Angiocentric T cell lymphoma of the skin presenting as inflammatory nodules of the leg

Clinicopathological and prognostic study of primary cutaneous extranodal natural killer/T-cell lymphoma, nasal type: A systematic review

Comprehensive studies of primary cutaneous extranodal natural killer/T-cell lymphoma (PCENKTL) are scarce. The objectives of this study are to describe PCENKTL in terms of its clinical features, histopathology, immunophenotypes, and prognosis, and to analyze factors affecting patient survival outcomes. We searched four databases and include studies with extractable data. We also searched the Asan Medical Center database for cases of PCENKTL. We include a total of 289 patients. The mean age at diagnosis was 52.8 years and the female to male ratio was 1:1.2. The most common clinical morphology was a subcutaneous nodule, followed by ulceration. About half of the patients presented with disseminated skin lesions. The median overall survival was 12.0 months and the 5-year survival rate was 22.0%. There was no correlation between the clinical morphology or the histopathological features of the skin lesions with the patient outcomes. Advanced TNM stage, a disseminated skin lesion, tumor location on the leg or trunk, the presence of B symptoms, and a high International Prognostic Index score were associated with a worse prognosis, and chemoradiotherapy was associated with a better survival outcome as compared with chemotherapy alone in univariable analyses. In multivariable analyses, only advanced TNM stage and tumor location on the leg were associated with a worse prognosis. In conclusion, PCENKTL is an aggressive cutaneous lymphoma and its prognosis is associated with TNM stage and tumor location.

Inflammatory nodules of the leg

There is a group of diseases characterized by inflammatory nodules which generally located on the lower leg. They have certain clinical appearances in common, which often makes a differential diagnosis difficult or impossible on clinical grounds alone. There is a great variation in histopathologic appearance, which depends on the duration of the lesions and sites from specimens are obtained for biopsy. Therefore, separating and subclassifying inflammatory nodule lesions of the legs, based on the subtle clinical and histological variation, is not easy. Despite all these difficulties, a specific diagnosis can be made with an adequate clinic-pathologic correlation.

Skin manifestations of intravascular lymphoma mimic inflammatory diseases of the skin

BACKGROUND

Intravascular lymphoma (IVL) is fatal when it is diagnosed late in the course. Sometimes skin lesions enable early diagnosis, but criteria for diagnosis are not well established.

OBJECTIVES

To demonstrate the clinical spectrum of skin lesions of IVL and to correlate it with clinical outcome; to identify features differentiating between B-cell and T-cell IVL with skin involvement.

METHODS

Review of 97 articles reporting on total of 224 patients with IVL.

RESULTS

Skin lesions were mentioned in 90 of 224 patients. They were nodules and/or plaques (49%) or macules (22.5%) of red (31%) or blue to livid (19%) colour on the leg (35%), the thigh (41%) and the trunk (31%). Telangiectases were present in only 20% of the patients. Oedema (27.5%) of the legs and pain (24%) were often accompanying. No criteria enabled distinction between lesions restricted to the skin and skin lesions concurrent with IVL in other organs, but when the disease was restricted to the skin, the prognosis was favourable (10% vs. 85% fatal outcome). Skin lesions of T-cell IVL are indistinguishable from those of B-cell IVL.

CONCLUSIONS

Forty per cent of all patients with IVL have skin lesions, these being red, sometimes painful plaques located typically on the lower extremities, accompanied by oedema. A clinician risks misinterpreting these changes as thrombophlebitis, erythema nodosum or erysipelas. Neither clinical course nor differentiation of the lymphoma can be predicted from the morphology of skin lesions, but involvement of other organs at the time of diagnosis indicates a poor prognosis.

Comparison of primary and secondary cutaneous CD56+ NK/T cell lymphomas

CD56+ NK/T cell lymphoma (NKTL) frequently involves skin and subcutaneous tissue. The characteristics of primary cutaneous nasal-type CD56+ NKTLs and secondary cutaneous involvement of nasal CD56+ NKTLs have not been clearly separated. This retrospective study analyzed 15 cases of NKTL (10 primary CD56+ NKTLs and 5 secondary CD56+ NKTLs) for their clinicopathologic and immunophenotypic characteristics using CD3, CD4, CD20, CD45RO, CD56, TIA-1, CD30, and Ki-67 antigens. In situ hybridization for Epstein-Barr virus RNA (EBERISH) and PCR for T cell receptor (TCR) gamma gene rearrangement were also performed. Clinically, NKTL-P was seen with equal frequency among male (five cases) and female (five cases) patients and presented with subcutaneous nodules without epidermal changes (nine cases), whereas all cases of NKTL-S occurred in male patients and presented with nodules or plaques with distinct epidermal changes (five cases). Microscopically, initial NKTL-P lesions had the panniculitic patterns of small to medium-sized cells (nine cases). NKTL-S lesions were extensive in both subcutis and dermis, with larger and more pleomorphic tumor cells (four cases) that also showed signs epidermotropism (five cases). In initial biopsies of CD56+ NKTL-P, a minority of tumor cells showed signals for EBERISH and in biopsies of CD56+ NKTL-S, virtually every tumor cell showed signals. While all five patients with secondary CD56+ NKTL died of disease with widespread systemic involvement within 16 months after onset of skin lesions, 7 out of the 10 primary CD56+ NKTL patients survived more than 20 months after onset of skin lesions, with slow progression and episodic recurrences. The primary and secondary cutaneous CD56+ NKTLs showed considerable clinicopathologic differences, suggesting differences in pathogenesis.

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.

Expression of cutaneous lymphocyte-associated antigen and TIA-1 by lymphocytes in pityriasis lichenoides et varioliformis acuta and lymphomatoid papulosis: immunohistochemical study

BACKGROUND

Pityriasis lichenoides et varioliformis acuta (PLEVA) and lymphomatoid papulosis (LyP) are benign self-healing cutaneous eruptions that may be clinically and histologically similar. The purposes of this study were to evaluate immunohistological characteristics of PLEVA and LyP and to investigate whether Epstein-Barr virus (EBV) may be present in PLEVA and LyP.

METHODS

We performed an immunohistochemical staining in 12 cases of PLEVA and 8 cases of LyP using nine antibodies for CD3, CD4, CD8, CD30, CD45RO, CD56, CD79, cutaneous lymphocyte-associated antigen (CLA), and TIA-1. In situ hybridization was performed using fluorescein-conjugated oligonucleotide probes for EBV early regions (EBER).

RESULTS

In PLEVA, immunohistochemical studies revealed that infiltrated lymphocytes consisted of mainly CD3-positive (5+), CD8-positive (4+ to 5+), CLA-positive (4+ to 5+) T cells and partly CD79 positive (+ to 2+) B cells. CD4-positive T cells were less than 25%. In LyP, immunohistochemical studies revealed that infiltrated lymphocytes consisted of partly CD3-positive (5+), CD8-positive (2+ to 3+), CLA-positive (3+ to 4+) T cells and partly CD79-positive (2+ to 3+) B cells. CD4-positive T cells were less than 10%. CD8 and CLA were more strongly expressed in PLEVA than in LyP. CD30 was strongly expressed in LyP but not expressed in PLEVA. CD79 was more expressed in LyP than in PLEVA. TIA-1 was not expressed in any cases. In situ hybridization using antisense EBER probe showed negative reaction in all cases.

CONCLUSIONS

Immunohistochemical stains for CD8, CD30, CD79 and CLA may be valuable tools in the differential diagnosis between PLEVA and LyP. TIA-1 was negative in LyP, which means cytotoxic cells may not be implicated in the pathogenesis of LyP. It was a contradictory result to the previous results. The absence of EBV in PLEVA and LyP suggests that this virus may not be operative in the pathogenesis of these diseases. These results suggest that LyP and PLEVA are separate disorders, thus accounting for their variable prognosis.

Angiotropic lymphoma: proliferation of B cells in the capillaries of cutaneous angiomas

We report a 52-year-old patient with cutaneous angiomas on the trunk in association with angiotropic lymphoma involving the nervous system. The lesional skin showed proliferation of atypical B cells in the capillaries. The diagnosis of angiotropic lymphoma with neurological deficits is often difficult before death. Thus, skin biopsy in this case proved to be diagnostic of the central nervous system disease without the risk of brain biopsy. The diagnosis of angiotropic lymphoma in the future may be achievable by biopsy of coincidental angiomas.

Clinicopathological features of CD56+ nasal-type T/natural killer cell lymphomas with lobular panniculitis

Nasal-type T/natural killer cell lymphoma (TNKCL) shows frequent extranodal involvement including the skin, and is associated with a poor prognosis. We have studied six patients with nasal-type TNKCL presenting with inflammatory subcutaneous nodular lesions with a subcutaneous lymphoid infiltrate. Clinical information was obtained from the medical records of the patients and at follow-up. All cases showed features of angiocentric lymphoma on histology, although there was diffuse cellular infiltration rather than an angiocentric pattern in the subcutis. All six patients were similar in immunophenotype: positive for CD56 and either cytoplasmic CD3 or CD45RO, but negative for B-cell markers and CD30. In situ hybridization using an anti-sense Epstein-Barr virus early regions probe showed a positive reaction in all cases. All patients either died with progressive disease or showed no response to combined chemotherapy. The diagnosis of nasal-type TNKCL, which has a fatal outcome, is facilitated by detection of CD56-positive tumour cells. In evaluating lobular panniculitis including apparently benign inflammatory subcutaneous nodules, nasal-type TNKCL should be considered in the differential diagnosis, especially in Asian countries.