CD8-positive juvenile onset mycosis fungoides: an immunohistochemical and genotypic analysis of six cases

Dupilumab-Associated Mycosis Fungoides with a CD8+ Immunophenotype

Dupilumab is a humanized IgG4 monoclonal-antibody that is approved by the United States Food and Drug Administration (FDA) for the treatment of moderate-to-severe atopic dermatitis (AD) in patients aged 12 years and older. In recent years, several case studies have associated the unmasking or progression of cutaneous T-cell lymphomas (CTCL) with dupilumab treatment. To date, all reported cases of dupilumab-associated CTCL have shown a CD4+ T-helper-cell-predominant immunophenotype. Here, we report a case of a 72-year-old man who presented with a 2-year history of a diffuse, pruritic eruption, who was started on dupilumab for 9 weeks. He subsequently developed mycosis fungoides (MF) with a CD8+-predominant immunophenotype. Overall, cases of CD8+ mycosis fungoides are less common and relatively less understood than their CD4+ counterparts, with varied presentations and courses. We present a case of dupilumab-associated CD8+ MF to highlight this presentation for pathologists and providers.

Pediatric Mycosis Fungoides: Retrospective Analysis of a Series With CD8 + Profile and Female Predominance

BACKGROUND

Mycosis fungoides (MF) in children is a rare disease and there are limited data regarding the behavior of the disease in this age group. We aimed to collect additional data to better understand the clinicopathologic features of MF in children.

MATERIALS AND METHODS

This study was a retrospective analysis of pediatric MF patients (diagnosed at age 0 to 18 y).

RESULTS

Thirteen pediatric patients with MF were identified. Female predominance was observed with a ratio of 1.6:1. Median values for age of onset of skin lesions and age at the time of histologic diagnosis were 5 and 12 years, respectively. All patients had early stage (stage IA to IIA) of MF at the time of diagnosis. Hypopigmented MF comprised 77% of all study patients, followed by classic MF (15%) and pagetoid reticulosis (8%). The lower extremity (especially proximal leg) followed by trunk and upper extremity were most commonly affected sites. Seven of 9 patients who had available immunohistochemistry data showed CD8 + predominance. Five of 8 patients whose follow-up data was available, achieved complete response with narrowband ultraviolet B treatment, while 2 and 1 had near complete response and partial response, respectively.

CONCLUSIONS

Our study demonstrated female sex and CD8 + profile predominance. Hypopigmented MF constituted the majority of cases. We observed good responses with narrowband ultraviolet B treatment.

Primary cutaneous T-cell lymphomas in childhood and adolescence

Primary cutaneous lymphomas are extranodal non-Hodgkin lymphomas of T- or B- cell origin, that predominantly affect older patients but have been reported in all age groups and as early as in the first years of life. Diagnosis of cutaneous lymphomas is challenging and requires high clinical suspicion and close collaboration between dermatologists, pediatric oncologists and pathologists. Skin involvement of non-Hodgkin lymphomas in children or adolescents can either be primary cutaneous or secondary due to an underlying nodal lymphoma. The most common primary cutaneous lymphomas encountered in children are of T-cell origin, with mycosis fungoides being the most prevalent cutaneous T-cell lymphoma, followed by CD30⁺ lymphoproliferative disorders. While cutaneous lymphomas share clinicopathologic characteristics between juvenile and adult forms, there are important differences in terms of clinical presentation, diagnosis and treatment. The hypopigmented variant of mycosis fungoides seems to be overrepresented in the pediatric age group. Prognosis and treatment of mycosis fungoides are stage dependent. The majority of children present with early-stage disease and respond well to topical corticosteroids and phototherapy.

Primär kutane T‐Zell‐Lymphome im Kindes‐ und Jugendalter

Primär kutane Lymphome sind extranodale T- oder B-Zell-Non-Hodgkin-Lymphome, die vorwiegend ältere Patienten betreffen, aber in allen Altersgruppen einschließlich der ersten Lebensjahre auftreten können. Die Diagnose kutaner Lymphome ist eine Herausforderung und erfordert einen hohen klinischen Verdacht sowie enge Zusammenarbeit zwischen Dermatologen, pädiatrischen Onkologen und Pathologen. Generell müssen primär kutane Lymphome von sekundär kutanen Lymphomen, welche meist von nodalen oder extranodalen Lymphomen ausgehen, unterschieden werden. Die häufigsten primär kutanen Lymphome im Kindesalter sind T-Zell Lymphome, wobei Mycosis fungoides das häufigste kutane T-Zell-Lymphom darstellt, gefolgt von CD30+ lymphoproliferativen Erkrankungen. Während klinisch-pathologische Merkmale kutaner Lymphome bei Jugendlichen und Erwachsenen ähnlich sind, gibt es wichtige Unterschiede bezüglich klinischer Präsentation, Diagnose und Behandlung. Die hypopigmentierte Variante der Mycosis fungoides scheint in der pädiatrischen Altersgruppe überrepräsentiert zu sein. Prognose und Behandlung der Mycosis fungoides sind stadienabhängig. Die Mehrheit der Kinder weist ein frühes Krankheitsstadium auf und spricht gut auf topische Kortikosteroide und Phototherapie an.

Hypopigmented Mycosis Fungoides: Loss of Pigmentation Reflects Antitumor Immune Response in Young Patients

Hypopigmented mycosis fungoides (HMF) is a form of cutaneous T-cell lymphoma (CTCL), a heterogeneous group of extranodal non-Hodgkin's lymphomas. HMF has a unique set of defining features that include light colored to achromic lesions, a predilection for darker skin phototypes, an early onset of disease, and predominance of CD8⁺ T-cells, among others. In the current review, we detail the known pathways of molecular pathogenesis for this lymphoma and posit that an active Th1/cytotoxic antitumor immune response in part explains why this variant is primarily seen in children/adolescents and young adults, who do not exhibit signs of immunosenescence. As a result of this potent cytotoxic response, HMF patients experience mostly favorable overall prognosis, while hypopigmentation may in fact represent a useful surrogate marker of cytotoxic immunity targeting the malignant cells. Understanding the molecular processes behind the specific features that define HMF may lead to improved diagnostic accuracy, personalized prognosis by risk stratification, and improved management of HMF. Moreover, improving our knowledge of HMF may aid our further understanding of other cutaneous lymphomas.

A Systematic Approach to the Cutaneous Lymphoid Infiltrates: A Clinical, Morphologic, and Immunophenotypic Evaluation

CONTEXT.—

The evaluation of cutaneous lymphoid infiltrates, both neoplastic and inflammatory, occurs very frequently in routine dermatopathologic examination and consultation practices. The "tough" cutaneous lymphoid infiltrate is feared by many pathologists; skin biopsies are relatively small, whereas diagnostic possibilities are relatively broad. It is true that cutaneous lymphomas can be difficult to diagnose and that in many circumstances multiple biopsies are required to establish a correct diagnostic interpretation. As a reminder, one should understand that low-grade cutaneous lymphomas are indolent disorders that usually linger for decades and that therapy does not result in disease cure. It is also important to remember that in most circumstances, those patients will die from another process that is completely unrelated to a diagnosis of skin lymphoma (even in the absence of specific therapy).

OBJECTIVE.—

To use a clinicopathologic, immunophenotypic, and molecular approach in the evaluation of common lymphocytic infiltrates.

DATA SOURCES.—

An in-depth analysis of updated literature in the field of cutaneous lymphomas was done, with particular emphasis on updated terminology from the most recent World Health Organization classification of skin and hematologic tumors.

CONCLUSIONS.—

A diagnosis of cutaneous lymphoid infiltrates can be adequately approached using a systematic scheme following the proposed ABCDE system. Overall, cutaneous T- and B-cell lymphomas are rare and "reactive" infiltrates are more common. Evaluation of lymphoid proliferations should start with a good sense of knowledge of the clinical presentation of the lesions, the clinical differential considerations, and a conscientious and appropriate use of immunohistochemistry and molecular tools.

CD8+ cytotoxic mycosis fungoides: a retrospective analysis of clinical features and follow-up results of 29 patients

BACKGROUND AND OBJECTIVE

Less than 5% of cases of mycosis fungoides (MF) present with a cytotoxic/suppressor CD8⁺ phenotype. This study aimed to evaluate the clinical characteristics, treatment modalities, and clinical course in CD8⁺ MF patients.

METHODS

In a retrospective analysis of 353 MF patients in a referral center at Ankara University, Turkey, 29 patients that were diagnosed with CD8⁺ MF were included in the study.

RESULTS

CD8⁺ MF cases constituted 8.2% of all MF patients. The age at the time of diagnosis ranged between 6 and 81 years with a median value of 46 years. The female-to-male ratio was 1.41. Patients presented with erythematous scaly (69%), hyperpigmented (58.6%), poikilodermic (17.2%), and hypopigmented (17.2 %) patches/plaques. The most common sites of involvement were the trunk and lower extremities. The most common comorbidity was hypertension (24.1%, n: 7) with 13 patients (44.8%) having a history of at least one autoimmune disease. At the time of diagnosis, 93.2% of the patients had early-stage disease, and 6.8% of the patients had advanced stage. The mean follow-up period was 6.68 ± 6.04 years (range 1-28 years). Most of the patients were treated with skin-directed therapies. Complete remission was achieved in 17 (58.6%) patients, eight (27.6%) patients had partial remission, and four (13.8%) patients had stable disease.

CONCLUSIONS

We concluded that CD8⁺ MF is associated with an indolent course and in most patients, skin-directed therapies were found to be efficient to control the disease.

Photo-photochemotherapy in Juvenile-onset Mycosis Fungoides: A Retrospective Study on 9 Patients

Mycosis fungoides (MF) is a rare disease and is considered the most common form of cutaneous T-cell lymphoma. Given the infrequent incidence of MF in patients under the age of 20, there are no established guidelines for the treatment of these patients; the overwhelming majority have an early-stage disease and progression to more advanced stages is very rare. This study presents the safety and effectiveness of photo-photochemotherapy as a first-line approach in the treatment of an early-stage MF even in young patients.

Hypopigmented Interface T-Cell Dyscrasia and Hypopigmented Mycosis Fungoides: A Comparative Study

Hypopigmented interface T-cell dyscrasia (HITCD) is a distinct form of lymphoid dyscrasia that may progress to hypopigmented mycosis fungoides (HMF). We compared both diseases as regards their CD4/CD8 phenotype and expression of granzyme B and tumor necrosis factor-alpha (TNF-α) and how these are affected by narrow-band UVB (nb-UVB). The study included 11 patients with HITCD and 9 patients with HMF. They received nb-UVB thrice weekly until complete repigmentation or a maximum of 48 sessions. Pretreatment and posttreatment biopsies were stained using anti CD4, CD8, TNF-α, and granzyme B monoclonal antibodies. Epidermal lymphocytes were CD8 predominant in 54.5% and 66.7% of HITCD and HMF cases, respectively, whereas dermal lymphocytes were CD4 predominant in 63.6% and 66.7%, respectively. Significantly, more dermal infiltrate was encountered in HMF (P = 0.041). In both diseases, granzyme B was only expressed in the dermis, whereas TNF-α was expressed both in the epidermis and dermis. No difference existed as regards the number of sessions needed to achieve repigmentation or cumulative nb-UVB dose reached at end of study. (P > 0.05). Narrow-band UVB significantly reduced only the epidermal lymphocytes in both diseases (P ≤ 0.05) with their complete disappearance in 8 (72.7%) HITCD and 6 (66.7%) HMF cases. In both diseases, nb-UVB did not affect granzyme B or TNF-α expression (P > 0.05). In conclusion, both diseases share the same phenotype, with HITCD being a milder form of T-cell dysfunction. In both diseases, epidermal lymphocytes are mainly CD8-exhausted cells lacking cytotoxicity, whereas dermal cells are mostly reactive cells exerting antitumor cytotoxicity. Tumor necrosis factor-alpha mediates hypopigmentation in both diseases and prevents disease progression. Repigmentation after nb-UVB in both diseases occurs before and independently from disappearance of the dermal infiltrate.

Juvenile-Onset Early-Stage Mycosis Fungoides-Associated Follicular Mucinosis: A Case Report

We report a juvenile case of mycosis fungoides with prominent follicular mucinosis (FM). The patient was a 9-year old boy who presented with a 2-month history of enlarging alopecic patch with fine scales on the scalp. Dermatologic examination revealed orange-tan slightly palpable plaques with follicular prominence on his trunk. The patient and his family were not aware of these asymptomatic truncal plaques. Histopathologic examination of both-scalp and trunk-lesions revealed folliculotropic lymphocytic infiltration with mucin. Immunohistochemical study showed that lymphocytic infiltration was CD4 dominant. Flow cytometry analyses of peripheral blood were normal. Any abnormal populations and Sézary cells were not observed on blood smear. Polymerase chain reaction testing showed monoclonality for the T-cell receptor4-[Latin Small Letter Rams Horn] gene. Our patient had the clinical and histopathological diagnosis of follicular mycosis fungoides-associated follicular mucinosis.

Cutaneous Hematolymphoid and Histiocytic Proliferations in Children

This article focuses on cutaneous hematopoietic neoplasms that are more likely to be encountered in the pediatric age-group and includes both lymphoproliferative and histiocytic disorders. The cutaneous hematologic disorders in children have a different epidemiologic profile to what is seen during adulthood. Although mycosis fungoides is the most frequent form of cutaneous lymphoma in adults, it is very rare in children. Because lymphoblastic leukemias and lymphomas are more frequent in the pediatric setting, cutaneous leukemic infiltrates are relatively common in this age-group. Similarly, histiocytic disorders are more common in children, particularly Langerhans cell histiocytosis and juvenile xanthogranuloma. Notably, the histiocytic disorders have undergone significant modifications on their nomenclature in the basis of the molecular characteristics that are present in them. A summary of the most frequent cutaneous hematopoietic disorders in children will be discussed further in this review.

Cutaneous Lymphomas with Cytotoxic Phenotype

Primary cutaneous cytotoxic lymphomas are T-cell or natural killer-cell lymphomas that express 1 or more cytotoxic markers. These neoplasms constitute a spectrum of diseases. In this review, an overview of clinical, morphologic, and phenotypical features of each subtype is provided. Differential diagnosis is discussed with attention to scenarios in which diagnostic difficulties are most frequently encountered.

Paediatric cutaneous lymphomas: a review and comparison with adult counterparts

Primary cutaneous lymphomas (CL) in children is rare. Only a few studies focused specifically on paediatric CL and therefore little is known whether primary CL in children are similar to or different from their adult counterparts with respect to the clinicopathological presentation, behaviour and prognosis. An extensive literature search using PubMed/MEDLINE from January 1995 through July 2014 was undertaken for articles reporting cases of paediatric CL. In addition, we identified 31 children with CL in our institutions. Mycosis fungoides and lymphomatoid papulosis are the two most prevalent lymphoma forms in children. A few entities of cutaneous lymphomas such as cutaneous diffuse large B-cell lymphoma leg type, and Sézary syndrome have not been reported so far in children. Other lymphoma entities such as hydroa vacciniforme-like lymphoma are mostly seen in certain geographic areas (Asia, Central and South America). In the paediatric population, low-malignant indolent forms such as primary cutaneous marginal zone lymphoma and primary cutaneous follicle centre lymphoma are very rare, whereas the more aggressive forms of B-cell lymphomas, precursor lymphoblastic lymphomas, and blastic plasmacytoid dendritic cell neoplasm are the most common forms in children, mostly involving the skin secondarily. Most paediatric lymphomas have similar clinicopathological features and course as their adults counterparts, particularly in the group of cutaneous T-cell lymphomas. The spectrum of cutaneous B-cell lymphomas in children significantly differs from the one in adults. Diagnostic work-up and treatment of paediatric patients with lymphomas are best achieved in close collaboration with paediatric haematopathologists and oncologists.

Aggressive epidermotropic cutaneous CD8+ lymphoma: a cutaneous lymphoma with distinct clinical and pathological features. Report of an EORTC Cutaneous Lymphoma Task Force Workshop

AIMS

Aggressive epidermotropic cutaneous CD8(+) lymphoma is currently afforded provisional status in the WHO classification of lymphomas. An EORTC Workshop was convened to describe in detail the features of this putative neoplasm and evaluate its nosological status with respect to other cutaneous CD8(+) lymphomas.

METHODS AND RESULTS

Sixty-one CD8(+) cases were analysed at the workshop; clinical details, often with photographs, histological sections, immunohistochemical results, treatment and patient outcome were discussed and recorded. Eighteen cases had distinct features and conformed to the diagnosis of aggressive epidermotropic cutaneous CD8(+) lymphoma. The patients typically present with widespread plaques and tumours, often ulcerated and haemorrhagic, and histologically have striking pagetoid epidermotrophism. A CD8(+) /CD45RA(+) /CD45RO(-) /CD2(-) /CD5(-) /CD56(-) phenotype, with one or more cytotoxic markers, was found in seven of 18 patients, with a very similar phenotype in the remainder. The tumours seldom involve lymph nodes, but mucosal and central nervous system involvement are not uncommon. The prognosis is poor, with a median survival of 12 months. Examples of CD8(+) mycosis fungoides, lymphomatoid papulosis and Woringer-Kolopp disease presented the typical features well documented in the CD4(+) forms of those diseases.

CONCLUSIONS

Aggressive epidermotropic cutaneous CD8(+) lymphoma is a distinct lymphoma that warrants inclusion as a distinct entity in future revisions of lymphoma classifications.

Multicenter case series of indolent small/medium-sized CD8+ lymphoid proliferations with predilection for the ear and face

We report 7 cases of a CD8 lymphoid proliferation of the ear and face with a cytotoxic T-cell phenotype, but an indolent clinical course. All patients presented with stable or slowly growing asymptomatic lesions on the ear, nose, or lower eyelid. Histopathology showed a dense diffuse dermal infiltrate of small- to medium-sized atypical lymphocytes without destructive features. The lymphocytes were positive for CD3, CD8, β-F1, and TIA-1 and negative for CD4, CD30, CD56, granzyme B, and PD-1. Of note, the proliferation index was low in available cases. All patients remained in complete remission at median follow-up of 14 months regardless of treatment modality. Staging was negative for extracutaneous disease in all patients. The clinically indolent behavior and histopathologic phenotype together with a low proliferation index (10%-15%) emphasize the importance of accurate diagnosis and appropriate clinical management to avoid overtreatment and complications of therapy.

Mycosis Fungoides Variants

Mycosis fungoides (MF) is a cutaneous T-cell lymphoma that usually manifests as patches and plaques with a propensity for nonphotoexposed areas. MF is a common mimicker of inflammatory and infectious skin diseases, because it can be manifested with a wide variety of clinical and pathologic presentations. These atypical presentations of MF may be difficult to diagnose, requiring a high level of suspicion and careful clinicopathologic correlation. Within this array of clinical presentations, the World Health Organization classification recognizes 3 MF variants: folliculotropic MF, pagetoid reticulosis, and granulomatous slack skin. These 3 variants, as well as hypopigmented MF, are addressed in this article.

TCR-γ expression in primary cutaneous T-cell lymphomas

Primary cutaneous γδ T-cell lymphomas (PCGD-TCLs) are considered a subgroup of aggressive cytotoxic T-cell lymphomas (CTCLs). We have taken advantage of a new, commercially available antibody that recognizes the T-cell receptor-γ (TCR-γ) subunit of the TCR in paraffin-embedded tissue. We have analyzed a series of 146 primary cutaneous T-cell lymphomas received for consultation or a second opinion in the CNIO Pathology Department. Cases were classified according to the World Health Organization 2008 classification as mycosis fungoides (MF; n=96), PCGD-TCLs (n=5), pagetoid reticulosis (n=6), CD30(+) primary cutaneous anaplastic large cell lymphomas (n=5), primary cutaneous CD8 aggressive epidermotropic CTCLs (n=3), primary cutaneous CTCL, not otherwise specified (n=4), and extranodal nasal-type NK/T-cell lymphomas primarily affecting the skin or subcutaneous tissue (n=11). Sixteen cases of the newly named lymphomatoid papulosis type D (LyP-D; n=16) were also included. In those cases positive for TCR-γ, a further panel of 13 antibodies was used for analysis, including TIA-1, granzyme B, and perforin. Clinical and follow-up data were recorded in all cases. Twelve cases (8.2%) were positive for TCR-γ, including 5 PCGD-TCLs, 2 MFs, and 5 LyP-Ds. All 5 PCGD-TCL patients and 1 MF patient died of the disease, whereas the other MF patient and all those with LyP-D were alive. All cases expressed cytotoxic markers, were frequently CD3(+)/CD8(+), and tended to lose CD5 and CD7 expressions. Eight of 12 and 5 of 11 cases were CD30(+) and CD56(+), respectively. Interestingly, 5/12 TCR-γ-positive cases also expressed TCR-BF1. All cases analyzed were negative for Epstein-Barr virus-encoded RNA. In conclusion, TCR-γ expression seems to be rare and is confined to cytotoxic primary cutaneous TCLs. Nevertheless, its expression is not exclusive to PCGD-TCLs, as TCR-γ protein can be found in other CTCLs. Moreover, its expression does not seem to be associated with bad prognosis by itself, as it can be found in cases with good and bad outcomes.

Cutaneous hematologic disorders in children

BACKGROUND

To determine and list the clinical and pathological features of cutaneous hematologic diseases in childhood.

PROCEDURE

We retrospectively analyzed the data for 51 patients up to 15 years of age, who presented with primary cutaneous hematologic disorders according to the WHO-EORTC classification, at Necker-Enfants Malades Hospital, Paris, France, over a 17-year period. The cases were classified into the following diagnostic categories: CD30+ T-cell lymphoproliferative disorders (24) all consisting of lymphomatoid papulosis (LyP, 24), lymphoblastic lymphoma (LL, 7), acute leukemias (AL, 7), mycosis fungoides (MF, 5), Epstein-Barr virus-related lymphoproliferative disorders (EBV-related LPD, 5), T/NK-cell lymphoma, nasal type (1), γ/δ T-cell lymphoma (1), and panniculitis-like T-cell lymphoma (1).

RESULTS

We encountered a majority of LyP. No secondary lymphoma was found in LyP patients with a median follow-up of 8 years. 29% and 80% of LyP and MF patients, respectively, presented with pityriasis lichenoides chronica (PLC) before onset of disease. Owing to a frequently misleading clinicopathological presentation, MF patients were first underdiagnosed. Clinicopathological features of LL and AL were highly stereotypical, leading to the diagnosis being suspected and confirmed more promptly. In the latter patients and in EBV-related LPD patients, skin lesions usually led to the discovery of systemic disease.

CONCLUSION

Distribution of cutaneous hematologic diseases seems to be different in adults and in children aged <15-year old. PLC was strongly correlated with MF and LyP. Physicians must be made aware of the stereotypical clinical presentations of LL and AL to allow prompt diagnosis and treatment.

A practical approach to the flow cytometric detection and diagnosis of T-cell lymphoproliferative disorders

The flow cytometric analysis of T-cell malignancies is difficult due to the heterogeneity of T-cells and the lack of convenient methods to detect T-cell clonality. Neoplastic T-cells are most often detected by their altered level of surface antigen expression, and detection requires an extensive knowledge of the phenotype of normal T-lymphocytes. This review focuses on the methods to distinguish malignant T-cells from their normal counterparts and the phenotypic features of the T-cell lymphoproliferative disorders.

Immunohistochemistry in the diagnosis of cutaneous neoplasms

In recent years, there has been a significant increase in the number of diagnostic immunohistochemical stains available to pathologists and dermatopathologists. Immunohistochemistry has become an indispensable tool in dermatopathology, not only in diagnosis but also in the treatment and prognostication of cutaneous neoplasms. In this review we attempt to outline current, as well as new, immunohistochemical stains of relevance in the diagnosis and classification of cutaneous neoplasms.

Juvenile-Onset Hypopigmented Mycosis Fungoides Mimicking Vitiligo

Background:

Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphoma and typically affects older adults. It is estimated that less than 5% of MF cases are of juvenile onset. An uncommon hypopigmented variant of MF exists, which has been more commonly observed in dark-skinned individuals and predominantly in juvenile-onset cases.

Methods:

We describe an 8-year-old otherwise healthy Hispanic male who, by 6 months of age, had developed asymptomatic hypopigmented patches on the lower legs, thighs, and buttocks, which have evolved over the past 7 years. This condition had previously been misdiagnosed as vitiligo. Recent immunohistologic and molecular biology studies are consistent with MF.

Results and Conclusions:

Given that hypopigmented MF is an uncommon condition, it may not be clinically suspected in the pediatric population. Histopathologic, immunophenotypic, and/or molecular biologic studies are sometimes equivocal, with findings similar to inflammatory dermatoses or autoimmune vitiligo, which may initially lead to a misdiagnosis, as in this patient's case.

Clinical characteristics and course of CD8+ cytotoxic variant of mycosis fungoides: a case series of seven patients

BACKGROUND

Fewer than 5% of cases of mycosis fungoides (MF) present with a cytotoxic/suppressor CD8+ phenotype which, despite immunophenotypic similarities with CD8+ aggressive lymphomas, is regarded as a phenotypic variant of MF. Poikilodermatous MF showing a CD8+ phenotype has been reported to have a nonaggressive clinical behaviour and a good response to psoralen plus ultraviolet A treatment.

OBJECTIVES

To perform a retrospective study of CD8+ MF cases diagnosed in the skin lymphoma clinic of Andreas Sygros Hospital.

METHODS

We analysed the clinical characteristics, the immunophenotypic and molecular indices, as well as the clinical course of these patients.

RESULTS

Seven cases of CD8+ MF (6.5% of all cases of cutaneous T-cell lymphoma) were diagnosed during 2002-2007. One of seven patients had stage IA, five stage IB and one stage IIB disease. Clinical characteristics were variable: four of seven patients presented with poikilodermatous plaques (in one of them lesions of lymphomatoid papulosis with CD8+ phenotype coexisted), one patient with classic MF, one with plantar MF and one with follicular MF. The time period between disease onset and diagnosis was long for most patients (up to 33 years). All patients received the recommended treatment according to TNM staging. Five of seven patients had complete remission, one partial response and one stable disease.

CONCLUSIONS

Special clinical characteristics, such as hyperpigmentation and poikiloderma, are often noted in CD8+ MF cases. In our series CD8+ MF presented with a long-standing disease and indolent course suggesting that CD8+ cytotoxic immunophenotype may represent a marker of mild biological behaviour.

CD8+ cutaneous T-cell lymphoma successfully treated with bexarotene: a case report and review of the literature

CD8+ cutaneous T-cell lymphoma (CTCL) is a relatively rare subset of the non-Hodgkins lymphomas. Bexarotene has been FDA-approved for the treatment of CTCL, but previous studies have been conducted on CD4+ CTL and there have been no reports about its use in CD8+ CTCL. Herein, we report on a patient whose CD8+ CTCL completely responded to treatment with bexarotene.

Mycosis fongoïde transformé chez un enfant : traitement par transplantation médullaire allogénique avec effet « graft-versus-lymphoma »

BACKGROUND

Mycosis fungoides is the most frequent cutaneous T-cell lymphoma but has been rarely reported in children and teenagers. Although transformation into large-cell T-cell lymphoma has been described in 10% of adult cases, it is seen very rarely in children. We report here the clinical case of mycosis fungoides in a child with an unusual transformed form at presentation and treated by bone marrow allograft.

CASE-REPORT

A 13 year-old boy, presenting guttate parapsoriasis for 5 years was referred to our Dermatology Department with a 2-month history of infiltrated plaques throughout the body and face. Large erythematous-squamous plaques on the trunk and face as well as a nodular lesion of the arm were also noted. On histology, typical features of mycosis fungoides were observed, in addition to transformed cells which were CD30-negative. Local treatment comprising caryolysin and dermal corticosteroids allowed initial regression of the lesions. However, a few months later, nodular lesions reappeared as well as axillary lymph nodes. Repeated histology confirmed the diagnosis of transformed mycosis fungoides with large CD30-positive cells. Despite chemotherapy, cutaneous and lymph node disease recurred, and bone marrow allograft was performed, resulting in rapid disease regression. Following the recurrence of skin lesions 2 years later, donor lymphocytes were administered in addition to treatment with interferon alpha, aiming at stimulating a graft-versus-lymphoma reaction. One year post-lymphocyte injection, the patient is in full remission.

DISCUSSION

This is a new case report of juvenile mycosis fungoides with unusual clinical features such as rapid course and transformed form at presentation. Juvenile mycosis fungoides represents 2.5 to 5% of cases of mycosis fungoides and transformation to large cell lymphoma is exceptional. Our case illustrates the aggressive pattern observed in some teenage patients as well as the efficacy of bone marrow allograft, most likely thanks chiefly to its graft-versus-lymphoma effect.

Muscle and nerve involvement in granulomatous mycosis fungoides

Occasional cases of peripheral neuropathy have been reported in classic mycosis fungoides. A rare variant of mycosis fungoides is the granulomatous form. We describe the occurrence of myopathy and peripheral neuropathy in a young woman who had skin lesions since the age of 12 years. At the age of 20 years they were diagnosed as granulomatous mycosis fungoides. The skin lesions resolved with interferon therapy and radiation. She then presented with cardiac and pulmonary symptoms and signs that were initially thought to be due to sarcoidosis or systemic vasculitis. A nerve and muscle biopsy showed granulomatous mycosis fungoides. To our knowledge, involvement of muscle and nerve by granulomatous mycosis fungoides has not been reported previously. Early reports suggested a favorable prognosis for the granulomatous subtype of mycosis fungoides. Based on a literature review and the course in our case, however, granulomatous mycosis fungoides seems to be an indicator of aggressive disease and ultimately a poor prognosis.

Lymphome T cutané épidermotrope cytotoxique CD8+ « agressif » : difficultés de prise en charge chez un malade atteint d’une dystrophie myotonique de Steinert

INTRODUCTION

Primary cutaneous "aggressive" CD8-positive epidermotropic cytotoxic T-cell lymphoma is a rare subset of cutaneous cytotoxic T/NK lymphomas that clearly differs from mycosis fungoides, whether CD4+ or CD8+, by the presence of rapidly evolving tumoral cutaneous lesions, foci of keratinocytes necrosis, a cytotoxic T phenotype and a poor prognosis.

CASE REPORT

A 33-year-old man with Steinert's myotonic dystrophy was referred for evaluation of rapidly worsening cutaneous tumors along with marked deterioration of general status. Clinical, histological and immunohistological data led to the diagnosis of primary cutaneous CD8+ epidermotropic cytotoxic T-cell lymphoma. CHOP chemotherapy was effective despite cardiac toxicity in the setting of Steinert's dystrophy, but the patient relapsed and died of pulmonary sepsis after chemotherapy was resumed.

DISCUSSION

The treatment of primary cutaneous epidermotropic CD8+ cytotoxic T-cell lymphoma is not codified. CHOP chemotherapy is usually the first-line therapy but relapses are frequent with median survival of no more than 34 months. In our patient, an additional difficulty was the cardiac toxicity of cytostatic drugs linked to the myopathy which prevented the use of high dosages, requiring a change of therapeutic regimen.

Pleomorphic CD8+ Small/Medium Size Cutaneous T-Cell Lymphoma

Pleomorphic small/medium-sized cutaneous T-cell lymphoma is a recently recognized rare type of cutaneous T-cell lymphoma which is clinicopathologically different from mycosis fungoides and Sezary syndrome. By definition the phenotype of the neoplastic lymphocytes in pleomorphic small/medium-sized cutaneous CD3CD4CD8 but CD8 pleomorphic small/medium sized cutaneous T-cell lymphoma cases have been occasionally described. We describe a 55-year-old female with a pruritic erythematous nodule on the lateral aspect of her right foot present for 1.5 years. Histology revealed a nonepidermotropic lichenoid infiltrate in the papillary dermis and a patchy infiltrate in the mid and lower dermis composed of small to medium-sized pleomorphic lymphocytes. The immunophenotype of these lymphocytes was CD3CD4CD8TIA-1. Staining for CD20, CD30, CD56, TdT, and LMP1 were negative, and the Ki-67 proliferation index was 5% to 10%. Gene rearrangement studies demonstrated a T-cell clone. The laboratory and imaging workup did not reveal extracutaneous involvement. The lesion was treated by local irradiation but a follow-up biopsy demonstrated only partial remission. Consequently, the lesion was treated by surgical excision.

CD4/CD8 double-negative epidermotropic cutaneous T-cell lymphoma: an immunohistochemical variant of mycosis fungoides

BACKGROUND

Mycosis fungoides (MF) is an epidermotropic cutaneous T-cell lymphoma in which the tumor cells express a mature T-helper memory phenotype, ie, CD3(+), CD4(+), CD8(-), CD45RO(+), with a T-cell receptor (TCR) of the alpha/beta heterodimer. A minority of patients have an unusual immunohistochemical profile consisting of a CD4(-), CD8(+) mature T-cell phenotype. An aberrant CD4/CD8 double-negative (DN) immunophenotype in patients with early MF has rarely been reported.

OBJECTIVES

We sought to evaluate the frequency of CD4/CD8 DN immunophenotype in patients with early MF, and to study their clinical, histopathologic, and immunohistochemical features, and the course of their disease.

METHODS

Our departmental archives were searched for patients with early-stage MF and CD4/CD8 DN immunophenotpye.

RESULTS

Of the 140 patients with early MF immunophenotyped in our laboratory, 18 (12%) showed CD4 and CD8 expression in less than 10% of their intraepidermal T cells on fresh-frozen and paraffin-embedded samples. The group included 13 male and 5 female patients; 14 adults and 4 children; and 15 Jews and 3 Arabs. In all, 8 had classic MF and 10 had unusual clinical variants (5 hypopigmented, 3 localized, 1 ichthyosiform, 1 purpuric). All received skin-targeted therapies and all had an indolent course (mean follow-up 3.5 years). Histopathology revealed early MF. Results of immunohistochemical analysis of the intraepidermal lymphocytes were as follows: CD3(+), CD4(-), CD8(-) in all patients; CD7(-) in all of 17; CD45RO(+) in 15 of 16; T-cell-restricted intracellular antigen-1(+) in 11 of 15; CD30(+) in 2 of 16; and CD56(+) in 2 of 16. A betaF1(+)/delta(-) phenotype, indicating a TCR of the alpha/beta heterodimer, was found in 8 of 16; betaF1(-)/delta(+) phenotype, indicating a TCR of the gamma/delta heterodimer, in 1 of 16; betaF1(-)/ delta(-) in 5 of 16; and no determinable phenotype in 2 of 16. The TCR gamma gene was clonally rearranged in 10 of 16 patients.

LIMITATION

This was a single-center case series.

CONCLUSIONS

There is a subgroup of patients with early MF that exhibit a CD4/CD8 DN immunophenotype. In our region, this aberrant immunophenotype is not as rare as reflected in the literature, is overrepresented in the unusual clinical variants of MF, and does not seem to have prognostic significance. Like CD4(+) MF, the tumor cells represent memory T cells and in many cases express alpha/beta TCR, but unlike CD4(+) MF, they have a mostly cytotoxic phenotype. We suggest that CD4/CD8 DN MF should be recognized as another immunohistochemical variant of this lymphoma.

Mycosis fungoides with a CD56+ immunophenotype

We report 3 cases of mycosis fungoides (MF) with a CD56+ cytotoxic immunophenotype. Each patient presented with a different clinical phenotype: one exhibited limited poikilodermatous patches (skin stage T1); one, widespread hypopigmented lesions (skin stage T2); and one, poikiloderma with a single cutaneous tumor (skin stage T3). MF was confirmed both histologically and by the presence of a T-cell receptor clone in lesional skin in all cases. CD56 and T-cell intracellular antigen-1 were expressed by the malignant lymphocytes in all patients and two expressed CD8. No sample demonstrated loss of the pan T-cell markers CD2 or CD3. None of the 3 developed systemic disease and T-cell receptor gene analysis of peripheral blood was polyclonal in all cases. Only 3 cases of CD56+ MF have been reported previously, none of which exhibited tumor-stage disease. Currently, the disease in our patients appears to be behaving in a manner similar to that predicted for MF with a normal immunophenotype but the prognosis has to be guarded in view of the rarity of this subtype.

The Role of Alemtuzumab in the Management of T-Cell Malignancies

T-cell malignancies are rare, making up 10% to 15% of all lymphoid neoplasms in adults. They include many different types of disorders such as T-cell prolymphocytic leukemia, T-cell large granular lymphocytic leukemia, adult T-cell leukemia/lymphoma, cutaneous T-cell lymphoma, and peripheral T-cell lymphoma, which are themselves divided into multiple subcategories. Most T-cell malignancies arise as a result of chromosomal abnormalities, including T-cell receptor rearrangement anomalies. Viral infections are implicated in the development of adult T-cell leukemia/lymphoma and some cases of peripheral T-cell lymphoma have been linked to Epstein-Barr virus or human immunodeficiency virus infection. With the possible exception of T-cell large granular lymphocytic leukemia, which often has an indolent course, T-cell malignancies have not responded well to conventional chemotherapeutic treatment. The introduction of monoclonal antibodies for the treatment of cancer has changed the outlook for patients with T-cell malignancies. Recent studies with single-agent alemtuzumab, an anti-CD52 monoclonal antibody, have shown improved response rates and survival in patients with T-cell prolymphocytic leukemia and cutaneous T-cell lymphoma. Preliminary data also suggest that alemtuzumab may have activity in patients with heavily pretreated peripheral T-cell lymphoma who are refractory to conventional chemotherapy. Preclinical studies with mice bearing human adult T-cell leukemia/lymphoma cells suggest that alemtuzumab may have a potential therapeutic role in this setting. Treatment of T-cell hematologic malignancies with alemtuzumab appears promising. Earlier treatment and combination with chemotherapeutic agents may improve treatment outcome for patients with these malignancies and allow for consolidation with stem cell transplant strategies in selected patients.

The New World Health Organization–European Organization for Research and Treatment of Cancer Classification of Cutaneous Lymphomas

The WHO-EORTC classification of cutaneous lymphomas is a good start to unifying nomenclature, a necessity before coherent consensus diagnoses can be made. There are three provisional diagnoses in this new classification that are not covered in detail in this review because they are rare diseases that still require further study for definitive classification. Much remains to be elucidated about cutaneous lymphomas, but understanding of the major entities within the new classification is an important first step in understanding these diverse diseases.

Fatal CD8+ Epidermotropic Cytotoxic Primary Cutaneous T-Cell Lymphoma with Multiorgan Involvement

A 70-year-old woman presented with a 3-month history of two ulcerated erythematous-violaceous nodular lesions over the nose and forehead, respectively. The patient's history included a similar cutaneous nodule on the glabella diagnosed as pseudolymphoma 2 years ago. At that time, despite the diagnosis of a benign disease, an adequate staging was performed, ruling out any extracutaneous involvement. During hospitalization, multiple purpuric papules developed over the abdomen, and the disease spread to mediastinal lymph nodes, lungs and the central nervous system. Based on the histologic, immunophenotypic and molecular biology findings, a diagnosis of CD8+ epidermotropic cytotoxic primary cutaneous T-cell lymphoma was made. Secondary skin involvement by a CD8+ extracutaneous T-cell lymphoma could not be excluded with certainty, but seemed to be unlikely because of the negativity of the initial workup. The patient died from complications of right femoral artery thrombosis before starting specific polychemotherapy 21 months after onset of the disease. Among primary cutaneous T-cell lymphomas, the CD8+ epidermotropic cytotoxic subset comprises rare, highly aggressive forms characterized by metastatic spread to unusual sites such as the oral cavity, lungs, testis and the central nervous system but usually not to the lymph nodes. These cases seem to be distinct from mycosis fungoides with CD8+ phenotype, which shows a nonaggressive clinical behavior.

Micose fungóide hipopigmentar com 20 anos de evolução

A micose fungóide hipopigmentar é uma forma rara de linfoma cutâneo de células T, em que lesões hipopigmentadas ocorrem na ausência de lesões clássicas dessa neoplasia. Na literatura latino-americana existem apenas três casos; relata-se aqui o caso de um homem negro, de 29 anos com lesões há 20 anos O tratamento é semelhante ao de outros tipos de linfomas T cutâneos, sendo o psoraleno mais ultravioleta A (Puva) e a mostarda nitrogenada tópica os mais relatados.

Clinicopathological spectrum of mycosis fungoides

Cutaneous lymphomas represent a heterogeneous group of T-, NK- and B-cell neoplasms, with mycosis fungoides (MF) being the most common subtype. MF has a plethora of clinicopathological manifestations. Many variants of this lymphoma differ substantially from the 'classical' Alibert-Bazin disease and are therefore sometimes referred to as 'atypical' forms of the disease. This review addresses the whole clinicopathological spectrum of mycosis fungoides with respect to epidemiology, clinical, histopathological, immunophenotypic and genotypic features and the clinical course and prognosis of its variants: classical, erythrodermic, follicular, syringotropic, bullous/vesicular, granulomatous, poikilodermic, hypo- and hyperpigmented, unilesional, palmoplantar, hyperkeratotic/verrucous, vegetating/papillomatous, ichthyosiform, pigmented purpura-like, pustular and mucosal involvement in MF.

Unilesional (segmental) mycosis fungoides presenting in childhood

Mycosis fungoides is rare in children, and a unilesional presentation is also rare. A 13-year-old Kuwaiti boy with unilesional mycosis fungoides is described. Clinically he had a single indurated large plaque on the left shoulder with histopathologic features typical of cutaneous T-cell lymphoma. The diagnosis was further supported by the presence of a T-cell clone discovered through molecular biology studies of paraffin-embedded material. No other lesions were detected. The lesion showed a favorable response to local radiotherapy.