Lymphomatoid Papulosis

CD30 in Cutaneous Pathology

ABSTRACT

The discovery of CD30 as a diagnostic marker was essential in the identification of not only some lymphomas but also many other solid tumors and benign reactive conditions. Many CD30+ cutaneous disorders and tumors have been categorized since the identification of the marker. With the design of targeted therapies against CD30+ tumoral cells, the interest in CD30 determination was not only diagnostic but also mainly therapeutic. In this article, we explore the historical aspects of the discovery of CD30 and examine the main CD30-related cutaneous pathology, susceptible of anti-CD30 modern treatments.

Clinicopathologic reassessment of non-mycosis fungoides primary cutaneous lymphomas during 17 years

BACKGROUND

New classification systems have recently been proposed for primary cutaneous lymphomas (PCLs). The aim of our study was to evaluate the applicability and significance of the new classification systems to the diagnosis and management of non-mycosis fungoides (non-MF) PCL.

METHODS

Immunohistochemical restaining, histological reclassification, and clinical follow-up of all new non-MF PCL cases during 17 consecutive years were performed. The histological reclassification was performed according to the Revised European-American Lymphoma (REAL) classification, except for lymphomatoid papulosis (Lyp), which was included as an indolent lymphoma, according to the European Organization for the Research and Treatment of Cancer (EORTC) classification.

RESULTS

During the period 1983-99, 251 new PCL cases were seen, 213 (85%) of which were MF and Sézary syndrome (eight cases), and 38 (15%) of which were non-MF. Of the latter, 20 (53%) were B-cell lymphomas, including eight (40%) follicle center lymphoma, follicular (FCLF), eight (40%) marginal zone lymphoma (MZL), two (10%) diffuse large cell lymphoma, and two (10%) unclassifiable cases. Most or all of the lesions did not stain for CD10, CD43, and bcl-2 protein, and immunostaining for kappa and lambda immunoglobulin light chain restriction was much more useful diagnostically in MZL. Of the 18 primary non-MF cutaneous T-cell lymphomas, 13 (72%) were Lyp, all of which were type A, four (22%) were CD30+ anaplastic large cell lymphoma, and one (6%) was natural killer (NK)/T-cell lymphoma. Except for the NK/T-cell lymphoma, all the other non-MF PCLs had an indolent course.

CONCLUSIONS

A minority of the routinely diagnosed PCLs are non-MF, equally divided between B- and T-cell lymphomas. The REAL classification is applicable to the majority, although it does not include entities such as Lyp; the clinical correlations are not as obvious because most of the non-MF PCLs tend to have a relatively indolent course.

Cutaneous T-cell lymphoproliferative disorders: approach for the surgical pathologist: recent advances and clarification of confused issues

Cutaneous T-cell lymphoproliferative disorders (CTCLs) remain a subject of confusion and controversy. In this review, the authors discuss diagnostic criteria and classification, including the role of immunohistochemistry and gene rearrangement studies. In addition, cutaneous T-cell pseudolymphomas, the current status of parapsoriasis and other premalignant syndromes, and the clinicopathological variants of mycosis fungoides are discussed. CD30-positive lymphoproliferative disorders and a number of rare variants of CTCL including granulamatous slack skin, subcutaneous (panniculitic) T-cell lymphoma, gamma-delta cutaneous lymphoma, NK/NK-like T-cell lymphoma, and primary cutaneous CD8-positive epidermotropic cytotoxic T-cell lymphoma are also considered.

Ki-1 skin lymphoproliferative disorders: management with radiation therapy

Lymphomatoid papulosis and anaplastic large Ki-1 lymphoma of skin share unique clinical and pathological features. Appropriate therapy for multiple Ki-1 lymphoproliferative lesions without systemic involvement remains controversial. This paper presents results achieved with local radiation therapy. Two patients with multiple Ki-1 skin lymphoproliferative tumors were treated with local radiation using various techniques determined by the size and the depth of tumor invasion. Most lesions received 3000 cGy in 3 weeks. Complete response was achieved in all treated areas. There was virtually no morbidity. After more than 3 years, none of the treated areas developed local recurrence, and there was no evidence of internal dissemination. Ki-1 skin lymphoproliferative disorders are highly radiosensitive. When the disease is confined to the skin, and there is no evidence of spontaneous regression, or if palliation of symptoms is necessary, local radiation therapy may be an effective modality.

Lymphomatoid papulosis: successful weekly pulse superpotent topical corticosteroid therapy in three pediatric patients

Lymphomatoid papulosis is a T-cell proliferation that occurs primarily in adults but has been well described in children. Lesions may regress spontaneously but often leave residual scarring and, as a result, intervention frequently is considered. Therapeutic modalities commonly employed for adults with lymphomatoid papulosis may be poorly tolerated by pediatric patients. We present a series of three children with lymphomatoid papulosis treated with superpotent topical corticosteroids (halobetasol or clobetasol propionate). When applied twice daily for 2 to 3 weeks followed by weekly pulsed application, this treatment resulted in complete resolution of nearly all cutaneous lesions. Three ulcerated lesions, occurring in two patients, required adjuvant therapy with intralesional triamcinolone. To date one patient remains free of cutaneous disease and two children experience occasional new lesions that respond to renewed treatment with topical clobetasol propionate. None of the children have evidence of systemic disease. We conclude that pulsed application of a superpotent topical corticosteroid is efficacious and safe in the management of cutaneous lesions of lymphomatoid papulosis and avoids the risks often associated with more aggressive interventions. Since these agents do not alter the risk of subsequent malignancy, careful ongoing surveillance of children with lymphomatoid papulosis is imperative.

Lymphomatoid papulosis and cutaneous CD30+ lymphoma

Lymphomatoid papulosis and cutaneous CD30+ lymphoma are closely related conditions in which large atypical lymphocytes that have similar immunophenotypic features occur. In lymphomatoid papulosis, the lesions are papules and nodules that spontaneously involute. There are two polar histologic patterns, type A and B, in which the large atypical cells resemble those of Hodgkin's disease and mycosis fungoides, respectively, but in many cases, features of both types are present, either separately or in the same lesions. Variants of lymphomatoid papulosis include cases with a perifollicular distribution and those with lymphocytic vasculitis or dermal mucin deposits. Clinical lesions that tend to be stable, a monomorphous cellular composition, and in the case of immunocompromised patients, the presence of Epstein-Barr viral genome characterize cutaneous CD30+ lymphoma. A loss of response to transforming growth factor-beta, which normally dampens cellular proliferation, may differentiate CD30+ lymphoma from lymphomatoid papulosis.

Eosinophilic histiocytosis. Histopathology and immunohistochemistry

We review the clinical features, histopathology, and immunohistochemistry in three cases of eosinophilic histiocytosis, comparing lymphomatoid papulosis and eosinophilic histiocytosis. Each of the patients presented with self-healing recurrent papules and ulcerative nodules that were associated with pruritus. Disease duration was 5 months to 9 years. Histologically, the lesions demonstrated spongiosis and lymphocytic exocytosis, epidermal hyperplasia, papillary dermal edema, and a superficial and deep mixed perivascular inflammatory infiltrate. The infiltrate showed numerous eosinophils, histiocytoid cells, lymphocytes, and large mononuclear cells with atypical hyperchromatic nuclei. Most of the lymphocytes and large mononuclear cells with atypical nuclei marked with UCHL-1 (T-cell marker). The histiocytoid cells marked with S-100 and were dendritic both in the epidermis and the dermis. Eosinophilic histiocytosis appears to differ from classic lymphomatoid papulosis. It presents with recurrent papules and nodules associated with marked pruritus. Eosinophilic histiocytosis uniformly has more eosinophils and does not have the Reed-Sternberg cells often observed in lymphomatoid papulosis type A. Eosinophilic histiocytosis does not have cells that mark with Ki-1 and shows numerous S-100-positive histiocytoid cells that are most likely Langerhans cells, unlike lymphomatoid papulosis. However, eosinophilic histiocytosis may be an unusual Ki-1-negative variant of lymphomatoid papulosis with histopathologic changes not typical of type A or type B. In addition, eosinophilic histiocytosis lacks multinucleated histiocytes and the atypical histiocyte with a reniform nucleus, findings that are characteristic of histiocytosis X. Further studies are needed to define the pathophysiology and prognosis of this apparently distinct entity more accurately.

A comparison of clinical, morphological and immunohistochemical features of lymphomatoid papulosis and primary cutaneous CD30(Ki-1)-positive anaplastic large cell lymphoma

The advent of immunoperoxidase technique on paraffin embedded tissue has identified a number of shared immunologic markers present in various lymphoproliferative cutaneous disorders. Two such disorders are the recently described primary cutaneous CD30-positive anaplastic large cell lymphoma (ALCL) and lymphomatoid papulosis; both entities are characterized by CD30-positive large atypical cells predominantly of T cell origin. We have compared the clinical, morphological and immunohistochemical features of 50 patients with lymphomatoid papulosis to a group of 27 patients with cutaneous CD30-positive ALCL. There are clear differences between the clinical presentation in these two diseases, and although both are characterized by similar atypical cells, the histologic pattern and distribution of atypical cells is sufficiently different to allow distinction and specific diagnosis based on hematoxylin and eosin stained sections supported by the immunohistochemical stains. In addition, both diseases are characterized by a long benign course, rarely complicated by development of lymphoreticular malignancy and invariably demonstrate CD30 (Ki-1) antigen positive large atypical cells.

Primary cutaneous Ki-1+ anaplastic large cell lymphoma: a morphologic, immunohistochemical and genetic study of an indolent case

A 59-year-old woman with a large nodular ulcerative lesion on her neck was presented. She had a 3 year history of recurrent cutaneous nodules which spontaneously regressed before regional lymphadenopathies appeared. She has followed an indolent clinical course for seven years after the first overt lymphadenopathies appeared. Histological findings were compatible with anaplastic large cell lymphoma (ALCL). The tumor cells strongly expressed Ki-1 (CD30), HLA-DR, IL-2 receptor (CD25) and leukocyte common antigen. These findings led to the diagnosis of primary cutaneous Ki-1+ ALCL. Although the majority of the tumor cells did not express T-cell related antigens, the detection of monoclonal TCR gene rearrangement clearly established the T-cell lineage nature.

Lymphomatoid papulosis

Lymphomatoid papulosis is a chronic disease of cutaneous lymphoid infiltration characterized clinically by involuting and recurring papules, plaques, and nodules. The intriguing combination of a usually benign clinical course, a cytologically malignant lymphoid infiltrate on histologic examination, and a clear, but sporadic association with extracutaneous lymphomas has stimulated significant investigation. Application of recent technical advances to research in lymphomatoid papulosis prompts this review.

Spectrum of primary cutaneous CD30 (Ki-1)-positive lymphoproliferative disorders. A proposal for classification and guidelines for management and treatment

Primary cutaneous CD30 (Ki-1)-positive, large cell lymphomas (LCLs) represent a recently recognized group of cutaneous T-cell lymphomas with a favorable prognosis. The characteristic features of this cutaneous lymphoma are reviewed, differences with primary noncutaneous CD30+ LCLs emphasized, and its relation with other CD30+ cutaneous lymphoproliferative disorders, in particular lymphomatoid papulosis, is discussed. These primary cutaneous CD30+ LCLs, lymphomatoid papulosis, and related conditions represent a clinical and histologic continuum. A classification with practical guidelines for the management and treatment of patients within this spectrum of lymphoproliferative disorders is presented.

Primary cutaneous CD30-positive large cell lymphoma: definition of a new type of cutaneous lymphoma with a favorable prognosis. A European Multicenter Study of 47 patients

BACKGROUND

CD30 (Ki-1)-positive anaplastic large cell lymphoma (LCL) has been described as a morphologically distinct group of LCL that generally are associated with a poor prognosis. Recent studies indicate that these lymphomas, when confined to the skin, have a favorable prognosis. However, there is no consensus regarding the definition of these primary cutaneous CD30-positive LCL. Reported patients have been selected variously on the basis of morphologic (anaplastic cytology) or immunophenotypical (expression of CD30 antigen) criteria.

METHODS

At two recent workshops aimed to achieve consensus on the definition and terminology of these lymphomas, the clinical, histologic, and immunophenotypical data of 47 patients with primary cutaneous CD30-positive LCL from five collaborating European centers were analyzed.

RESULTS

Characteristic clinical features were presentation with solitary or localized skin lesions (42 of 47 patients), frequent cutaneous relapses (15 patients), and partial or complete spontaneous remission of skin lesions (11 patients). Twelve of 47 (25%) patients developed extracutaneous disease. The favorable prognosis of these lymphomas is indicated by the follow-up data that show that 36 of 47 patients are alive and in complete remission, only four disease-related deaths have occurred, and the overall median survival is 42 months (range, 2-130 months). There were no differences in clinical presentation, course, or prognosis between anaplastic and nonanaplastic CD30-positive LCL.

CONCLUSION

The results of this study indicate that primary cutaneous CD30-positive LCL, regardless of their morphologic classification (anaplastic or nonanaplastic) can be considered as a distinct type of cutaneous T-cell lymphoma. Recognition of this type of cutaneous lymphoma is important because it may prevent patients from unnecessary aggressive treatment.

Lethal midline granuloma (peripheral T-cell lymphoma) after lymphomatoid papulosis

A Japanese woman with an 8-year history of lymphomatoid papulosis (LP) had lethal midline granuloma (LMG) develop at the age of 51 years. There were histologic similarities between LP and LMG seen in this patient. Surface phenotypic studies on nasal and cutaneous lesions demonstrated a population of T-cells expressing CD2, CD4, CD25, CD30, and histocompatibility antigen-DR (HLA-DR). Genotypic analyses of nasal and skin biopsy specimens disclosed a clonal rearrangement of the beta T-cell receptor gene with the same rearrangement pattern. These data indicate that this patient had LMG characterized by clonal peripheral T-cell lymphoma, which probably resulted from progression of the LP.

The prognosis of patients with lymphomatoid papulosis associated with malignant lymphomas

Lymphomatoid papulosis (LyP) is a disorder which generally runs a benign course, but can sometimes be associated with a malignant lymphoma. Information about the prognosis of these LyP-associated lymphomas is, however, fragmentary. In this study, the clinical data of 50 LyP-associated malignant lymphomas, including 11 patients of our own group and 39 reported in the literature, are evaluated. Three main groups of LyP-associated malignant lymphomas could be distinguished: cases associated with mycosis fungoides (19/50 cases). Hodgkin's disease (12/50 cases) and (CD30+) large-cell lymphomas (16/50). The results of this study demonstrate that patients with mycosis fungoides. Hodgkin's disease, and (CD30+) large-cell lymphomas limited to the skin have a favourable prognosis. However, the prognosis of patients developing a systemic (CD30+) large-cell lymphoma proved generally poor. The results of this study also indicate that the risk of an individual LyP patient developing systemic lymphoma is less than 5%.

Lymphomatoid papulosis followed by large-cell lymphoma: immunophenotypical and genotypical analysis

The immunophenotype and genotype of atypical cells in skin and lymph node infiltrates were investigated in a patient with lymphomatoid papulosis (LyP) complicated by anaplastic large-cell lymphoma of the lymph nodes. The large atypical cells in both skin and lymph nodes displayed an almost identical immunophenotype, i.e. CD30+ and CD25+. Southern blot analysis for T-cell receptor beta-chain gene rearrangement revealed an identical gene configuration in DNA extracted from skin and lymph node. Our results strongly support the hypothesis that clonal populations of T cells arising in cutaneous LyP lesions may undergo malignant transformation, spread into regional lymph nodes, and give rise to secondary malignant lymphomas, such as anaplastic large-cell lymphoma.

Hodgkin's disease followed by lymphomatoid papulosis. Immunophenotypic evidence for a close relationship between lymphomatoid papulosis and Hodgkin's disease

The clinical association of lymphomatoid papulosis and Hodgkin's disease and the striking morphologic similarity of atypical cells in lymphomatoid papulosis to Reed-Sternberg cells in Hodgkin's disease suggest that lymphomatoid papulosis and Hodgkin's disease are related. To test this possibility we studied the antigenic profile of Reed-Sternberg cells in the lymph nodes and of atypical cells in cutaneous lesions of lymphomatoid papulosis in two patients with Hodgkin's disease and lymphomatoid papulosis. In paraffin sections both cell types expressed CD30, CD45 T cell-restricted antigens, and occasionally CD15 antigens. They were negative for CD45 B cell-restricted antigens and for lysozyme. In cutaneous lymphomatoid papulosis lesions a similar immunologic profile of the atypical cells was found; that is, they were positive for CD30, CD2, CD3, and CD25 but negative for B cell and macrophage antigens. The similarity of the immunophenotype of Reed-Sternberg cells in lymph nodes affected by Hodgkin's disease and the immunophenotype of atypical cells of lymphomatoid papulosis lesions in the same patients suggests that the malignant cells in both conditions are derived from activated T cells and that they are closely related if not identical.