Is it lymphoma or lymphomatoid papulosis?

Deep Sequencing of Immunoglobulin Genes Identifies a Very Low Percentage of Monoclonal B Cells in Primary Cutaneous Marginal Zone Lymphomas with CD30-Positive Hodgkin/Reed–Sternberg-like Cells

The spectrum of cutaneous CD30-positive lymphoproliferative disorders encompasses both inflammatory and neoplastic conditions. CD30+ Hodgkin and Reed–Sternberg-like cells have been occasionally reported in primary cutaneous marginal zone lymphoma, where they are thought to represent a side neoplastic component within a dominant background of lymphomatous small B cells. Herein, we describe the histological and molecular findings of three cases of primary cutaneous marginal zone lymphomas with CD30+ H/RS cells, in which next-generation sequencing analysis revealed the clonal population to consist in less than 5% of the cutaneous B-cell infiltrate, providing a thought-provoking focus on a possible main role for CD30+ cells in primary cutaneous marginal zone lymphoproliferations.

Ethnic disparity in primary cutaneous CD30+ T-cell lymphoproliferative disorders: an analysis of 1496 cases from the US National Cancer Database

Primary cutaneous CD30⁺ T cell lymphoproliferative disorders (PCLPD), the second most common type of primary cutaneous T cell lymphomas, accounts for approximately 25-30% of cutaneous T-cell lymphoma cases. However, only small retrospective studies have been reported. We aimed to identify prognostic factors and evaluate the overall survival (OS) of patients with PCLPD stratified by ethnicity. We identified 1496 patients diagnosed with PCLPD between 2004 and 2014 in the US National Cancer Database. Chi-square test and anova were used to evaluate differences in demographic and disease characteristics, socioeconomic factors and treatments received. OS was evaluated with the log-rank test, Cox proportional hazard regression analysis, and propensity score matching. The study included 1267 Caucasians, 153 African Americans (AA), 43 Asians, and 33 of other/unknown ethnicity. Older age, higher Charlson-Deyo score, higher clinical stage and receipt of chemotherapy were predictors of shorter OS. Primary disease site on a lower extremity was associated with shorter OS, while a head and neck location was associated with longer OS. AA patients had shorter OS when compared to Caucasian patients on multivariate analysis. This ethnic disparity persisted on propensity-score matched analysis and after matching Caucasian and AA patients on demographic and disease characteristics, socioeconomic factors and treatments received, and age and gender-matched relative survival analyses.

A Severe Case of Lymphomatoid Papulosis Type E Successfully Treated with Interferon-Alfa 2a

Lymphomatoid papulosis (LyP) is a benign papulonodular skin eruption with histologic features of malignant lymphoma. A new variant of LyP which was termed “type E” was recently described with similar clinical and histological features to angiocentric and angiodestructive T-cell lymphoma. LyP type E is characterized with recurrent papulonodular lesions which rapidly turn into hemorrhagic necrotic ulcers and spontaneous regression by leaving a scar. None of the available treatment modalities affects the natural course of LyP. For therapy various modalities have been used such as topical and systemic steroids, PUVA, methotrexate, bexarotene, and IFN alfa-2b. Here we present a severe and devastating case with a very rare variant of LyP type E, which is, to our knowledge, the first case successfully treated with IFN alfa-2a. Now disease has been maintaining its remission status for six months.

Clonal T-cell receptor β-chain gene rearrangements in differential diagnosis of lymphomatoid papulosis from skin metastasis of nodal anaplastic large-cell lymphoma

BACKGROUND

In patients with a history of nodal anaplastic large-cell lymphoma (ALCL), differentiation of type C lymphomatoid papulosis from cutaneous involvement of systemic ALCL may be challenging because the 2 entities may exhibit identical histologic features. Although metastatic ALCL generally carries the same clone as the primary lymphoma, expression of a distinct clone likely represents a distinct process.

OBSERVATIONS

A 54-year-old white man had a history of anaplastic lymphoma kinase 1-negative ALCL in the right inguinal lymph node 6 years ago. A complete response was achieved after 6 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine [Oncovin], and prednisone administered in 21-day cycles) and radiation therapy. After 3½ years, the patient observed waxing and waning papules and nodules. Examination of the biopsy specimen revealed a dense CD30(+) lymphocytic infiltrate; no evidence of systemic malignancy was evident on positron emission tomography. Although clinically the presentation was consistent with lymphomatoid papulosis, metastatic ALCL had to be excluded. Polymerase chain reaction analysis with T-cell receptor γ-chain gene rearrangement (TCR-γR) was performed on the original lymph node and new skin lesions. Results of the TCR-γR analysis were positive for clonality in both lesions. However, separate clonal processes were identified. The identification of distinct clones supported the clinical impression of lymphomatoid papulosis.

CONCLUSION

Polymerase chain reaction analysis of TCR-γR is a useful method for distinguishing different clonal processes and is recommended when differentiation of primary and secondary lymphoproliferative disorders is required.

Primary cutaneous anaplastic large cell lymphoma arising from lymphomatoid papulosis, responding to low dose methotrexate

CD30+ cutaneous lymphoproliferative disorders (CLPDs) present variable clinical and histological manifestations. We report here a case of an adult male patient who progressed from lymphomatoid papulosis to anaplastic large cell lymphoma. The patient responded satisfactorily to a low dose of methotrexate.

Consequences of misdiagnosis of lymphomatoid papulosis

We report two patients with lymphomatoid papulosis (LyP), who were initially diagnosed as systemic T-cell lymphoma. The patients presented with recurrent self-healing cutaneous lesions and skin biopsies showed a lymphocytic infiltrate with malignant features. Clinico-pathological correlation of findings was not performed and results of staging investigations were misinterpreted. Consequently, both patients were unnecessarily treated with multi-agent chemotherapy, radiotherapy and stem cell/bone marrow transplants and sustained long-term adverse effects. The clinical and histological features of LyP are described and appropriate management discussed in detail. Factors leading to the unnecessary treatment of both patients are examined and several learning points highlighted such as the importance of a multidisciplinary approach.

Lymphomatoid papulosis from childhood with anaplastic large-cell lymphoma of the small bowel

Lymphomatoid papulosis (LyP) is a lymphoproliferative disorder that exists on a spectrum of diseases with cutaneous CD30+ anaplastic large-cell lymphoma (ALCL). Multiple treatment options are available, although none are curative. The typical age of onset for LyP is in the third and fourth decades, but it has been seen occasionally in children. Lymphomatoid papulosis is associated with primary cutaneous ALCL and other lymphoproliferative malignancies, but is rarely associated with extranodal systemic ALCL. A 43-year-old man developed lymphomatoid papulosis lesions at 3 years of age, which persisted into adulthood, and he later developed ALCL of the duodenum. Treatment with standard CHOP (cyclophosphamide/doxorubicin/vincristine/prednisolone) chemotherapy resulted in complete remission of his gastrointestinal lymphoma and temporary improvement of his skin lesions. However, the LyP relapsed and proved refractory to psoralen plus ultraviolet-A phototherapy, and was only temporarily and partially responsive to bexarotene and denileukin diftitox.

Lymphomatoid papulosis in an HIV-positive man

Lymphomatoid papulosis (LyP) is a rare cutaneous lymphoproliferative condition characterized by a chronic, recurrent eruption of papules and nodules that undergo spontaneous regression. The disorder is usually clinically benign; with a minority of cases progressing to malignant lymphoma. LyP is divided into two subtypes based on histologic appearance. Type A resembles Hodgkin's disease with up to 20% of large CD30+ lymphocytes. Type B resembles mycosis fungoides showing an infiltrate of CD4+ lymphocytes and scattered CD30+ cells. Clinically LyP often resembles pityriasis lichenoides et varioliformis acuta but has a strikingly different histological appearance. Histologically, LyP resembles lymphoma (anaplastic T-cell or Hodgkin's) but is distinguished by its benign course. Here we present a case of LyP in a severely immune-repressed HIV-positive patient. This patient presented with pruritic papules involving the upper extremities and a CD4+ T-cell count of 4. Histopathologic examination showed a dense superficial dermal infiltrate comprising normal-sized lymphocytes admixed with larger lymphocytes. Immunophenotyping showed most of the lymphocytes to be CD3+ (T cells). The scattered larger cells were CD30+. The smaller lymphocytes were CD8+ rather than CD4+ as expected for non-HIV-appointed LyP. This may be because of the immune disregulation of HIV disease and the absolute and relative paucity of CD4+ T cells relative to CD8+ T cells.

Cd30+ cutaneous lymphoproliferative disorders: The stanford experience in lymphomatoid papulosis and primary cutaneous anaplastic large cell lymphoma

BACKGROUND

CD30+ cutaneous lymphoproliferative disorders (CLPDs) include lymphomatoid papulosis, borderline cases of CD30+CLPDs, and primary cutaneous anaplastic large cell lymphoma (PCALCL). Prior studies have shown CD30+CLPDs have an excellent prognosis.

OBJECTIVE

We sought to present the single-center experience of Stanford University, Stanford, Calif, in the management of CD30+CLPDs.

METHODS

A retrospective cohort analysis of 56 patients with CD30+CLPDs treated at our institution was performed.

RESULTS

No patients with lymphomatoid papulosis died of disease, and overall survival was 92% at 5 and 10 years. Disease-specific survivals at 5 and 10 years for PCALCL were 85%. Disease-specific survival at 5 years for localized versus generalized PCALCL was 91% versus 50% (P =.31). PCALCL was highly responsive to treatment, but the relapse rate was 42%. In all, 3 patients progressed to extracutaneous stage of disease. No clinical or histologic factors analyzed were predictive of worse outcome in lymphomatoid papulosis and PCALCL.

CONCLUSION

Similar to prior reports from multicenter European groups, the single-center experience at our institution demonstrates CD30+CLPDs have an overall excellent prognosis; however, cases of PCALCL with poor outcome do exist.

Primary cutaneous CD30-positive lymphoproliferative disorders

Primary cutaneous CD30-positive (anaplastic) large T-cell lymphoma and lymphomatoid papulosis have many overlapping clinical, histologic, and immunophenotypic features. These entities are currently considered as parts of a spectrum of primary cutaneous CD30-positive lymphoproliferative disorders. We provide the clinician with practical guidelines for the diagnosis, management, and treatment of patients within this spectrum of primary cutaneous CD30-positive lymphoproliferative disorders. Most patients within this spectrum of disease have an excellent prognosis. Multi-agent chemotherapy should be reserved for patients who have extracutaneous disease.

A case of lymphomatoid papulosis with prominent myxoid change resembling a mesenchymal neoplasm

Lymphomatoid papulosis is a chronic recurrent eruption of self-regressing papules and nodules. Histologically this disorder is characterized by large atypical lymphoid cells resembling Reed-Sternberg (RS) cells that are set in a background of a mixed inflammatory infiltrate. Depending on the architecture of the infiltrate and the percentage of atypical cells, the histologic appearance is subclassified as type A, B, or C. The different histologic patterns do not seem to correlate with distinct clinical appearances. We report a case of lymphomatoid papulosis with unusual histologic features affecting a 14-year-old girl. The presence of anaplastic cells in a background of myxoid stroma closely resembled a sarcoma on histologic examination.

Peripheral T-cell lymphoma

Peripheral (post-thymic) T-cell lymphoma consists of a wide spectrum of disorders with marked differences in biology and behavior. Proper classification is pivotal for evaluating treatment results, and most studies performed a decade ago lump together different disease entities and cannot be interpreted. With improved use of immunophenotyping and molecular methods for these disorders, their exact nature is better defined in the Revised European-American Lymphoma and subsequent World Health Organization (WHO) classifications. The WHO classification of post- thymic T/natural killer (NK)-cell lymphoma consists of 15 entities, including about 30% that are unclassified cases. A wide range in incidence exists between different populations, but it is likely to be lower than previously estimated. Certain entities, like nasal/nasal-type T/NK-cell lymphoma and human T-cell leukemia/lymphoma virus 1, are much more prevalent in certain racial groups and show exquisite viral association. In these entities as a group, prognosis and treatment seem inferior to those of their B-cell counterparts, but treatment must be tailored to the exact pathologic diagnosis and prognostic index. Aggressive combination chemotherapy appears to be curative for certain entities (eg, anaplastic lymphoma kinase-positive), whereas purine analogues may be useful for low-grade entities. The role of autologous and allogeneic stem cell transplantation is still poorly defined. Specific antibody-based therapy is also on the horizon.

Regression of multifocal, skin-restricted, CD30-positive large T-cell lymphoma with interferon alfa and bexarotene therapy

We report the case of a 43-year-old male patient with persistent multifocal, skin-restricted, CD30-positive, large T-cell lymphoma. Combination therapy of systemic interferon alfa and oral bexarotene was initiated on an experimental basis in the hope of circumventing therapies such as methotrexate, radiotherapy, or multiple-agent chemotherapy that may be required in such cases. This treatment was associated with rapid and marked regression of the patient's cutaneous lesions.

Posttransplantation primary cutaneous CD30 (Ki-1)-positive large-cell lymphoma

We describe the case of a 51-year-old female renal transplant recipient with primary cutaneous CD30-positive large-cell lymphoma of T-cell origin. Cutaneous T-cell lymphomas are rarely reported in organ transplant recipients, and we believe they should be considered in the differential diagnosis of cutaneous neoplastic and infectious diseases affecting this patient group.

Mucosal involvement in a patient with lymphomatoid papulosis

We report a 38-year-old woman with lymphomatoid papulosis (LyP) who had nodular and papulovesicular lesions develop on the genital area and oral commissure. Mucosal involvement in LyP is a rare event, and its clinical relevance is still unknown. Aggressive therapies are not recommended in patients with LyP with either cutaneous or mucosal involvement.

T Cell and NK Cell Lymphoproliferative Disorders

This review covers the diagnosis and management of natural killer and peripheral T-cell lymphomas (PTCL). Problems with PTCL include their rarity, representing usually 10-15% of non-Hodgkin's lymphomas in the Western Hemisphere, morphologic heterogeneity, and lack of immunophenotypic markers for clonality. Additionally, their clinical behavior is variable and may not correlate with morphology.

Dr. Kinney gives a general overview of the diagnosis of PTCL and NK cell neoplasms. Emphasis will be placed on extranodal T cell and natural killer (NK) cell lymphomas such as hepatosplenic lymphoma, subcutaneous panniculitis-like lymphoma and nasal/nasal type T/NK-cell lymphoma. The use of ALK gene regulation in the classification of anaplastic large cell lymphoma is also reviewed.

Dr. Loughran describes current understanding of the pathogenesis of large granular lymphocyte (LGL) leukemia. The discussion focuses on LGL leukemia as an instructive model of dysregulated apoptosis causing both malignant and autoimmune disease. Current management options and mechanisms of therapeutic response are also described.

Dr. Greer addresses whether PTCL should be treated differently from the more common diffuse large B cell lymphomas. He discusses the therapeutic options for anaplastic large cell lymphoma (ALCL), from a conservative approach for primary cutaneous ALCL to combination chemotherapy for the highly chemosensitive ALCL expressing anaplastic lymphoma kinase. He reviews therapy options for the extranodal subtypes of PTCL by drawing from series in adults, pediatrics, dermatology, and the Far East.

Lymphomatoid papulosis associated with both severe hypereosinophilic syndrome and CD30 positive large T-cell lymphoma

BACKGROUND

Previous reports have found an association between lymphomatoid papulosis and hypereosinophilic syndrome, as well as lymphomatoid papulosis and lymphoma. In the current study the authors report what to their knowledge is the first reported case of these three diseases occurring simultaneously in the same patient.

METHODS

The authors followed the clinical course of a 64-year-old man with lymphomatoid papulosis associated with severe hypereosinophilic syndrome complicated by involvement of the lungs and heart.

RESULTS

After 6 years of follow-up, the patient developped a large T-cell, CD30 positive lymphoma. The bone marrow biopsy was typical of hypereosinophilic syndrome associated with fibrosis, with focal lymphomatous infiltrates comprised of large cells resembling the type A cells of lymphomatoid papulosis. Complete remission of the lymphoma was obtained with chemotherapy.

CONCLUSIONS

This exceptional case report suggests a link between the three diseases. Lymphomatoid papulosis belongs to the spectrum of CD30 positive lymphoproliferative disorders and CD30 positive lymphocytes of lymphomatoid papulosis are known to have a Th2 profile with possible secretion of eosinopoietic cytokines.

Critical review of lymphomatoid papulosis of the oral cavity with case report

A 60-year-old woman was referred to the Department of Dental Medicine at Long Island Jewish Medical Center for evaluation of multiple lesions of the tongue. She reported a long history of recurrent papular cutaneous eruptions that waxed and waned. A biopsy specimen of one of the cutaneous lesions was diagnosed as lymphomatoid papulosis. Sporadic, recurrent oral ulcers that resolved spontaneously were noted 10 to 14 days before the initial visit. These ulcers had recurred for the past 17 years. The most recent oral lesion was an erythematous, irregular, solitary ulcerated area on the middle third dorsum of tongue. The area quickly enlarged, ultimately developing extensive surface necrosis. Shortly after, a similar lesion on the posterior dorsum of the tongue developed. Biopsy specimens of the former lesion showed numerous, large, atypical, pleomorphic, and hyperchromatic cells with abundant mitoses. The large, atypical cells were immunohistochemically proven to be T lymphocytes. A diagnosis of lymphomatoid papulosis was made. Two weeks later, the tongue lesions had spontaneously and totally resolved. The clinical, histomorphologic, and immunohistochemical features, as well as gene rearrangement studies of this rare entity, are presented.

A case of mycosis fungoides after CD30 positive anaplastic large cell lymphoma

A 55-year-old woman presented with mycosis fungoides (MF) after the total excision of primary cutaneous CD30+ anaplastic large cell lymphoma (ALCL). In the specimens obtained from the nodule of CD30+ ALCL and the plaque lesion of MF, the same pattern of T-cell receptor gene rearragement was detected.

Primary and secondary cutaneous CD30+lymphoproliferative disorders: a report from the Dutch Cutaneous Lymphoma Group on the long-term follow-up data of 219 patients and guidelines for diagnosis and treatment

To evaluate our diagnostic and therapeutic guidelines, clinical and long-term follow-up data of 219 patients with primary or secondary cutaneous CD30+ lymphoproliferative disorders were evaluated. The study group included 118 patients with lymphomatoid papulosis (LyP; group 1), 79 patients with primary cutaneous CD30+ large T-cell lymphoma (LTCL; group 2), 11 patients with CD30+ LTCL and skin and regional lymph node involvement (group 3), and 11 patients with secondary cutaneous CD30+ LTCL (group 4). Patients with LyP often did not receive any specific treatment, whereas most patients with primary cutaneous CD30+ LTCL were treated with radiotherapy or excision. All patients with skin-limited disease from groups 1 and 2 who were treated with multiagent chemotherapy had 1 or more skin relapses. The calculated risk for systemic disease within 10 years of diagnosis was 4% for group 1, 16% for group 2, and 20% for group 3 (after initial therapy). Disease-related 5-year-survival rates were 100% (group 1), 96% (group 2), 91% (group 3), and 24% (group 4), respectively. The results confirm the favorable prognoses of these primary cutaneous CD30+ lymphoproliferative disorders and underscore that LyP and primary cutaneous CD30+ lymphomas are closely related conditions. They also indicate that CD30+ LTCL on the skin and in 1 draining lymph node station has a good prognosis similar to that for primary cutaneous CD30+ LTCL without concurrent lymph node involvement. Multiagent chemotherapy is only indicated for patients with full-blown or developing extracutaneous disease; it is never or rarely indicated for patients with skin-limited CD30+ lymphomas.

Primary and secondary cutaneous CD30+lymphoproliferative disorders: a report from the Dutch Cutaneous Lymphoma Group on the long-term follow-up data of 219 patients and guidelines for diagnosis and treatment

To evaluate our diagnostic and therapeutic guidelines, clinical and long-term follow-up data of 219 patients with primary or secondary cutaneous CD30+ lymphoproliferative disorders were evaluated. The study group included 118 patients with lymphomatoid papulosis (LyP; group 1), 79 patients with primary cutaneous CD30+ large T-cell lymphoma (LTCL; group 2), 11 patients with CD30+ LTCL and skin and regional lymph node involvement (group 3), and 11 patients with secondary cutaneous CD30+ LTCL (group 4). Patients with LyP often did not receive any specific treatment, whereas most patients with primary cutaneous CD30+ LTCL were treated with radiotherapy or excision. All patients with skin-limited disease from groups 1 and 2 who were treated with multiagent chemotherapy had 1 or more skin relapses. The calculated risk for systemic disease within 10 years of diagnosis was 4% for group 1, 16% for group 2, and 20% for group 3 (after initial therapy). Disease-related 5-year-survival rates were 100% (group 1), 96% (group 2), 91% (group 3), and 24% (group 4), respectively. The results confirm the favorable prognoses of these primary cutaneous CD30+ lymphoproliferative disorders and underscore that LyP and primary cutaneous CD30+ lymphomas are closely related conditions. They also indicate that CD30+ LTCL on the skin and in 1 draining lymph node station has a good prognosis similar to that for primary cutaneous CD30+ LTCL without concurrent lymph node involvement. Multiagent chemotherapy is only indicated for patients with full-blown or developing extracutaneous disease; it is never or rarely indicated for patients with skin-limited CD30+ lymphomas.

Cutaneous lymphoma. Understanding the new classification schemes

Both the REAL and EORTC classification schemes classify lymphomas according to their cell of origin. These schemata also incorporate clinical features that allow for the distinction of some of these disorders. The EORTC classification scheme for primary cutaneous tumors uses terminology similar to that of the REAL classification and should allow for the recognition of teleologically similar tumors in cutaneous and extracutaneous sites. Future investigations will no doubt yield information regarding the true nature of the low-grade B-cell lymphomas of the skin and sort out the ever-increasing number of tumors found to express CD30. Most important, the continued expansion of knowledge regarding cutaneous lymphomas should enhance the ability of physicians to predict prognosis and to arrive at the most effective therapy for patients with these diseases.