Primary cutaneous CD8-positive epidermotropic cytotoxic T cell lymphomas. A distinct clinicopathological entity with an aggressive clinical behavior

Cutaneous T cell lymphomas (CTCL) generally have the phenotype of CD3+, CD4+, CD45RO+ memory T cells. CTCL expressing a CD8+ T cell phenotype are extremely rare and ill-defined. To elucidate whether these CD8+ CTCL represent a distinct disease entity, the clinical, histological, and immunophenotypical features of 17 CD8+ CTCL were reviewed. None of the 17 cases expressed markers characteristic of natural killer cells or gamma/delta T cells. Nine of 17 cases showed the characteristic clinical and histological features as well as clinical behavior of well defined types of CTCL, such as mycosis fungoides (2 cases), pagetoid reticulosis (2 cases), lymphomatoid papulosis (2 cases), and CD30+ large T cell lymphoma (2 cases), all of which usually express a CD4+ T cell phenotype, and 1 case of subcutaneous panniculitis-like T cell lymphoma. The other 8 cases formed a homogeneous group showing a distinctive set of clinicopathological and immunophenotypical features, not consistent with that of other well defined types of CTCL. Clinical characteristics included presentation with generalized patches, plaques, papulonodules, and tumors mimicking disseminated pagetoid reticulosis; metastatic spread to unusual sites, such as the lung, testis, central nervous system, and oral cavity, but not to the lymph nodes; and an aggressive course (median survival, 32 months). Histologically, these lymphomas were characterized by band-like infiltrates consisting of pleomorphic T cells or immunoblasts, showing a diffuse infiltration of an acanthotic epidermis with variable degrees of spongiosis, intraepidermal blistering, and necrosis. The neoplastic cells showed a high Ki-67 proliferation index and expression of CD3, CD8, CD7, CD45RA, betaF1, and TIA-1 markers, whereas CD2 and CD5 were frequently lost. Expression of TIA-1 pointed out that these lymphomas are derived from a cytotoxic T cell subset. The results of this and other studies reviewed herein suggest that these strongly epidermotropic primary cutaneous CD8+ cytotoxic T cell lymphomas represent a distinct type of CTCL with an aggressive clinical behavior.

Syringolymphoid hyperplasia and follicular mucinosis in a patient with cutaneous T-cell lymphoma

Syringolymphoid hyperplasia with alopecia is an uncommon chronic dermatosis of which 9 cases have been reported, with or without follicular mucinosis or cutaneous T-cell lymphoma. We report a patient with cutaneous T-cell lymphoma and syringolymphoid hyperplasia and follicular mucinosis and review the previously reported cases. All reported cases with syringolymphoid hyperplasia were men (10 of 10), with the clinical findings of alopecia (9 of 10) and anhidrosis (3 of 10). Only 3 of 10 cases had associated follicular mucinosis. Of the 7 cases investigated, 6 were found to hve cutaneous T-cell lymphoma. Three patients were not investigated for cutaneous T-cell lymphoma. Although syringolymphoid hyperplasia can be idiopathic, it can also reflect a syringotropic cutaneous T-cell lymphoma. Careful follow-up with a biopsy of persistent lesions is recommended to evaluate for the presence of lymphoma.

Unresponsive eczematous dermatitis: a case of pancreatic cancer masquerading as cutaneous T cell lymphoma

Skin diseases may be the presenting sign of malignancy, but strict criteria are required to make the diagnosis of a paraneoplastic syndrome. Common dermatoses may also herald an underlying malignancy without meeting these criteria. We report the case of an elderly man with an unresponsive eczematous dermatitis whose evaluation eventually revealed a pancreatic carcinoma. This case is presented to alert the clinician that a common dermatosis may be the first sign of an occult malignancy, especially if it behaves in an atypical or aggressive manner or is recalcitrant to standard therapies.

Use of the polymerase chain reaction in the evaluation of cutaneous T-cell infiltrates

Histologic evaluation of suspected cutaneous T-cell neoplasia is challenging. There is significant overlap with features of benign condition, and neoplastic cells often occur in a reactive background. Recently, molecular techniques using paraffin-embedded tissue have been applied to the diagnosis of cutaneous T-cell infiltrates. These methods are useful for determining whether a clonal population of T-cells is present. The advantages and limitation of molecular diagnostic methods in the diagnosis of cutaneous T-cell infiltrates are discussed.

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.

Clonal T-cell receptor gamma-chain gene rearrangement by PCR-based GeneScan analysis in advanced cutaneous T-cell lymphoma: a critical evaluation

Detection of clonal T-cell receptor gamma (TCRgamma)-chain gene rearrangement is a promising approach to distinguish between cutaneous T-cell lymphomas (CTCLs) and reactive T-cell infiltrates. Despite the improved sensitivity by using the polymerase chain reaction (PCR) rather than Southern blot analysis, monoclonality could be demonstrated in only 53-90 per cent of CTCL biopsies in recent studies. In the present study, formalin-fixed, paraffin-embedded specimens of 21 selected patients with clear-cut advanced-stage CTCL were analysed using a semi-nested TCRgamma PCR with newly developed consensus primer pairs. Detection of PCR products was done by GeneScan analysis (GSA); this technique is advantageous due to its sensitivity and accuracy in the detection and size determination of PCR products and it is easier to interpret than direct read-outs from TGGE or DGGE gels. In serial dilution experiments, TCRgamma-PCR-GSA allowed the detection of clonal, rearranged T-cells with a high in vitro sensitivity against a polyclonal background (1-6 per cent). Despite the selection of clear-cut, advanced-stage CTCL cases, however, dominant clonal TCRgamma-chain gene rearrangement was found in only 16 of the 21 patients analysed, indicating an overall clinical sensitivity of 76 per cent. Specificity was evaluated using biopsy specimens from 21 control patients suffering from long-standing psoriasis (n=13) and eczema (n=8). Surprisingly, GeneScan profiles showing apparently single dominant peaks were detected in 14 per cent of these skin lesions, but these profiles turned out to be pseudo-monoclonal by repeated determinations. In conclusion, TCRgamma-PCR-GSA does not suffice reliably to exclude malignancy, due to its limited clinical sensitivity, but with precautions taken to detect pseudo-monoclonality and to secure specificity, TCRgamma-PCR-GSA is a valuable instrument in the diagnosis of CTCL.

Cutaneous T-cell lymphoma presenting as benign dermatoses

Cutaneous T-cell lymphoma, also known as mycosis fungoides, is a malignancy of the T helper (CD4+) cells. Diagnosis is difficult early in the course of this disease because it mimics several benign skin disorders, including eczema, psoriasis and contact dermatitis. Cutaneous T-cell lymphoma is also difficult to identify histologically, and multiple biopsies may be necessary to confirm the diagnosis. Treatment may require a combination of topical and systemic agents. Patients with limited skin disease have a good prognosis, but the prognosis is less hopeful in those with extracutaneous involvement. As the disease progresses, the normal T-cell population is eliminated, and the patient becomes significantly immunosuppressed. Infection is the primary cause of mortality in patients with cutaneous T-cell lymphoma.

Diagnosis of cutaneous T-cell lymphoma detecting T-cell receptor gamma chain gene monoclonality by denaturing gradient gel electrophoresis

Cutaneous T-cell lymphomas represent a group of malignant lymphoproliferative disorders characterised by the occurrence of a monoclonal population of T-lymphocytes. Diagnosis of early stages of this disease is a difficult challenge for both the dermatologist and the dermatopathologist. With the aid of the polymerase chain reaction it is possible to amplify specific regions of the T-cell receptor gamma gene. The amplification products can then be separated by denaturing gradient gel electrophoresis in order to detect a monoclonal population of T-lymphocytes in the infiltrate. We studied 4 patients with the clinicopathologic diagnosis of mycosis fungoides and 2 patients diagnosed as large plaque parapsoriasis. A monoclonal population was detected in 3 of the 4 mycosis fungoides cases and in 1 of the patients with large plaque parapsoriasis. This indicates that our analysis can help us establishing a diagnosis, and it can also help us to identify patients with a possible early stage of the disease, which clinically or histologically is not yet recognised as such.

CD30-positive anaplastic large cell lymphoma (ALCL) of T-cell lineage in a 14-month-old infant with perinatally acquired HIV-1 infection

PURPOSE

CD30-positive anaplastic large cell lymphoma (ALCL) has been described in adults with HIV-1 infection but is extremely rare in HIV-1-infected infants and children.

PATIENT AND METHODS

A 14-month-old girl with congenitally acquired HIV-1 infection presented with fever and a tender, erythematous, cystic mass on the right labium majorum. The mass was biopsied. Histologic examination and immunohistochemistry were performed.

RESULTS

Histologic examination showed Touton-like giant cells resembling histiocytes and focally abundant neutrophils obscuring the lymphoid infiltrate. Immunocytochemistry revealed a CD30-positive ALCL of T-cell lineage.

CONCLUSION

Although non-Hodgkin's lymphoma is known to be associated with HIV-1 infection in children, large cell lymphomas of T-cell lineage are extremely rare in this population. Early diagnosis should be aggressively pursued in an HIV-1-infected child who presents with a fever and cutaneous mass.

Early detection of cutaneous lymphoma

Cutaneous lymphomas comprise a spectrum of diseases characterized by infiltration of the skin by malignant lymphocytes. The clinical manifestations of cutaneous lymphomas vary, and they can mimic benign dermatoses, as well as nodal or visceral malignancies with cutaneous spread. Cutaneous lymphomas are divided into T-cell lymphomas and B-cell lymphomas. Cutaneous T-cell lymphomas include mycosis fungoides, Sézary syndrome, lymphomatoid papulosis, CD30+ large cell lymphoma, and adult T-cell leukemia/lymphoma. The extent and severity of skin manifestations in cutaneous T-cell lymphomas are prognostic indicators of extracutaneous involvement. Primary cutaneous B-cell lymphomas comprise 10% to 25% of all primary cutaneous non-Hodgkin's lymphomas and are classified according to their cell of origin. Most cutaneous B-cell lymphomas have an indolent course and excellent prognosis when compared to their nodal counterparts. Many factors have been implicated in the etiology of cutaneous lymphomas, including chemical and drug exposures, as well as microbial agents, such as the Epstein-Barr virus (EBV), human T-lymphocyte virus-1 (HTLV-1), and Borrelia burgdorferi. Immunohistochemistry and lymphocyte-receptor gene rearrangement studies are useful in distinguishing malignant from benign conditions.

[Chronic sclerodermiform syndrome disclosing subcutaneous T-cell lymphoma]

INTRODUCTION

Subcutaneous tissue is an uncommon primary localization for T-cell lymphomas. Panniculitis with recurrent papulonodules are reported in most cases.

CASE REPORT

We report a case in which small-cell pleiomorphic non-Hodgkin lymphoma developed initially in subcutaneous tissue followed by secondary systemic extension. The first clinical manifestation was a sclerodermiform syndrome involving the four limbs.

DISCUSSION

This type of lymphoma appears to have a polymorphic clinical presentation. Physicians should be aware of this type of lymphoma and use immunohistological techniques for early diagnosis.

Antinuclear antibody seropositivity in patients with cutaneous T-cell lymphoma

BACKGROUND

We attempted to determine the frequency and clinical relevance of antinuclear antibody (ANA) testing and positive ANA test results in patients with cutaneous T-cell lymphoma (CTCL).

METHODS

A retrospective chart and computer record review was conducted to determine the frequency of ANA testing in CTCL patients and the rate of seropositivity. Patients with a positive ANA were further examined to define possible explanations of the positive test.

RESULTS

Of 381 patients with CTCL, 66 (17%) had ANA tests; 8 of these (12.1%) were found to have an ANA titer greater than or equal to 1:40. Of patients with a positive ANA test, one was found to have chronic cutaneous lupus erythematosus histologically and clinically mimicking CTCL. Others were found to have a comorbid connective tissue disorder, some had apparent drug-induced antinuclear antibodies, and some had no identifiable reason for a positive ANA test.

CONCLUSION

ANA seropositivity does not appear to be increased in CTCL patients, and the ANA test remains a useful screening tool for differentiating between CTCL and connective tissue disorders.

Cutaneous T-cell lymphoma: centuries of controversy

Two hundred years have passed since the description of mycosis fungoides by Alibert. During this time, the disease has been the focus of intense controversy and research, with these two intimately intertwined. In this article, the major components of the controversies surrounding cutaneous T-cell lymphoma are examined. The next millenium will see the resolution of these controversies and the fruition of continued research into this condition.

Cutaneous T-cell lymphoma with intracerebral and bilateral intraocular spread

Brain metastasis from systemic or cutaneous lymphoma is infrequently encountered. We present a case report of cutaneous T-cell lymphoma (CTCL) that metastasized to the brain. A literature review identified fourteen other cases of brain infiltration with CTCL. This report focuses attention on the typical presentation and markedly poor prognosis that characterize this rare problem. It also emphasizes the suspicion with which a brain mass in a lymphoma patient with neurological changes should be regarded.

Advances in the management of cutaneous T-cell lymphoma

This article focuses on the management of specific T-cell components of cutaneous T-cell lymphomas. Advances in the management of these lymphomas are evaluated and classified. New treatment strategies and therapies are discussed.

T-cell technology in the diagnosis & management of cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a malignancy of mature, clonal, helper (CD4+) T-cells that have a propensity for localizing in the skin. This article discusses the new immunologic and molecular advances and their practical application in the management of CTCL.

Cutaneous presentation of nasal lymphoma: a report of two cases

Two patients with nasal lymphoma were seen with cutaneous lesions. Multiple biopsy specimens, immunohistochemical techniques, and gene rearrangement studies were required to establish the diagnosis.

Use of serum soluble interleukin-2 receptor levels to monitor the progression of cutaneous T-cell lymphoma

BACKGROUND

The serum concentration of soluble alpha chain of the interleukin-2 receptor (sIL-2R) correlates with tumor burden in cutaneous T-cell lymphoma (CTCL). Therefore the sIL-2R level may be useful to monitor the condition of patients treated with extracorporeal photopheresis or other treatments.

OBJECTIVE

Our goal was to determine the utility of serum sIL-2R as a test in monitoring of patients with advanced CTCL.

METHODS

Serum sIL-2R was measured serially in 36 patients with advanced CTCL treated with extracorporeal photopheresis and other modalities (interferon alfa, methotrexate, topical nitrogen mustard, electron beam).

RESULTS

Serum concentrations of sIL-2R as well as lactate dehydrogenase (LDH) correlated strongly with lymph node size, but only sIL-2R correlated significantly with the severity of skin manifestations in erythrodermic patients. In addition, serum sIL-2R, but not LDH, was significantly higher in patients with nodal involvement. The level of sIL-2R also was significantly higher in patients with large-cell transformation in the skin or lymph nodes compared with patients without transformed disease. During treatment, serum concentrations of both serum sIL-2R and LDH correlated with changes in clinical status, but only sIL-2R showed statistically significant differences in mean levels for different relative global response scores. Pretreatment levels of both sIL-2R and LDH correlated significantly with survival, but only sIL-2R retained significance when both were entered into the Cox proportionate hazards model.

CONCLUSION

The concentration of serum sIL-2R correlates well with disease status and is more useful than LDH or Sézary cell counts to monitor clinical change in patients with advanced CTCL. Moreover, our data suggest that sIL-2R is produced at a relatively low rate by tissue-based lymphoma cells, and that large-cell transformation in CTCL results in marked increase in sIL-2R production in some patients.

Differentiation between actinic reticuloid and cutaneous T cell lymphoma by T cell receptor gamma gene rearrangement analysis and immunophenotyping

AIMS

Differentiation between actinic reticuloid and cutaneous T cell lymphoma can be extremely difficult. Demonstration of clonal T cell receptor (TCR) gene rearrangements has been suggested as a potential diagnostic criterion, but the results obtained thus far have been conflicting. This study investigated whether TCR gamma gene rearrangement analysis, using polymerase chain reaction (PCR) in combination with denaturing gradient gel electrophoresis (DGGE) and immunohistochemistry, can serve as a diagnostic criterion.

METHODS

PCR/DGGE was performed on skin, peripheral blood mononuclear cells, and/or lymph nodes of seven patients with actinic reticuloid, 11 patients with Sézary syndrome, and 15 patients with a benign form of erythroderma. The results of PCR/DGGE and Southern blot analysis of TCR beta gene rearrangements were compared. In addition, CD4:CD8 ratios in skin and peripheral blood samples were investigated.

RESULTS

Clonal T cell populations were detected in 19 of 21 samples obtained from patients with Sézary syndrome but were not detected in any of the 12 samples from patients with actinic reticuloid. Clonal T cells were detected in the peripheral blood of only one of 15 patients with a benign form of erythroderma. PCR/DGGE and Southern blot analysis gave concordant results in 28 of 29 samples. Immunophenotypic analysis demonstrated increased proportions of CD8+ T cells in skin (seven of seven cases) and peripheral blood (four of seven cases) of patients with actinic reticuloid.

CONCLUSION

The results of this study demonstrate that gene rearrangement analysis, in combination with immunohistochemistry, may be an important adjunct in differentiating between actinic reticuloid and cutaneous T cell lymphoma. In patients suspected of having actinic reticuloid, application of both techniques is recommended.