Hodgkin's disease followed by mycosis fungoides in the same patient. Case report and literature review

Cutaneous Localization of Classic Hodgkin Lymphoma Associated with Mycosis Fungoides: Report of a Rare Event and Review of the Literature

Mycosis fungoides and nodal classic Hodgkin lymphoma (cHL) have been reported to occur concurrently or sequentially in the same patient. A long-lasting mycosis fungoides more often precedes the onset of nodal cHL, although few cases of nodal cHL followed by mycosis fungoides have been observed. Skin involvement is a rare manifestation of cHL that may be observed in the setting of advanced disease. The decrease in skin involvement in cHL is mainly due to the improved therapeutic strategies. The concurrent presence of mycosis fungoides and cutaneous localization of classic Hodgkin lymphoma represents a very uncommon event, with only two cases reported so far. Herein, we describe the case of a 71-year-old man, with a history of recurrent nodal cHL, who developed MF and, subsequently, the cutaneous localization of cHL. The clinicopathological features of the two diseases are described focusing on the main differential diagnoses to be taken into consideration, and a review of the literature is performed.

β-Catenin and FGFR2 regulate postnatal rosette-based adrenocortical morphogenesis

Rosettes are widely used in epithelial morphogenesis during embryonic development and organogenesis. However, their role in postnatal development and adult tissue maintenance remains largely unknown. Here, we show zona glomerulosa cells in the adult adrenal cortex organize into rosettes through adherens junction-mediated constriction, and that rosette formation underlies the maturation of adrenal glomerular structure postnatally. Using genetic mouse models, we show loss of β-catenin results in disrupted adherens junctions, reduced rosette number, and dysmorphic glomeruli, whereas β-catenin stabilization leads to increased adherens junction abundance, more rosettes, and glomerular expansion. Furthermore, we uncover numerous known regulators of epithelial morphogenesis enriched in β-catenin-stabilized adrenals. Among these genes, we show Fgfr2 is required for adrenal rosette formation by regulating adherens junction abundance and aggregation. Together, our data provide an example of rosette-mediated postnatal tissue morphogenesis and a framework for studying the role of rosettes in adult zona glomerulosa tissue maintenance and function.

Concurrent Hodgkin's disease (mixed cellularity type) and T-cell chronic lymphocytic leukemia/prolymphocytic leukemia

We describe a patient with leukopenic T-cell chronic lymphocytic leukemia/prolymphocytic leukemia (T-CLL/PLL), according to the Revised European-American Classification of Lymphoid Neoplasms. This patient simultaneously developed classic Hodgkin's disease (HD), a combination previously unreported. The leukemic cells were small and mature, did not have cytoplasmic granulation, and appeared similar to B-cell chronic lymphocytic leukemia. Immunophenotyping of the bone marrow-infiltrating cells revealed a postthymic suppressor/cytotoxic phenotype of CD2+, CD3+, CD4, CD5+, CD8+, CD25-, TCR-alpha beta. A lymph node biopsy showed the histological features of HD (mixed cellularity) with infiltrating CD8+ lymphocytes, and immunohistochemical examination revealed the following phenotype of Reed-Sternberg cells: LeuM1/CD15+, BerH2/CD30+, L26/PanB-, UCHL-1/CD45RO-, cyCD3-, CD4, CD8-, CD20-, CD79a-, EMA-, EBER-1+, LMP-1+. Southern blot analysis of the bone marrow and lymph node revealed the same rearrangement of bands of T-cell-receptor genes. Although the HD was treated with chemotherapy that resulted in complete remission, the T-PLL/CLL took an indolent course. This case may suggest the existence of a subtype of T-CLL/PLL with leukopenia and an indolent clinical course. Both diseases were believed to be independent and not a transformation of one to the other.

Epstein-Barr virus-negative Hodgkin's lymphoma after mycosis fungoides: molecular evidence for distinct clonal origin

The association of mycosis fungoides (MF) and Hodgkin's lymphoma is a relatively frequent occurrence, but the potential clonal relationship of the two neoplasms is still controversial. We report a case of a patient with a history of MF in Clinical Stage 1A who developed retroperitoneal lymphadenopathy 9 years after the initial diagnosis of MF. A bone marrow biopsy obtained at this time showed nodular involvement by a mixed cellular infiltrate with large, atypical cells consistent with Hodgkin and Reed-Sternberg (RS) cells. These atypical cells were positive for CD30 and CD15 and did not express B- or T-cell markers. In addition, they lacked evidence of infection by Epstein-Barr virus, both by immunohistochemical staining for latent membrane protein 1 and by in situ hybridization for EBER1/2. The background population consisted mainly of small T cells without morphological or phenotypical signs of malignancy. Review of the skin biopsy obtained 9 years before showed the typical features of MF. Polymerase chain reaction analysis of the T-cell receptor T-gene confirmed the presence of a clonal T-cell rearrangement in the skin specimen. The bone marrow biopsy, however, showed a polyclonal pattern both for the T-cell receptor gamma-gene, as well as for immunoglobulin heavy chain genes. Isolation of RS cells stained for CD30 was performed by laser capture microdissection. Polymerase chain reaction analysis of several groups of RS cells showed a reproducible biallelic rearrangement of IgH genes, which was confirmed by cloning and sequencing of polymerase chain reaction products. To our knowledge, this is the first case in which a distinct clonal origin of MF and Hodgkin's lymphoma arising in the same patient is clearly demonstrated, based on molecular analysis of microdissected RS cells.

Meningeal involvement by a transformed mycosis fungoides following Hodgkin's disease

A 58-year-old man had long-standing lesions of presumed large plaque parapsoriasis. Following treatment for nodal Hodgkin's disease (HD), these became more infiltrated, with a diagnosis of mycosis fungoides (MF). A few months later, nodules appeared on the right leg, which was lymphoedematous after inguinal irradiation for HD. Histopathological examination showed CD3+, CD30-, CD15- large pleomorphic lymphocytes, leading to the diagnosis of transformed MF. The cutaneous lesions were successfully treated with topical nitrogen mustard and interferon alfa-2b then methotrexate, but his general health worsened with depression and malaise, without specific neurological symptoms or extracutaneous spreading of the lymphoma. Cerebral computed tomographic scan revealed a cerebellar subdural collection, arachnoid cyst and quadriventricular hydrocephaly, initially considered to be non-specific. After a few weeks, clinical symptoms of intracranial hypertension appeared, and a cerebrospinal fluid (CSF) examination revealed meningeal involvement by the lymphoma. These cells were CD3-negative and the diagnosis was confirmed by polymerase chain reaction (PCR) study, which revealed an identical clonal rearrangement of the T-cell receptor gamma gene between cutaneous biopsies and the CSF. Repeated intrathecal injections of methotrexate and cranial irradiation were performed and the patient was still alive after 13 months. This case illustrates the possible meningeal involvement of MF that may be preceded by atypical and mild neurological or psychiatric symptoms, which may be dissociated from the evolution of the cutaneous lesions. Moreover, PCR study may be useful for both diagnosis and monitoring.

Mycosis fungoides and cutaneous Hodgkin's disease in the same patient: a case report

We describe a case of a 34-year-old man who presented with a 10-year history of mycosis fungoides and recent onset of inguinal lymphadenopathy, fever, and cutaneous nodules on the right hip. Biopsy of the inguinal lymph node showed mixed cellularity Hodgkin's lymphoma. Biopsy of the pre-existing skin lesions showed mycosis fungoides, while that of the nodules on the hip revealed cutaneous Hodgkin's lymphoma. Immunohistochemical and molecular analysis demonstrated a null phenotype in the Reed-Sternberg cells of the Hodgkin's disease lesions, and a T-cell phenotype in the lymphoid cells of the mycosis fungoides lesions. He was treated with chemotherapy for Hodgkin's disease, which is in remission 11 years later. Topical nitrogen mustard and maintenance PUVA therapy have been used for the mycosis fungoides, which is also in remission.

The interrelationship between Hodgkin's disease and non-Hodgkin's lymphomas

BACKGROUND

While Hodgkin's disease (HD) and the non-Hodgkin's lymphomas (NHLs) have long been regarded as distinct disease entities, recent observations suggest a closer association. The analysis of cases in which both diseases are present in the same anatomic site (composite lymphomas), or in separate sites (simultaneous or sequential HD and NHL), indicates that this phenomenon occurs more frequently than would be expected by chance alone.

DESIGN

We reviewed our experience with composite, simultaneous, and sequential cases of HD and NHL, including both nodular lymphocyte-predominant HD (NLPHD) and the other (so-called 'usual') subtypes of HD. Cases analyzed included 43 cases of NLPHD and large-cell lymphoma (LCL); 14 cases of NHL following HD; 12 cases of composite lymphoma; 2 cases of simultaneous HD and NHL involving different sites; 8 cases of chronic lymphocytic leukemia (CLL) with Reed-Sternberg (RS) cells; and 22 cases of HD following NHL. Immunophenotypic analysis of both components (HD & NHL) was performed when possible. In addition, in situ hybridization for Epstein-Barr virus (EBV) EBER1 mRNA was performed in 35 cases of usual HD associated with NHL.

RESULTS

The most common form of composite lymphoma was coexistent NLPHD with LCL of B-cell immunophenotype. With the abnormal cells of NLPHD also being of B-cell lineage, this finding suggests the existence of a clonal relationship between the two components. The association of nodular sclerosis or mixed cellularity HD and NHL was less common but still significant. The vast majority of the NHL associated with HD were of B-cell origin, most commonly follicular lymphomas. EBV was identified more frequently in the NHL of composite NHL + HD (4/12 cases; 33%) than the other patient groups studied (2/23; 9%). Moreover, in 4/5 composite lymphomas both the HD and NHL component were EBV-positive, suggesting an origin from a common EBV-infected progenitor cell.

CONCLUSION

These findings suggest that, at least in some cases, HD may be clonally related to an underlying B-cell malignancy, and that the Reed-Sternberg cell may be an altered B lymphocyte. A process that may have a different pathogenesis is the late occurrence of aggressive, usually EBV-negative (12/14 cases), B-cell NHL in patients successfully treated for HD. Such tumors may be related to an underlying and persistent immunodeficiency in these patients, and may be of similar pathogenesis to the Burkitt-like lymphomas associated with HIV-infection.

Non-Hodgkin's lymphoma arising in patients treated for Hodgkin's disease in the BNLI: a 20-year experience. British National Lymphoma Investigation

Twenty-two of 3033 patients with Hodgkin's disease (HD) randomised into the clinical trials of the BNLI have developed non-Hodgkin's lymphomas (NHLs) at periods up to 16 years after presentation (1 simultaneous and 1 composite), giving an incidence of 0.7%. The frequency of NHL varied from 3.8% in lymphocyte-predominant HD to 0.3% in nodular sclerosing HD. In this series, 16 patients developed high-grade NHL (12 B cell; 4 peripheral T cell) and 6 developed low-grade NHL (all B cell). The histological subtype of NHL did not appear to be related to initial histological subtype of HD or the treatment received. In histological subtypes other than lymphocyte predominant, there was commonly evidence of immunosuppression in the form of low presentation lymphocyte counts, advanced stage and systemic (B) symptoms. The results suggest that these patients have a propensity for lymphoproliferative disorders, possibly associated with some immune deficiency and the subsequent development of NHL is not treatment related. The findings also emphasise how important it is to biopsy recurrent disease.

A case of lymphomatoid papulosis and Hodgkin's disease

Lymphomatoid papulosis is a unique paradoxic entity characterized by recurrent self-healing papulonodular lesions with histologic features of malignancy. Usually the disease has a protracted benign course; however, it can be associated with or evolve to a lymphoproliferative disorder. Thus "lymphoma-associated papulosis" represents the malignant end of a wide spectrum. We describe a case of a patient with lymphomatoid papulosis who developed Hodgkin's disease 8 years after the onset of skin lesions. Systemic chemotherapy achieved complete remission of Hodgkin's disease, but recurrent papulonodular lesions continued to form in the subsequent 18 months.

Two lymphomas: a potential diagnostic dilemma

We report a patient with mycosis fungoides of 20 years standing who developed mixed cellularity Hodgkin's disease. Full investigation, including biopsy, is essential when recurrent mycosis fungoides is suspected to outrule a second lymphoma as the results may affect management. Case History A Caucasian male presented aged 41 years with an eczematous rash affecting his trunk and upper and lower limbs. There was no lymphadenopathy/organomegaly or mucosal disease. Biopsy showed mucosis fungoides. This was controlled over the next two decades with simple emulsifying creams and topical corticosteroids, the disease remaining confined to the skin. Nineteen years after the diagnosis of mucosis fungoides, he developed an isolated left groin node, biopsy of which showed mixed cellularity Hodgkin's disease. Staging investigations were undertaken and the patient was found to have stage 1A disease (Ann Arbor). He was treated with combination chemotherapy (Nitrogen Mustard, Vincristine, Procarbazine and Prednisolone) and has had no recurrence of his Hodgkin's lymphoma, follow-up being seven years. His mycosis fungoides skin lesions improved temporarily with the cytotoxic therapy, but have subsequently progressed to the tumorous stage. Only temporary improvements in these lesions have resulted from total skin electron therapy, local electron irradiation and P.U.V.A.

Risk of second malignancy after cutaneous T-cell lymphoma

Risk of second primary malignancy was assessed in a population-based follow-up survey of all persons who developed cutaneous T-cell lymphoma (CTCL) in nine geographic areas of the United States covered by the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute during the period 1973 to 1983. Among 544 patients with a first primary tumor reported as CTCL, a second cancer developed in 35 (6%), yielding a significantly elevated relative risk (RR) of 1.7, which reflects excesses for cancers of the lung and colon and non-Hodgkin's lymphoma. Although the excess of lymphoma may be related to the evolution of CTCL to less differentiated T-cell lymphoma, additional studies are needed to clarify the immunologic, genetic, viral, and environmental factors that may contribute to the development of second cancers.

Common activated helper-T-cell origin for lymphomatoid papulosis, mycosis fungoides, and some types of Hodgkin's disease

A hypothesis is proposed to explain the nature of the Reed-Sternberg (RS) cell and the unexpectedly common clinical associations between lymphomatoid papulosis, mycosis fungoides, and some types of Hodgkin's disease. The RS cell appears to be a lymphoblast arising from activated helper T cells. In lymphomatoid papulosis, a cutaneous eruption with histological features of Hodgkin's disease, there is a spectrum of activated helper T cells, including cerebriform cells and large transformed RS-like cells. Clonal expansion of cerebriform cells in lymphomatoid papulosis leads to mycosis fungoides. Similar expansion of large transformed cells results in Hodgkin's disease. Progressive transformation of T4-positive cerebriform cells to Ki-1-positive RS cells accounts for rare cases of coexistent mycosis fungoides and Hodgkin's disease. Confirmation of this hypothesis should focus attention on the family of human T-cell leukaemia/lymphoma viruses as possible aetiological agents in these helper-T-cell disorders.

T-cell receptor gene rearrangements as clinical markers of human T-cell lymphomas

The ability to detect immunoglobulin-gene rearrangements has proved useful in confirming diagnoses of suspected B-cell lymphomas and in establishing their monoclonality. By analogy, we employed a cloned DNA probe for the beta chain of the T-cell receptor gene to determine whether gene rearrangements were present in human T-cell neoplasms representing various stages of T-cell development. Gene rearrangements were present in all cases of T-cell disorders except a single case of T gamma lymphocytosis, a disorder that has not been proved to be a clonal T-cell neoplasm. A germline gene configuration was present in all patients with non-T-cell neoplasms and in normal tissues from patients with T-cell lymphoma. The probe promises to be useful for confirming the pathological an immunologic diagnosis in difficult cases of T-cell disorders and for assessing the extent of disease.