Specific cutaneous involvement in Hodgkin's disease

Secondary skin involvement in classic Hodgkin lymphoma: Results of an international collaborative cutaneous lymphoma working group study of 25 patients

BACKGROUND

Cutaneous involvement by classic Hodgkin lymphoma (CHL) is an extraordinarily rare phenomenon in the current era. To date, no single large case series of cutaneous involvement by Hodgkin lymphoma has ever been reported in the literature.

METHODS

A comprehensive search for cases designated "skin" and "Hodgkin" was performed at different institutions between 1990 and 2020. Twenty-five cases were identified, and each case was independently reviewed by at least three board-certified dermatopathologists and/or hematopathologists.

RESULTS

All cases represented examples of systemic CHL with secondary skin dissemination. A single lesion, usually a tumor, nodule or infiltrative plaque was observed in 56% of cases and multiple lesions were present in 28% of cases. Most patients (86%-12/14) had a diagnosis of stage IV disease at first diagnosis. The interval between the clinical (first) diagnosis of HL and the development of skin lesions ranged between 6 and 108 months (average 33.75 months). Comprehensive histopathologic evaluation of these cases (at the initial diagnosis) revealed a diagnosis of classic HL not otherwise specified (NOS) in 60% of cases (15/25), nodular sclerosis type in 24% (6/25), mixed cellularity in 12% (3/25), and lymphocyte depleted in 4% (1/25).

CONCLUSIONS

We provide documentation of a large series of CHL with secondary skin involvement in association with CHL with additional clinical, morphologic, and immunophenotypic features.

Hodgkin Lymphoma in Children and Adolescents: Advances in Pathology, Diagnosis, and Treatment Strategies

Strategies used for the treatment of children with Hodgkin lymphoma (HL) over the last four decades have resulted in excellent long-term survivals. However, the short- and long-term treatment-associated morbidities were high. In an attempt to reduce complications, the current treatment strategies apply initial risk stratification principles based on certain host and tumor risk factors to help assign patients to the appropriate risk group and tailor therapy based on response to chemotherapy (CTR). Radiotherapy (RT) was only given to certain groups of patients who show suboptimal response to CTR. Enrollment of patients in clinical trials allowed testing newer treatment strategies, which has improved the outcome significantly. High-dose CTR with stem cell support remains the mainstay of treatment for relapsed and refractory HL. Newer targeted medications are being increasingly used for the treatment of patients with relapsed and refractory HL, but results are variable. In this review report, we give extensive account about the pathophysiology, clinical presentation, histopathological diagnosis, modern investigation techniques, the most recent risk adapted treatment strategies, and the use and effect of novel medications. In addition, we discuss in details the short- and long-term therapy-related complications and future prospects in the management of HL.

Mummified Cells are a Common Finding in Cutaneous Hodgkin Lymphoma and Can Be Used as a Diagnostic Clue

Specific cutaneous involvement in Hodgkin lymphoma is rare. In cutaneous lesions, the diagnosis is usually based on the recognition of diagnostic Reed-Sternberg cells and its variants. In nodal Hodgkin lymphoma, so-called mummified cells (cells with condensed cytoplasm and pyknotic eosinophilic or basophilic nuclei) are often seen. They are sometimes conspicuous and easy to recognize, thus serving as a clue to the diagnosis. Our objective was to study cases of cutaneous Hodgkin lymphoma to identify the occurrence of mummified cells. We studied 12 patients (4 women and 8 men; age range 23-80 years). In 6 patients, cutaneous and extracutaneous disease was identified almost simultaneously; in 4 patients, lymph node disease preceded cutaneous involvement; and in the remaining 2 patients, the skin lesions were the presenting sign, whereas lymph node involvement occurred later. Histopathological, immunohistochemical, and molecular-genetic studies, including rearrangements for TCR, IgH genes, and PCR for EBV, were performed. Cutaneous biopsy specimens revealed either a multinodular or diffuse infiltrate, included small lymphocytes, eosinophils, plasma cells, and macrophages, but in all cases, diagnostic Reed-Sternberg cells and its variants were identified. Mummified cells were detected in 9 cases, either as occasional scattered mummified cells often requiring a search (6 cases) or being conspicuous, grouped and therefore easily identified (3 cases). Immunohistochemically, in all 7 cases studied, mummified cells were positive for both CD30 and CD15. It is concluded that mummified cells are encountered in a majority of cases of cutaneous Hodgkin lymphoma.

Epstein-Barr Virus-associated Lymphoproliferative Disorders in the Skin

Epstein-Barr virus (EBV)-associated lymphoproliferations involving the skin are a rare but important group of diseases with a broad spectrum of behavior, ranging from self-limiting spontaneously resolving disorders to highly aggressive malignancies. They may be of B, T, or natural killer (NK) cell type and include EBV-positive mucocutaneous ulcer, lymphomatoid granulomatosis, EBV-positive diffuse large B-cell lymphoma, hydroa vacciniforme-like lymphoproliferative disorder, and extranodal NK/T-cell lymphoma of nasal type. Recognition and distinction of these entities is important in view of their differing prognoses and treatments. An association with EBV may be the first indication that a patient is immunosuppressed.

Skin Involvement in Hodgkin's Disease

Hodgkin's disease involving the skin is an unusual occurrence and is found in 0.5-3.4 percent of these patients. The most common clinical presentation is of single or multiple dermal or subcutaneous nodules. The mechanisms usually implicated include direct extension from an underlying nodal focus, hematogenous dissemination, and, most often, retrograde lymphatic spread, distal to involved lymph nodes. We report the case of a patient with refractory Hodgkin's disease who presented with skin involvement.

Cutaneous Hodgkin's disease

Cutaneous Hodgkin's disease is a rare condition that usually occurs late in the course of Hodgkin's lymphoma. This rare condition is thought to have decreased in incidence in recent decades, likely owing to improved treatment of patients with Hodgkin's disease, who are receiving improved chemotherapy and radiation therapy, and the advent of peripheral blood stem cell transplantation. We present the case of a man who developed specific cutaneous Hodgkin's lymphoma 6 months after nonmyeloablative allogenic stem cell transplantation for his recurrent systemic disease. The patient's manifestation of relapse was cutaneous dissemination of the tumor, manifested by erythematous papules and ulcerated nodules. At the time of the cutaneous relapse he had minimal systemic disease. This case illustrates an example of this complication of Hodgkin's disease and stresses the importance of a timely diagnosis to direct appropriate therapy. A review of the literature demonstrates that the patient's lesion morphology and distribution are typical of specific manifestations of cutaneous Hodgkin's disease.

Rare syndromes in Hodgkin's disease

The presentation of Hodgkin's disease is in the vast majority of cases rather classical. However, there are some rare syndromes which might be very puzzling. In this contribution, we will discuss some of these rare syndromes. We will concentrate on following topics: (1) pruritus (itching), (2) cutaneous manifestations of HD, (3) alcohol-related pain, (4) nephrotic syndrome, (5) hemolytic anemia, (6) idiopathic thrombocytopenia purpura (UTP), (7) ivory vertebrae, and (8) CNS involvement.

An unusual cutaneous presentation of Hodgkin's disease

Hodgkin's disease is a neoplasm of lymphoid tissue defined histopathologically by the presence of Reed-Sternberg cells in an appropriate cellular background. Hodgkin's disease extends only rarely into the skin. Sinus and fistula formation has been reported in very occasional cases. We now report a case of a 34-year-old woman presenting with a cutaneous lesion surrounding a discharging blind-ending sinus in the neck, subsequently diagnosed as Hodgkin's disease. To our knowledge this form of presentation of Hodgkin's disease has not been reported in the English literature before, and at the same time we would like to outline the difficulties in diagnosis encountered with these cutaneous lymphoid lesions.

Specific skin lesions occurring in a patient with Hodgkin's lymphoma

A 47-year-old man presented with a several month history of non-specific acquired ichthyosis, an unknown period of generalized lymphadenopathy and a short history of erythematous papules and nodules affecting the cutaneous drainage area of his right axillary lymph nodes. Histology confirmed these lesions to be specific lesions of Hodgkin's lymphoma; that is, metastatic retrograde lymphatic spread from his axillary lymph nodes of CD30+, CD15+, Reed-Sternberg cells as well as mononuclear Hodgkin's cells. This is the most common site and mode of spread of Hodgkin's disease to the skin. As is typical of advanced Hodgkin's disease, as evidenced by specific cutaneous involvement, this patient died shortly after definitive diagnosis was made.

Skin as the primary site of Hodgkin's disease: a case report of primary cutaneous Hodgkin's disease and review of its relationship with non-Hodgkin's lymphoma

We report an elderly patient who presented with a single cutaneous nodule of primary cutaneous Hodgkin's disease (PCHD). Reed-Sternberg cells, expressing CD30 and CD15, but not leukocyte common antigen (CD45RB), were identified in the neoplastic cells. Southern blot analysis failed to detect T-cell receptor or immunoglobulin gene rearrangement. A work-up for systemic disease at the time of presentation was negative, supporting the diagnosis of PCHD. Nevertheless, 1 year later, the disease course was complicated by the development of nodal HD and nonHodgkin's lymphoma (NHL). This case report supports the existence of this rare, but distinct, cutaneous tumor.

Cutaneous Hodgkin's disease: an immunohistochemical analysis

Studies of skin involvement in Hodgkin's disease are infrequent in the literature. In particular, immunophenotypic analyses of specific cutaneous infiltrates have been performed in only a few cases. We analyzed the clinical, histological and immunohistochemical features of specific cutaneous manifestations of Hodgkin's disease comparing histologic and immunophenotypic aspects of skin lesions with those of the nodal counterpart. Seven patients with Hodgkin's disease of the lymph nodes and specific cutaneous lesions, where both nodal and skin biopsies were available for histologic and immunohistochemical analyses, were included in this study. Immunohistochemical stains were performed with a 3-step immunoperoxidase technique on routinely-fixed, paraffin-embedded tissue sections. All 7 patients had nodular sclerosis Hodgkin's disease of the lymph nodes. In the skin, clinical presentations included reddish-brown papules, plaques, nodules and ulcerated tumors. Histologic examination of cutaneous lesions showed features consistent with nodular sclerosis Hodgkin's disease in 6 cases and unclassifiable Hodgkin's disease in one. Reed-Sternberg cells and lacunar cells were present in 4 cases (57.1%). Immunohistochemical analysis of Hodgkin's and Reed-Sternberg cells revealed a constant positivity for CD30 (BerH2) and negativity for CD45 (LCA) in both the lymph nodes and the skin. Staining with CD15 (M1) revealed positivity in 7/7 nodal samples and 5/7 skin biopsies. Cytoplasmic expression of immunoglobulin light chains (both lambda and kappa) was observed in one cutaneous case. The accompanying infiltrate was mostly composed of T-lymphocytes admixed with variable numbers of monocytes/macrophages and eosinophils. Our results indicate that the histology of cutaneous specific manifestations of Hodgkin's disease correlates with that of the nodal counterpart in most cases.(ABSTRACT TRUNCATED AT 250 WORDS)