Long-term efficacy, curative potential, and prognostic factors of radiotherapy in primary cutaneous B-cell lymphoma

Advanced stage cutaneous T-cell lymphoma treated with high-dose external beam radiation therapy: A case report

INTRODUCTION

The treatment for advanced-stage or refractory cutaneous T-cell lymphoma (CTCL) is largely palliative. Due to the rarity of the disease, there are few randomized controlled trials and large-scale prospective studies. Therefore, the treatment of advanced-stage CTCL remains challenging.

PATIENT CONCERNS AND DIAGNOSIS

A 64-years-old man who had received narrowband UVB phototherapy for several years presented with a generalized rash with widespread polycyclic erosions and painful ulcers on his hands and feet. We restaged him as stage III CTCL.

INTERVENTIONS AND OUTCOMES

He was treated with high-dose radiation for curative purposes and 3-dimensional conformal radiation therapy to both hands and feet. At the 2-year follow-up after the end of radiotherapy, the irradiated skin had recovered to normal soft, smooth skin with localized fibrosis and hypopigmented skin. He reported an excellent quality of life, and his hands and feet were free to move.

CONCLUSION

CTCL at an advanced stage could require dose escalation with local radiotherapy for curative purposes. High-dose 3-dementional conformal radiation therapy could be effective and has tolerable toxicities.

Radiotherapie kutaner Lymphome

Hintergrund

Primär kutane Lymphome (KL) sind sehr strahlenempfindlich. Deshalb ist die Strahlentherapie ein integraler Bestandteil der multimodalen Behandlung.

Ziel der Arbeit

Die vorliegende Arbeit ermöglicht einen Überblick über Indikationen, Entwicklungen der Techniken und Dosiskonzepte der Ganzhautelektronenbestrahlung (TSEBT), der lokalen Radiatio sowie Erhaltungstherapien und aktuelle Kombinationsstudien kutaner T‑ und B‑Zell-Lymphome.

Material und Methoden

Es erfolgte eine selektive Literaturrecherche über die Datenbank PubMed zur Radiotherapie der KL, eine Recherche aktueller Studien mittels clinicaltrials.gov, Darstellung interner Behandlungsstrategien sowie Zusammenfassung der nationalen und internationalen Leitlinien.

Ergebnisse

Die Niedrigdosis-TSEBT wird als Alternative zur konventionellen 36-Gy-TSEBT national und international empfohlen. Die wichtigsten Vorteile sind die bessere Verträglichkeit, die Möglichkeit der Wiederholung, ein verkürzter Verlauf (ca. 3 Wochen) und eine kurze Dauer bis zum Ansprechen. In den aktuellen Studien wird die TSEBT in der Regel mit 12 Gy durchgeführt und mit unterschiedlichen Immuntherapeutika und epigenetischen Regulatoren kombiniert. Die lokale Radiatio ist indiziert bei Tumoren der Mycosis fungoides und ein kuratives Behandlungsschema für andere KL, insbesondere bei primär kutanen B‑Zell-Lymphomen.

Diskussion

Die TSEBT ist eine sehr effektive Behandlungsoption der Mycosis fungoides (MF) und bietet einen wichtigen palliativen Nutzen, da sie zügig zur Symptomlinderung und Verbesserung der Lebensqualität führt. Sie ist eine wichtige Behandlungsoption, insbesondere bei Patienten mit ausgeprägten generalisierten Plaques oder im Tumorstadium. Die lokale Radiatio wird im Rahmen der TSEBT für Tumoren und Aufsättigung unterversorgter Areale eingesetzt. Andere KL sind primär kurativ mit einer lokalen Radiatio behandelbar.

High-dose-rate brachytherapy of primary cutaneous B-cell lymphoma: the first reported case series

Purpose

Cutaneous B-cell lymphomas (CBCLs) are a rare group of diseases. External beam radiation therapy is recommended to treat CBCLs in all subtypes for locally advanced cases. However, there are no reports on high-dose-rate brachytherapy (HDR-BT) exclusively dedicated to CBCLs. The purpose of this paper was to report the first case series of CBCLs treated with HDR-BT.

Material and methods

Seven patients were treated between 2011 and 2019, with 12 skin lesions histopathologically proven as CBCLs. There were four T1a and eight T2a lesions. HDR-BT was prescribed as the first-line treatment for all cases, as the second-line treatment for recurrences after surgical failure for 4 patients, and as an adjuvant treatment for 1 case. The median total dose was 36 Gy (range, 30-40 Gy) in 10 fractions (range, 6-10 fractions), with a median overall treatment time of 11 days (range, 4-11 days). Treatment toxicity was assessed accordingly to the RTOG scale.

Results

The mean follow-up was 41 months. Local control was 100%. The rates of early toxicity were as follows: erythema (G1) - 33%, patchy epidermal desquamation (G2) - 25%, confluent epidermal desquamation (G3) - 25%, and minor bleeding (G4) - 17%. The reported rates of late toxicity included slight depigmentation (G1) - 59%, small telangiectasia (G2) - 8%, massive telangiectasia (G3) - 25%, and small ulceration (G4) in one site irradiated interstitially (8%).

Conclusions

HDR-BT allows for achieving high local control of CBCLs with relatively low-late toxicity in the form of skin discoloration in most patients.

The Safety of Radiotherapy in the Treatment of Primary Cutaneous B-Cell Lymphoma: A Multidisciplinary Systematic Review

Primary cutaneous B-cell lymphomas (PCBCL) are rare types of extranodal non-Hodgkin's lymphoma. The choice of treatment usually depends on the variant of PCBCL, number, size, and location of the lesions, involved body surface area as well as patient's age and health condition. The efficacy of radiotherapy (RT) in the treatment of PCBCL has been widely reported conversely, data about the acute and late skin toxicity, patient's treatment satisfaction and quality of life are scarce. A systematic search using PubMed, Scopus, and Cochrane library was performed to identify full original articles analyzing the safety of RT in patients with PCBCL with the primary outcome to assess the acute and late skin toxicity. Secondary outcomes were complete remission, disease free survival, and overall survival. The literature search resulted in 276 articles including eight studies assessing the safety of RT for the treatment of PCBCL. Most patients (median 73%, range 11.9-99.9%) were recorded as having acute skin toxicity of grade 1-2, while acute grade 3-4 toxicity occurred in a median of 8% (range 4-23%) of patients. A median of 20% (range 4-54%) of patients had late skin toxicity of grade 1-2. No late grade 3-4 toxicity was reported. Only one study evaluated patient's satisfaction showing that the 97% of patients were satisfied with radiation therapy. This systematic review confirms the safety of RT in the treatment of PCBCL. Patients with a PCBCL should be managed in highly specialized centers in the context of a multidisciplinary team including dermatologist, hematologist, pathologist, and radiation oncologist.

De-escalated radiotherapy for indolent primary cutaneous B-cell lymphoma

OBJECTIVE

Radiotherapy (RT) has an established role in the curative treatment of indolent primary cutaneous B‑cell lymphoma (PCBCL). With the role of low-dose regimens such as 2 × 2 Gy being uncertain, we compared conventional-dose RT to a low-dose approach and investigated outcome and toxicities.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 26 patients with 44 cutaneous lesions treated at our institution between 2007 and 2017, comprising 22 marginal zone lymphoma (PCMZL) lesions and 22 follicle center lymphoma (PCFCL) lesions. Seven lesions (16%) were treated with low-dose RT (LDRT) (4 Gy) and 37 (84%) with conventional-dose RT (≥24 Gy, median 40 Gy). Median follow-up duration was 76 months.

RESULTS

The overall response rate (ORR) was 91% (complete response rate [CRR]: 75%). The 5‑year local control rate (LCR) was 88% and the 10-year LCR was 84%. The response rates were significantly higher following conventional-dose RT (ORR: 92% vs. 86%; CRR: 84% vs. 29%; P = 0.007). In terms of radiation dose, the rate of infield relapses (14% vs. 11%, P = 0.4) and the 5‑year LCR (86% vs. 90%, P = 0.4) were comparable in the LDRT and conventional-dose RT groups. During RT courses, about two-thirds of patients experienced mild toxicities, with grade I and II acute toxicity rates of 61% and 9%, respectively, with lower incidences of grade I (14% vs. 70%) and grade II (0% vs. 8%, P = 0.004) toxicities following LDRT.

CONCLUSION

This long-term analysis confirms the excellent outcome of RT in the management of PCBCL. The LDRT concept with 4 Gy was associated with a comparable LCR and reduced rates of acute toxicity. However, the response rates were significantly lower for this group and LDRT may therefore not be recommended as standard treatment.

Outcomes of radiation therapy of indolent cutaneous B-cell lymphomas and literature review

BACKGROUND

Primary cutaneous B-cell lymphomas represent approximately 25% of primary cutaneous lymphomas. Follicular centre cell lymphomas (PCFCL) and marginal zone lymphomas (PCMZL) are the two histological subtypes that present an indolent evolution. Radiotherapy is one of the recommended treatment options with few series reported.

OBJECTIVE

This study aimed to evaluate radiotherapy outcomes in term of overall survival (OS) and disease-free survival (DFS) for patients suffering from a PCMZL or PCFCL, to search for predictive factors of recurrence, and to evaluate chronic and aesthetics adverse events and patient's satisfaction.

METHODS

Patients treated with contact low energy radiotherapy for a PMZCL or PCFCL from April 2009 to June 2017 in Saint Louis hospital were retrospectively analysed. Total dose ranged from 18 to 30 Gy. Objective response (OR) rates, DFS and OS as patterns of recurrence according to radiation fields were analysed. Univariate analysis of DFS has been performed according to clinical and biological parameters. Acute toxicity, long-term adverse events and satisfaction were collected via individualized questionnaires.

RESULTS

Forty-six patients were included. Median follow-up was 43.5 months. OR was achieved for 100% of cases. Recurrence occurred in 39% of cases. Median DFS was 44 months. Three-year DFS and 5-year DFS were 56% and 51%, respectively. OS at 3 and 5 year was 100%. Only sex was significantly associated with DFS. Acute AEs occurred in 48% of cases without grade 3 and 4. 55% reported some moderate aesthetic sequelae for long-term AEs. 97% were satisfied with treatment.

CONCLUSION

This study confirms the good risk-benefit of radiotherapy for the treatment of primary cutaneous indolent B-cell lymphomas due to the high response rate and a long DFS. No significant factor for recurrence was identified, except female sex. Long-term aesthetic evaluation was good or excellent for most of the patients.

[Aggressive primary cutaneous B-cell lymphomas and novel EBV+ entities]

Primary cutaneous large B‑cell lymphomas (PCBLT), EBV-positive large B‑cell lymphomas, not otherwise specified (EBV+ DLBCL, NOS), and primary cutaneous intravascular large B‑cell lymphomas (PCIVLBL) are recognized as cutaneous lymphomas with intermediate to poor prognosis. Differentiation from indolent B‑cell lymphomas or other pathologies of the skin can be complex, both clinically and histologically, but vital for the outcome of the patient. The combination of immunotherapy and polychemotherapy regimens, such as R‑CHOP, has led to significant improvements in prognosis, especially in diffuse large B‑cell lymphomas. Therapeutic decisions need to be individually made for each patient, ideally within an interdisciplinary tumor conference. Immunosenescence may be an important factor in the pathogenesis of EBV+ DLBCL, NOS in elderly individuals. Their prognosis is less favorable than that of patients with EBV-negative PCBLT, whereby this has been observed particularly in elderly patients. One third of patients with PCIVLBL progress to systemic disease. The occurrence of nodal manifestation is rarely observed. Symptoms may vary depending on the organ system involved. Currently there are no evidence-based therapy recommendations due to the rarity of the disease. EBV-positive mucocutaneous ulcer is a new provisional category in the current WHO classification for lymphoid neoplasms. It has been segregated from EBV+ DLBCL, NOS due to its self-limiting course and good response to conservative therapy.

[Treatment of indolent cutaneous B‑cell lymphoma]

Primary cutaneous B‑cell lymphomas are rarely encountered and represent 25% of all cutaneous lymphomas. Follicular B‑cell lymphoma and marginal zone lymphoma belong to indolent subtypes which as a rule have no systemic dissemination and, thus, a mostly unchanged life expectancy. Therefore, skin-directed treatment options such as excision or radiotherapy are usually sufficient to control the disease. In contrast, cutaneous diffuse large B‑cell lymphoma and EBV-associated B‑cell lymphomas of the skin belong to more aggressive entities which demand a systemic first-line upfront therapy with R‑CHOP. Nevertheless, mortality is still high and comparable to that of systemic/nodal large B‑cell lymphomas so that the identification of pathogenetic driver mutations or novel therapeutic targets may pave the way to better target-oriented therapies.

Cutaneous primary B-cell lymphomas: from diagnosis to treatment

Primary cutaneous B-cell lymphomas are a heterogeneous group of mature B-cells neoplasms with tropism for the skin, whose biology and clinical course differ significantly from the equivalent nodal lymphomas. The most indolent forms comprise the primary cutaneous marginal zone and follicle center B-cell lymphomas that despite the excellent prognosis have cutaneous recurrences very commonly. The most aggressive forms include the primary cutaneous large B-cell lymphomas, consisting in two major groups: the leg type, with poor prognosis, and others, the latter representing a heterogeneous group of lymphomas from which specific entities are supposed to be individualized over time, such as intravascular large B-cell lymphomas. Treatment may include surgical excision, radiotherapy, antibiotics, corticosteroids, interferon, monoclonal antibodies and chemotherapy, depending on the type of lymphoma and on the type and location of the skin lesions. In subtypes with good prognosis is contraindicated overtreatment and in those associated with a worse prognosis the recommended therapy relies on CHOP-like regimens associated with rituximab, assisted or not with local radiotherapy. We review the primary cutaneous B-cell lymphomas, remembering the diagnostic criteria, differential diagnosis, classification, and prognostic factors and presenting the available therapies.

Primary cutaneous B-cell lymphoma (non-leg type) has excellent outcomes even after very low dose radiation as single-modality therapy

Primary cutaneous B cell lymphomas (PCBCL) are rare; although data on outcomes and treatment are limited, traditionally they have been treated with radiation doses in excess of 24 Gy. We retrospectively identified and reviewed all cases of PCBCL treated at our institution from 2002-2014. Thirty-nine patients with PCBCL (42 lesions) were identified. Radiation was the only treatment for most patients. All lesions had a complete response and none had in-field failures; seven patients had out-of-field relapses, three of which were salvaged with radiation therapy. No differences in PFS or OS were found for patients given low-dose (≤ 12 Gy) versus high-dose (> 12 Gy) radiation. PCBCL is an indolent entity with a long clinical course and excellent response to radiation therapy and successful salvage of recurrent disease, even when doses are as low as 4 Gy. Given the above findings, we recommend the initial use of low-dose irradiation for PCBCL.

Modern radiation therapy for primary cutaneous lymphomas: field and dose guidelines from the International Lymphoma Radiation Oncology Group

Primary cutaneous lymphomas are a heterogeneous group of diseases. They often remain localized, and they generally have a more indolent course and a better prognosis than lymphomas in other locations. They are highly radiosensitive, and radiation therapy is an important part of the treatment, either as the sole treatment or as part of a multimodality approach. Radiation therapy of primary cutaneous lymphomas requires the use of special techniques that form the focus of these guidelines. The International Lymphoma Radiation Oncology Group has developed these guidelines after multinational meetings and analysis of available evidence. The guidelines represent an agreed consensus view of the International Lymphoma Radiation Oncology Group steering committee on the use of radiation therapy in primary cutaneous lymphomas in the modern era.

Clinical features and treatment outcomes of primary cutaneous B-cell lymphoma: a single-center analysis in South Korea

Clinical features and treatment outcomes of primary cutaneous B-cell lymphoma (PCBCL) have rarely been reviewed, due to the rarity and pathologic obscurity of this disease. We reviewed 21 patients who were pathologically diagnosed with PCBCL from Samsung Medical Center's lymphoma cohort, following the WHO-EORTC classification system: primary cutaneous follicle-center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL, LT), and cutaneous diffuse large B-cell lymphoma, other (PCDLBCL, other). Of 2831 B-cell lymphoma cases, PCBCL comprised only 0.74 % of cases (N = 21, eight PCLBCL, LT (0.28 %), 10 PCMZL (0.35 %), two PCDLBCL, other (0.06 %), and one PCFCL (0.03 %)). Eighteen of 21 patients received treatment for PCBCL (12 chemotherapy alone, three radiotherapy alone, three chemotherapy following radiotherapy) and complete response (CR) was observed in 17 patients. The median progression-free survival was 44 months [95 % confidence interval (CI): 11-61 months]. Two patients had died at the time of analysis, with a median follow-up duration of 85 months [95 % confidence interval (CI): 55-118 months]. PCBCL cases in this study have a higher proportion of disseminated PCMZL and PCLBCL, LT, and excellent outcomes were observed with chemotherapy, including R-CHOP or R-CVP irrespective of staging and pathologic subtype.

Primary cutaneous B-cell lymphoma in Nottinghamshire U.K.: prognosis of subtypes defined in the WHO-EORTC classification

BACKGROUND

Primary cutaneous B-cell lymphomas (PCBCL), with the exception of large B-cell lymphoma of leg type and intravascular large B-cell lymphoma, are associated with an excellent prognosis. These lymphomas have become much better understood in recent years leading to the publication in 2005 of the World Health Organization-European Organisation for Research and Treatment of Cancer classification.

OBJECTIVES

To determine the relative frequency of occurrence of subtypes of PCBCL in a defined population, and the survival of patients with these subtypes.

METHODS

During the period 1987-2009, 61 consecutive patients with PCBCL were identified from the Nottingham Lymphoma Registry (population 1·1 million). After histological review, the number of patients with each subtype was as follows: marginal zone, 18; follicle centre, 14; diffuse large B cell, leg type, 16; diffuse large B cell, other sites, 12; and intravascular large B cell, one.

RESULTS

The 5- and 10-year lymphoma-specific survival for patients with marginal zone lymphoma was 100%. The only patient with intravascular large B-cell lymphoma died from widespread disease in spite of chemotherapy. The 4-year lymphoma-specific survival for follicle centre cell lymphoma was 90%. Patients with the other subtypes had the following 5-year lymphoma-specific survival rates: diffuse large B cell, leg type, 61% and diffuse large B cell, other, 40%. The median age at diagnosis for patients with diffuse large B-cell lymphoma, leg type was 82 years and as a consequence the 5-year overall survival was only 15%. There was a 3·4-fold increase in the incidence of PCBCL from the period 1987-1997 to the period 1998-2009.

CONCLUSIONS

PCBCL is a rare disease (incidence around three per million population per year). It is, in our view, essential that it is diagnosed by a pathologist with an interest in cutaneous lymphoma and that the very different prognosis of the individual subtypes is appreciated by the treating clinician.

The three dimensional conformal radiotherapy for hyperkeratotic plantar mycosis fungoides

The localized early-stage of Mycosis fungoides (MF) (stage IA-IIA) is usually treated with topical agents, such as nitrogen mustard, steroids, and phototherapy (UVB/PUVA) as first line therapy; response to these initial treatments is usually good. However, hyperkeratotic plantar lesions are clinically rare and have decreased responsiveness to topical agents. For such cases, physicians may consider local radiotherapy. Here, a case of an 18-year-old Korean woman who was treated with three-dimensional conformal radiotherapy (3D-CRT) for hyperkeratotic plantar lesions that were refractory to UVA-1, methotrexate, and topical steroids is reported. Complete remission was attained after radiotherapy. During the one-year follow-up period, there has been no evidence of disease recurrence and no chronic complications have been observed.

Primary cutaneous diffuse large B-cell lymphoma, leg-type, treated with a modified R-CHOP immunochemotherapy - diagnostic and therapeutic challenges

BACKGROUND

Primary cutaneous diffuse large B-cell lymphoma (PCLBCL) represents a rare subtype among primary cutaneous B-cell lymphoma exhibiting a characteristic genetic background, an aggressive clinical course and a high relapse rate under different therapeutic regimen. Therefore, PCLBCL has a rather restricted prognosis.

PATIENTS AND METHODS

Four patients with PCLBCL were treated at our institution with age- and toxicity-adapted first-line immunochemotherapy with rituximab and modified CHOP (cyclophosphamid, vincristin, liposomal doxorubicin, prednisolon). On relapse, the same regimen with R-CHOP or different antineoplastic strategies (radiation, polychemotherapy, immunotherapy, stem cell transplantation) were applied. Toxicity, clinical response and overall survival was documented.

RESULTS

Under this regimen, clinical response to modified R-CHOP was achieved in all patients with tolerable toxicity - however, being characterized by a rapid disease progression with inconsistent response towards the subsequent therapeutic armentarium and unsecure impact on overall survival.

CONCLUSIONS

So far, it is still unknown, if an extensive multimodal therapy for PBLBCL improves overall survival. Immunochemotherapy with R-CHOP currently represents the most effective treatment.

Survival and recurrence in nonmycosis fungoides primary cutaneous lymphoma

PURPOSE

To evaluate overall and relapse-free survival (RFS) in patients with nonmycosis fungoides (non-MF) primary cutaneous lymphoma (PCL).

METHODS

Thirty-eight patients with PCL excluding cases of MF treated between 1993 and 2006 were analyzed retrospectively. Survival statistics were estimated by the methods of Kaplan and Meier, and univariate and multivariate significance testing were performed by Cox regression analysis.

RESULTS

The median follow-up was 34.6 months (range, 2-138.3 months). The overall survival for the entire study population, at 5 and 10 years, was 97% and 78%, respectively. The RFS for the entire study population, at 5 and 10 years, was 30% and 22%, respectively. For those who received radiotherapy (RT) as a component of their initial therapy, the RFS at 5 and 10 years was 48% and 36%, respectively. Among those receiving RT who relapsed, the site of relapse was out-of-field in 82% of the cases. In our multivariate analysis, only RT as a component of the initial therapy and the absence of bulky disease had a statistically significant improvement in RFS (P = 0.01 and <0.01, respectively).

CONCLUSION

RT improves the local control and RFS of patients with non-MF PCL.

Low-dose palliative radiotherapy for cutaneous B- and T-cell lymphomas

PURPOSE

To determine the efficacy of low-dose palliative radiotherapy for both low-grade malignant cutaneous B-cell lymphomas (CBCLs) and cutaneous T-cell lymphomas (mycosis fungoides).

METHODS AND MATERIALS

A total of 18 patients with low-grade CBCL (10 primary cutaneous marginal zone B-cell and 8 primary cutaneous follicle center lymphomas) with 44 symptomatic plaques and tumors underwent low-dose (4 Gy in two fractions) local radiotherapy. A total of 31 patients with mycosis fungoides were treated at 82 symptomatic sites, initially with 4 Gy and later with 8 Gy in two fractions.

RESULTS

The complete response rate for CBCL lesions was 72%. Of the 44 B-cell lymphoma lesions, 13 were re-treated to the same site after a median of 6.3 months because of persistent (n = 8) or recurrent (n = 5) symptomatic disease. Of the mycosis fungoides patients treated with 4 Gy in two fractions (17 lesions), 70% failed to respond. Increasing the dose to 8 Gy in two fractions yielded a complete response rate of 92% (60 of 65 lesions). The patients in whom low-dose radiotherapy failed were retreated with 20 Gy in eight fractions.

CONCLUSION

Our results have demonstrated that low-dose involved-field radiotherapy induces a high response rate in both CBCL and cutaneous T-cell lymphoma lesions without any toxicity. Therefore, this treatment is now our standard palliative treatment. At progression, it is safe and feasible to apply greater radiation doses.

European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas

Primary cutaneous B-cell lymphomas (CBCL) represent approximately 20% to 25% of all primary cutaneous lymphomas. With the advent of the World Health Organization-European Organization for Research and Treatment of Cancer (EORTC) Consensus Classification for Cutaneous Lymphomas in 2005, uniform terminology and classification for this rare group of neoplasms were introduced. However, staging procedures and treatment strategies still vary between different cutaneous lymphoma centers, which may be because consensus recommendations for the management of CBCL have never been published. Based on an extensive literature search and discussions within the EORTC Cutaneous Lymphoma Group and the International Society for Cutaneous Lymphomas, the present report aims to provide uniform recommendations for the management of the 3 main groups of CBCL. Because no systematic reviews or (randomized) controlled trials were available, these recommendations are mainly based on retrospective studies and small cohort studies. Despite these limitations, there was consensus among the members of the multidisciplinary expert panel that these recommendations reflect the state-of-the-art management as currently practiced in major cutaneous lymphoma centers. They may therefore contribute to uniform staging and treatment and form the basis for future clinical trials in patients with a CBCL.

Cutaneous Lymphomas

The skin is the most common site of extranodal non-Hodgkin lymphoma, with a yearly incidence approaching 1 per 100,000 individuals in the United States. Skin lymphomas are classified broadly into cutaneous T-cell lymphoma (CTCL) and cutaneous B-cell lymphoma (CBCL). Within these broad categories, multiple unique pathologic entities exist with a wide array of natural histories and treatment options. Radiotherapy plays an important role in the curative treatment of localized CTCL and CBCL and may be used to palliate cutaneous and visceral symptoms associated with advanced disease. This review highlights the role of radiotherapy in the multidisciplinary management of cutaneous lymphoma.

Reclassification of 300 Primary Cutaneous B-Cell Lymphomas According to the New WHO–EORTC Classification for Cutaneous Lymphomas: Comparison With Previous Classifications and Identification of Prognostic Markers

Purpose

In the new WHO–European Organisation for Research and Treatment of Cancer (WHO-EORTC) classification for cutaneous lymphomas three major groups of primary cutaneous B-cell lymphoma (CBCL) are distinguished: primary cutaneous marginal zone B-cell lymphoma (PCMZL) and primary cutaneous follicle center lymphoma (PCFCL) with a good prognosis, and primary cutaneous large B-cell lymphoma, leg type (PCLBCL-LT), with an intermediate-level prognosis. This study aimed to assess the clinical significance of the new classification compared with previous classification schemes (EORTC 1997; WHO 2001) and to define prognostic factors within the newly defined categories.

Patients and Methods

In the present study clinical data and histologic sections of 300 patients with CBCL, formerly classified according to the EORTC classification, were reviewed and reclassified according to the WHO and the new WHO-EORTC classification schemes.

Results

After reclassification, the study comprised 71 patients with PCMZL, 171 patients with PCFCL, and 58 patients with PCLBCL-LT, showing 5-year disease-specific survivals of 98%, 95%, and 50%, respectively. When compared with the EORTC and WHO schemes, 5.3% and 36.3% of patients with CBCL were reclassified into another prognostic category. Multivariate analysis of PCFCL revealed localization on the leg and expression of FOXP1 as independent parameters associated with a poor prognosis. Expression of Bcl-2 or MUM-1 had no significant effect on survival in this group. In PCLBCL-LT, no independent prognostic parameters were found.

Conclusion

These results emphasize the clinical significance of the WHO-EORTC classification, but suggest that within the group of PCFCL, distinction should be made between lymphomas presenting on the legs and lymphomas presenting at other sites.

The Cutaneous B-Cell Lymphoma Prognostic Index: A Novel Prognostic Index Derived From a Population-Based Registry

Purpose

Three classification and prognostic systems exist for primary cutaneous B-cell lymphoma (PCBCL). Whereas the WHO classification defines its categories based on histology, both the European Organisation for Research and Treatment of Cancer classification and the conventional staging system consider skin site. We sought to incorporate both histology and skin site into a single prognostic index designed to predict survival in patients with PCBCL.

Methods

The associations between histology, skin site, and survival were determined using adjusted proportional hazards analysis conducted on 926 patients with PCBCL identified in the Surveillance, Epidemiology, and End Results data, spanning 1973 to 2001.

Results

Four primary CBCL prognostic index (CBCL-PI) groups were identified. Group IA included indolent histologies involving any skin site. Group IB included diffuse large B-cell histology involving favorable skin sites (head/neck, arm). Group II included diffuse large B-cell histology involving unfavorable skin sites (trunk, legs, disseminated) or immunoblastic large B-cell histology involving favorable skin sites. Group III included immunoblastic large B-cell histology involving unfavorable skin sites. The adjusted mortality hazards ratios were 1.0, 1.3 (95% CI, 0.99 to 1.7), 2.1 (95% CI, 1.6 to 2.7), and 4.5 (95% CI, 2.8 to 7.2) for groups IA/B to III, respectively. The corresponding 5-year relative survivals were 94%, 86%, 60%, and 34%.

Conclusion

The CBCL-PI identifies adverse combinations of histology and skin site, helping to reconcile differences in current classification and prognostic systems for PCBCL.

[Large B-cell lymphoma of the lower leg]

Primary cutaneous B cell lymphomas are rare malignant lymphoproliferative disorders of the skin. The prognosis is dependent on the clinical and histologic subtype; generally, these disorders show an indolent clinical course. We describe a 80-year-old woman with a large cutaneous B cell lymphoma of the lower leg. In contrast to other variants of cutaneous B cell lymphomas, this entity is characterized by an aggressive clinical course with an unfavorable prognosis. The mean survival rate is approximately 50%. This should be taken into account in the choice of treatment.

Primary Cutaneous B-Cell Lymphoma Treated With Radiotherapy: A Comparison of the European Organization for Research and Treatment of Cancer and the WHO Classification Systems

Purpose

To determine the relationship between the WHO and European Organization for Research and Treatment of Cancer (EORTC) pathologic classifications for primary cutaneous B-cell lymphoma (CBCL) and the implication of this relationship on initial treatment.

Patients and Methods

Patients with primary CBCL treated with radiotherapy were identified retrospectively. Initial biopsy specimens were reviewed by two dermatopathologists and classified according to the EORTC and WHO systems. Primary outcomes were recurrence-free and overall survival.

Results

Thirty-four patients were identified; initial biopsy specimens were adequate for classification in 32 patients. Four different composite histopathologic subtypes of lymphoma were identified: 53% (17 of 32) follicle center cell by EORTC and diffuse large B-cell by WHO (FCC/DLB), 25% (eight of 32) follicle center cell by EORTC and follicular by WHO (FCC/Fol), 13% (four of 32) marginal zone by EORTC and WHO (MZ/MZ), and 9% (three of 32) large B-cell of the leg by EORTC and diffuse large B-cell by WHO (Leg/DLB). Five-year relapse-free survival ranged from 62% to 73% for FCC/DLB, FCC/Fol, and MZ/MZ but was 33% for Leg/DLB (P = .6). Five-year overall survival was 100% for FCC/DLB, FCC/Fol, and MZ/MZ but was 67% for Leg/DLB (P = .07). At 5 years, 21% of all patients had developed extracutaneous disease.

Conclusion

Two-thirds of primary cutaneous FCC lymphomas by EORTC criteria satisfy WHO criteria for DLB lymphoma. Unlike DLB lymphoma presenting in nodal or noncutaneous sites, these lesions are associated with an indolent course and may be treated with local radiotherapy alone.