Effective in vivo purging with rituximab and autologous peripheral blood stem cell transplantation in a woman with CD5 positive primary cutaneous diffuse large B-cell lymphoma

CD5+ Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type, Presenting as an Asymptomatic Nodule

Primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT), is a rare and aggressive variant of primary cutaneous lymphoma that typically expresses B cells as well as MUM1/IRF4, BCL2, and FOXP1, whereas BCL6 may be present or undetectable. We present a case of CD5+ PCDLBCL-LT presenting as a 6 mm pink-bluish nodule on the mid-left thigh, which was concerning for basal cell carcinoma. The histological examination reveals the presence of an intradermal proliferation of large, atypical CD5+, CD20+ BCL2+, BCL6+, MUM-1+, and Cyclin-D1+ lymphocytes in a nodular, diffuse interstitial and perivascular distribution. Because the patient presented with a small, single nodule, the systemic treatment of multiagent chemotherapy was avoided and localized electron beam radiation therapy with rituximab was initiated instead, achieving complete response. Early identification of PCDLBCL-LT is key for maximal therapeutic benefit and prognosis; it is important to consider PCDLBCL-LT on the differential when evaluating small, single nodules on the lower extremities of elderly patients.

CD5-Positive Primary Cutaneous Diffuse Large B-Cell Lymphoma-Leg Type

Most primary cutaneous B-cell lymphomas (PCBCL) are CD5 negative, and only a few cases were found to express CD5. We report the first well-documented CD5+ primary cutaneous diffuse large B-cell lymphoma-leg type (PCDLBCL-LT). A 71-year-old woman with a history of Multiple Sclerosis was admitted because of a nodule at the left thigh. Histological examination of the skin biopsy disclosed a diffuse dermal infiltration by large lymphoid cells. Immunohistochemistry revealed that these large cells were positive for CD5, CD20, CD79a, MUM1/IRF4, Bcl6, Bcl2, and cytoplasmic IgM/λ, whereas CD3, CD56, CD23, CD21, CD10, CD30, cyclin D1, CD68, lysozyme, myeloperoxidase, and CD34 were not detected. Thus, the diagnosis of a CD5+ PCDLBCL-LT was made. Despite treatment, the patient died 11 months after initial diagnosis.

Primary cutaneous diffuse large B cell lymphoma-other successfully treated by the combination of R-CHOP chemotherapy and surgery: A case report and review of literature

RATIONALE

The occurrence of primary cutaneous diffuse large B cell lymphoma-other (PCDLBCL-O) has been rarely reported in the literature. Its diagnosis is based on histopathological and immunohistochemical examinations. To improve the clinical diagnosis and treatment for PCDLBCL-O, we report a case of PCDLBCL-O successfully treated by the combination of R-CHOP (A chemotherapy protocol consists of cyclophosphamide, doxorubicin, vincristine, prednisone plus Rituximab) chemotherapy and surgery. The clinical manifestations, pathological characteristics, treatment and prognosis of the case were analyzed.

PATIENT CONCERNS

The patient was a 56-year-old female, presenting with red plaques and nodules in her left breast for 6 months.

DIAGNOSES

Based on the clinical manifestation, histopathological and immunohistochemical results, the patient was diagnosed with PCDLBCL-O.

INTERVENTIONS

She was treated with 6 courses of R-CHOP chemotherapy combined with surgical resection.

OUTCOMES

In the present case, fairly good curative effect was appeared with no recurrence within the 3 years' follow-up.

LESSONS

Primary cutaneous diffuse large B cell lymphoma commonly occurs on the legs (leg type), rarely on other sites of the body. The clinical manefestations are so variant that its diagnosis depends on histopathological and immunohistochemical examinations. Like systemic diffuse large B cell lymphoma, patients should be treated with systemic chemotherapy.

Clinical manifestations and pathogenesis of cutaneous lymphomas: current status and future directions

The primary cutaneous lymphomas are a heterogeneous group of T-, Natural Killer- and B- cell neoplasms with a wide range of clinical and pathological presentations, and with very different prognoses compared to systemic lymphomas. Recent studies have shown that the skin microenvironment, which is composed of various immune cell subsets as well as their spatial distribution and T-cell interactions through different chemokines and cytokines, has an important role in the development and pathogenesis of cutaneous lymphomas and has assisted in the development of novel and more effective immunotherapies. The following review will focus on the major subtypes of primary cutaneous lymphomas, including the clinical and histological patterns, molecular hallmarks, and current and future treatment strategies.

Rituximab: applications in dermatology

Rituximab is a chimeric anti-CD20 monoclonal antibody which has been used extensively for B-lymphocytic malignancies. In addition, applications for autoimmune diseases have emerged in recent years. Case reports support the use of rituximab in certain dermatologic conditions, including paraneoplastic pemphigus, pemphigus vulgaris, graft versus host disease, and cutaneous B-cell malignancies. Clinical trials are lacking and would be an appropriate next step.

Standard and new treatments in cutaneous B-cell lymphomas

BACKGROUND

Primary cutaneous B-cell lymphomas (PCBCL) are cutaneous non-Hodgkin lymphomas and can be classified clinically and by prognosis. The aim of this paper is to perform a review of standard and new treatments.

METHOD

This paper provides a literature review of the different treatments of PCBCL.

RESULTS

Surgery and radiotherapy remain the standard therapies in isolated cutaneous lesions. Systemic or intralesional interferon (IFN)-alpha may be an alternative in PCBCL with diffuse cutaneous lesions. In aggressive forms with poor prognosis, polychemotherapy is the first line of treatment although rituximab and radioimmunotherapy are evolving therapeutic options.

CONCLUSION

In the majority of cases, the treatment of CBCL is straightforward. In aggressive forms, new therapies and biologic therapies may be of real interest.