Subcutaneous panniculitis-like T-cell lymphoma

Subcutaneous panniculitis like T-cell lymphoma derived from α/β T-cells (SPTCL-AB) belongs to the group of primary cutaneous T-cell lymphoma, and it represents less than the 1% of all primary cutaneous T-cell lymphomas. It affects patients in the 4th decade of life (median age of 36 years) with a female preference (male/female ratio 0.5) with 19% of patients being 20 years or younger. It can be sometime complicated by a hemophagocytic syndrome, and patients without hemophagocytic syndrome had a significantly better survival (5-year OS: 91% vs. 46%). Histopathologically, SPTCL-AB is characterized by a lobular lymphocytic panniculitis. Tumor cells distribute between individual adipose lobules, proliferating and forming "rim" and "capping" images, conferring a lace-like appearance at scanning magnification. This is not an entirely disease-specific feature, and can also be seen in other lobular lymphocytic panniculitis, either of inflammatory and neoplastic origin. Tumor cells are phenotypically CD45RO+, βF1+ (a monoclonal antibody able to identify the alpha/beta chain of TCR), CD3+, CD4-, CD8+, and express cytotoxic granules (TIA-1, granzyme and perforin), whereas they show variable deletion of T-cell restricted antigens like CD2, CD5 and CD7. The majority of cases show a monoclonal rearrangement for TCR beta and gamma genes and do not show genomic integration of EBV. The present review will focus on histopathologic, immunophenotypical and molecolare data useful to overcome to a specific diagnosis of SPTCL-AB and to differentiate SPTCL-AB from other lymphomas of T-cell or NK/T cell origin and with benign panniculitidis sharing with SPTCL-AB a predominant lobular lymphocytic pattern of involvement of subcutaneous tissue.

Erythrodermic CTCL: updated clues to diagnosis and treatment

Erythroderma is a rare but severe cutaneous condition characterized from a clinical point of view by a complete involvement (as per definition more than 80% body surface) of the skin surface. Pre-existing dermatoses account for about 70% of erythroderma cases, drug reactions are responsible for erythroderma in about 20%, whilst primary cutaneous T-cell lymphoma (CTCL) constitute less than 10% of and are represented by erythrodermic mycosis fungoides and Sézary syndrome. The challenge in these patients is represented by the identification of the etiological agents or conditions, which is clearly of overwhelming relevance in the clinical management and treatment strategies. In recent years, the development of multiparameter flow-cytometry, which allows to identify specific antigens expressed or not expressed on the surface of atypical lymphoid T-cells, and T-cell molecular biology techniques, which are aimed to identify the presence of a clonal T-cell population in the skin and blood on the basis of the finding of rearrangement of the T-cell receptor, have represented relevant useful tool in the differential diagnosis between benign and lymphomatous erythroderma. Moreover, a better understanding of the immunological and molecular pathways in CTCL disease evolution provided the identification of specific therapeutical targets, as well as the constant improvement in the laboratory techniques lead to the development of new and promising agents in CTCL.

Various faces of Hansen's disease

Leprosy is a chronic granulomatous disease caused by Mycobacterium leproe. Leprosy once considered a taboo is still misdiagnosed and underdiagnosed. In many cases leprosy is treated as common disorders like psoriasis, pyoderma, angioedema, pre vitiligo. Leprosy can present in many diverse ways which can be confused with many treatable and non treatable, infectious and non infectious forms. Leprosy is considered on the verge of elimination. But Leprosy cases are being newly diagnosed day by day. Here we are presenting 4 atypical cases of leprosy which did not seem to have classical presentation but were diagnosed as leprosy when investigated.

Primary cutaneous aggressive epidermotropic CD8+ T cell lymphoma with a chronic and indolent course. Is this different from peripheral T cell lymphoma?

Cutaneous T cell lymphomas most commonly have a CD4+ memory T cell phenotype and exhibit a relatively indolent course, but may in rare cases present with a CD8+ cytotoxic phenotype with a strikingly more aggressive clinical behavior. Primary cutaneous aggressive epidermotropic CD8+ T cell lymphoma is an extremely rare entity with distinct clinicopatological features. The clinical features and prognosis of the recently-described CD8+ peripheral lymphoma are very different from cytotoxic CD8+ epidermotropic lymphoma, but the histological and phenotypic characteristics are very similar. We report a new case of CD8+ epidermotropic lymphoma with a chronic course and suggest the possibility of an overlap between these two types of lymphoma.

Consistency and distribution of reflectance confocal microscopy features for diagnosis of cutaneous T cell lymphoma

Reflectance confocal microscopy (RCM) represents a noninvasive imaging technique that has previously been used for characterization of mycosis fungoides (MF) in a pilot study. We aimed to test the applicability of RCM for diagnosis and differential diagnosis of MF in a clinical study. A total of 39 test sites of 15 patients with a biopsy-proven diagnosis of either MF, parapsoriasis, Sézary syndrome, or lymphomatoid papulosis were analyzed for presence and absence of RCM features of MF. Cochran and Chi(2) analysis were applied to test the concordance between investigators and the distribution of RCM features, respectively. For selected parameters, the Cochran analysis showed good concordance between investigators. Inter-observer reproducibility was highest for junctional atypical lymphocytes, architectural disarray, and spongiosis. Similarly, Chi(2) analysis demonstrated that selected features were present at particularly high frequency in individual skin diseases, with values ranging from 73% to 100% of all examined cases.

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma: a retrospective case series and review of the provisional cutaneous lymphoma category

BACKGROUND AND OBJECTIVE

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma (PCSM-TCL) is a rare and provisional subcategory of cutaneous T-cell lymphoma, associated with a favorable prognosis. We present five cases of PCSM-TCL and review the literature to address questions surrounding its diagnosis and treatment.

METHODS

A retrospective review was conducted of 353 patients with non-mycosis fungoides cutaneous lymphomas evaluated at the M.D. Anderson Cancer Center Cutaneous Lymphoma Clinic over 10 years. A retrospective search of the English literature using PubMed was conducted to identify additional cases.

RESULTS

Only five patients had a diagnosis of PCSM-TCL. Three patients had unique multifocal presentations that responded well to topical therapy or excision. One patient with localized disease initially treated with radiation therapy had an aggressive relapse requiring systemic therapy. One patient had an isolated nodule that fully resolved with excision. The review of the English literature found 232 additional cases. The presentation of PCSM-TCL was heterogeneous and included solitary/localized papules, nodules, plaques, and tumors. Multiple differential diagnoses were considered and PCSM-TCL diagnosis was based on histopathologic features and clinical correlation. Treatment of solitary/localized lesions included excision or radiation therapy. Multifocal lesions were uncommon and associated with an aggressive course requiring systemic chemotherapy.

CONCLUSIONS

The heterogeneous presentation, variable histologic overlap with other lymphoproliferative disorders, and uncertain prognosis of PCSM-TCL creates diagnostic and management dilemmas for clinicians. For treatment, a distinction should be made between indolent and aggressive subtypes. Further investigation is needed to determine if PCSM-TCL is indeed a distinct lymphoma category and, additionally, if aggressive subtypes should remain part of the same diagnostic category.

Cutaneous T-cell lymphoma: 2011 update on diagnosis, risk-stratification, and management

DISEASE OVERVIEW

Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS).

DIAGNOSIS

The diagnosis of MF or SS requires the integration of clinical and histopathologic data.

RISK-ADAPTED THERAPY

Tumor, node, metastasis, and blood (TNMB) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers, denileukin diftitox, and histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy may be used for those patients with extensive visceral involvement requiring rapid disease control. In highly-selected patients with disease refractory to standard treatments, allogeneic stem-cell transplantation may be considered.

Photolichenoid plaques with associated vitiliginous pigmentary changes

A 49-year-old man with advanced HIV/AIDS on anti-retroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) presented with a several-month history of pruritic, erythematous, lichenified papules that coalesced into hyperkeratotic plaques on the trunk and extremities in a sun-exposed distribution. He shortly thereafter developed a progressive depigmentation over more than 80 percent of his body surface area. A biopsy specimen of an erythematous plaque on the trunk showed a superficial and mid-dermal infiltrate of lymphocytes with eosinophils, most consistent with either chronic lichenoid drug eruption or atypical lymphoproliferative disorder (ACLD) of HIV. The patient's lichenoid skin disease has persisted despite discontinuation of TMP-SMX, although it has improved partially with administration of topical glucocorticoids and acitretin. His depigmentation has continued to progress. We discuss the overlapping diagnostic entities which may be comprised by this patient's clinical disease, and highlight a unique presentation of the complex interaction between HIV infection and the skin.

Erythroderma of unknown etiology

We present a 46-year-old man with a greater than 15-year history of erythroderma. A definitive diagnosis has not been established. The differential diagnosis is discussed.

Survival data for 299 patients with primary cutaneous lymphomas: a monocentre study

The aim of this study was retrospectively to assess the validity of the 2005 WHO-EORTC classification for primary cutaneous lymphomas (PCL) in a large cohort of patients of a single German skin cancer unit. All patients with PCLs consecutively visiting our hospital between January 1980 and December 2005 were included in a retrospective monocentre study, analysing their histological and clinical data. A total of 312 patients fulfilled the inclusion criteria for PCL. In 299 patients clinical information and paraffin material were sufficient for detailed classification. Of the 299 patients, 63% expressed a T-cell and 37% a B-cell phenotype. Mycosis fungoides was the entity with the highest frequency (30.9%), followed by primary cutaneous follicle centre lymphomas (16.9%) and lymphomatoid papulosis (15.9%). The mean follow-up period was 38.4 months. Five-year disease-specific survival was 80.5% for mycosis fungoides, 92.5% in primary cutaneous anaplastic large cell lymphoma, 100% in lymphomatoid papulosis, 98.1% in primary cutaneous follicle center lymphoma, 100% in primary cutaneous marginal zone lymphoma and 63.2% in diffuse large B-cell lymphoma, leg type. Our data are in line with the data collected by the WHO-EORTC. This is further evidence for the reliability of the WHO-EORTC classification and staging system.

Polo-like kinase 1 (Plk1) is expressed by cutaneous T-cell lymphomas (CTCLs), and its downregulation promotes cell cycle arrest and apoptosis

Polo-like kinases are serine/threonine kinases crucial for mitosis and DNA integrity. Plk1, the most well studied member of this family, is upregulated in several cancers, as well as in dividing cells with peak expression during G2/M phase. Recently, employing lesional skin from patients with cutaneous T-cell lymphoma (CTCL), we showed that Plk1 was increased mainly in advanced lesions. In this study, employing western blot and quantitative RT-PCR analyses, we demonstrated that Plk1 was overexpressed in multiple CTCL cell lines (HH, Hut78, MyLa, SeAx and SZ4). Further, a genetic knockdown (by short hairpin RNA) or enzyme activity inhibition (via a small molecule inhibitor, GW843682X) was found to result in a decrease in cell growth, viability and proliferation. Plk1 inhibition in CTCL cells also resulted in: (1) increased G(2)/M phase cell cycle arrest, (2) alteration in key mitotic proteins, (3) apoptosis and (4) multiple mitotic errors. Given our findings, clinical trials of Plk1 inhibitors in CTCL may be a promising area for further translational investigation. We speculate that overexpression of Plk1 may prove to be relevant to the progression and prognosis of CTCL through its direct impact on the regulation of tumor cell proliferation and indirect influence on the acquisition of somatic mutations by proliferating tumor cells.

An unusual cause of abdominal pain

We report a case of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) (they are always alpha/beta) in a 36-year-old male who presented with a 6-week history of abdominal pain, fever and significant weight loss. Definitive diagnosis required a full thickness skin biopsy with PCR analysis for clonal T-cell gene arrangement. A literature search showed that SPTCL is a very rare cutaneous lymphoma limited to case reports.

[Epitheliotropic lymphomas: better identification for improved treatment]

Mycosis fungoides is the most frequent cutaneous T cell lymphoma. Mycosis fungoides-related cutaneous T cell lymphomas include folliculotropic mycosis fungoides, with or without mucinosis, pagetoid reticulosis and granulomatous slack skin. Sezary syndrome is characterized by pruriginous erythroderma, adenopathies, atypical lymphocytes in the blood and a more aggressive course. B cell lymphomas represent 25 % of cutaneous lymphomas. Primary cutaneous follicle center cell lymphomas are the most frequent. They are often located on the head and trunk and have an indolent course. Primary cutaneous marginal zone B-cell lymphomas, which are more frequently multicentric and located on the limbs, also have an indolent course. In contrast, primary cutaneous diffuse large B-cell lymphomas, leg type, and primary cutaneous intravascular large B-cell lymphomas have a more aggressive course. Treatment must be adapted to each case. Unnecessarily aggressive treatments must be avoided in patients with indolent lymphomas.

[Lymphomatoid papulosis in children: report of 9 cases and review of the literature]

BACKGROUND

Lymphomatoid papulosis is a rare lymphoproliferative T cell CD30+ disease with excellent prognosis which affects almost exclusively adult patients, being rarely in the childhood; thus the clinic and pathologic spectrum and the risk of evolution to another type of lymphoma are not well defined in the pediatric group.

OBJECTIVE

The aim of this article is to analyze the characteristics of infantile lymphomatoid papulosis and review the literature.

MATERIAL AND METHOD

A retrospective study analyzing the characteristics of 9 patients aged up to 18 diagnosed of lymphomatoid papulosis attended in our department from 1995 to 2009 was performed.

RESULTS

The study included 7 boys and 2 girls aged between 2 and 17. Pityriasis lichenoides acuta's lesions appeared associated before and after lymphomatoid papulosis' development in 2 and 1 cases respectively. The lesions resolved spontaneously, leaving a postinflammatory hyperpigmentation (77%) or hypopigmentation (23%). The development of varioliform scars occurred in over 77% of cases. Histologically, all cases showed features compatible with type A of lymphomatoid papulosis. Molecular studies showed monoclonality in the 3 cases in which this technique was done.

CONCLUSIONS

Infantile lymphomatoid papulosis is a rare entity clinically manifested as the adult form. This lymphoproliferative disease, which is occasionally associated with pityriasis lichenoides acuta, shows features compatible with the type A or histiocytoid pattern in the histological analysis. The development of other lymphoproliferative disorders is less frequent in the infantile form than in the adulthood. The prevalent association among pityriasis lichenoides and lymphomatoid papulosis observed in our analysis, as well as the difficulties which supposed to differentiate between these two pathologies in various cases, suggest that those entities could be part of a common clinical and pathological spectrum.

Clinical pathway for melanoma detection using comprehensive cutaneous analysis with Melanoscan

The usefulness of a comprehensive cutaneous photography system (Melanoscan) was tested using the following parameters: 1) decision to screen pathway, 2) clinical pathway, 3) clinical outcome, and 4) patient acceptance. The results indicate that 55 percent of those with criteria for scanning were reimbursed by insurance (AMA CTP category 1 code status 96904 for total body photography). In this model of whole body scanning, the ratio of time demand on physicians, patients, and technicians is 1:8:12. In 53 patients, 394 lesions of concern were identified. Of these lesions, 48 (12.31%) were scars, 306 (78.46%) were changed, and 36 (9.23%) were new. The decision to biopsy was made for 18 of the 394 lesions analyzed in the follow-up studies. Sensitivity of the process in determining malignant lesions is 75.00 percent and specificity is 73.70 percent. Preliminary results suggest that change detection analysis reduces the number of biopsies and improves diagnostic accuracy. Assessment of survey results revealed a high degree of patient satisfaction with ease of following Melanoscan directions (81.25%), as well as overall satisfaction with the process (73.44%). These results suggest that whole body screening using the Melanoscan provides a device in which accuracy of lesion tracking, patient confidence in lesion documentation, and clinician time are optimized.