Differentiation between malignant B-cell lymphomas and pseudolymphomas of the skin

Cutaneous Reactive B-cell Lymphoid Proliferations

Cutaneous lymphoid hyperplasia (CLH), also known as cutaneous pseudolymphoma, is a spectrum of benign conditions characterized by reactive B- and T-cell cutaneous lymphocytic infiltrates. B-cell lymphoid proliferations are a heterogenous group of non-neoplastic cutaneous diseases that must be histopathologically distinguished from cutaneous B-cell lymphomas. These proliferations can be observed as reactive phenomena to infections, medications, allergens, neoplasms, and more. Further, there are many inflammatory conditions that present with reactive B-cell infiltrates, including actinic prurigo, Zoon balanitis, Rosai-Dorfman, and cutaneous plasmacytosis. This review summarizes multiple cutaneous B-cell lymphoid proliferations within the major categories of reactive and disease-associated CLH. Further we discuss major discriminating features of atypical CLH and malignancy. Understanding the specific patterns of B-cell CLH is essential for the proper diagnosis and treatment of patients presenting with such lesions.

Follicular Lymphoma with Widespread Skin Lesions and Chromosome 14;18 Translocation in the Skin

Background:

We report a case of systemic follicular B-cell lymphoma presenting with widespread skin lesions.

Objective:

The clinical features, histology, and treatment of primary and secondary cutaneous follicular lymphomas are discussed.

Conclusion:

The demonstration of chromosome 14; 18 translocation in the skin that is commonly found in primary, but rare in secondary, cutaneous follicular lymphoma can be helpful in confirming the diagnosis.

Case for diagnosis

A fifty-five year old Caucasian male presented with infiltrated plaques and nodules on the left leg. The lesions had been present for 6 months. He presented associated cardiopathy, nephropathy and endocrinopathy. Histopathological and immunohistochemical examinations confirmed the diagnosis of cutaneous diffuse B cell lymphoma. CD 20, CD 79a and Ki-67 were positive. Chemotherapy with cyclophosphamide, adriamycin and vincristine promoted partial remission.

Abnormal AP-1 protein expression in primary cutaneous B-cell lymphomas

BACKGROUND

Primary cutaneous B-cell lymphoma (PCBCL) consists mainly of primary cutaneous marginal zone B-cell lymphoma (PCMZL), primary cutaneous follicle centre lymphoma (PCFCL) and primary cutaneous large B-cell lymphoma, leg type (PCLBCL-LT). The activator protein 1 (AP-1) transcription factor includes JUN, FOS and other family members.

OBJECTIVES

To assess the expression pattern of AP-1 transcription factors in PCBCL.

METHODS

We analysed paraffin tissue sections from nine cases of PCMZL, seven PCFCL, six PCLBCL-LT and two unspecified PCBCL cases by using immunohistochemistry with antibodies against c-JUN, JUNB, JUND, c-FOS, RAF1, alphaPAK, CD30 and CCND1.

RESULTS

A positive staining for JUND (++) was observed in six cases of PCFCL (86%), five PCLBCL-LT (83%) and five PCMZL (56%). Positive CCND1 protein expression was present in four cases of PCLBCL-LT (67%), four PCFCL (57%) and four PCMZL (44%), and the two unspecified PCBCL cases. Expression of alphaPAK protein was seen in three cases of PCLBCL-LT (50%), two PCMZL (22%) and one PCFCL. However, c-JUN, c-FOS and RAF1 protein were rarely expressed in the PCBCL cases analysed; JUNB and CD30 protein expression was absent in these cases.

CONCLUSIONS

These findings suggest that the presence of abnormal AP-1 protein expression is associated with upregulation of JUND, CCND1 and alphaPAK and downregulation of JUNB in PCBCL.

JA. Processos linfoproliferativos da pele: Parte 1 - Linfomas cutâneos de células B

Os linfomas cutâneos primários de células B pertencem ao grupo das neoplasias malignas originadas de linfócitos B, do tipo não-Hodgkin. A rotina diagnóstica nos processos linfoproliferativos de células B é realizada pela biópsia da pele lesada para a análise histopatológica, imuno-histoquímica e pesquisa do rearranjo gênico. A classificação dos linfomas cutâneos primários vem sendo discutida nos últimos anos; as usualmente utilizadas são as propostas pela World Health Organization - WHO e pela European Organization for Research and Treatment of Cancer - EORTC. A recente classificação consensual proposta por WHO-EORTC deverá substituí-las. Entretanto, apesar dos recentes progressos, ainda existem controvérsias e dificuldades quanto à classificação, ao diagnóstico e ao tratamento dos linfomas cutâneos primários de células B.

Lymphoma of the skin

This chapter describes the various ways in which the non-Hodgkin's lymphomas can involve the skin, how these diseases should be assessed, standard treatments available in 2002, and new directions in research. The goal of the session is to succinctly review recent developments in lymphoma classification and treatment as they apply to the unique aspects of lymphoma when manifest in the skin. In Section I, Dr. Eric Hsi reviews the special characteristics of the lymphomas seen when they proliferate in the skin and the application of the new World Health Organization classification system to the cutaneous lymphomas, emphasizing the unique challenges of recognizing and correctly classifying these diseases. He summarizes the evidence in favor of including the skin lymphomas in the overall lymphoma classification scheme and concludes with a practical description of the specific skin lymphoma entities. In Section II, Dr. Joseph Connors describes the current optimal treatment of the B-cell lymphomas when they present in or metastasize to the skin. Building on the classification scheme described by Dr. Hsi, Dr. Connors outlines a treatment approach based on current understanding of pathophysiology of these diseases and application of each of the effective modalities available for cutaneous lymphoma including radiation, chemotherapy, and immunotherapy. In Section III, Dr. Francine Foss concludes the session with a discussion of the different T-cell lymphomas that start in or spread to the skin concentrating on mycosis fungoides, cutaneous anaplastic large cell lymphoma and peripheral T-cell lymphoma. She includes comments on the newer anti-T-cell chemo- and immuno-therapeutics focusing on agents and techniques specific for cutaneous T-cell lymphomas.

Primary cutaneous B-cell lymphoma: review and current concepts

PURPOSE

Primary cutaneous B-cell lymphoma (PCBCL) has only recently been recognized as a distinct clinical entity. With the advent of improved immunophenotyping and immunogenotyping, increasing numbers of PCBCL cases are being diagnosed. However, there is much confusion regarding the classification, treatment, and prognosis of these patients. The purpose of this article is to review and analyze the available data to provide the clinician with a concise summary of the diagnosis, prognosis, and treatment of PCBCL.

DESIGN

We conducted a thorough review of the medical literature on PCBCL, with a focus on classification, prognosis, and treatment trials.

RESULTS AND CONCLUSION

PCBCL is defined as a B-cell lymphoma originating in the skin. There is no evidence of extracutaneous disease at presentation and for 6 months after diagnosis, as assessed by adequate staging procedures. Currently, the European Organization for Research and Treatment of Cancer classification is the most concise disease classification scheme, dividing the subtypes of PCBCL by clinical behavior and histopathologic findings. Based on this classification, the most common subtype of PCBCL is follicular center cell lymphoma. PCBCL is generally an indolent form of lymphoma with a good prognosis. Although local cutaneous recurrences are observed in 25% to 68% of patients, dissemination to internal organs is rare. Five-year survival rates typically range from 89% to 96%. A specific subtype, large B-cell lymphoma of the leg, is noted to have a poorer prognosis, with a 5-year survival rate of 58%. Overly aggressive treatment of PCBCL has not been shown to improve survival or prevent relapse. The treatment of choice usually varies depending on the type of PCBCL, the body surface area, and the location of the involvement, as well as the age and general health condition of the patient. The majority of studies indicate that PCBCL is highly responsive to radiation therapy. Polychemotherapy should be reserved for involvement of noncontiguous anatomic sites or those with extracutaneous spread.

Cutaneous lymphoid hyperplasia and cutaneous marginal zone lymphoma: comparison of morphologic and immunophenotypic features

Cutaneous marginal zone lymphoma (MZL) is a recently described low-grade B-cell lymphoma that usually follows an indolent course. This tumor shares many histologic and clinical features with cutaneous lymphoid hyperplasia (CLH), a benign reactive lymphoid proliferation. Sixteen biopsy specimens from 14 patients with CLH were studied, and compared with 16 cases of cutaneous MZL (9 primary cutaneous, 7 with secondary involvement of the skin) to determine whether there were features that would permit their distinction on routinely fixed, paraffin-embedded tissue sections. Both disorders showed a female preponderance (CLH: 9 F, 5 M; MZL: 11 F, 5 M). The median age was also similar (CLH: 54 years; cutaneous MZL: 55 years). CLH was most common on the arm (8) and the head and neck (7) but also involved the trunk (1); primary cutaneous MZL most often involved the limbs (3), trunk (3), and head and neck (3). Lymphoma did not develop in any of the 14 CLH patients (follow-up ranging from 9 to 246 months, mean 62 months). Six of 9 patients with primary cutaneous MZL and all 7 patients with secondary cutaneous MZL experienced relapses, most commonly isolated to skin or a subcutaneous site. On hematoxylin-eosin stained sections, a diffuse proliferation of marginal zone cells (p < 0.0001), zones of plasma cells (p = 0.01), the absence of epidermal change (p = 0.01), reactive germinal centers (p = 0.03), and a diffuse pattern of dermal or subcutaneous infiltration (p = 0.03) were more often seen in cutaneous MZL. A dense lymphocytic infiltrate, bottom-heavy or top-heavy growth pattern, eosinophils, and a grenz zone were seen equally often in both disorders. Dutcher bodies were observed only in cutaneous MZL. Immunoperoxidase stains on formalin-fixed paraffin-embedded tissue sections showed monotypic expression of immunoglobulin light chains by plasma cells in 11 of 16 MZL cases. By definition, no case with monotypic plasma cells was diagnosed as CLH. In CLH, T cells usually outnumbered B cells, and a B:T cell ratio > or = 3:1 was not observed in any case. By contrast, 40% of the MZL cases showed a B:T cell ratio > or = 3:1. No coexpression of CD20 and CD43 was seen in any case of either MZL or CLH. In summary, the clinical presentations of CLH and MZL are similar. In contrast to historical criteria for diagnosing cutaneous lymphoid infiltrates, the presence of reactive follicles favors a diagnosis of cutaneous B-cell lymphoma (CBCL). In addition, a bottom-heavy or top-heavy growth pattern is not a distinctive finding. Marginal zone cells and zones or sheets of plasma cells are strong morphologic indicators of marginal zone lymphoma. The diagnosis of CBCL can be supported in 40% of the cases by demonstrating a B:T cell ratio of > or = 3:1, and confirmed in 70% of the cases by demonstrating monotypic light chain expression of plasma cells on paraffin sections.

Experts and gold standards in dermatopathology: qualitative and quantitative analysis of the self-assessment slide seminar at the 17th colloquium of the International Society of Dermatopathology

The diagnosis of lymphoproliferative and melanocytic skin lesions is one of the most vexing problems in dermatopathology, a problem that is compounded by the far-reaching therapeutic and psychosocial consequences of the diagnosis for both patient and physician. On the occasion of a self-assessment slide seminar held during a dermatopathology meeting, 30 unusual lymphoproliferative and melanocytic lesions, each provided with four differential diagnoses, were evaluated by "expert pathologists" and other participants ("nonexperts") of the slide seminar. The final diagnosis was pinpointed by the majority of the experts in 16 of 30 cases (56%). The group of experts returned an unanimous decision on the diagnosis in only 2 of the 30 cases (7%). In contrast to the expert group, the preferred diagnoses given by the nonexperts showed a wider range. In 20 of 30 cases (66%), the final diagnosis could only be established after consideration of clinical, histologic, immunophenotypic, and molecular features. Our findings agree with the results of recent studies indicating quite a high degree of discordance among expert pathologists. The discordance between experts and, to a higher extent, nonexperts may have some crucial consequences for dermatopathology. Full agreement on diagnosis, particularly in unusual skin lesions, cannot be achieved only by an accumulation of expertises. Instead of relying on one single finding or diagnostic procedure ("gold standard") as the main criterion upon which to base a diagnosis, the diagnoses become more reliable if based on the integration of several factors including an evaluation of clinical and histomorphologic features and immunophenotypic and molecular findings ("diagnostic elements"), particularly in the field of lymphoproliferative and melanocytic lesions. In addition, a continuous retrospective work-up of difficult or unusual cases is recommended to ensure a long-term improvement in diagnostic reliability.

Cutaneous pseudolymphomas

Cutaneous pseudolymphoma refers to a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes of diverse causes that simulate cutaneous lymphomas clinically and/or histologically. The inflammatory infiltrate is bandlike, nodular, or diffuse and is composed predominantly of lymphocytes with or without other inflammatory cells. Depending on the predominant cell type in the infiltrate, cutaneous pseudolymphomas are divided into T- and B-cell pseudolymphomas. Cutaneous T-cell pseudolymphomas include idiopathic cutaneous T-cell pseudolymphoma, lymphomatoid drug reactions, lymphomatoid contact dermatitis, persistent nodular arthropod-bite reactions, nodular scabies, actinic reticuloid, and lymphomatoid papulosis. Cutaneous B-cell pseudolymphomas include idiopathic lymphocytoma cutis, borrelial lymphocytoma cutis, tattoo-induced lymphocytoma cutis, post-zoster scar lymphocytoma cutis, and some persistent nodular arthropod-bite reactions. This review attempts to discuss current aspects of the classification, pathogenesis, clinical spectrum, histopathologic and immunohistochemical diagnosis, and laboratory investigations for clonality in the various types of cutaneous pseudolymphomas.

A case of cutaneous B-cell lymphoma with a storiform stromal reaction

A case of cutaneous B-cell lymphoma is described. The patient was treated only by surgical excision of the skin tumors five times during a period of about two years from February of 1984 to October of 1986. After the last surgical excision, a continuous disease-free period was achieved. Biopsy samples showed dense lymphocytic infiltrations with discrete masses in the dermis and subcutis; one of them showed a storiform pattern. At the time, the infiltrating cells were composed of medium and large lymphoid cells and spindle-shaped cells. The medium and large lymphoid cells were positive for CD20, CD22 and HLA-DR and negative for CD3, CD4, CD5, CD8, CD43, and kappa and lambda light chain. The spindle-shaped cells were negative for CD20, CD43, kappa and lambda light chain, lysozyme, and S-100 protein.

A case of cutaneous B-cell lymphoma treated successfully with MACOP-B

A case of cutaneous B-cell lymphoma successfully treated by MACOP-B therapy is described. The patient was a 43-year-old man with reddish tumors measuring 3 to 7 cm in diameter on the right cheek and the post-auricles. Histopathologically, massive infiltrations of medium-sized atypical lymphoid cells were found in the reticular dermis and subcutis. A clear zone beneath the epidermis was also detected. The atypical lymphoid cells were positive for CD19, CD20, CD22 and HLA-DR but negative for CD3, CD4, CD5, CD10, CD43, CD45RO and CDw75. The patient was treated successfully with the MACOP-B protocol from March of 1990 to May of 1990. Since April of 1990, he has been free of disease.

Primary cutaneous B-cell lymphoma. Diagnosis, treatment, and prognosis

BACKGROUND

An elderly woman with B-cell lymphoma confined to the skin of the lower extremity was treated with combination chemotherapy and radiation therapy. She relapsed with new skin lesions outside the original radiation port that responded to additional radiation therapy and remains in remission 12 months after her last treatment.

OBJECTIVE

This article investigates the diagnosis, treatment, and prognosis of primary cutaneous B-cell lymphoma.

METHODS

The relevant literature was researched through computer data bases and bibliographies.

RESULTS

Patients who present with localized lesions of primary cutaneous B-cell lymphoma have a favorable prognosis regardless of the type of therapy, although relapses may occur in the absence of systemic disease.

CONCLUSION

We advocate the use of local therapies as initial treatment in patients with localized primary cutaneous B-cell lymphoma.

Lymphocytoma cutis: a series of five patients successfully treated with cryosurgery

BACKGROUND

Lymphocytoma cutis is a rare cutaneous eruption that may possess clinical and histologic features resembling malignant lymphoma.

OBJECTIVE

Our purpose was to find a good method to treat patients with lymphocytoma cutis.

METHODS

Five patients with lymphocytoma cutis were seen; each agreed to cryosurgery.

RESULTS

In each patient the lesions responded well to cryosurgery.

CONCLUSION

Cryosurgery appears to be an excellent therapeutic option for patients with lymphocytoma cutis. To our knowledge this is the first time liquid nitrogen has been used to eradicate these lesions.

Pseudolymphoma of the earlobes due to ear piercing

Keloids are commonly seen as a complication of earlobe piercing. As biopsies are usually not performed routinely in many instances, some of the lesions might, in fact, represent other entities, such as cutaneous pseudolymphoma. Contrary to keloids, for which surgery alone is not recommended, a simple excision or superficial x-ray is sufficient in such cases.