Subcutaneous panniculitic T-cell lymphoma in childhood: successful response to chemotherapy

Panniculitic primary cutaneous gamma delta T-cell lymphoma with concomitant features of autoimmune disease emphasizing a pathophysiologic continuum of lupus profundus with the panniculitic T cell lymphomas

Certain T-cell lymphomas exhibit unique homing properties of the neoplastic lymphocytes for the subcutaneous fat. There are two primary forms of subcutaneous panniculitic lymphomas of T-cell origin. One falls under the designation of primary cutaneous gamma-delta T-cell lymphomas (PGD-TCL) whereby there is dominant involvement of the fat defininng a panniculitic form of PGD-TCL. The neoplastic cells are of the gamma-delta subset and are either double negative for CD4 and CD8 and/or can express CD8. They often have an aggressive clinical course. The other form of panniculitic T-cell lymphoma falls under the designation of subcutaneous panniculitis-like T-cell lymphoma (SPTCL). It represents a subcutaneous lymphoma derived from CD8+ T cells of the alpha-beta subset and typically has an indolent course. These two forms of panniculitic T-cell lymphoma exhibit overlapping histologic features with lupus profundus (LP), a putative form of panniculitic T-cell dyscrasia. We present three cases of PGD-TCL of the fat in the setting of lupus erythematosus (LE) (two cases) and dermatomyositis (DM) (one case), respectively. There were concurrent features of LE and DM in their lymphoma biopsies in two cases while a prior biopsy in one was interpreted as LP. In this latter case, the LP diagnosis presaged the diagnosis of panniculitic PGD-TCL by three years. One patient diagnosed with panniculitic PGD-TCL had hemophagocytic syndrome after developing a lupus-like complex including certain supportive serologies such as antibodies to double-stranded DNA following initiation of statin therapy. The second patient presented with PGD-TCL and concomitant features of anti-nuclear matrix 2 (NXP2) DM. The third patient presented in 2003 with LP and overlying skin features of acute LE, initially responding to Plaquenil, and then four years later was diagnosed with PGD-TCL heralded by Plaquenil treatment resistance. Two of the patients died of their lymphoma. All biopsies showed a characteristic histopathology of PGD-TCL. In two cases, the PGD-TCL was associated with overlying LE-cutaneous findings; another case had skin changes of lymphocyte-rich DM. In two cases, the MXA stain was strikingly positive, the surrogate type I interferon marker that is typically upregulated in biopsies of LE and DM. There are eight prior reported cases describing SPTCL with concomitant cutaneous changes of LE. In six cases there was an established history of LE, including LP responding initially to Plaquenil, similar to one of our cases. In the context of SPTCL or panniculitic PGD-TCL, panniculitic T-cell lymphomas can be associated with concomitant clinical and histologic features of LE or DM, including an upregulated type I interferon signature. Identifying histologic features associated with either of these prototypic autoimmune conditions should not be considered exclusionary to diagnosing any panniculitic T-cell lymphoma. A clinical, histomorphologic, and pathophysiologic continuum exists with LP, SPTCL and panniculitic PGD-TCL.

Primary Cutaneous Lymphomas in Children and Adolescents

Primary cutaneous lymphomas are rare in children and mostly represented by mycosis fungoides and CD30(+) lymphoproliferative disorders. Most pediatric cutaneous lymphomas have similar clinical/pathological features as their adult counterparts, particularly the T-cell subtypes. With regard to outcome, adult cutaneous mature T-cell lymphomas have a tendency to progression, while this appears to be relatively infrequent in children. The outcome of cutaneous B-cell lymphomas depends on subtype, with the B-lymphoblastic entity being associated with similar outcomes to precursor B acute lymphoblastic leukemia, while there are insufficient data on other entities. The diagnosis and treatment of these patients require a close collaboration between experienced pediatric pathologists, dermatologists, and oncologists. Prospective collection of longitudinal clinical and biological data from children with these rare lymphomas is needed to better understand their biological and clinical behavior and to ultimately discover the best therapeutic strategies.

Subcutaneous Panniculitis-Like T-Cell Lymphoma in Children: A Review of the Literature

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a type of skin lymphoma. Pleomorphic T-cells infiltrate the subcutaneous tissue and mimic lobular panniculitis. We report a case occurring in a 12-year-old Chinese boy who presented with multiple indolent erythematous subcutaneous nodules on both extremities without systemic symptoms. He had a protracted course of multiple erythematous subcutaneous nodules for 1 year and underwent biopsy of lesional skin for histology and T-cell receptor (TCR) gene analysis. Histopathology showed infiltration of medium to large atypical pleomorphic cells involving the subcutis with characteristic rimming of fat spaces. TCR gene rearrangement shows monoclonal rearrangements of the TCR β and γ chains. Immunophenotypic studies showed that CD3, CD4, and CD8 were strongly and diffusely positive in lesional cells and that CD56 was focally positive. In contrast, these cells were negative for CD20, CD30, and CD68. The combined morphology, characteristic histologic features, and positive T-CR gene rearrangement supported a diagnosis of SPTCL. He is being treated with combination chemotherapy of cyclophosphamide, doxorubicin, vincristine, and prednisolone.

Uncommon non-Hodgkin lymphomas of childhood: pathological diagnosis, clinical features and treatment approaches

We provide a review of the pathological and clinical features for uncommon B-cell and T-cell lymphomas of childhood with a specific focus on advances in treatment approaches and outcomes. There is clearly a need for prospective investigation of both the clinical and biological features of the uncommon non-Hodgkin lymphoma subtypes in childhood. These results should lead to more uniform and more effective treatment approaches.

Indolent subcutaneous panniculitis-like T cell lymphoma in a 1-year-old child

Subcutaneous panniculitis-like T-cell lymphoma is an uncommon form of CD8-positive cytotoxic T-cell lymphoma of the skin that predominantly affects the subcutaneous tissue and is extremely rare in early childhood (<3 yrs). Here, we present an early pediatric case with an indolent form of subcutaneous panniculitis-like T-cell lymphoma occurring at 12 months old. The subcutaneous nodules gradually disappeared spontaneously, and the girl showed excellent prognosis with no aggressive treatment.

Subcutaneous panniculitis-like T-cell lymphoma in a child with trisomy 21

Subcutaneous Panniculitis-Like T-cell Lymphoma (SPTCL) is a rare lymphoma with fewer than twenty cases reported in children less than 18 years of age. Trisomy 21 is a chromosomal abnormality associated with a risk of malignancy that differs from their normal counterparts. Leukemia is diagnosed 10-20 times over the general population while solid tumors are underrepresented. The risk for Lymphoma historically has been elevated as well. We describe a case of a 3 year-old girl with Down syndrome who was successfully treated for SPTCL.

Panniculitis in children

The panniculitides include a group of disorders of varied etiology that manifest as inflamed nodules in the subcutaneous tissue. They are rarely seen in infants and children. The panniculitides of the newborn represent a unique response of the infant's fat to different injuries, and are a specific type of panniculitis that is only seen in neonates and very young infants. These specific panniculitides of children include subcutaneous fat of the newborn, poststeroid panniculitis, sclerema neonatorum, and cold panniculitis. This article reviews in detail the specific types of panniculitis of the newborn and discusses the pediatric aspects of the panniculitis that is often seen in adults.

Subcutaneous panniculitislike T-cell lymphoma with hemophagocytosis: complete remission with BFM-90 protocol

Subcutaneous panniculitislike T-cell lymphoma (SPTCL) is an uncommon type of cutaneous lymphoma. In many cases, SPTCL is accompanied by hemophagocytic syndrome (HPS), resulting in prominent systemic symptoms. The natural history, optimal treatment strategy, and prognostic factors associated with this malignancy are not well defined. We report an 11-year-old boy of SPTCL with HPS who was initially treated with conventional cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy, but progressed later on therapy. Subsequently, the child was treated with multiagent combination chemotherapy as per BFM-90 protocol and achieved complete remission, and has remained so for 3 years. This report suggests the value of this particular multiagent combination chemotherapy regimen in the treatment of patients with SPTCL and HPS.

Peripheral T-cell lymphoma in childhood: population-based experience in the United Kingdom over 20 years

BACKGROUND

Peripheral T-cell lymphomas (PTCL) are very rare in children and this has prevented assessment of best treatment and prognosis.

PROCEDURE

Registry-based experience in England, Scotland and Wales over a 20-year period was studied to address these shortfalls. Anaplastic large cell lymphoma and mycosis fungoides were excluded due to recent publications describing UK experience with these disorders.

RESULTS

Twenty-five cases were identified, comprising 1.6% of non-Hodgkin lymphoma (NHL) registrations; 17 (68%) children with PTCL-unspecified (PTCL-u), 3 (12%) with angiocentric PTCL, 3 (12%) with angioimmunoblastic PTCL, and 2 (8%) with subcutaneous panniculitis-like T-cell lymphoma. Eighteen children were male, with a male/female ratio of 2.6:1. Median age was 7 (range 1-14) years. Eleven children (44%) died and actuarial survival was 76% at 1 year, 64% at 3 years and 59% at 5 years. Treatments given were subdivided between group T (regimens for T NHL or acute lymphoblastic leukaemia) or group B (regimens for B NHL). Amongst the 17 children with PTCL-u, 9/12 children in group T survived compared with 1/5 group B.

CONCLUSIONS

The Children's Cancer and Leukaemia Group recommendation that children with PTCL-u receive group T therapy is supported by this series. The numbers of children with other types of PTCL were too small to allow conclusions on best therapy.

Subcutaneous panniculitis-like T-cell lymphoma in a 26-month-old child with a review of the literature

Subcutaneous panniculitis-like T-cell lymphoma is a rare cytotoxic T-cell lymphoma of the skin that preferentially infiltrates the subcutaneous tissue. We report here this lymphoma occurring in a 26-month-old Korean girl. She presented with multiple erythematous subcutaneous nodules on both extremities and her back along with systemic symptoms. She had a protracted course of multiple erythematous subcutaneous nodules for 1 month and a spiking fever was often noted. The histopathologic findings for the subcutaneous nodules were lobular panniculitis-like material that was composed of atypical lymphocytes and histiocytes. The atypical lymphocytes characteristically rimmed individual fat cells in a lace-like pattern and some of the histiocytes showed phagocytosed white blood cells occasionally. Immunophenotypic studies showed CD3(+), CD45RO(+), CD20(-), CD4(-), CD8(+), and CD56(-). She is currently being treated with combination chemotherapy of cyclophosphamide, doxorubicin, vincristine, and prednisolone.

Immunophenotypic and molecular features, clinical outcomes, treatments, and prognostic factors associated with subcutaneous panniculitis-like T-cell lymphoma: a systematic analysis of 156 patients reported in the literature

BACKGROUND

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an uncommon type of skin lymphoma. The natural history, optimal treatment strategy, and prognostic factors associated with this malignancy are not well defined.

METHODS

The authors performed a systematic analysis of all patients with SPTCL reported on in the English-language medical literature, with emphasis on specific clinical features, experiences involving the use of radiotherapy and systemic agents, and prognostic factors predictive of treatment response and clinical outcome.

RESULTS

One hundred fifty-six patients with SPTCL were identified in the literature. Hemophagocytic syndrome (HPS) was a presenting feature in 37% of patients, and > 90% of patients required treatment at diagnosis. Prednisone was used frequently as initial therapy in patients who had less aggressive disease at presentation; however, durable complete remissions (CR) were infrequent. Anthracycline-based chemotherapy regimens were the most commonly used and most effective systemic treatment options, producing long-term CR in approximately 30% of patients. Among patients who received high-dose chemotherapy and stem cell transplantation (HDT-SCT) for refractory or recurrent disease, 92% achieved CR, with a median response duration of > or = 14 months. The presence of HPS at diagnosis and expression of the gamma/delta T-cell receptor (TCR) by tumor cells were associated with poor survival, whereas age was not. After a median follow-up of 24 months, 48% of patients died of disease. The median survival duration was 27 months.

CONCLUSIONS

SPTCL has an aggressive natural history. Nonetheless, a subgroup of patients with SPTCL can have long-term disease remission following anthracycline-based initial therapy or subsequent HDT-SCT. HPS and the TCR phenotype may be useful prognostic markers for patients with this malignancy.

Subcutaneous panniculitic T-cell lymphoma in children: response to combination therapy with cyclosporine and chemotherapy

We describe 2 adolescent boys with facial swelling and/or subcutaneous nodules and fever. Extensive evaluation, including several biopsy specimens, led to a diagnosis of subcutaneous panniculitic T-cell lymphoma, an entity rarely seen in children. Both patients were treated with oral cyclosporine in an effort to suppress the cytokine release from T-cells that has been thought to induce the hemophagocytic syndrome. The patients responded dramatically to cyclosporine treatment with defervescence of the fever and reduction in number and size of the subcutaneous nodules. Subsequent therapy with multidrug chemotherapy achieved complete remission in the first patient. This report suggests the value of cyclosporine as a first-line agent coupled with chemotherapy in the treatment of patients with subcutaneous panniculitic T-cell lymphoma. A clinicopathologic review of 8 described pediatric cases of subcutaneous panniculitic T-cell lymphoma is also presented.