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.

Primary cutaneous angioimmunoblastic T-cell lymphoma histologically mimicking an inflammatory dermatosis

Angioimmunoblastic T-cell lymphoma (AITL) is a systemic lymphoproliferative disease characterized by a polymorphous neoplastic infiltrate involving lymph nodes as well as extranodal locations, including the skin. Cutaneous involvement is seen in approximately 50 percent of cases and is usually secondary to systemic disease. Patients with cutaneous involvement classically present with a transient morbilliform eruption of the trunk; however, papules, nodules, urticarial plaques and erythroderma have also been reported. In contrast, primary cutaneous AITL is exceedingly rare. The authors report a case of a 79-year-old woman with AITL who presented with primary cutaneous tumors and ulcerated nodules, with no evidence of systemic involvement, hypergammaglobinemia, or B symptoms. Histologically, a subtle lymphoid infiltrate was present, dominated by marked fibrosis and a diffuse infiltrate of neutrophils, eosinophils and plasma cells, mimicking an inflammatory or infectious etiology. This presentation presents a unique diagnostic challenge; careful investigation and strong clinical suspicion must be utilized in order to correctly identify AITL in this setting.

Case report: epitheliotropic lymphoma in a zebrafish (Danio rerio)

A proliferative disorder of lymphocytes was observed in a macroscopically normal young adult wild-type zebrafish (Danio rerio) during routine histological screening in a two-generation toxicity study. Proliferating lymphocytes were observed to invade the gill arches, infiltrate the cranial skeletal muscle and inner ear, and accumulate at distant sites in the frontal epidermis. The test compound, tetrabromobisphenol A (TBBPA, a flame retardant), is not known as a carcinogen and no tumours were detected in any of the 53 other fish in the study, including tank mates. Although neoplastic lymphoid proliferation in the thymus region is occasionally observed, we have never seen epitheliotropism in zebrafish during other similar exposure studies or brood stock. Our findings indicate that epitheliotropic lymphoma can occur spontaneously in zebrafish but at a low incidence.

Clinical outcome of patients with subcutaneous panniculitis-like T-cell lymphoma

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare form of cytotoxic T-cell lymphoma. The objective of this study was to characterize the clinical presentation, treatment, and prognosis of patients with SPTCL. Twenty-one patients with SPTCL were seen at Mayo Clinic (Rochester, Minnesota, USA) between July 1973 and June 2004. The median age at diagnosis was 42 years (range 23-80 years) and 15 (71%) were women. Constitutional symptoms occurred in 14 (67%) patients, including fever, serositis, arthralgias and myalgias. The Eastern Cooperative Oncology Group performance score was poor (3-4) in 3 (15%) patients. Liver enzymes (at least 2 enzymes, Aspartate aminotransferase (AST), alkaline phosphatase and/or lactate dehydrogenase) were elevated in 11 (52%) patients. Therapy consisted of chemotherapy in 13 (62%) patients, or other therapeutic interventions in 8 (38%) patients, including surgical excision, corticosteroids alone or in combination with either plaquenil, colchicine, hydroxychoroquine, or azathioprine. Bone marrow transplantation was performed in 5 (24%) patients, 3 autologous and 2 allogeneic. The median overall survival from diagnosis was 15 months (range 0.1-104 months). Two groups of patients were identified and categorized as having a favorable or unfavorable disease course. The factors associated with an unfavorable disease course were a low white blood cell count or elevated lactate dehydrogenase. Patients treated aggressively with stem cell transplantation appeared to have an improved overall survival.

Atopic Dermatitis-Like Non-Erythrodermic Leukemic Variant of CD3−/+dimCD4+Cutaneous T-Cell Lymphoma Preceded by Cutaneous Papular Xanthomatosis

We report a patient with cutaneous papular xanthomatosis who 4 years later developed a CD3(-/+dim)/CD4(+) T-cell lymphoma. Pruritic xerotic non-erythrodermic skin, eosinophilia and hyper-IgE were present and erroneously classified as atopic dermatitis. Flow cytometry and DNA ploidy analysis of both blood and skin lymphocytes, skin histology and blood T-cell receptor gene rearrangement studies confirmed diagnosis of T-cell lymphoma. Monoclonal CD3(-/+dim)/CD4(+) T-cells were especially prone to the synthesis of IL-13, a cytokine that is involved in IgE-secretion, and comprised both a medium (diploid) and large (hyperploid) sized T-cell populations with a similar immunophenotype. The majority of the normal residual T-cells were large granular lymphocytes, expressed activation-related and natural-killer-associated markers and secreted high levels of interferon gamma, suggesting that they might correspond to active cytotoxic cells directed against the neoplastic T-lymphocytes.

Cutaneous T cell lymphoma-mycosis fungoides and Sezary syndrome: an update

Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphoma (CTCL) and, for unclear reasons, its incidence appears to be increasing. Due to significant differences in biological behavior, cutaneous T cell lymphomas have recently been reclassified. MF and Sezary syndrome (SS) are now separately classified as indolent and aggressive CTCLs, respectively. The cause of MF and SS remains elusive. Because establishing the diagnosis of MF, particularly in early stages of disease, is often difficult, a guideline with clinical and histological diagnostic criteria has recently been proposed. With the exception of very early stage disease, no cure is available. However, the number of available therapeutic options has increased considerably in recent years, and partial and complete remissions are achievable. Prognosis and selection of appropriate therapy largely depends on stage of disease. A detailed practice guideline with an algorithmic, stage-based approach to therapy has recently been put forth and will likely aid clinicians in managing patients with MF and SS. Despite the indolent nature in most individuals, the disease has a tremendous psychological impact, not only because of the visible nature of the skin lesions, but also due to the rarity of the disease and its chronicity. Knowledge of this disease, therapeutic options and expectations of therapy will greatly enhance care of afflicted patients.

Sézary cell counts in erythrodermic cutaneous T-cell lymphoma: Implications for prognosis and staging

In this retrospective study, quantitative Sézary cell counts were performed at presentation on 192 patients with erythrodermic cutaneous T-cell lymphoma (E-CTCL). Per recommendation of the International Society of Cutaneous Lymphomas (ISCL), the impact on staging of using an absolute Sézary cell count of 1.0 K microL-1 or more as equivalent to lymph node involvement was investigated. Of 132 patients with disease initially classified at stage III using the current TNM staging system, 25% were up staged to IVa, resulting in a clearer separation of associated survival curves between the stages. Furthermore, the current ISCL definition of B0, B1 and B2 ratings were improved using Sézary cell count levels of < 1.0 K microL-1, > or = 1.0 - 4.99 K microL-1 and > or = 5.0 K microL-1, respectively. These modified B ratings potentially could be used in an alternative staging system for E-CTCL without N rating. Advanced age, prior exposure to multiple systemic drugs, enlargement of peripheral lymph nodes (>3 cm), other measures of blood tumor burden (CD4/CD8 ratio > or = 10, chromosomally-abnormal clone) and 2-fold increase in serum LDH level were other factors of prognostic significance. The clinical importance of these variables vis-à-vis the modified TNBM staging system will need to be clarified in future studies.

Current Concepts of the Immunobiology and Immunotherapy of Cutaneous T Cell Lymphoma: Insights Gained through Cross-talk between the Clinic and the Bench

An understanding of the immunologic features of cutaneous T cell lymphoma (CTCL) has led to insights into the life cycle of the malignancy. The identification of the T cell lineage of the neoplastic CTCL cells has allowed unification of diverse clinical presentations under a single entity. The CD4 inducer T cell phenotype of the malignant cells has provided an understanding of the patient's ability to resist infection with certain bacteria. The clonality of the tumor cells, beyond its diagnostic implications, has made them a valuable resource for studying both normal and neoplastic T cell biology. The recently identified immunosuppressive features of the malignant T cells and their dependency for survival on an interaction with immature dendritic cells have explained previously cryptic clinical observations and identified new targets for immunotherapy. Future insights gained both from the bedside and the bench will provide not only an understanding of the immunobiology of the malignancy but also open new avenues for therapeutic intervention.

Eruptive keloids: spontaneous reactivation after 60 years

An 84-year-old man with keloids since early adulthood, was referred to our clinic because of the recent appearance of erythematous, tumid plaques upon the old keloids and upon uninvolved skin. The plaques were located mainly on the trunk in a linear distribution. On the back there were round, nodular, erythematous nodules and plaques, with central crusts, that had just appeared on normal skin. A skin biopsy was performed on the plaques that appeared over the older lesions. The histological appearance was consistent with keloid. Similar histology was found in a biopsy taken from a plaque that had erupted on normal skin.