In search of prognostic indicators for lymphomatoid papulosis: A retrospective study of 123 patients

Paediatric-onset lymphomatoid papulosis: results of a multicentre retrospective cohort study on behalf of the EORTC Cutaneous Lymphoma Tumours Group (CLTG)

BACKGROUND

Lymphomatoid papulosis (LyP) is a rare cutaneous T-cell lymphoproliferative disorder. Comprehensive data on LyP in the paediatric population are scarce.

OBJECTIVES

To characterize the epidemiological, clinical, histopathological and prognostic features of paediatric LyP.

METHODS

This was a retrospective multicentre international cohort study that included 87 children and adolescents with LyP diagnosed between 1998 and 2022. Patients aged ≤ 18 years at disease onset were included. LyP diagnosis was made in each centre, based on clinicopathological correlation.

RESULTS

Eighty-seven patients from 12 centres were included. Mean age at disease onset was 7.0 years (range 3 months-18 years) with a male to female ratio of 2 : 1. Mean time between the onset of the first cutaneous lesions and diagnosis was 1.3 years (range 0-14). Initial misdiagnosis concerned 26% of patients. LyP was most often misdiagnosed as pityriasis lichenoides et varioliformis acuta, insect bites or mollusca contagiosa. Erythematous papules or papulonodules were the most frequent clinical presentation. Pruritus was specifically mentioned in 21% of patients. The main histological subtype was type A in 55% of cases. When analysed, monoclonal T-cell receptor rearrangement was found in 77% of skin biopsies. The overall survival rate was 100%, with follow-up at 5 years available for 33 patients and at 15 years for 8 patients. Associated haematological malignancy (HM) occurred in 10% of cases (n = 7/73), including four patients with mycosis fungoides, one with primary cutaneous anaplastic large cell lymphoma (ALCL), one with systemic ALCL and one with acute myeloid leukaemia. If we compared incidence rates of cancer with the world population aged 0-19 years from 2001 to 2010, we estimated a significantly higher risk of associated malignancy in general, occurring before the age of 19 years (incidence rate ratio 87.49, 95% confidence interval 86.01-88.99).

CONCLUSIONS

We report epidemiological data from a large international cohort of children and adolescents with LyP. Overall, the disease prognosis is good, with excellent survival rates for all patients. Owing to an increased risk of associated HM, long-term follow-up should be recommended for patients with LyP.

Primary cutaneous T-cell lymphoma: a review of the most common entities with focus on recent updates

Cutaneous T-cell lymphomas are an heterogeneous group of uncommon lymphoid neoplasms that are challenging to diagnose and require close collaboration between dermatologists, pathologists and hematologists/oncologists. This article reviews the most common cutaneous T-cell lymphomas: mycosis fungoides (both classic and variant forms) as well as its leukemic counterpart Sézary syndrome, CD30+ T-cell lymphoproliferative disorders including the ever-expanding group of lymphomatoid papulosis and primary cutaneous anaplastic large cell lymphoma, and primary cutaneous CD4+ small/medium lymphoproliferative disorder. We discuss the classic clinical and histopathologic features of these lymphomas and review how they can be distinguished from reactive entities. In particularly, updates to these diagnostic categories and current controversies in classification are highlighted. Moreover, we review the prognosis and treatment for each entity. These lymphomas exhibit variable prognosis, and therefore it is important to correctly classify atypical cutaneous T-cell infiltrates for appropriate patient treatment and prognosis. Cutaneous T-cell lymphomas are at the interface of several medical specialties; this review seeks to summarize key features of these lymphomas and highlight new and emerging insights into these lymphomas.

Primary cutaneous T-cell lymphoma: a review of the most common entities with focus on recent updates

Cutaneous T-cell lymphomas are an heterogeneous group of uncommon lymphoid neoplasms that are challenging to diagnose and require close collaboration between dermatologists, pathologists and hematologists/oncologists. This article reviews the most common cutaneous T-cell lymphomas: mycosis fungoides (both classic and variant forms) as well as its leukemic counterpart Sézary syndrome, CD30+ T-cell lymphoproliferative disorders including the ever-expanding group of lymphomatoid papulosis and primary cutaneous anaplastic large cell lymphoma, and primary cutaneous CD4+ small/medium lymphoproliferative disorder. We discuss the classic clinical and histopathologic features of these lymphomas and review how they can be distinguished from reactive entities. In particularly, updates to these diagnostic categories and current controversies in classification are highlighted. Moreover, we review the prognosis and treatment for each entity. These lymphomas exhibit variable prognosis, and therefore it is important to correctly classify atypical cutaneous T-cell infiltrates for appropriate patient treatment and prognosis. Cutaneous T-cell lymphomas are at the interface of several medical specialties; this review seeks to summarize key features of these lymphomas and highlight new and emerging insights into these lymphomas.

CD30-positive lymphoproliferative disorders-An Australian Clinical Practice Statement from the Peter MacCallum Cancer Centre

The CD30-postive lymphoproliferative disorders, including lymphomatoid papulosis and primary cutaneous anaplastic large cell lymphoma, account for up to 30% of all cutaneous T-cell lymphomas (CTCLs) and are the second most common form of CTCLs after mycosis fungoides. Both conditions differ in their clinical presentations; however, they share the expression of the CD30 antigen as a common immunophenotypic hallmark. There is a wide spectrum of management options depending on factors such as extent of disease, staging and treatment tolerability. This Clinical Practice Statement is reflective of the current clinical practice in Australia.

Etiopathogenesis, Diagnosis, and Treatment Strategies for Lymphomatoid Papulosis with Particular Emphasis on the Role of the Immune System

Lymphomatoid papulosis (LyP) is a very rare disease that belongs to the group of CD30+ lymphoproliferative skin diseases. LyP is localized or generalized and usually presents as isolated or clustered red/brown-red lesions in the form of nodules and/or papules. The course of the disease is in most cases mild; however, depending on concomitant risk factors and history, it may progress to lymphoma, significantly reducing the survival rate and prognosis. Importantly, the clinical picture of the disease remains somewhat ambiguous, leading to a large number of misdiagnoses that result in inappropriate treatment, which is usually insufficient to alleviate symptoms. In addition to clinical manifestations, the histological characteristics vary widely and usually overlap with other conditions, especially those belonging to the group of lymphoproliferative disorders. Although diagnosis remains a challenge, several recommendations and guidelines have been introduced to standardize and facilitate the diagnostic process. This article reviews the available literature on the most important aspects of etiopathogenesis, clinical and histopathological features, diagnostic criteria, and possible treatment strategies for LyP, with particular emphasis on the role of the immune system.

Genetics Abnormalities with Clinical Impact in Primary Cutaneous Lymphomas

Simple Summary

The genetic landscape of cutaneous T-cell lymphomas analyzed by sequencing high throughput techniques shows a heterogeneous somatic mutational profile and genomic copy number variations in the TCR signaling effectors, the NF-κB elements, DNA damage/repair elements, JAK/STAT pathway elements and epigenetic modifiers. A mutational and genomic stratification of these patients provides new opportunities for the development or repurposing of (personalized) therapeutic strategies. The genetic heterogeneity in cutaneous B-cell lymphoma parallels with the specific subtype. Damaging mutations in primary cutaneous diffuse large B-cell lymphoma of the leg type, involving MYD88 gene, or BCL6 and MYC translocations or CDKN2A deletions are useful for diagnostic purposes. The more indolent forms, as the primary cutaneous lymphoma of follicle center cell (somatic mutations in TNFRSF14 and 1p36 deletions) and the cutaneous lymphoproliferative disorder of the marginal zone cells (FAS gene), present with a more restricted pattern of genetic alterations.

Abstract

Primary cutaneous lymphomas comprise a heterogeneous group of extranodal non-Hodgkin lymphomas (NHL) that arise from skin resident lymphoid cells and are manifested by specific lymphomatous cutaneous lesions with no evidence of extracutaneous disease at the time of diagnosis. They may originate from mature T-lymphocytes (70% of all cases), mature B-lymphocytes (25–30%) or, rarely, NK cells. Cutaneous T-cell lymphomas (CTCL) comprise a heterogeneous group of T-cell malignancies including Mycosis Fungoides (MF) the most frequent subtype, accounting for approximately half of CTCL, and Sézary syndrome (SS), which is an erythrodermic and leukemic subtype characterized by significant blood involvement. The mutational landscape of MF and SS by NGS include recurrent genomic alterations in the TCR signaling effectors (i.e., PLCG1), the NF-κB elements (i.e., CARD11), DNA damage/repair elements (TP53 or ATM), JAK/STAT pathway elements or epigenetic modifiers (DNMT3). Genomic copy number variations appeared to be more prevalent than somatic mutations. Other CTCL subtypes such as primary cutaneous anaplastic large cell lymphoma also harbor genetic alterations of the JAK/STAT pathway in up to 50% of cases. Recently, primary cutaneous aggressive epidermotropic T-cell lymphoma, a rare fatal subtype, was found to contain a specific profile of JAK2 rearrangements. Other aggressive cytotoxic CTCL (primary cutaneous γδ T-cell lymphomas) also show genetic alterations in the JAK/STAT pathway in a large proportion of patients. Thus, CTCL patients have a heterogeneous genetic/transcriptional and epigenetic background, and there is no uniform treatment for these patients. In this scenario, a pathway-based personalized management is required. Cutaneous B-cell lymphoma (CBCL) subtypes present a variable genetic profile. The genetic heterogeneity parallels the multiple types of specialized B-cells and their specific tissue distribution. Particularly, many recurrent hotspot and damaging mutations in primary cutaneous diffuse large B-cell lymphoma of the leg type, involving MYD88 gene, or BCL6 and MYC translocations and BLIMP1 or CDKN2A deletions are useful for diagnostic and prognostic purposes for this aggressive subtype from other indolent CBCL forms.

Clinicopathological Factors Associated with the Prognosis and Chronicity of Lymphomatoid Papulosis: A Retrospective Cohort Study

BACKGROUND

The clinical and pathological features of lymphomatoid papulosis (LYP) are diverse. The objective of this study is to evaluate the clinical and pathological features associated with the prognosis and clinical course of LYP.

PATIENTS AND METHODS

The clinical and pathological features of LYP in a medical center database were retrospectively retrieved.

RESULTS

Overall, 58 LYP patients were included in the study. The mean age at diagnosis was 39.1 years and the female-to-male ratio was 1:1.2. More than two-thirds (40/58, 69.0%) of the patients showed a chronic and recurrent disease course. A longer pre-diagnosis duration (odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03) was significantly associated with secondary lymphoma development. Lower extremity involvement (OR, 10.40; 95% CI, 1.17-92.28) and the absence of eosinophils in the lesions (OR, 11.28; 95% CI, 1.01-126.24) were found to be significantly associated with the chronic and recurrent course of LYP.

CONCLUSION

A longer pre-diagnosis duration is associated with secondary lymphoma, while a lower extremity involvement and the absence of lesional eosinophil infiltration are associated with the chronicity of LYP.

Oral manifestation of lymphomatoid papulosis: systematic review

Introduction: Lymphomatoid Papulosis (LyP) is a lymphoproliferative disorder with typical histopathological criteria and a spontaneous regression. Only few cases of oral involvement have been reported. We wondered about their clinical characteristics and their association with lymphoma. Method: This systematic review is conducted according to the PRISMA statement. The Oxford Centre for Evidence Based Medicine table (OCEBM) and the scoring from the National Agency for Accreditation and Assessment in Health (ANAES) was assigned to each study. Results: We have included 16 references. LyP can occur at any age with a female predilection. Oral lesions were unique ulcer and tongue was mostly affected. Histological types A, and C were dominant and LyP resolved spontaneously. 1 case was associated with a lymphoma. Discussion: Cutaneous LyP more affects men and are mostly classified as type A while those orals are type A or C. Oral LyP is probably a progressive lesion whose evolution is not illustrated by the histological aspect which often reflects only the initial acute period. Conclusion: Our literature review has shown that the epidemiological aspects between oral and cutaneous LyP are not the same. LyP may be associated with an increased risk of developing systemic lymphoproliferative disorders.

Primary cutaneous T-cell lymphomas in childhood and adolescence

Primary cutaneous lymphomas are extranodal non-Hodgkin lymphomas of T- or B- cell origin, that predominantly affect older patients but have been reported in all age groups and as early as in the first years of life. Diagnosis of cutaneous lymphomas is challenging and requires high clinical suspicion and close collaboration between dermatologists, pediatric oncologists and pathologists. Skin involvement of non-Hodgkin lymphomas in children or adolescents can either be primary cutaneous or secondary due to an underlying nodal lymphoma. The most common primary cutaneous lymphomas encountered in children are of T-cell origin, with mycosis fungoides being the most prevalent cutaneous T-cell lymphoma, followed by CD30⁺ lymphoproliferative disorders. While cutaneous lymphomas share clinicopathologic characteristics between juvenile and adult forms, there are important differences in terms of clinical presentation, diagnosis and treatment. The hypopigmented variant of mycosis fungoides seems to be overrepresented in the pediatric age group. Prognosis and treatment of mycosis fungoides are stage dependent. The majority of children present with early-stage disease and respond well to topical corticosteroids and phototherapy.

Primary cutaneous T-cell lymphomas other than Mycosis Fungoides and Sezary Syndrome - Part I: Clinical and histologic features and diagnosis

Primary cutaneous T-cell lymphomas (CTCLs) are defined as lymphomas with a T-cell phenotype that present in the skin without evidence of systemic or extracutaneous disease at initial presentation. CTCLs other than Mycosis Fungoides (MF) and Sézary syndrome (SS) account for approximately one-third of CTCLs and encompass a heterogenous group of non-Hodgkin lymphomas ranging from indolent lymphoproliferative disorders to aggressive malignancies with a poor prognosis. The spectrum of CTCLs continues to broaden as new provisional entities are classified. Given the morphologic and histologic overlap among CTCLs and other diagnoses, a thorough clinical history, physical evaluation, and clinicopathologic correlation are essential in the workup and diagnosis of these rare entities. This article will summarize the epidemiologic, clinical, pathologic, and diagnostic features of CTCLs other than MF and SS.

Primär kutane T‐Zell‐Lymphome im Kindes‐ und Jugendalter

Primär kutane Lymphome sind extranodale T- oder B-Zell-Non-Hodgkin-Lymphome, die vorwiegend ältere Patienten betreffen, aber in allen Altersgruppen einschließlich der ersten Lebensjahre auftreten können. Die Diagnose kutaner Lymphome ist eine Herausforderung und erfordert einen hohen klinischen Verdacht sowie enge Zusammenarbeit zwischen Dermatologen, pädiatrischen Onkologen und Pathologen. Generell müssen primär kutane Lymphome von sekundär kutanen Lymphomen, welche meist von nodalen oder extranodalen Lymphomen ausgehen, unterschieden werden. Die häufigsten primär kutanen Lymphome im Kindesalter sind T-Zell Lymphome, wobei Mycosis fungoides das häufigste kutane T-Zell-Lymphom darstellt, gefolgt von CD30+ lymphoproliferativen Erkrankungen. Während klinisch-pathologische Merkmale kutaner Lymphome bei Jugendlichen und Erwachsenen ähnlich sind, gibt es wichtige Unterschiede bezüglich klinischer Präsentation, Diagnose und Behandlung. Die hypopigmentierte Variante der Mycosis fungoides scheint in der pädiatrischen Altersgruppe überrepräsentiert zu sein. Prognose und Behandlung der Mycosis fungoides sind stadienabhängig. Die Mehrheit der Kinder weist ein frühes Krankheitsstadium auf und spricht gut auf topische Kortikosteroide und Phototherapie an.

A case of lymphomatoid papulosis type E in a young adult: An uncommon entity

Lymphomatoid papulosis (LyP) type E is a rare variant of the primary cutaneous CD30+ lymphoproliferative disorders, characterized clinically by large necrotic eschar-like lesions and histopathologically by angiodestructive and angioinvasive infiltrates of CD30+ lymphocytes. As in other forms of lymphomatoid papulosis, type E lesions may undergo spontaneous regression after weeks, with frequent recurrences. We report a 21-year old male with an angiodestructive infiltrate of CD30+ lymphocytes manifesting as a papular eruption rather than ulceration, and suggest that this clinical phenotype might be related to the presence of CD4+ lymphocytes in the inflammatory cell infiltrate.

Evaluation of Associated Lymphomas and Their Risk Factors in Patients with Lymphomatoid Papulosis: A Retrospective Single-Center Study from Turkey

Objective:

Lymphomatoid papulosis (LyP) is an indolent skin disease with variable clinical features classified among the primary cutaneous CD30+ T-cell lymphoproliferative disorders. It may show association with cutaneous and systemic lymphomas. We aimed to identify the frequency and characteristics of associated lymphomas among Turkish patients with LyP and to determine the risk factors for secondary lymphomas.

Materials and Methods:

The files of patients diagnosed with LyP between 1998 and 2018 in a tertiary dermatology clinic were retrospectively analyzed. Univariate and multivariate models were used to assess the possible risk factors for secondary lymphomas, such as demographic and clinical characteristics of the patients.

Results:

Among 61 patients (47 adults, 14 children) with LyP, a total of 22 secondary lymphomas were observed in 20 patients. Nineteen of them were adults. Mycosis fungoides (MF) was the major associated lymphoma (n=19) followed by systemic anaplastic large cell lymphoma (ALCL) (n=2) and primary cutaneous ALCL (n=1). The most common stage in patients with accompanying MF was stage IB (n=11). While 18 patients showed the classical type of MF, one patient had folliculotropic MF. When the risk factors for association between LyP and other lymphomas were evaluated, only older age was found to be a significant risk factor and existence of ulcerated lesions was found to be a negative indicator.

Conclusion:

LyP is not rare in the pediatric population. MF is the most common associated lymphoma in patients with LyP. Adult LyP patients are more commonly associated with secondary lymphomas than pediatric patients. Older age at the time of diagnosis of LyP is a significant risk factor for associated lymphomas.

Outlines of the Japanese guidelines for the management of primary cutaneous lymphomas 2020

Since the publication of the Japanese "Guidelines for the management of cutaneous lymphomas" in 2011, the World Health Organization (WHO) classification of hematolymphoid neoplasms and the WHO-European Organisation for Research and Treatment of Cancer classification for primary cutaneous lymphomas were updated and a number of novel systemic drugs for cutaneous T-cell lymphoma had been approved in Japan. In 2020, we revised the Japanese guidelines for the management of cutaneous lymphomas with consideration of the recent advances in the understanding of the pathophysiology and classification of cutaneous lymphomas together with the update of treatment strategies reflecting the advent of novel drugs. In addition to a brief explanation of epidemiology, diagnosis, staging system, prognosis and management of each subtype of cutaneous lymphomas, the recommendations for nine clinical questions regarding treatment options that can vary even among experts are also described. A systematic review process and determination of recommendations in answer to each clinical question have been performed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation scheme by a multidisciplinary expert panel consisting of dermatologists, a hematologist and a radiation oncologist. In this article, we present the outlines of the revised Japanese "Guidelines for the management of cutaneous lymphomas".

A case of pediatric lymphomatoid papulosis treated with photodynamic therapy and narrowband ultraviolet B

We report a case of a 13-year-old boy with extensive lymphomatoid papulosis (LyP) involving his elbows, forearms, proximal thighs, and right hip, with treatment-resistant nodules on his right forearm. He was treated with full-body narrowband ultraviolet B and targeted photodynamic therapy (PDT) with 20% aminolevulinic acid (ALA). After two months, there was complete resolution of the right forearm nodules. Due to its minimal toxicity, PDT offers unique advantages and may be considered for pediatric LyP patients with symptomatic, localized disease resistant to conventional treatments.

Lymphomatoid papulosis in children and adolescents: A clinical and histopathologic retrospective cohort

BACKGROUND, AIMS AND OBJECTIVES

Lymphomatoid papulosis (LyP) is a CD30+ lymphoproliferative disorder that is rare and not well described within the pediatric subpopulation. We sought to review the literature and characterize clinical and pathologic features among pediatric and adolescent patients diagnosed with LyP at a tertiary care center.

MATERIALS AND METHODS

A retrospective cohort of 27 pediatric and adolescent patients (defined as <20 years old) diagnosed with LyP at the Weill Cornell Medicine Dermatopathology division from 2006 to 2016 was identified. Subsequently, we reviewed the histopathologic characteristics and collected clinical follow-up data from patients and their providers. The parameters assessed included the pathological LyP subtype including the immunohistochemical staining pattern, the development of secondary lymphoma, disease duration and rate of remission.

RESULTS

While type A was the most prevalent subtype, B and C subtypes were also frequently observed. CD8 predominance was a common finding, especially among type B LyP patients and those with eccrinotropic granulomatous features. None of the patients with clinical follow-up have developed secondary lymphoma, and some patients experienced remission of their disease.

CONCLUSION

While type A appears to be the dominant variant described in children, types B, C, and even the newly described variants E and F may occur more often than previously reported. Pediatric LyP may be more indolent than the adult variant, but close clinical follow-up is still warranted.

Frequency and prognosis of associated malignancies in 504 patients with lymphomatoid papulosis

Background

Lymphomatoid papulosis (LyP) can be associated with other haematological malignancies (HM), but reported percentages vary from 20% to over 50%.

Objective

To evaluate the frequency and prognostic significance of associated HM and non‐HM in LyP patients.

Methods

In this multicentre cohort study, the complete Dutch LyP population was included from the Dutch Cutaneous Lymphoma Registry between 1985 and 2018. Clinical and histopathological information was retrieved from every individual patient.

Results

After a median follow‐up of 120 months (range, 6–585), an associated HM was observed in 78/504 (15.5%) patients. Most common associated HM were mycosis fungoides (MF; n = 31) and anaplastic large‐cell lymphoma (ALCL; n = 29), while 19 patients had another HM of B‐cell (n = 14) or myeloid origin (n = 5). Even after a 25‐year follow‐up period, percentages of associated HM did not exceed 20%. Thirty‐nine of 465 patients (8.4%) without a prior or concurrent associated HM developed an associated HM during follow‐up, after a median of 68 months (range of 3–286 months). Nine of 78 patients died of associated HM, including 6/22 patients developing extracutaneous ALCL, while all patients with associated MF or skin‐limited ALCL had an excellent prognosis. Compared with the general population, LyP patients showed an increased risk (relative risk, 2.8; 95% confidence intervals, 2.4–3.3) for non‐HM, in particular cutaneous squamous cell carcinoma, melanoma and intestinal/lung/bladder cancer.

Conclusions

An associated HM was reported in 15.5% of the LyP patients, particularly MF and ALCL. Although the frequency of associated HM is lower than suggested and the prognosis of most patients with associated HM is excellent, a small subgroup will develop aggressive disease, in particular extracutaneous ALCL. Furthermore, LyP patients have a higher risk of developing other malignancies. Clinicians should be aware of these risks, and LyP patients require close monitoring.

Linked article: F. Rongioletti. J Eur Acad Dermatol Venereol 2020; 34: 216–217. https://doi.org/10.1111/jdv.16157.

Lymphomatoid papulosis: an update and review

Lymphomatoid papulosis (LyP) is a benign chronic often relapsing skin condition that belongs to the CD30-positive cutaneous lymphoproliferative disorders. LyP typically presents as crops of lesions with a tendency to self-resolve, and morphology can range from solitary to agminated or diffuse papules and plaques to nodules or tumours. The clinical-histological spectrum can range from borderline cases to overlap with primary cutaneous anaplastic cell lymphoma (pcALCL). Histology and immunophenotype commonly show overlap with other CD30-positive disorders and sometimes may be identical to pcALCL, making its diagnosis more difficult. Patients with LyP have an increased risk of developing a second neoplasm such as mycosis fungoides, pcALCL and/or Hodgkin lymphoma. Clinical correlation allows its proper classification and diagnosis, which is fundamental for treatment and prognosis. This review focuses on the clinical appearance, histopathological features, diagnosis, differential diagnosis and management of LyP.

ALK-negative anaplastic large cell lymphoma arising in the thrombus of an aortic prosthesis preceeded by clonally related lymphomatoid papulosis

We report on a 73-year-old male patient with recurrent thrombosis of his infrarenal aortic prosthesis. Histologically, the thrombus contained cells of an ALK-negative anaplastic large cell T cell lymphoma (ALCL). Imaging studies were negative for other lymphoma manifestations; however, 3 months before, the patient had developed skin lesions consistent with lymphomatoid papulosis type A (LypA) which were clonally related to the ALCL. Due to recurrent thrombosis of larger peripheral arteries with the presence of ALCL cells in the thrombi, the patient is now referred to systemic chemotherapy. We present the first case of ALCL manifesting in the thrombus of an aortic prosthesis. This case shows similarities to the well-established entity of breast implant-associated ALCL and anecdotal reports of ALCL occurring at the site of foreign material implants. These cells show a peculiar propensity to aggregate in vessels and thrombi, known primarily from subtypes of diffuse large B cell lymphomas associated with chronic inflammation.

Lymphomatoid papulosis localized to the oral mucosa: case report and literature review

Introduction: Lymphomatoid papulosis is a primary CD 30+ cutaneous lymphoproliferation. Observation: We report the case of a 39-year-old patient who presented with ulcers on the back of the tongue, gums, buccal mucosa, and soft palate, which evolved as spontaneously regressive flare-ups. The diagnosis of inflammatory bowel disease was initially proposed. Several years later, the patient presented an ulcer on the left middle finger. Histological examination confirmed the diagnosis of lymphomatoid papulosis. Discussion: This chronic dermatosis manifests a single rash or multiple papulonodular rashes, evolving as spontaneously regressive flare-ups. Mucosal involvement is rare, and no prognostic factor for this location has been highlighted to this date. Pathological examination is essential. Conclusion: The mucosal involvement of lymphomatoid papulosis is one of the diagnoses to be considered for recurrent mouth ulcers.

Primary Pediatric Cutaneous T-Cell Lymphoproliferative Disorders: 3 New Cases

Primary cutaneous lymphoproliferative disorders are a composite group of diseases with considerable differences in histopathologic, immunophenotypic, and clinical features. They are exceedingly rare in children and in the literature only few cases are reported with extremely different therapeutic approaches. Because of the rarity of cutaneous lymphomas we consider crucial to increase the knowledge of these diseases providing every single case. We present 3 pediatric cases of primary cutaneous T-cell lymphomas occurred to our center with different features and therapeutic approach.

An uncommon diagnosis for a recurrent erythematous patch in a paediatric patient

A 14-year-old girl presented with a circular erythematous patch over the left buttock for approximately 10 years, with ongoing ulceration and papules developing over the last 4 years. Punch biopsies were taken within and above the patch for diagnosis. Both revealed marked inflammatory infiltrates with atypical, irregular lymphocytes and increased mitosis. Immunostaining revealed CD8 positivity and a pan T helper cell phenotype. T cell receptor gene rearrangement analysis showed T cell clonality in both biopsies. These findings were consistent with mycosisfungoides and associated lymphomatoid papulosis. Both are rare conditions but have been associated in 5%-20% of cases. A definitive association has not yet been established; however, T cell monoclonality shows 50%-60% share a common origin. Management options are extensive with no one treatment showing superiority. Our patient received low-dose radiotherapy with good outcomes, but subsequently required further radiotherapy.

T-cell Lymphoma Epidemiology: the Known and Unknown

T-cell lymphoma, a collection of subtypes of Non-Hodgkin lymphoma, is a rare malignancy. The low prevalence of this disease has made it challenging to identify subtype-specific risk factors. Potential risk factors could enable us to identify high-risk patients and predict patient outcomes. Here, we report on the current epidemiologic and prognostic factors data associated with the individual subtypes both of peripheral T-cell lymphoma (PTCL) and cutaneous T-cell lymphoma (CTCL) found in large cohort and case studies. Additionally, with recent findings, as well as updates in the new World Health Organization (WHO) classification of lymphoid neoplasms, we consider what this could do to change our approach to this group of diseases.

Associated Hematolymphoid Malignancies in Patients With Lymphomatoid Papulosis: A Canadian Retrospective Study

BACKGROUND

Lymphomatoid papulosis is one of the primary cutaneous CD30+ T-cell lymphoproliferative disorders. Although considered a benign disease, lymphomatoid papulosis has been associated potentially with an increased risk of secondary hematolymphoid malignancies.

OBJECTIVE

The aim of this study was to assess the clinical characteristics and histologic subtypes of lymphomatoid papulosis, identify the prevalence and types of secondary hematolymphoid malignancies, and determine the potential risk factors for development of these hematolymphoid malignancies.

METHODS AND MATERIALS

A retrospective chart review was performed for all histologically confirmed cases of lymphomatoid papulosis between 1991 and 2016.

RESULTS

Seventy patients with lymphomatoid papulosis were identified. Thirty patients (43%) experienced a secondary hematolymphoid malignancy. Twenty-four (80%) of the hematolymphoid malignancies occurred after the onset of lymphomatoid papulosis. Older age at diagnosis of lymphomatoid papulosis, male sex, histology type B, and the presence of T-cell receptor gene rearrangement are associated with higher risk of developing hematolymphoid malignancy.

CONCLUSION

Lymphomatoid papulosis is associated with increased risk of developing secondary hematolymphoid malignancies, particularly mycosis fungoides and cutaneous anaplastic large cell lymphoma.

CD30+ Lymphoproliferative Disorders of the Skin

Primary cutaneous CD30⁺ lymphoproliferative disorders encompass lymphomatoid papulosis (LyP), primary cutaneous anaplastic large cell lymphoma (pcALCL), and indeterminate cases. LyP is a benign disorder characterized by recurrent crops of red or violaceous papulonodules. Patients with LyP are at an increased risk of a secondary malignancy. pcALCL is characterized by a solitary red to violaceous nodule or tumor larger than 20 mm. LyP is benign, is limited to the skin, and self-resolves, with a 5-year survival rate of 100%; pcALCL is limited to the skin and responsive to directed therapies, with a 5-year survival rate of over 95%. Aggressive chemotherapeutic regimens should be avoided.

Biological and clinical significance of tryptophan-catabolizing enzymes in cutaneous T-cell lymphomas

Indoleamine 2,3-deoxygenase 1 (IDO1) induces immune tolerance in the tumor microenvironment (TME) and is recognized as a potential therapeutic target. We studied the expression of both IDO1 and the related tryptophan 2,3-dioxygenase (TDO) in several different subtypes of cutaneous T-cell lymphoma (CTCL), and evaluated the kynurenine (KYN) pathway in the local TME and in patient sera. Specimens from the total of 90 CTCL patients, including mycosis fungoides (MF, n = 37), lymphomatoid papulosis (LyP, n = 36), primary cutaneous anaplastic large cell lymphoma (pcALCL, n = 4), subcutaneous panniculitis-like T-cell lymphoma (SPTCL n = 13), and 10 patients with inflammatory lichen ruber planus (LRP), were analyzed by immunohistochemistry (IHC), immunofluorescence (IF), quantitative PCR, and/or liquid chromatography-tandem mass spectrometry (LC-MS/MS). Three CTCL cell lines also were studied. Expression of both IDO1 and TDO was upregulated in CTCL. In MF specimens and in the MF cell line MyLa2000, IDO1 expression exceeded that of TDO, whereas the opposite was true for LyP, ALCL, and corresponding Mac1/2A cell lines. The spectrum of IDO1-expressing cell types differed among CTCL subtypes and was reflected in the clinical behavior. In MF, SPTCL, and LyP, IDO1 was expressed by malignant cells and by CD33⁺ myeloid-derived suppressor cells, whereas in SPTCL CD163⁺ tumor-associated macrophages also expressed IDO1. Significantly elevated serum KYN/Trp ratios were found in patients with advanced stages of MF. Epacadostat, an IDO1 inhibitor, induced a clear decrease in KYN concentration in cell culture. These results show the importance of IDO1/TDO-induced immunosuppression in CTCL and emphasize its role as a new therapeutic target.

Acquired Bilateral Dyspigmentation on Face and Neck: Clinically Appropriate Approaches

Facial dyspigmentation in Asian women often poses diagnostic and therapeutic challenges. Recently, a distinctive bilateral hyperpigmentation of face and neck has occasionally been observed. This study was performed to investigate the clinico-pathological features of this dyspigmentation as well as proper treatment approaches. We retrospectively investigated the medical records including photographs, routine laboratory tests, histopathologic studies of both lesional and peri-lesional normal skin and patch test of thirty-one patients presented acquired bizarre hyperpigmentation on face and neck. The mean age of patients was 52.3 years and the mean duration of dyspigmentation was 24.2 months. In histologic evaluations of lesional skin, a significantly increased liquefactive degeneration of basal layer, pigmentary incontinence and lymphocytic infiltration were noted, whereas epidermal melanin or solar elastosis showed no statistical differences. Among 19 patients managed with a step-by-step approach, seven improved with using only topical anti-inflammatory agents and moisturizer, and 12 patients gained clinical benefit after laser therapy without clinical aggravation. Both clinical and histopathologic findings of the cases suggest a distinctive acquired hyperpigmentary disorder related with subclinical inflammation. Proper step-by-step evaluation and management of underlying subclinical inflammation would provide clinical benefit.

A new era for cutaneous CD30-positive T-cell lymphoproliferative disorders

Cutaneous CD30+ T-cell lymphoproliferative disorders (CD30+ T-LPD) represent a spectrum encompassing lymphomatoid papulosis (LyP), primary cutaneous anaplastic large-cell lymphoma (pcALCL) and borderline lesions. They share the expression of CD30 as a common phenotypic marker. They differ however in their clinical presentation, the histological features and clinical course. Moreover, LyP and PcALCL show numerous clinical, histological and phenotypic variants. Overlapping features of LyP and pcALCL with themselves and with other cutaneous and systemic lymphomas emphasize the importance of careful clinicopathologic correlation and staging in the diagnosis of CD30+ T-LPD. Furthermore, an increasing number of inflammatory and infectious skin disorders harboring medium-sized to large CD30+ cells have to be considered in the differential diagnosis. Whereas the expression of CD30 in cutaneous CD30+ T-LPD stands for a favourable prognosis, its expression in other cutaneous and systemic lymphomas has a divergent impact. The assessment of CD30 expression does not only provide prognostic information, but is of potential therapeutic relevance as CD30 can serve as a therapeutic target. This review focuses on the clinicopathological and phenotypic spectrum of CD30+ T-LPD, its differential diagnoses and the role of CD30 as a diagnostic, prognostic and therapeutic marker.

Lymphomatoid Papulosis in Children and Adolescents: A Systematic Review

BACKGROUND

Lymphomatoid papulosis (LyP) is a lymphoproliferative disorder that is rare among adults and even rarer among children. In adults, LyP is associated with an increased risk of secondary lymphomas.

OBJECTIVE

The aim of this systematic review was to describe the clinical and histopathological features of LyP in children, to assess the risk of associated lymphomas, and to compare the disease to the adult form.

METHODS

A systematic review was conducted using the MEDLINE (PubMed), EMBASE, Scopus, and Cochrane databases from inception to June 2015. Articles were included if data were extractable from studies, case series, and single reports of pediatric LyP patients.

RESULTS

A total of 251 children and adolescents with LyP were identified, with the mean age at diagnosis being 9.3 ± 4.6 years (n = 187). The female to male ratio was 1:1.4, and the majority of children reported on were Caucasian (n = 74, 85.1 %). The predominant histologic subtype was type A (n = 106, 79.1 %). Clinically, LyP lesions presented as erythematous papules or nodules, appearing preferentially on the extremities and the trunk. LyP has to be differentiated from pityriasis lichenoides (PL) and primary cutaneous anaplastic large cell lymphoma (ALCL). PL and associated lymphomas were diagnosed before, with, and after LyP in 19 and 14 cases, respectively. Of the 14 subjects with associated lymphomas, two children developed systemic ALCL.

CONCLUSION

LyP has to be differentiated from ALCL to avoid erroneous treatments. Due to the increased risk of development of non-Hodgkin lymphomas, lifelong follow-up and proper patient counseling are warranted.

A Primary Cutaneous CD30-Positive T-Cell Lymphoproliferative Disorder Arising in a Patient With Multiple Myeloma and Cutaneous Amyloidosis

CD30-positive cutaneous lymphoproliferative disorders, a group of T-cell neoplasms, including lymphomatoid papulosis (LyP) and cutaneous anaplastic large cell lymphoma, require careful clinicopathologic correlation for diagnosis. An association between LyP and the development of a second hematolymphoid malignancy has been established in the literature. LyP has also been reported with systemic amyloidosis, but no such reports have documented coexisting cutaneous amyloid deposition with LyP to our knowledge. A 66-year-old woman with cutaneous amyloidosis, secondary to multiple myeloma, in remission, presented with erythematous and dark-brown papules involving the right arm, scalp, and torso. Punch biopsy of the arm showed a dermal infiltrate of intermediate-sized lymphocytes, some of which displayed a plasmacytoid morphology and prominent nodular subepidermal amyloid deposition. Punch biopsy of the scalp similarly showed a nonepidermotropic dense dermal infiltrate of intermediate-sized plasmacytoid lymphocytes and multifocal amyloid deposition. Both infiltrates were immunophenotypically CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoproliferative processes. Subsequent studies showed no systemic involvement, and clinical correlation suggested a final diagnosis of LyP. We present this case of LyP, which histologically mimics a B-cell proliferation with a plasmacytoid morphology arising in association with cutaneous amyloidosis to highlight the importance of clinicopathologic correlation, a thorough battery of immunohistochemical studies, and consideration for a second hematologic malignancy arising in the setting of LyP.

Frequency and Risk Factors for Associated Lymphomas in Patients With Lymphomatoid Papulosis

BACKGROUND

Lymphomatoid papulosis (LyP) is classified as an indolent cutaneous lymphoma, but outcome dramatically worsens if LyP is associated with lymphoma. The frequency of this association remains unclear in the literature. Here, we assess the frequency and risk factors of association between LyP and another lymphoma in an 11-year retrospective study conducted in 8 dermatology departments belonging to the French Study Group on Cutaneous Lymphoma (FSGCL).

PATIENTS AND METHODS

Patients with LyP were identified and data extracted from the FSGCL registry between 1991 and 2006. Patients were followed up to January 2014. Age, sex, number of skin lesions, histologic subtype, and genotype were recorded at baseline. Risk factors were determined using univariate and multivariate analysis. Cumulative probability of association was calculated using the Kaplan-Meier method.

RESULTS

We observed 52 cases of lymphomas (cutaneous, n = 38; systemic, n = 14) in 44 of 106 patients (41%). Lymphoma diagnosis was concomitant with or prior to LyP diagnosis in 31 cases and occurred during the course of LyP in 21 cases (cutaneous, n = 14; systemic, n = 7; median delay: 5 years; interquartile range: 1.5-7 years). In multivariate analysis, main prognostic factors for association between LyP and another lymphoma were older age (odds ratio [OR]: 1.05 per year; 95% confidence interval [CI]: 1.01-1.08; p = .011) and presence of a T-cell clone in LyP lesions (OR: 7.55; 95% CI: 2.18-26.18; p = .001).

CONCLUSION

Older age and presence of a T-cell clone in LyP lesions are risk factors for associated lymphomas in patients with LyP. These findings should help to identify patients who require close management in clinical practice.

IMPLICATIONS FOR PRACTICE

The management of lymphomatoid papulosis (LyP) is that of an indolent cutaneous lymphoma, based on its excellent prognosis. However, this good prognosis is altered if LyP is associated with lymphoma. Furthermore, risk factors for and frequency of this association remain unclear in the literature. The results presented here demonstrate a high rate of association between LyP and other lymphomas (41%) as well as a long median delay of occurrence (5 years), which emphasizes the need for prolonged follow-up of patients with LyP. Moreover, two main risk factors (i.e., older age and presence of a T-cell clone in LyP lesions) are highlighted, which should help clinical practitioners to identify patients who require close management.

Contribution of longitudinal follow up and clinical pathological correlation in the diagnosis CD30-positive skin infiltrates

The diagnosis of a CD30+ cutaneous infiltrate is often difficult and requires clinicopathologic correlation. To further evaluate this challenge, initial clinical and histopathologic diagnoses were correlated with final clinicopathologic diagnosis in 44 cases with CD30 immunopositivity. Dermatopathologic evaluation confirmed the initial clinical diagnosis in 65% of the suspected benign cases, all cases of suspected lymphomatoid papulosis (LyP), and 72% of clinically malignant cases. In the 25 patients with clinical suspicion for lymphoma, the histopathologic diagnoses included lymphoma in 18, LyP in 2, CD30+ lymphoproliferative disorder (CD30 LPD) in 3 and hypersensitivity reaction in 2 patients. Clinicopathologic correlation led to a change in three cases diagnosed histopathologically as anaplastic large cell lymphoma (ALCL) reclassified as LyP type C, and one patient diagnosed as CD30 LPD clinically evolved as herpes virus infection. Furthermore, five cases reported as CD30 LPD received more specific diagnoses after clinicopathologic correlation (LyP type C in three, and ALCL in two patients). Clinicopathologic correlation is essential in establishing the correct diagnosis of CD30 LPD, in particular the distinction of ALCL from LyP type C. In this setting, the histopathologic diagnosis of CD30 LPD is advisable in the absence of clinical data.

[Mucosal lymphomatoid papulosis: 2 cases]

BACKGROUND

Lymphomatoid Papulosis (LP) is a chronic dermatosis progressing by flare-up. According to the WHO-EORTC classification, LP is a form of CD30+ primitive cutaneous lympho-proliferation. Mucosal lesions are rare, with 15 published cases. We report two new cases of oral localizations, without any cutaneous involvement.

PATIENTS AND METHODS

Two women, 32 and 63 years old, presented with an isolated painful oral ulceration, of the maxillary tuberosity and of the inner side of the cheek respectively. The general state of health was preserved. Immunohistochimical analysis of the biopsies showed two Type A LPs. Lesions spontaneously resolved.

DISCUSSION

Among the rare published cases, oral localization involved exclusively the tongue and the labial mucosa and almost all patients presented with previous cutaneous lesions. Isolated maxillary tuberosity or cheek involvements were not described yet.

A unique case of concurrent chronic lymphocytic leukemia/small lymphocytic lymphoma and lymphomatoid papulosis in the same biopsy

Chronic lymphocytic leukemia (CLL/SLL) is the most common leukemia in the western world and its cutaneous dissemination a very uncommon phenomenon. Lymphomatoid papulosis (LyP) is a CD30+ lymphoproliferative disorder characterized by chronic, recurrent and self healing skin lesions. Up to 20% of patients with LyP have a coexistent lymphoma. While the association between the two entities has been reported, their coexistence has never been documented. We describe a 74-year-old man with known CLL and thrombocytopenia who presented with a 2 year history of recurrent nodules and plaques to both arms and legs that resolved within 4-6 weeks after administration of rituximab and bendamustin for his CLL treatment. His biopsies showed an atypical lymphoid infiltrate, composed of large and pleomorphic cells with a nodular and interstitial pattern in a background of eosinophils. Immunohistochemical staining revealed a pattern of two separate yet coexisting neoplastic processes; a large CD30 positive T-cell lymphoproliferative disorder, while the other one was diagnostic of a neoplastic B-cell process (leukemia cutis). A diagnosis of coexistent LyP and cutaneous involvement by CLL/SLL was rendered. The simultaneous presence of both disorders can be a pitfall in the differential diagnosis of large cell lymphomas, such as Richter's transformation of CLL/SLL.