Cutaneous B-cell lymphoma--a clinical, pathological and immunohistochemical study

Assessment of tumor burden and treatment response by 18F-fluorodeoxyglucose injection and positron emission tomography in patients with cutaneous T- and B-cell lymphomas

18F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is a unique functional/metabolic imaging modality that is efficacious in nodal staging and detection of extranodal involvement for a variety of lymphomas. We report its novel use in evaluating tumor burden and response to therapy in two patients with cutaneous lymphomas. A 24-year-old woman with aggressive subcutaneous panniculitic T-cell lymphoma associated with fever, arthralgias, lymphadenopathy, mild anemia, and widespread painful lesions refractory to multiple treatment strategies exhibited intense uptake of a glucose analogue at sites of clinically apparent (and clinically imperceptible) disease. Denileukin diftitox therapy resulted in clinical remission, and a repeat PET scan failed to detect residual foci of malignancy. A 38-year-old man with a more indolent multifocal primary cutaneous follicle center B-cell lymphoma characterized by few systemic symptoms and slowly evolving lesions demonstrated only mild glucose analogue uptake at sites of disease. Remission was achieved by radiotherapy and intravenous rituximab, and confirmed by a repeat PET scan. Extracutaneous disease was not evident in either patient by this technique. These preliminary data suggest that FDG-PET may be useful in determining disease activity at the time of initial diagnosis, after treatment, and evaluating a suspected recurrence.

A case of mistaken identity: primary cutaneous lymphoma presenting as venous ulceration

A 88-year-old woman was referred to the surgical outpatient department with a recurrent, long-standing leg ulcer. On examination she was found to have signs of chronic venous hypertension (varicose veins, varicose eczema and lipodermatosclerosis), and a 10 mm ulcer which was thought to be a benign venous ulcer. Four-layer bandaging was instituted, but the ulcer failed to heal. A punch biopsy was therefore performed which supported the clinical diagnosis of a stasis ulcer. Three months later healing had not taken place, and the ulcer had grown in size and taken on a sinister appearance (Figure 1). A presumptive diagnosis of Marjolin's ulcer was made, and she subsequently underwent wide local excision and skin grafting. Histology revealed a high grade cutaneous B cell lymphoma. Excision was complete, with no evidence of regional or distant disease, and no further treatment was undertaken. She unfortunately died soon afterwards from an unrelated problem.

Cutaneous lymphoma. Understanding the new classification schemes

Both the REAL and EORTC classification schemes classify lymphomas according to their cell of origin. These schemata also incorporate clinical features that allow for the distinction of some of these disorders. The EORTC classification scheme for primary cutaneous tumors uses terminology similar to that of the REAL classification and should allow for the recognition of teleologically similar tumors in cutaneous and extracutaneous sites. Future investigations will no doubt yield information regarding the true nature of the low-grade B-cell lymphomas of the skin and sort out the ever-increasing number of tumors found to express CD30. Most important, the continued expansion of knowledge regarding cutaneous lymphomas should enhance the ability of physicians to predict prognosis and to arrive at the most effective therapy for patients with these diseases.

Molecular analysis of the immunoglobulin VH gene rearrangement in a primary cutaneous immunoblastic B-cell lymphoma by micromanipulation and single-cell PCR

The immunoglobulin VH gene rearrangement in a primary cutaneous, large-cell (centroblastic and immunoblastic) B-cell lymphoma was analyzed using a micromanipulation/single-cell polymerase chain reaction technique. In all single B cells obtained from CD20-stained skin sections that gave a polymerase chain reaction product (eight of 27 in biopsy I), the same VHDJH rearrangement, consisting of DP-54-DIR1-JH3a genes, was detected, with no intraclonal nucleotide diversity. Comparison with the most closely related germline counterpart showed significantly altered complementarity determining gene regions as a result of somatic mutations, suggesting an antigen-driven selection and expansion ofthis particular B-cell clone. Interestingly, in a biopsy obtained from the patient 9 mo later, during disease progression (deep muscle infiltration), the lymphoma cells again contained the same VHDJH gene rearrangement (six of 18 in biopsy II) without any further somatic mutations. Therefore, it is suggested that the cutaneous lymphoma characterized throughout this study descended from postgerminal center B-cells.