Are most primary cutaneous B-cell lymphomas 'marginal cell lymphomas'?

The new World Health Organization classification of haematopoietic and lymphoid tumours: a dermatopathological perspective

The World Health Organization (WHO) has published a new consensus classification of tumours of haematopoietic and lymphoid tissue, based on recognizable disease entities defined by clinical and scientific criteria. The WHO does not support the use of stand-alone organ-related classifications, such as for skin. The Royal College of Pathologists (London) has adopted the WHO classification in its minimum dataset for the histopathological reporting of lymphoma and this will be used in the National Health Service Skin Cancer Dataset. The purpose of this review is to highlight the principal primary and secondary cutaneous haematopoietic and lymphoid tumours that are defined in the WHO classification. The review also discusses selected problematical areas in the WHO classification relevant to the skin and contains suggestions to encourage a unified approach in the use of the WHO coded summary. These represent an attempt to facilitate future progress and research in the field of cutaneous lymphoma. They are perceived as possible building-blocks for wider discussion and not as alterations to the classification. The WHO classification has been compared with a road map that indicates directions for future clinical and scientific research.

Primary cutaneous follicular lymphoma: a clinicopathologic and molecular study of 16 cases in support of a distinct entity

Primary cutaneous B-cell lymphomas displaying a prominent follicular growth pattern are rare and remain poorly defined, particularly in terms of the frequency of detection of t(14;18) and whether or not, as a group, they represent an entity distinct from follicular lymphoma arising in lymph nodes. The morphologic, immunophenotypic, and clinical features of 16 cases of primary cutaneous follicular lymphoma, identified during a review of all PCBCL in the Scotland and Newcastle Lymphoma Group database, were studied and the number of cases harboring t(14;18) assessed by polymerase chain reaction using primers to the major breakpoint cluster region. Comparisons were made with stage I follicular lymphoma arising in lymph nodes and follicular lymphoma secondarily involving the skin. All cases of primary cutaneous follicular lymphoma had undergone thorough staging, including physical examination and CT scans of chest and abdomen, with 15 of 16 cases also having bone marrow aspiration and/or trephine performed. The morphology and immunophenotype of the lesions were similar to that expected in lymph nodes. All cases displayed a follicular architecture complete with follicular dendritic cell networks and comprised an admixture of CD10 and/or bcl-6-positive neoplastic centrocytes and centroblasts with 13 of 16 cases also expressing bcl-2 protein. None harbored t(14;18), a significantly different finding compared with cases of stage I nodal follicular lymphoma (p <0.001) and secondary cutaneous follicular lymphoma (p <0.039). Relapses occurred in five of 15 patients with a median time to first relapse of 20 months (range 1-73 months; mean 27.2 months). These were multiple in two patients and involved extracutaneous sites in two patients. The propensity for relapse was similar to that in a comparative cohort of stage I nodal follicular lymphoma, but the group of primary cutaneous follicular lymphoma were significantly more likely to attain complete remission; all cases of primary cutaneous follicular lymphoma were in complete remission when last seen compared with 49 of 87 patients with stage I nodal follicular lymphoma (p <0.005). No lymphoma-related deaths were encountered in 15 cases with a mean follow-up >60 months (range 5-119 months). These results support the concept of a subtype of follicular lymphoma lacking t(14;18) involving the major breakpoint cluster region, and with a propensity to arise in the skin. Despite a high relapse rate patients with primary cutaneous follicular lymphoma are more likely to achieve complete remission and may ultimately have a more favorable long-term prognosis than those with equivalent nodal disease.

Primary cutaneous follicle center cell lymphoma

The exact classification of primary cutaneous follicle center cell lymphomas (FCCLs) has been the subject of ongoing debate. In the classification of cutaneous lymphomas proposed by the European Organization for Research and Treatment of Cancer (EORTC)-Cutaneous Lymphoma Project Group, cutaneous follicle center cell lymphoma (FCCL) is defined as a proliferation of centrocytes and centroblasts showing a diffuse pattern of growth in the great majority of cases, and presenting only rarely a true follicular pattern. CD10 and Bcl-2 are usually not expressed by neoplastic cells, and the t(14:18) is absent. By contrast, nodal follicular lymphoma is a tumor with a follicular pattern, characterized by the proliferation of CD10+, Bcl-2+ follicular cells, and by the presence of the t(14;18) in most cases. In this review we outline the clinicopathologic, phenotypic, and molecular features of primary cutaneous FCCL, reviewing criteria for diagnosis and differential diagnosis of this peculiar variant of cutaneous B-cell lymphoma.

Cutaneous follicle center cell lymphoma, follicular type

This article discusses the clinicopathologic and molecular features of primary cutaneous follicle center cell lymphoma, follicular type. Synthesis of morphologic, immunohistochemical, and molecular studies have clearly characterized this peculiar morphological variant of the cutaneous B-cell lymphomas. Although local recurrences can be frequently observed, the overall prognosis of these patients is very good and extracutaneous dissemination is very rare.

Cutaneous follicular B-cell lymphoma: description of a series of 18 cases

The lack of precise and homogeneous criteria for the recognition of primary cutaneous follicular lymphoma has hindered gaining data on the frequency and clinical and molecular features of this entity. In the course of a review of a series of primary cutaneous lymphoma from different Spanish hospitals, we collected a series of 18 cases of primary cutaneous follicular lymphoma and analyzed its clinical, morphologic, and biologic characteristics. In this review only cases with a follicular pattern of growth, germinal center cytology, and restriction to the skin in a minimum follow-up of 6 months have been included. Cases of primary cutaneous follicular lymphoma were characterized by the expression of classic markers of the germinal center, such as bcl6, CD10, and the presence of aggregates of follicular dendritic cells. They frequently express bcl2 protein, although classical t(14;18) was not found in any of the cases analyzed. Analysis of the bcl6 noncoding first exon showed somatic mutations in two of four cases analyzed, as would be expected in lymphoma deriving from the germinal center. Clinically, most cases showed initial involvement of the head and neck, with relapses in eight cases (involving the skin in five cases, both skin and lymph node in two cases, and lymph node in one case). No death attributable to the tumor was recorded. These data seem to imply that follicular lymphoma may present initially in the skin, lacking the characteristic t(14;18) and having a relatively indolent course. Recognition of these tumors and elucidation of their molecular alterations could lead to properly adapted staging and treatment protocols for these patients.

Primary cutaneous follicle center cell lymphoma with follicular growth pattern

Cutaneous B-cell infiltrates showing a prominent follicular growth pattern with germinal centers are thought by some authors to represent either marginal zone lymphomas with reactive germinal centers or pseudolymphomas. To establish whether a true primary cutaneous follicular lymphoma exists, we studied biopsies from 15 patients with skin lesions characterized histopathologically by the presence of B-cell infiltrates with follicular pattern. Staging investigations, including bone marrow biopsy, were negative in all patients. All were negative for bcl-2 protein expression and did not present the t(14;18). In all biopsy specimens neoplastic follicles showed 1 or more morphologic or immunophenotypic criteria of malignancy (presence of a reduced mantle zone, absence of tingible body macrophages, reduced proliferation rate). In 9 specimens a monoclonal rearrangement of JH genes could be detected by polymerase chain reaction analysis. After laser beam microdissection, a band of the same length could be observed in 6 probes from different follicles from the same specimen, indicating the presence of the same monoclonal population of follicle center cells. Follow-up examinations in all patients revealed no evidence of extracutaneous spread (mean follow-up, 48.7 months). Our study demonstrates that primary cutaneous follicular lymphoma represents a distinct entity of the cutaneous B-cell lymphomas.

Primary cutaneous follicle center cell lymphoma with follicular growth pattern

Cutaneous B-cell infiltrates showing a prominent follicular growth pattern with germinal centers are thought by some authors to represent either marginal zone lymphomas with reactive germinal centers or pseudolymphomas. To establish whether a true primary cutaneous follicular lymphoma exists, we studied biopsies from 15 patients with skin lesions characterized histopathologically by the presence of B-cell infiltrates with follicular pattern. Staging investigations, including bone marrow biopsy, were negative in all patients. All were negative for bcl-2 protein expression and did not present the t(14;18). In all biopsy specimens neoplastic follicles showed 1 or more morphologic or immunophenotypic criteria of malignancy (presence of a reduced mantle zone, absence of tingible body macrophages, reduced proliferation rate). In 9 specimens a monoclonal rearrangement of JH genes could be detected by polymerase chain reaction analysis. After laser beam microdissection, a band of the same length could be observed in 6 probes from different follicles from the same specimen, indicating the presence of the same monoclonal population of follicle center cells. Follow-up examinations in all patients revealed no evidence of extracutaneous spread (mean follow-up, 48.7 months). Our study demonstrates that primary cutaneous follicular lymphoma represents a distinct entity of the cutaneous B-cell lymphomas.