Cutaneous findings in chronic lymphocytic leukaemia

Extramedullary and extranodal manifestations in chronic lymphocytic leukemia - an update

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common leukemia characterized by clonal expansion of mature CD5+/CD23 + B cells in the blood, bone marrow (BM) and lymphoid tissues. CLL can undergo extramedullary and extranodal infiltration, with one study noting an incidence of only 0.3 per 100,000 people, and in 17.6% of CLL patients in another report. The most common extranodal sites of leukemic involvement are the skin and central nervous system; however, other organs, including liver, lungs, kidney, gastrointestinal tract, bone, prostate and heart, are occasionally involved. The prognostic significance of extra-medullary CLL is still under debate, but the prognosis in such patients seems to be better in the era of novel targeted drugs. Following a diagnosis of extranodal CLL, survival appears to depend on the site of infiltration. This review presents an overview of CLL in patients with extramedullary and extranodal leukemic lesions, focusing on its epidemiology, pathogenesis, prognosis, clinical characteristics and treatment results.

Impending splenic rupture as indicator of atypical chronic lymphocytic leukemia: A case report from Saudi Arabia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is one of the hematological malignancies in which the bone marrow overproduces mature, dysfunctional lymphocytes. Affected lymphocytic cells can affect the lymph nodes, spleen, liver, bone marrow, and rarely other organs. Spontaneous rupture of the spleen is a rare health condition, with a few cases caused by CLL. Since the preliminary presentation of either impending or real splenic rupture is unusual and requires recording and reporting, this case report was developed.

CASE REPORT

A 55-year-old male patient presented with a significant weight loss of 20 kg, loss of appetite, fatigue, abdominal pain, and early satiety. Clinical examination revealed massive splenomegaly 22 cm below the costal margin, otherwise unremarkable on systemic examination. The size and dimensions of the spleen were confirmed by computed tomography of the body. The patient underwent a bone marrow biopsy, which was suggestive of atypical CLL. Due to the rapid progression of the size of the spleen and the pattern of impending rupture of the spleen, an emergency splenectomy was performed, and the histopathological report confirmed low-grade B-cell non-Hodgkin's lymphoma, mostly typical of CLL.

CONCLUSION

Given the rarity of cases, continuous data recording and reporting is required to enrich the scientific literature and share experiences from case to case. This will create a complete picture of this health condition across diverse regions and countries.

The Immune Microenvironment in Basal Cell Carcinoma

The immune system plays a key role in the suppression and progression of basal cell carcinoma (BCC). The primary aetiological factor for BCC development is exposure to ultraviolet radiation (UVR) which, particularly in lighter Fitzpatrick skin types, leads to the accumulation of DNA damage. UVR has roles in the generation of an immunosuppressive environment, facilitating cancer progression. Rates of BCC are elevated in immunosuppressed patients, and BCC may undergo spontaneous immune-mediated regression. Histologic and immunohistochemical profiling of BCCs consistently demonstrates the presence of an immune infiltrate and associated immune proteins. Early studies of immune checkpoint inhibitors reveal promising results in BCC. Therefore, the host immune system and tumor responses to it are important in BCC pathogenesis. Understanding these interactions will be beneficial for disease prognostication and therapeutic decisions.

Immunosenescence and Skin: A State of Art of Its Etiopathogenetic Role and Crucial Watershed for Systemic Implications

Immunosenescence is a complex multifactorial phenomenon consisting of wide-ranging remodeling of the immune system during the life span, resulting in an age-related qualitative-quantitative decline of immune cells and cytokines. A growing body of evidence in the international literature is highlighting the etiopathogenetic role of skin immunosenescence in the onset of various dermatologic conditions. Skin immunosenescence also serves as an interesting watershed for the onset of system-wide conditions in the context of allergic inflammation. Moreover, in recent years, an increasingly emerging and fascinating etiopathogenetic parallelism has been observed between some mechanisms of immunosenescence, both at cutaneous and systemic sites. This would help to explain the occurrence of apparently unconnected comorbidities. Throughout our review, we aim to shed light on emerging immunosenescent mechanisms shared between dermatologic disorders and other organ-specific diseases in the context of a more extensive discussion on the etiopathogenetic role of skin immunosenescence. A promising future perspective would be to focus on better understanding the mutual influence between skin and host immunity, as well as the influence of high inter-individual variability on immunosenescence/inflammaging. This can lead to a more comprehensive "immunobiographic" definition of each individual.

Wells’ syndrome possibly caused by hematologic malignancy, influenza vaccination or ibrutinib: A case report

BACKGROUND

Wells’ syndrome (eosinophilic cellulitis) is an uncommon eosinophilic dermatosis of uncertain pathogenesis, characterized by clinical polymorphism and suggestive but nonspecific histopathologic traits. Its course is recurrent, and response to therapy is unpredictable. In a case in which the patient has a number of potential triggers for the manifestation of Wells’ syndrome skin rash, the treating physician must decide or must make an assumption in order to establish the most likely clinical scenario. This is important for the patient’s future treatment plans.

CASE SUMMARY

We describe the clinical case of a 46-year-old female with chronic lymphocytic leukemia who had already received treatment for several months with ibrutinib. She was diagnosed with Wells’ syndrome 10 d after an influenza vaccination containing thimerosal. Based on the literature, the patient was treated with a course of oral steroids. Resolution of clinical symptoms and rash were observed in response to the treatment. Ibrutinib was not discontinued.

CONCLUSION

The etiology of Wells’ syndrome remains unknown. Clinically, it resembles bacterial cellulitis. Lack of response to antibiotic treatment should lead the physician to consider a diagnosis of Wells’ syndrome. Treating the underlying condition is important and may lead to resolution of the syndrome. However, the most common and effective treatment to limit the course of the disease are systemic steroids.

Clinicopathological characteristics of individuals with co-existing melanoma and chronic lymphocytic leukaemia: a multicentre cohort study

BACKGROUND

Individuals with a prior diagnosis of chronic lymphocytic leukaemia (CLL) have a higher risk of developing melanoma (MM) and exhibit poorer outcomes when compared to patients without CLL. However, there are limited data reporting the clinicopathological features of MM diagnosed in patients with CLL.

OBJECTIVES

To review clinicopathological characteristics of patients with co-existing diagnoses of MM and CLL.

METHODS

A retrospective review was undertaken for patients with co-existing diagnoses of MM and CLL between 2005-2015 in 11 centres in the UK and Ireland.

RESULTS

Overall, 46 cutaneous MM identified in 45 patients were included. In 28 (62.2%) patients, MM was diagnosed after an existing diagnosis of CLL. In this group, mean Breslow thickness was 2.7 mm (range = 0.2-25 mm). Ten (35.7%) tumors developed locoregional recurrence and 8 (28.6%) developed distant metastases. Melanoma-specific mortality was 5/28 (17.9%) and all-cause mortality was 13/28 (46.4%). In 17 patients, MM was diagnosed before CLL. In this group, mean BT was 2.9 mm (range = 0.4-14 mm), 5 (29.4%) developed locoregional recurrence and 3 (17.6%) distant metastases. Melanoma-specific mortality was 1/17 (5.8%) and all-cause mortality was 5/17 (29.4%) in this group.

CONCLUSIONS

To our knowledge, this is the first and largest cohort study to report clinicopathological data of co-existing melanoma and CLL in the UK and Ireland. Although the thickness of primary melanoma was not different before or after a CLL diagnosis, melanoma recurrence and melanoma-specific mortality appear to be more common in patients with a prior diagnosis of CLL.

Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia: a systematic review of the literature

The continuous improvement of life expectancy of patients with chronic lymphocytic leukemia (CLL) has resulted in increased risk of second primary malignancy that potentially may affect survival and quality of life of CLL patients. We performed a systematic review to assess the risk and the clinical‐pathological features and prognosis of cutaneous squamous cell carcinoma (cSCC) in patients with CLL. We searched PubMed, Embase, and Cochrane Central Register of Control Trials databases for articles published from database inception to December 31, 2019. English‐language studies reporting original data on patients with a specific diagnosis of CLL and cSCC were included. Data were extracted using a standardized extraction form, and any discordance was resolved by consensus. Descriptive data were generated by pooling patients from eligible studies. Of the 4588 non‐duplicate records identified, 55 articles met our inclusion criteria. These studies reported that CLL patients have a 3.2% prevalence of cSCC, with an 11.5% cSCC‐related lethality and an overall risk of metastasis of 5.7% (7.3% for regional lymph node involvement and 3.8% for distant metastasis). The quality of evidence was limited by the high heterogeneity in the design, populations, and objectives of the included studies. This systematic review suggests that cSCC in CLL patients tends to behave less aggressively compared with the solid organ transplant recipients but has a higher morbidity and mortality than in the general population. Future prospective studies are needed to increase the quality of evidence and to determine the best treatment modalities and screening intervals for these patients.

An unusual case of T-cell prolymphocytic leukemia mimicking a cutaneous vasculitis

T-cell prolymphocytic leukemia (T-PLL) is an aggressive post-thymic T-cell malignancy, which accounts for 2% of mature lymphocytic leukemias in adults. Though typically presenting with a brief history of B symptoms, hepatosplenomegaly, and marked lymphocytosis, erythematous or nodular skin rashes involving the trunk or limbs may be seen in 25% to 30% of patients, as well as a purpuric rash in a periorbital distribution. Cutaneous involvement typically presents in the context of patients with an established history of T-PLL, but it can less frequently present as an initial symptom heralding the diagnosis. An unusual case of T-PLL is described, presenting initially as palmoplantar ulcerated nodules with an initial biopsy suggestive of perniosis, followed by rapid progression of dark violaceous and bright red papules throughout the body after initiation of Obinutuzumab. The diagnosis of T-PLL was subsequently fully supported by the clinical, laboratory, cytologic, and immunophenotypic findings. This case highlights the importance of a multidisciplinary team approach to address such rare and atypical presentations.

Leukemia Cutis as an Early Presentation or Relapsing Manifestation of Chronic Lymphocytic Leukemia (CLL)

Background and Objective:

Cutaneous infiltration by Chronic Lymphocytic Leukemia (CLL) is a rare complication. The clinical presentation, impact of it on disease prognosis, and the proper treatment choice are not clear. Here in our review, we try to answer these questions.

Acquisition of evidences:

A systematic search of PubMed, and Google Scholar for English language articles published from Jan 2000 to June 2019.

Synthesis of evidences:

A total of 56 cases were identified, with a median age of 66 years. Of these cases 43 were males and 12 were females, and one missing data, with a ratio of 3,6:1. Head and neck were most commonly involved. The commonest clinical presentation was papulonodular lesions, and the majority were diagnosed at an early stage. CLL skin involvement at the site of old herpetic lesions was common. Because of the rarity of the disease, treatment modalities varied widely, and there are no consensus on treatment. The majority were treated with chemotherapy. In general, 35 (77.8% - of the non-missing data) patients responded to treatment (25 patients had a complete remission and 10 a partial remission). All patients ≤60 years had an early-stage disease, on the other hand, all patients with advanced-stage were >60 years.

Conclusion:

Patients with early-stage and localized leukemia cutis can benefit from observation alone strategy, while intervention in young patients with advanced disease is warranted. Skin infiltration by CLL does not affect prognosis, as most patients attained complete or partial remission with a very low progression rate.

Chronic lymphocytic leukemia and the skin: implications for the dermatologist

B-cell chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in the United States, and its diagnosis can have many dermatologic implications. For one, the cutaneous manifestations of CLL include several entities, most notably leukemia cutis, eosinophilic dermatosis of hematologic malignancy, and a heightened risk of skin infections. Additionally, CLL patients are at an increased risk of secondary malignancies, most commonly of the skin. Furthermore, a number of commonly utilized treatments for CLL have cutaneous implications which should be considered in the interdisciplinary management of CLL patients. In this review, we will provide an update on the diverse cutaneous manifestations of CLL and CLL-directed therapies in order to help guide dermatologic management of this increasingly prevalent patient population.

The contribution of human papilloma virus infection to cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia

Patients with chronic lymphocytic leukemia (CLL), a B‐cell malignancy characterized by impaired humoral and cellular immunity, are at increased risk of developing cutaneous squamous cell carcinoma (cSCC). Human papilloma virus (HPV) is the most common sexually transmitted infection worldwide and it has been associated with various malignancies, including cSCC. Impaired cell‐mediated immunity is considered a primary risk factor in HPV‐induced cSCC. We examined cSCC lesions from CLL patients with consensus review and HPV genetic analysis to further characterize the relationship between HPV and prevalence of cutaneous malignancy in this population. Eleven patients with CLL contributed 35 cSCCs. Treatment with chemotherapy shortened the latency time to first cSCC. HPV was detected in 54% of the lesions. Among the HPV‐positive cSCC lesions, 84% of the lesions contained alpha‐genus HPV, 42% contained beta‐genus HPV, and 26% of the lesions contained both genera. There was a significant association between HPV‐containing lesions and peritumoral lymphocytic inflammation, suggesting this as a future area for further characterization. The majority of the lesions, including those with alpha‐genus HPV, occurred in sun‐exposed areas, such as the scalp and face. These findings may lead to practice‐changing recommendations for skin cancer, including the use of vaccinations to reduce HPV‐associated skin cancer.

Primary cutaneous lymphomas in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): A series of 12 cases

BACKGROUND

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is associated with an increased risk of a second malignancy.

METHODS

We conducted a retrospective clinicopathologic review of 12 patients with CLL/SLL who developed a second lymphoma in the skin. Demographic data, clinical information, and histopathology from 31 biopsies were recorded. Cases of secondary cutaneous involvement by CLL/SLL (leukemia cutis) and non-primary cutaneous lymphomas were excluded.

RESULTS

A wide variety of primary cutaneous lymphomas was identified, including classic mycosis fungoides (3), cutaneous marginal zone lymphoma (2), primary cutaneous peripheral T-cell lymphoma unspecified (2), folliculotropic mycosis fungoides (1), Sézary syndrome (1), cutaneous gamma-delta T-cell lymphoma (1), cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1), and cutaneous anaplastic large cell lymphoma (1). A male predominance was observed, and the average age was 74.1 years. In all patients, CLL/SLL predated the development of the second lymphoma, which was aggressive in the majority of cases (58%). Aggressive cytotoxic T-cell lymphomas, generally rare neoplasms, were relatively common (30%).

CONCLUSIONS

CLL/SLL patients may develop a second lymphoma in the skin, which may be aggressive. Atypical cutaneous lymphoid infiltrates in this patient population should not be assumed to represent secondary CLL/SLL involvement and require thorough immunohistochemical analysis.

A Needle in the Haystack: A Rare Case of Spontaneous Tumor Lysis in Newly Diagnosed Chronic Lymphocytic Leukemia Unmasked by Acute Renal Failure

Tumor lysis syndrome (TLS) is the phenomenon of metabolic derangements that typically follows the initiation of cytotoxic chemotherapy. Metabolic disturbances include hyperphosphatemia, hyperkalemia, hyperuricemia and hypocalcemia. Hematological malignancies are associated with spontaneous TLS (STLS), which is cell lysis in the absence of chemotherapy. STLS is extremely rare in chronic lymphocytic leukemia (CLL). This has been documented only once in the medical literature, making this an extraordinarily uncommon case. We present here a 68-year-old male with a history of benign prostatic hyperplasia (BPH) who is admitted for a two-week history of abdominal pain and three days of anuria, despite adequate fluid intake. Laboratory values yielded a greatly elevated leukocyte count with a lymphocytic predominance and smudge cells. Potassium, phosphorus, and uric acid were also significantly increased. EKG revealed peaked T-waves. Flow cytometry confirmed the presence of an abnormal B-cell population consistent with B-cell chronic lymphocytic leukemia, with the following markers: CD19+, CD20+, CD23+, CD5+, CD10-. He was diagnosed with CLL and treated with aggressive fluid resuscitation, allopurinol and rasburicase. The patient had another similar episode within one month. His CLL fluorescence in-situ hybridization (FISH) showed complex cytogenetics with unmutated IgVH and he was subsequently started on ibrutinib.

Cutaneous manifestations of B-cell chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a malignant lymphoproliferative disease characterized by the accumulation of immature monoclonal B lymphocytes in blood cells, bone marrow, spleen and lymph nodes. This is the most common type of leukemia among the Caucasoid race. When CLL skin lesions occur in about 25% of patients, they are extremely diverse. These lesions can be divided into specific, including infiltration of the skin by leukemic cells and the skin form of Richter's syndrome, secondary skin tumors, nonspecific lesions and associated skin diseases.Leukemic infiltration of the skin in patients with leukemia is called specific skin lesions (SSL). Many authors associate the unfavorable prognosis with the transformation of CLL with specific infiltration of the skin into Richter syndrome, as well as the appearance of SSL before the diagnosis of CLL. The risk of developing various cancer pathologies in patients with CLL is three times higher than in healthy people identical in sex and age. It was found that the risk of skin cancer in these patients is eight times higher than in the healthy population. The most common secondary skin tumors in CLL are basal-cell carcinoma, squamous-cell carcinoma, melanoma, and Merkel tumor.Nonspecific skin changes are extremely diverse and occur in patients with CLL in 30-50% of cases. The most common secondary changes in the skin in CLL are those of infectious nature. There are also increased reactions to insect bites, generalized itching, exfoliative erythroderma, nodular erythema, paraneoplastic pemphigoid, bullous pemphigoid, drug eruption. Concomitant dermatoses in these patients are more severe and often torpid to the previously conducted therapy. There is no doubt that together with the clarification of the etiology and pathogenesis of CLL, particular issues related to the study of clinical and morphological changes in individual organs and systems, in particular the skin, formed at various stages of the development of this disease should be studied in detail. This can not only expand and clarify our understanding of this pathology, but also can help to clarify the essence of the disease.

The Role of the Immune System in Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer. In immunosuppressed populations it is a source of considerable morbidity and mortality due to its enhanced recurrence and metastatic potential. In common with many malignancies, leucocyte populations are both protective against cancer development and also play a role in 'sculpting' the nascent tumor, leading to loss of immunogenicity and tumor progression. UV radiation and chronic viral carriage may represent unique risk factors for cSCC development, and the immune system plays a key role in modulating the response to both. In this review, we discuss the lessons learned from animal and ex vivo human studies of the role of individual leucocyte subpopulations in the development of cutaneous SCC. We then discuss the insights into cSCC immunity gleaned from studies in humans, particularly in populations receiving pharmacological immunosuppression such as transplant recipients. Similar insights in other malignancies have led to exciting and novel immune therapies, which are beginning to emerge into the cSCC clinical arena.

Chronic lymphocytic leukaemia masquerading as a labial lump

We report a case of an 82-year-old woman who presented with a 2-week history of a left labial lump. She had a history of chronic lymphocytic leukaemia (CLL) for several years and remained stable without clinical evidence of disease progression. She was observed with regular blood tests and clinical assessment. She was hypogammaglobulinaemic from the CLL and due to frequent symptomatic infections requiring hospitalisation, was commenced on monthly intravenous immunoglobulin. A tissue biopsy of the labial lump confirmed involved CLL in the genital area and further investigations and management followed.

Presence of varicella zoster virus in zosteriform leukaemia cutis

Leukaemia cutis is a relatively rare manifestation in chronic lymphocytic leukaemia, characterized by a diverse morphology of skin lesions. We report two patients who developed zosteriform skin symptoms; however, the histological analysis revealed leukaemia infiltration as the cause of their symptoms. Contrary to previous reports, varicella zoster virus DNA was detectable in the lesions. These findings suggest that varicella zoster virus plays an active role in the development of zosteriform leukaemia cutis.

Response to R-CHOP in HPV-related squamous cell carcinoma of base of tongue: a case report

Background

Synchronous squamous cell carcinoma of the head and neck (HNSCC) and non-Hodgkin's lymphoma is a rare clinical scenario. It is unknown whether the R-CHOP chemotherapy for lymphoma would also be active against HNSCC. Herein, we present such a case and a review of the literature.

Case presentation

A 64 year-old female presented with painless jaundice. CT demonstrated a retroperitoneal mass and pathology showed follicular lymphoma. A base-of-tongue HPV⁺ squamous cell carcinoma was found incidentally on staging CT. R-CHOP chemotherapy was initiated. After 3 cycles of R-CHOP the lymphoma had a complete metabolic response and, unexpectedly, the HNSCC also demonstrated excellent response. The patient received another 3 cycles followed by radiation to the HNSCC and to date is in remission for both cancers.

Conclusions

This case highlights the exquisite sensitivity of HPV-related HNSCC, which should be taken into consideration in treatment prioritization of a concurrent diagnosis of a second cancer.

Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians

Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam^™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam^™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.

Risk of cutaneous T-cell lymphoma in patients with chronic lymphocytic leukemia and other subtypes of non-Hodgkin lymphoma

BACKGROUND

Second hematologic cancers in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) are well documented and include Hodgkin lymphoma, therapy-related acute myeloid leukemia/myelodysplastic syndromes, and transformation to diffuse large B-cell lymphoma. Although cutaneous T-cell lymphoma (CTCL) has been reported in patients with CLL, the incidence and comparison to expected rates are unknown. We evaluated the incidence of CTCL among patients with CLL or other non-Hodgkin lymphoma (NHL) subtypes using data from the Surveillance, Epidemiology, and End Results (SEER) Program.

METHODS

We searched the SEER 13 registries for patients with a diagnosis of CLL and NHL between 1992 and 2008. Among patients identified, we evaluated the incidence of CTCL.

RESULTS

Among 31,286 patients with CLL, the incidence of CTCL was not significantly higher in men than women: 104.2 (95% CI, 50.0-191.8) and 28.1 (95% CI, 3.4-101.3) per 1,000,000 person-years, respectively (P = 0.06). Among 97,691 patients with NHL, the incidence of CTCL was similar in men and women (97.9 [95% CI, 62.0-146.9] and 92.0 [95% CI, 56.2-142.1] per 1,000,000 person-years, respectively; P = 0.84). The incidence of CTCL among males with CLL (standardized incidence ratio [SIR], 3.0 [95% CI, 1.4-5.5]), males with NHL (SIR, 3.7 [95% CI, 2.3-5.5]), and females with NHL (SIR, 5.9 [95% CI, 3.6-9.1]) was significantly higher than expected in the general population (all P < 0.001).

CONCLUSION

The risk of CTCL is greater in men with CLL than in the general population. In patients with NHL, both men and women are at greater risk for CTCL than in the general population.

Dermatological Findings in Turkish Paediatric Haematology-Oncology Patients

OBJECTIVE

Diagnoses of skin, mucosae, hair and nail manifestations in malignant diseases are often challenging because of life-threatening drug reactions, opportunistic infections or skin involvement of primary processes. Description of morphology, configuration and distribution of lesions is important in order to differentiate the self-healing eruptions from serious side effects of chemotherapy. There are case reports from Turkey including dermatological manifestations of malignancies and case series in adult patients but there are no published large group studies assessing all manifestations in children. The aim of this study was to evaluate the morphological features of dermatological findings in children with haemato-oncological diseases.

MATERIALS AND METHODS

The study was performed at the Erciyes University, Faculty of Medicine Pediatric Hematology-Oncology Clinic, Turkey. Three dermatologists daily consulted all patients admitted to the clinic during a one-year period.

RESULTS

The study group comprised of 157 children (79 female/78 male) aged 1-16 years (mean 7.19±4.63). Detailed dermatological examinations were performed, including oral-genital mucosae, hair and nails. Thorough skin examination revealed that 70% of the patients exhibited at least one dermatological finding. Generalized xerosis and hyperpigmentation were the most common findings among patients undergoing chemotherapy (24.19%). Multiple nevi on at least 10 covered areas were very frequent among patients undergoing long-term chemotherapy (18.47%). Three were identified as dysplastic nevus, but malignant transformation was not observed during the one-year study period.

CONCLUSION

Regular dermatological consultation may help resolve the diagnostic and therapeutic problems in paediatric haemato-oncology clinics.

Spectrum of mucocutaneous manifestations in an Asian cohort of patients with leukemia

BACKGROUND

Literature on cutaneous manifestations of leukemia is limited.

OBJECTIVE

To determine the pattern of mucocutaneous manifestations in adult Asian patients with leukemia and to establish their relation with the leukemia type.

SUBJECTS AND METHODS

After previous consent, 196 consecutively registered patients with leukemia aged ≥18 years were recruited. All patients were prospectively followed for 3 months to evaluate the patterns of mucocutaneous involvement. The mucocutaneous manifestations were categorized into specific lesions with leukemic infiltration and non-specific lesions.

RESULTS

Seventy-nine (40.3%) of 196 (males 128 and females 68) recruited patients showed one or more mucocutaneous manifestations. The total number of complaints observed was 87 with mean number of dermatoses per patient being 0.44. Specific manifestations (leukemia cutis) were present in six (3.06%) and nonspecific mucocutaneous manifestations in 73 (37.2%, reactive dermatoses n = 21 and infections n = 52). Cutaneous viral infections were significantly associated with acute lymphoblastic leukemia (P < 0.005). Antiviral prophylaxis with acyclovir significantly reduced the incidence of varicella-zoster infection (P = 0.016).

CONCLUSION

Cutaneous manifestations are common in Asian patients with leukemia, and a thorough cutaneous examination will aid in their management.

Effect of Non-Hodgkin Lymphoma on Survival in Patients With Malignant Fibrous Histiocytoma, Kaposi Sarcoma, and Sebaceous Carcinoma: A SEER Population-Based Study

OBJECTIVE

To quantify the behavior of dermatofibrosarcoma protuberans (DFSP), malignant fibrous histiocytoma (MFH), Kaposi sarcoma (KS), and sebaceous carcinoma (SC) in patients with a history of non-Hodgkin lymphoma (NHL).

PATIENTS AND METHODS

Subjects with a diagnosis of DFSP, MFH, KS, or SC between 1990 and 2006 were identified in the Surveillance, Epidemiology, and End Results Program database. For each skin cancer type, the standardized mortality ratio (SMR) for death due to any cause and death due to skin cancer was estimated.

RESULTS

From 1990 through 2006, 25,357 skin cancers were identified: 4,192 DFSP, 6,412 MFH, 10,543 KS, and 4,222 SC. For patients with a history of non-CLL NHL, SMRs for death due to any cause were 1.45 (95% confidence interval [CI], 1.03-2.04; p = 0.04) for MFH, 2.90 (95% CI, 2.50-3.36; p < 0.001) for KS, and 3.25 (95% CI, 1.84-5.75; p < 0.001) for SC and SMRs for death due to skin cancer were 0.55 (95% CI, 0.23-1.31; p = 0.18) for MFH, 2.93 (95% CI, 2.49-3.43; p < 0.001) for KS, and 4.07 (95% CI, 1.28-12.94; p < 0.001) for SC.

CONCLUSION

Among patients with KS and SC, patients with a history of non-CLL NHL have a greater risk of overall and cause-specific death than expected.

Voriconazole exposure and the risk of cutaneous squamous cell carcinoma in allogeneic hematopoietic stem cell transplant patients

BACKGROUND

Voriconazole is a commonly used antifungal medication in allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients. In solid organ transplantation, voriconazole use has been associated with the development of cutaneous squamous cell carcinoma (SCC). We sought to determine if voriconazole use was associated with SCC in patients undergoing allo-HSCT.

METHODS

We retrospectively reviewed consecutive adult patients who underwent allo-HSCT at Mayo Clinic from January 2007 through July 2012. Multivariable Cox models were created to assess the relationship of SCC with two time-dependent voriconazole exposure variables: (i) history of voriconazole exposure (yes/no), and (ii) cumulative days of voriconazole use.

RESULTS

In our cohort of 381 allo-HSCT patients, SCC developed in 26 of 312 patients exposed to voriconazole (25 post-voriconazole) and in 1 of 69 patients who received alternative antifungal agent(s). Cumulative incidence of SCC was estimated to be 19% at 5 years post allo-transplant. Cumulative days of voriconazole use was found to be a risk factor for SCC, and this relationship persisted in a multivariable model using previously identified risk factors as covariates (hazard ratio 1.859 for each 180 days of use, P < 0.001).

CONCLUSION

This is the first study, to our knowledge, to identify cumulative days of voriconazole use as a risk factor for SCC development following allo-HSCT, and may help guide appropriate antifungal use in this patient population.

Synchronous metastatic cutaneous squamous cell carcinoma and chronic lymphocytic leukaemia/small lymphocytic lymphoma in a cervical lymph node: Case report of an unusual event

The synchronous occurrence of two different neoplasias is an uncommon event, which may arise between tumors originating in the same organ or in cancer-to-cancer metastasis. We report a rare case of chronic lymphocytic leukaemia / small lymphocytic lymphoma associated with a cutaneous metastatic squamous cell carcinoma in a cervical lymph node. In the affected lymph node, it was observed an effacement of the normal architecture by neoplastic lymphocytes and it was noted the presence of neoplastic invasive epithelial islands. Immunohistochemical analysis demonstrated that lymphocytic proliferation was positive for CD20, CD5, CD23 and Kappa, and negative for CD3, CD10, Cyclin D1 and Lambda. The morphological and immunohistochemical profile lead to a phenotype of B-cell chronic lymphocytic leukaemia / small lymphocytic lymphoma. The epithelial cells were positive for CK5, thus rendering the diagnosis of synchronous metastatic cutaneous squamous cell carcinoma and chronic lymphocytic leukaemia/small lymphocytic lymphoma. Literature supports the poor prognosis in cases that present coexistence of squamous cell carcinoma and chronic lymphocytic leukaemia / small lymphocytic lymphoma. Thus, it is necessary to be aware about this unusual finding in order to provide specific treatment.

KEY WORDS

Chronic lymphocytic leukaemia, small lymphocytic lymphoma, squamous cell carcinoma, metastasis.

Eosinophilic Pustular Folliculitis Post Chemotherapy in a Patient of Non-Hogkins Lymphoma: A Case Report

Eosinophilic pustular folliculitis (EPF) was originally described by Ofuji in Japanese patients without any systemic disease. Later it was widely associated with HIV. Lately a large number of hematological malignancies have been associated with EPF. We hereby report an association of non-Hogkins lymphoma with EPF, probably the first in Indian context.

Small lymphocytic lymphoma with florid perniosis-like features: a case report

BACKGROUND

Small lymphocytic lymphoma is a relatively rare B-cell non-Hodgkin lymphoma that is considered to be the tissue equivalent of the much more common entity chronic lymphocytic leukemia. Cutaneous manifestations of small lymphocytic lymphoma are infrequent and the literature regarding them sparse. We describe here a case of a patient with a history of small lymphocytic lymphoma who developed perniosis-like features of the digits.

CASE PRESENTATION

An 86-year old male patient with previously diagnosed small lymphocytic lymphoma developed painful erythematous swelling of the periungual area of his fingers and toes. This was associated with a dense dermal infiltration of CD5-positive B-lymphoid cells consistent with his low-grade B-cell lymphoma. Although partially refractory to local radiotherapy, the painful swelling of the fingers and toes resolved fully following systemic therapy with chlorambucil and rituximab.

CONCLUSIONS

This unusual cutaneous manifestation of a lymphoma and the favourable response to systemic therapy may be instructive for the management of other patients who develop similar perniosis-like features.

Melanoma and non-melanoma skin cancers in hairy cell leukaemia: a Surveillance, Epidemiology and End Results population analysis and the 30-year experience at Memorial Sloan Kettering Cancer Center

Few studies have examined melanoma and non-melanoma skin cancer (NMSC) incidence rates after a diagnosis of hairy cell leukaemia (HCL). We assessed 267 HCL patients treated at Memorial Sloan Kettering Cancer Center (MSKCC) and Surveillance, Epidemiology and End Results (SEER) data for melanoma and NMSC incidence rates after HCL. Incidence data from MSKCC patients demonstrated a 10-year combined melanoma and NMSC skin cancer rate of 11·3%, melanoma 4·4% and NMSC 6·9%. Molecular analysis of skin cancers from MSKCC patients revealed activating RAS mutations in 3/9 patients, including one patient with melanoma. Of 4750 SEER patients with HCL, 55 (1·2%) had a subsequent diagnosis of melanoma. Standardized incidence ratios (SIRs) did not show that melanoma was more common in HCL patients versus the general population (SIR 1·3, 95% CI 0·78-2·03). Analysis of SEER HCL patients diagnosed before and after 1990 (approximately before and after purine analogue therapy was introduced) showed no evidence of an increased incidence after 1990. A better understanding of any potential association between HCL and skin cancer is highly relevant given ongoing trials using BRAF inhibitors, such as vemurafenib, for relapsed HCL, as RAS-mutant skin cancers could be paradoxically activated in these patients.

Increased incidence of malignant melanoma and other rare cutaneous cancers in the setting of chronic lymphocytic leukemia

BACKGROUND

Patients with chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), or non-Hodgkin lymphoma (NHL) are at increased risk for the development of skin malignancies.

OBJECTIVES

This study was conducted to estimate the incidences of rare skin malignancies in patients with CLL/SLL or NHL.

METHODS

Patients with a diagnosis of CLL/SLL or NHL recorded in the Surveillance, Epidemiology and End Results (SEER) database during 1992-2007 were identified. Diagnoses of specific skin malignancies were identified from SEER files.

RESULTS

During 1992-2007, a total of 128,674 patients with first diagnoses of CLL/SLL or NHL were recorded in SEER; 4743 were excluded because follow-up data were unavailable. Among the remaining 123,931 patients, 28,964 had CLL/SLL and 94,967 had NHL. Standardized incidence ratios (SIRs) for invasive malignant melanoma, Merkel cell carcinoma, malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, Kaposi's sarcoma, and sebaceous carcinoma were 2.3, 8.2, 3.6, 2.5, 2.9, and 1.4, respectively, in CLL/SLL patients and 1.6, 3.2, 1.5, 1.3, 17.6, and 0.8, respectively, in NHL patients. When invasive melanoma was stratified by patient age and sex, the highest SIR (17.8) was found in men aged 0-49 years with CLL (P < 0.001).

CONCLUSIONS

Patients with CLL/SLL or NHL have a higher risk for the subsequent development of rare skin cancers. Given the more aggressive nature of these malignancies in this setting, regular monitoring for the development and prompt treatment of cutaneous malignancy is prudent in patients with NHL and particularly in patients with CLL. Regular use of sun protection may decrease the morbidity associated with skin cancer in this immunosuppressed population.

Cutaneous manifestations in a patient with chronic lymphocytic leukemia involving the head, neck and distal extremities

Chronic lymphocytic leukemia (CLL) infiltrating the skin is uncommon and can present in many different ways. The present study reports a case of CLL infiltrating multiple body areas. A 57-year-old male with a 10-year history of subclinical B-cell chronic lymphocytic leukemia (B-CLL) presented with skin hypertrophic changes of the ears, eyebrows, tip of the nose, toes and fingers. In addition, the patient had erythematous plaques on the buttocks. Histopathology revealed a lymphocytic infiltrate. The patient rejected the recommended chemotherapy and, following a three-year follow-up, remained alive with mildly aggravated symptoms. It has previously been reported that infiltrative CLL can involve the head and neck; however, involvement of multiple body areas, particularly toes and fingers is rare. This case highlights the importance of considering leukemia cutis in patients with underlying CLL who present with unusual clinical features.

Merkel cell carcinoma with partial B-cell blastic immunophenotype: a potential mimic of cutaneous richter transformation in a patient with chronic lymphocytic lymphoma

Merkel cell polyomavirus (MCPyV) is a DNA virus whose pathogenic mechanisms in Merkel cell carcinoma (MCC) are still being unraveled. Emerging reports of an association between MCPyV and chronic lymphocytic lymphoma (CLL) have begun to broaden our understanding of the oncogenic mechanisms of this virus and the known association between these 2 malignancies. Herein, we report a case of MCC demonstrating a B-cell immunophenotype arising in a patient with CLL being treated with rituximab. In this context, we discuss the differential diagnostic considerations, especially with cutaneous Richter transformation (diffuse large B-cell lymphoma). We also assessed for the presence of MCPyV in both the patient's MCC and the CLL. Finally, we provide a large meta-analysis of patients with CLL and MCC. Patients with both MCC and CLL have a dismal prognosis, with greater than 50% overall mortality within the first year and a half after MCC diagnosis.

Optimal management of skin cancer in immunosuppressed patients

Skin cancer is the most common malignancy in humans with basal cell carcinoma representing the majority of cases in the general population. The prevalence of skin cancer is increased amongst immunosuppressed patients such as those with lymphoproliferative disorders including non-Hodgkin lymphoma and chronic lymphocytic leukemia or those with iatrogenic immunosuppression following organ transplantation. In addition, these patients experience greater morbidity and mortality associated with skin cancers. The most common skin cancer in immunosuppressed patients is squamous cell carcinoma, which often presents with more aggressive features and has a greater rate of metastasis. This article reviews the risk factors, etiology, clinical presentation, and prevalence of skin cancer amongst immunosuppressed patients, including organ transplant, lymphoproliferative disorders, autoimmune disorders, and human immunodeficiency virus. We also provide a comprehensive review of treatment guidelines for immunosuppressed patients with cutaneous malignancy. Surgical therapy is the cornerstone of treatment; however, we also discuss pharmacologic treatment options, lifestyle modifications, and revision of immunosuppressive regimens.

Merkel cell carcinoma - recent advances in the biology, diagnostics and treatment

Merkel cell carcinoma (MCC) is an uncommon primary cutaneous carcinoma with neuroendocrine differentiation. Since recent discovery of MCCs strong association with Merkel cell polyomavirus (MCPyV), there has been a rapid increase in the understanding of the carcinomas genetics, molecular biology and pathogenesis. In our study, we reviewed recent advances and controversies concerning MCC histogenesis, epidemiology, diagnostic and prognostic markers. We analyzed the association of MCPyV with MCC and the possible new targets for therapy. We also examined English-based literature regarding MCC pathogenesis published between 2008 and 2013, which lead to a deeper understanding of the topic. Our study showed that the association of MCPyV strongly influences the course of MCC. Additionally, it has been shown that a immunological response to MCPyV may in the future give hope to identify new therapeutic strategies in treatment of this fatal malignancy. This article is part of a Directed Issue entitled: Rare Cancers.

Cutaneous T-cell lymphoma in patients with chronic lymphocytic leukemia: clinical characteristics, temporal relationships, and survival data in a series of 14 patients at Mayo Clinic

BACKGROUND

We examined the course of cutaneous T-cell lymphoma (CTCL), which has been associated with chronic lymphocytic leukemia (CLL) in patients with CLL.

MATERIALS AND METHODS

A search was conducted of the master diagnosis index at our institution to identify patients with both CLL and CTCL from 1980 to 2010. A retrospective chart review was then conducted.

RESULTS

Of the 14 patients with CTCL and CLL, eight had mycosis fungoides (MF; two with patch stage, two with plaque stage, two with tumor stage, and two with erythrodermic stage), four had Sézary syndrome, one had natural killer cell lymphoma involving the skin, and one had peripheral T-cell lymphoma involving the skin. Eight had concurrent diagnoses, five received a CLL diagnosis first, and one received a CTCL diagnosis first. Ten patients were deceased at the time of data abstraction due to unknown causes (n = 4), lymphoma (n = 2), pneumonia (n = 2), MF (n = 1), or respiratory failure (n = 1). Of the nine patients with concurrent or prior CTCL, seven were deceased, with a median time to death of 10.2 months (range, 6-89 months). Of the five patients with CLL prior to CTCL, three were deceased at 18, 27, and 47 months, respectively, after the CTCL diagnosis. The median survival for the two groups was 12 and 47 months, respectively.

CONCLUSIONS

Patients with CTCL concurrent with or prior to CLL have a worse overall survival than patients with CLL in whom CTCL later develops. Larger studies are needed.