Mycosis fungoides palmaris et plantaris or acral pagetoid reticulosis?

Pagetoid Reticulosis: Report of Two Cases and Review of the Literature

Pagetoid reticulosis is a rare variant of mycosis fungoides that presents with a large, usually single, erythematous, slowly growing scaly plaque containing an intraepidermal proliferation of neoplastic T lymphocytes. Histopathologically, this disease has distinctive attributes. In this report, we present two cases of pagetoid reticulosis, compare its microscopic features to those of ‘classical’ mycosis fungoides, and provide a brief review of the pertinent literature.

Oral-Cutaneous CD4-Positive T-cell Lymphoma: A Study of Two Patients

We describe two slowly progressive cases of T-cell lymphoma that involved both acral skin and oral cavity. One patient presented with a tongue nodule, completely responded to chemotherapy and then developed recurrent lymphoma involving tongue and skin a few months later that also responded to therapy. The second patient presented with a skin nodule that spontaneously resolved without therapy, and subsequently recurred in tongue and skin a few years later. In both cases, the neoplasms were composed of atypical lymphoid cells with epidermotropism and were of T-helper cell lineage (CD4+). The initial lesions were also negative for CD30. Identical T-cell receptor gene rearrangements were detected in the initial and recurrent lesions of one case. Although these neoplasms were classified as unspecified peripheral T-cell lymphoma because of the unusual distribution of disease, both cases also had histopathologic features of mycosis fungoides. These cases are strikingly similar, and may represent an unusual clinicopathologic type of T-cell lymphoma that can hone to cutaneous and oral mucosal sites with a slowly progressive natural history.

Defining early mycosis fungoides

This editorial review summarizes the results of 5 meetings sponsored by the International Society for Cutaneous Lymphoma at which the clinicopathologic and ancillary features of early mycosis fungoides were critically examined. Based on this analysis, an algorithm was developed for the diagnosis of early mycosis fungoides involving a holistic integration of clinical, histopathologic, immunopathologic, and molecular biological characteristics. A novel aspect of this algorithm is that it relies on multiple types of criteria rather than just one, for example, histopathology. Before its finalization, the proposed diagnostic algorithm will require validation and possibly further refinement at multiple centers during the next several years. It is anticipated that a more standardized approach to the diagnosis of early mycosis fungoides will have a beneficial impact on the epidemiology, prognostication, treatment, and analysis of clinical trials pertaining to this most common type of cutaneous lymphoma.

History: Frederic Woringer (1903-1964) and Woringer-Kolopp disease

The two most famous dermatologic eponyms born in Strasbourg are Pautrier microabscess and Woringer-Kolopp disease. Frederic Woringer (1903-1964) was one of Pautrier's students, who had been in charge of the Laboratoire d'Histopathologie Cutanée in Strasbourg from 1930 until his death. He achieved a brilliant career in the field of dermatopathology and was very active during the great period between World War I and II. His name is linked to a rare disease, pagetoid reticulosis, which he actually misunderstood, as he was at first convinced that the characteristic intraepidermal changes were due to Paget cells. In this article, we show for the first time the original correspondence between Kolopp (who sent the case to Strasbourg) and Woringer, including discussion with masters such as Pautrier and Civatte. Civatte suggested that these mysterious intraepidermal cells might have common morphologic features with the recently described Sezary cells. After the first publication of pagetoid reticulosis, it took almost 40 years to establish a clear link with mycosis fungoides. It was Braun Falco who named the disease after Woringer and Kolopp in 1974. Woringer would certainly be surprised to know that his name is still world famous, thanks to a rare disease he was the first to extensively describe in 1939, a few days before the declaration of war.

Mycosis-fungoides-type cutaneous T cell lymphoma of the hands and soles: a variant causing delay in diagnosis and adequate treatment of patients with palmoplantar eczema

BACKGROUND

The etiopathology of chronic eczematous lesions of the palms and/or soles remains elusive in a considerable proportion of patients. Accumulating evidence suggests that a rare variant of mycosis fungoides (MF)-type cutaneous T cell lymphoma (CTCL) restricted to the palms and/or soles may mimic common palmoplantar dermatoses.

OBJECTIVE

In the present study, we analyzed the clinical and histological characteristics of 3 adult patients with preexisting nonclassified chronic palmoplantar eczema poorly responding to standard therapies. Palmar and/or plantar MF was eventually diagnosed.

METHODS

The course of the disease, response to previous therapies and dermatological features are described, results of histochemical and immunohistochemical analyses are reported, including T cell receptor gamma gene rearrangement where obtainable.

RESULTS

Onset of cutaneous lesions with broad clinical variation was experienced 2-10 years prior to diagnosis; conventional therapies led to short-time or partial remission only; except for 1 patient, the epidermotropic infiltrate was predominantly composed of CD4-positive cells; topical photochemotherapy seems to result in more durable responses.

CONCLUSION

As therapeutic strategies for this disease variant differ from symptomatic standard treatment regimens, awareness of MF-type CTCL as a relevant differential diagnosis of palmoplantar eczema should be expanded to prevent delay in diagnosis and adequate therapy.

Pagetoid reticulosis: a case report and review of the literature

The histologic finding of a pagetoid epidermotropic growth pattern is associated with a variety of conditions that range from reactive to neoplastic in nature. Included among these conditions is the uncommon skin disorder pagetoid reticulosis. Pagetoid reticulosis may present clinically as a solitary, indolent plaque-like lesion. Conversely, it may manifest as a more generalized clinically aggressive disease. The generalized form may develop into systemic lymphoma, leading to severe morbidity and death. We present a case of pagetoid reticulosis of the perioral region, a rare anatomic site for this condition. Histopathologic and immunohistochemical findings were consistent with a diagnosis of isolated pagetoid reticulosis. This review discusses the nature of pagetoid reticulosis and addresses past and current concepts regarding the condition.

Practical evaluation and management of cutaneous lymphoma

Accurate evaluation of patients with suspected or known cutaneous lymphoma requires the integration of many sources and types of information, including clinical evaluation, microscopic analysis of tissue, immunophenotyping, gene rearrangement studies, clinical staging, and longitudinal observation. Diagnoses should be based on knowledge of specific lymphoma types as described in modern classification systems. Management of patients with cutaneous lymphoma requires collaboration among dermatologists, dermatopathologists, hematopathologists, and medical, surgical and radiation oncologists. (J Am Acad Dermatol 2002;46:325-57.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should better understand how to evaluate and manage patients for suspected or established lymphoma of the skin. Components include the clinical history and physical examination, optimal biopsy and tissue handling, interpretation of pathology and adjunctive test results, clinicopathologic correlation, and therapy. Participants should also understand the basis for establishing a specific diagnosis of cutaneous lymphoma based on current classification and staging.

Low CD7 expression in benign and malignant cutaneous lymphocytic infiltrates: experience with an antibody reactive with paraffin-embedded tissue

Loss of CD7 expression by neoplastic lymphocytes is considered a distinguishing characteristic of mycosis fungoides (MF) and cutaneous T-cell lymphoma. Reports to date examining for the CD7 immunophenotype in MF have been performed on fresh-frozen tissue. In this study, we used a paraffin-reactive antibody directed against CD7 to determine its range of expression in MF and to compare these results with those in controls. Examining 22 cases of MF and 61 controls, we found minimal CD7 expression by lymphocytes in MF and in a few cases of benign inflammatory dermatosis (BID). The lowest mean CD7 counts (as a percentage of total lymphocytes) were found in MF (patch stage: 5% +/- 5%, range: 0-10; plaque and tumor stages: 15% +/- 5%, range: 5-25), and these counts were significantly lower than those for BID (35% +/- 20%, range: 5-80; p = 0.001). By logistic regression analysis, low CD7 expression (<10% lymphocytes labeling) had sensitivity and positive predictive values of 80% and 72%, respectively, and specificity and negative predictive values of 93% and 96%, respectively, for the diagnosis of patch stage MF. False-positive results were found for spongiotic dermatitis. Moreover, spongiotic dermatitides exhibited a progressive decrease in mean CD7 counts from acute to subacute to chronic stages (50% versus 35% versus 30%, respectively). In conclusion, minimal CD7 expression is a specific finding for MF. Benign inflammatory infiltrates can also show low CD7 expression, however, which rarely matches that of patch stage MF. Progressive loss of CD7 expression in BID is the likely consequence of expansion of antigen-selected CD3+CD4+CD7- T cells. These inflammatory CD4+CD7- T cells may represent the physiologic counterpart to the neoplastic lymphocyte of MF.

Pagetoid reticulosis (Woringer-Kolopp disease): an immunophenotypic, molecular, and clinicopathologic study

Pagetoid reticulosis (PR), also known as Woringer-Kolopp disease, is a form of cutaneous T-cell lymphoma that demonstrates striking epidermotropism on histologic examination. We present the histologic, immunologic, and molecular findings for seven patients who had PR. The patients ranged in age from 33 to 67 years. All patients presented with one or several thick plaques involving the distal extremities except for one patient, who presented with a tongue lesion. Immunohistochemical staining of the atypical lymphoid cells demonstrated a T-cell phenotype in all cases. In one of four frozen cases, the neoplastic cells were of T-helper cell phenotype (CD4 positive). Four of seven cases demonstrated a T-cytotoxic/suppressor cell phenotype (CD8 positive). The T-cell subset for the remaining two cases could not be determined. CD30 positivity and a high growth fraction as indicated by staining with Ki-67 were seen in three of seven and three of four cases, respectively. Genotypic analysis performed on three of our cases revealed T-cell receptor (gamma and/or beta) rearrangement, indicating a clonal proliferation. The clinical follow-up ranged from 15 months to 13 years. Four of seven patients are alive and free of disease after treatment with excision or local irradiation. One patient relapsed twice after treatment with radiation and photochemotherapy with 8-methoxypsoralen and UVA and was then lost to follow-up. The lesions of another patient resolved spontaneously but recurred at the same and in an additional site 5 years later. One patient recurred after electron beam therapy. The recurrent lesion improved with radiation therapy and local wound care but never resolved completely. The patient died of unrelated causes. Our findings suggest that PR is a distinct clinicopathologic entity, separate from unilesional mycosis fungoides, demonstrating a slow disease course. The disease is a clonal cutaneous T-cell lymphoma with relatively consistent clinical and histopathologic findings but a heterogeneous immunophenotypic profile.

Cutaneous T-cell lymphoma. Refinement in the application of controversial histologic criteria

The term cutaneous T-cell lymphoma was originally coined to encompass the spectrum of mycosis fungoides and Sézary syndrome. It has become increasingly evident that the histopathologic diagnosis of CTCL can be exceedingly challenging. A series of recent studies, however, have helped clarify the nature of the histologic findings in CTCL. Recently reported histologic data on mycosis fungoides, Sézary syndrome, and their variants is emphasized in this article, with special focus given to the findings in early lesions. A brief summary of lymphocyte immunophenotyping and the role of T-cell reception gene rearrangements in CTCL is included.