Treatment of cutaneous lymphoid hyperplasia with thalidomide: report of two cases

Lymphocytoma cutis (cutaneous B-cell pseudolymphoma): study of 102 cases with emphasis on the histological characteristics and immunohistochemistry of the miliarial type

BACKGROUND

Lymphocytoma cutis (LC) is a benign reactive lymphoproliferative B-cell process. It has two variants: localized type with solitary lesions and miliarial type with numerous lesions. The objective was to investigate the characteristics of LC with emphasis on the miliarial type.

METHODS

Retrospective study, patients with clinical and histopathological diagnosis of LC were included. Age, sex, evolution time, affected site, and type of treatment were investigated. In miliarial-type LC, the histological and immunohistochemical characteristics were also investigated.

RESULTS

In an 18-year period, there were 102 patients found with LC: 72 (71%) corresponded to females, the median age was 45 years, the median evolution time was 4 months, and the face was the most predominant affected area in 81 (79%) cases. Localized-type LC corresponded to 88 (86%) cases, and miliarial type in 14 (14%). The most common treatment was surgery, which was used in 32 (31%) patients, all of whom had localized type (P < 0.01). The most frequent treatment for miliarial-type LC was corticosteroids in five (36%, P = 0.32), the predominant histopathological pattern was nodular in 10 (71%) specimens, and immunohistochemistry was performed in 11 (79%), where all were positive for CD20 with polyclonality to kappa and lambda light chains.

CONCLUSIONS

The importance of LC lies in that it can be clinically and histopathologically confused with cutaneous lymphoma and that it is a rare entity, with its miliarial variant being rarer still. This study provides information on the clinical-histological characteristics of LC and its immunohistochemistry.

Radiotherapy in aggressive cutaneous pseudolymphoma: a case report and review of literature

Pseudolymphoma is a nonspecific disease characterized by lesions with lymphomatous-appearing but benign accumulation of inflammatory cells. They generally present as small ulcero-nodular lesions confined to skin which often respond to local therapies. We describe an unusual presentation of an extensive and locally aggressive cutaneous pseudolymphoma in a 21-year-old male patient who presented with extensive cutaneous eruptions gradually progressing over 6 years to involve the entire circumference of his left arm. Magnetic resonance imaging scans of his left arm showed a lesion deeply infiltrating into the soft tissue reaching up to the humerus with intense periosteal reaction. He was successfully treated with radiotherapy after many failed attempts with surgery and chemotherapy.

Treatment of cutaneous lymphoid hyperplasia with the monoclonal anti-CD20 antibody rituximab

B-cell lymphoproliferative disorders are a continuum from benign cutaneous lymphoid hyperplasia (CLH) or "pseudolymphoma" to primary cutaneous B-cell lymphoma (PCBCL). Historically, CLH was treated with a combination of antibiotics, topical or intralesional corticosteroids, and/or localized radiotherapy. Rituximab, a monoclonal antibody that targets the CD20 marker on B cells, is an effective and well-reported treatment for PCBCL. We review the pathogenesis and current treatments of B-cell lymphoproliferative disorders and assess the role of rituximab for potential therapy in the setting of refractory CLH. We describe a case of CLH that was treated with intralesional rituximab. The patient had notable clinical improvement over the treatment period with rituximab. Because of some persistent and recurrent erythematous areas, topical tacrolimus was initiated, with significant clinical improvement. There were no reported side effects. Management of CLH with intralesional rituximab has been described. The treatment presented in this report substantiates rituximab as a reasonable therapeutic option for refractory CLH after failure of several other widely accepted treatments. Treatment with intralesional rituximab should be reserved for patients with documented CD20(+) lesions.

Very good partial response in a patient with MALT-lymphoma of the lung after treatment with low-dose thalidomide

Pulmonary MALT lymphoma is a rare disease entity and generally follows an indolent clinical course. Due to scarce information from randomized prospective trials, no standardized therapy protocols exist. Besides irradiation and chemotherapy, novel biological agents such as the anti CD20-antibody rituximab and thalidomide constitute a promising new approach. In this report we demonstrate the case of a 52-year-old male patient with extra-intestinal MALT lymphoma of the lung. After 10 months of treatment with low dose thalidomide (100mg/d), very good partial response of the intrapulmonary lesions was achieved.

Dermatologic and nondermatologic uses of thalidomide

OBJECTIVE

To review published data on thalidomide, with emphasis on current knowledge about mechanism of action, new and/or potential dermatologic and nondermatologic therapeutic applications, well-known and emerging adverse effects, and current indications for its safe use.

DATA SOURCES

Review articles, in vitro research studies, references from retrieved articles, case reports, and clinical trials were identified from a computerized literature search using MEDLINE and OVID (1966-January 2003) and on the Cochrane Clinical Trials Register (January 2003). Information available from meetings' abstract books, Internet, or pharmaceutical companies was also considered.

STUDY SELECTION AND DATA EXTRACTION

All articles identified as relevant, including those from non-English literature, were considered in an attempt to provide to the reader both the theoretical basis and practical guidelines for thalidomide pharmacotherapy.

DATA SYNTHESIS

Thalidomide has hypnosedative, antiangiogenic, antiinflammatory, and immunomodulatory properties. Moreover, it has been shown to selectively inhibit the production of tumor necrosis factor-alpha and reduce the expression of various integrin receptors on the membrane of leukocytes and other cell types in a dose-dependent fashion. Controlled trials demonstrated the efficacy of thalidomide in a number of diseases, including erythema nodosum leprosum, lupus erythematosus, aphthosis, graft-versus-host disease, prurigo nodularis, and actinic prurigo. Single case reports or studies in small series have also suggested a possible role for thalidomide in numerous other dermatologic and nondermatologic disorders. Possibly severe and sometimes irreversible risks related to the clinical use of thalidomide include teratogenicity and neurotoxicity.

CONCLUSIONS

Although teratogenicity and neurotoxicity are significant adverse effects requiring cautious use, thalidomide is an effective therapeutic modality in a variety of difficult-to-treat disorders and, providing careful selection of patients, should offer an acceptable risk-to-benefit ratio.

Thalidomide in dermatology

Thalidomide is an effective agent to treat over 25 seemingly unrelated dermatological conditions that have an inflammatory or autoimmune basis. The main side-effects of teratogenesis and peripheral neuropathy limit its use. Currently, in Australia no assurance is given as to the quality, safety and efficacy of thalidomide. The use of thalidomide for toxic epidermal necrolysis can lead to an increase in mortality, and its use as a prophylactic agent for the prevention of chronic graft-versus-host disease following bone marrow transplantation has raised more speculations as to the safety of this notorious drug. A review of the therapeutic indications for thalidomide in dermatology as well as the mechanisms of action and side-effects of this drug are presented. The current suggested guidelines for its use in clinical practice in Australia are discussed.

CD30-positive T-cell-rich pseudolymphoma induced by gold acupuncture

Cases of pseudolymphoma induced by intradermal gold injection or gold piercing have previously been described. Most of these cases showed the histopathological finding of B-lymphocyte predominant lymphocytoma cutis. We describe a patient with gold acupuncture-induced T-cell-rich pseudolymphoma. Some T cells showed positive staining with CD30. The lesions responded to an intralesional injection of triamcinolone acetonide.

Cutaneous lymphoid hyperplasias

Benign hyperplastic lymphoid infiltrates of the skin (pseudolymphoma, older term) simulate lymphoma clinically and histologically. They can be divided into B-cell predominant (typical cutaneous lymphoid hyperplasia (CLH), angiolymphoid hyperplasia, Kimura's disease, and Castleman's disease) and T-cell predominant (T-cell CLH, lymphomatoid contact dermatitis, and lymphomatoid drug eruption). Both types may represent exaggerated reactions to diverse external antigens (insect bite, tattoo, zoster, trauma, among others). A composite assessment of clinical presentation and behavior, routine histology, immunophenotyping, and molecular studies is essential for the diagnosis of benign cutaneous lymphoid infiltrates. Treatment includes antibiotics, intralesional and systemic corticosteroids, excision, radiotherapy, and immunosuppressants. Treatment depends on the assessment and biologic behavior, which is usually benign. Molecular biologic analysis has shown that a significant proportion of cases harbor occult B- or T-cell clones (clonal CLH). Progression to overt cutaneous lymphoma has been observed in a minority of cases. Patients with clonal populations of B or T cells and persistent lesions should be closely observed for emergence of a lymphoma.