Primary cutaneous peripheral T-cell lymphoma not otherwise specified a rare and aggressive lymphoma

Erythroderma: psoriasis or lymphoma? A diagnostic challenge and therapeutic pitfall

BACKGROUND

Psoriasis and lymphoma risk is widely debated, but few is known about misdiagnosis risk between erythrodermic psoriasis and lymphoma . In fact erythroderma might represent a clinical presentation of psoriasis, cutaneous T cell lymphomas and skin dissemination of systemic lymphomas.

METHODS

All patients referred to psoriasis outpatient service with a diagnosis of erythrodermic psoriasis were re-examined. Among them, all the patients with a subsequent lymphoma diagnosis were included. For each patient data concerning age, gender, age at erythroderma onset, age at lymphoma diagnosis, immune-suppressive therapy, type of lymphoma and relative stage, lymphoma treatment and outcome were obtained.

RESULTS

Twenty-five patients (15 females and 10 males) with a diagnosis of erythrodermic psoriasis were retrieved. Among them, 9 patients (5 males and 4 females) were affected by erythrodermic lymphoma, including 4 patients with Sèzary syndrome, 3 with mycosis fungoides, and 2 with peripheral T-cell lymphoma not otherwise specified. Prior to lymphoma diagnosis all the patients (9/9) received cyclosporine, two (2/9) of them methotrexate, one (1/9) azatioprine, and two (2/9) systemic corticosteroids. The prognosis of our patients was poor, due to immune-suppressive drugs administration in patients with undiagnosed lymphoma. The only exception was one (1/9) patient with Sèzary syndrome still alive with disease after 120 months of follow up.

CONCLUSIONS

In case of patients with erythroderma, multiple skin biopsies and specific peripheral blood studies like flow cytometry and T-cell receptor gene rearrangement analysis are required in order to avoid misdiagnosis risk between psoriasis and lymphoma.

Primary cutaneous peripheral T-cell lymphoma, not otherwise specified: results of a multicentre European Organization for Research and Treatment of Cancer (EORTC) cutaneous lymphoma taskforce study on the clinico-pathological and prognostic features

BACKGROUND

Cutaneous peripheral T-cell lymphoma, not otherwise specified (PTL NOS) is an aggressive, but poorly characterized neoplasm.

OBJECTIVES

The European Organization for Research and Treatment of Cancer cutaneous lymphoma taskforce (EORTC CLTF) investigated 33 biopsies of 30 patients with primary cutaneous PTL NOS to analyse their clinical, histological, immunophenotypic features and outcome.

METHODS

Retrospective analysis of clinical data and histopathological features by an expert panel.

RESULTS

Cutaneous PTL NOS manifested clinically either with solitary or disseminated rapidly grown ulcerated tumours or disseminated papulo-nodular lesions. Histologically, a mostly diffuse or nodular infiltrate in the dermis and often extending into the subcutis was found. Epidermotropism was rarely present and only mild and focal. Unusual phenotypes were frequent, e.g. CD3⁺ /CD4^- /CD8^- and CD3⁺ /CD4⁺ /CD8⁺ . Moreover, 18% of the cases exhibited an aberrant expression of the B-cell marker CD20 by the tumour cells. All solitary tumours were located on the limbs and presented a high expression of GATA-3 but this did not correlate with outcome and therefore could not serve as a prognostic factor. The prognosis was shown to be generally poor with 10 of 30 patients (33%) dying of lymphoma within the follow-up of 36 months (mean value; range 3-144). The survival rates were 61% after 3 years (CI, 43-85%) and 54% after 5 years (CI, 36-81%). Small to medium-sized morphology of tumour cells was associated with a better outcome than medium to large or large tumour cells. Age, gender, clinical stage, CD4/CD8 phenotype and GATA-3 expression were not associated with prognosis. Chemotherapy was the most common treatment modality, but surgical excision and/or radiotherapy may represent an appropriate first-line treatment for solitary lesions.

CONCLUSIONS

Cutaneous PTL NOS shows an aggressive course in most patients independent of initial presentation, age and phenotype. Cytomorphology was identified as a prognostic factor. The data indicate a need for more effective treatment modalities in PTL NOS.

How do we treat cutaneous T-cell lymphoma?

Cutaneous T-cell lymphomas are a heterogeneous group of non-Hodgkin lymphomas which are based on the malignant proliferation of skin-related T lymphocytes. The clinical appearance, as well as the course and the associated therapeutic approach, are sometimes very different between the different subtypes. Since allogeneic stem cell transplantation is currently the only curative option, and the morbidity and mortality are not insignificant, a therapy concept should be developed that considers its often rather indolent but chronic course. This concept should enable a good disease control with as few side effects as possible and preserve or improve the quality of life. In the early stages of the disease, skin-oriented therapies are generally used first before systemic and increasingly aggressive therapeutic agents are used as the disease progresses. Considering the current guidelines, literature and subjective experience, we summarize in this review how we treat cutaneous T-cell lymphomas.