMed was conducted to identify additional cases.

RESULTS

Only five patients had a diagnosis of PCSM-TCL. Three patients had unique multifocal presentations that responded well to topical therapy or excision. One patient with localized disease initially treated with radiation therapy had an aggressive relapse requiring systemic therapy. One patient had an isolated nodule that fully resolved with excision. The review of the English literature found 232 additional cases. The presentation of PCSM-TCL was heterogeneous and included solitary/localized papules, nodules, plaques, and tumors. Multiple differential diagnoses were considered and PCSM-TCL diagnosis was based on histopathologic features and clinical correlation. Treatment of solitary/localized lesions included excision or radiation therapy. Multifocal lesions were uncommon and associated with an aggressive course requiring systemic chemotherapy.

CONCLUSIONS

The heterogeneous presentation, variable histologic overlap with other lymphoproliferative disorders, and uncertain prognosis of PCSM-TCL creates diagnostic and management dilemmas for clinicians. For treatment, a distinction should be made between indolent and aggressive subtypes. Further investigation is needed to determine if PCSM-TCL is indeed a distinct lymphoma category and, additionally, if aggressive subtypes should remain part of the same diagnostic category.

Cutaneous T-cell lymphoma: 2011 update on diagnosis, risk-stratification, and management

DISEASE OVERVIEW

Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS).

DIAGNOSIS

The diagnosis of MF or SS requires the integration of clinical and histopathologic data.

RISK-ADAPTED THERAPY

Tumor, node, metastasis, and blood (TNMB) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers, denileukin diftitox, and histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy may be used for those patients with extensive visceral involvement requiring rapid disease control. In highly-selected patients with disease refractory to standard treatments, allogeneic stem-cell transplantation may be considered.

Photolichenoid plaques with associated vitiliginous pigmentary changes

A 49-year-old man with advanced HIV/AIDS on anti-retroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) presented with a several-month history of pruritic, erythematous, lichenified papules that coalesced into hyperkeratotic plaques on the trunk and extremities in a sun-exposed distribution. He shortly thereafter developed a progressive depigmentation over more than 80 percent of his body surface area. A biopsy specimen of an erythematous plaque on the trunk showed a superficial and mid-dermal infiltrate of lymphocytes with eosinophils, most consistent with either chronic lichenoid drug eruption or atypical lymphoproliferative disorder (ACLD) of HIV. The patient's lichenoid skin disease has persisted despite discontinuation of TMP-SMX, although it has improved partially with administration of topical glucocorticoids and acitretin. His depigmentation has continued to progress. We discuss the overlapping diagnostic entities which may be comprised by this patient's clinical disease, and highlight a unique presentation of the complex interaction between HIV infection and the skin.

Erythroderma of unknown etiology

We present a 46-year-old man with a greater than 15-year history of erythroderma. A definitive diagnosis has not been established. The differential diagnosis is discussed.