Non-invasive Skin Imaging in Cutaneous Lymphomas

The diagnosis of cutaneous lymphomas is challenging and requires skin tissue for histology and immunophenotyping using immunohistochemistry and molecular studies. In recent years, the role of non-invasive imaging techniques has been described as part of the clinical assessment of cutaneous lymphoma lesions. Imaging modalities such as dermoscopy, reflectance confocal microscopy (RCM), and high frequency ultrasound (HFUS) have been shown to be very valuable in raising the clinical suspicion for lymphomas of the skin, and in distinguishing cutaneous lymphomas from inflammatory dermatoses such as lupus, psoriasis, or eczema. These non-invasive methods can be used to direct the clinician to the optimal biopsy site to maximize the histopathological results and minimize false negatives. These methods also have a potential place in monitoring treatment response. In this review we present a concise summary of the dermoscopic imaging, RCM, and HFUS features seen in cutaneous T-cell lymphomas (CTCL) and B-cell lymphomas (CBCL).

A unilateral slow-growing yellow nodule of the glans penis

A 54-year-old man presented with a slow-growing yellow nodule on the glans penis. Histology revealed a dense nodular infiltrate throughout the entire dermis, composed of a predominance of large mononucleated histiocytes with a few multinucleated cells; the overlying epidermis was slightly hyperplastic. The cells were positive for CD68 and negative for S100 and CD1a.

Prognostic value of Bcl2 and Bcl6 in primary cutaneous large B-cell lymphoma: A systematic review and meta-analysis

AIMS

To assess the prognostic value of Bcl2 and Bcl6 in primary cutaneous diffuse large B-cell lymphoma (pcDLBCL), through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to April 2021 for studies reporting Bcl2 and Bcl6 expression and survival outcomes in pcDLBCL series. Kaplan-Meier and Cox regression survival analyses with hazard ratio calculation were performed for overall survival (OS), with a significant p-value< 0.05.

RESULTS

Eight studies with 148 patients were included. OS was significantly decreased in Bcl2-pos itive pcDLBCLs (5-year OS= 52.9 ± 5.2%) compared to Bcl2 negative pcDLBCLs (5-year OS= 86.6 ± 7.2%), with a HR of 4.615 (95% CI, 1.827-11.657; p = 0.001); no significant difference in OS was found between Bcl6-positive pcDLBCLs (5-year OS= 61.3 ± 6.5%) and Bcl6-negative pcDLBCLs (5-year OS= 56.8 ± 7.2%), with a HR of 0.789 (95% CI, 0.462-1.350; p = 0.388).

CONCLUSIONS

In pcDLBCL, Bcl2 expression is a strong unfavourable prognostic marker; Bcl6 does not seem to be associated with survival instead. Further studies are necessary in this field.

A Rare Case of Primary Cutaneous Follicle Center Lymphoma Mimicking Leprosy

Cutaneous B-Cell Lymphoma is a rare type of cutaneous lymphoma with a plethora of clinical manifestations ranging from macules, papules, nodules, or plaques. The lesions are often painless and certain subtypes such as the primary cutaneous follicle center lymphoma (PCFCL) are indolent. The disease is often misdiagnosed with other dermatoses including bacterial and fungal infections. Here we report a 55-year-old female patient with clinical manifestations resembling multibacillary leprosy that was then confirmed to be PCFCL through aid of dermoscopy and histopathology. The patient then undergone chemotherapy using the R-CHOP regiment which resulted in significant clinical improvement and no signs of metastases or extracutaneous involvement upon follow-up.

Dermatoscopy of nodular/plaque-type primary cutaneous T- and B-cell lymphomas: A retrospective comparative study with pseudolymphomas and tumoral/inflammatory mimickers by the International Dermoscopy Society

BACKGROUND

Limited data on dermatoscopy of nodular/plaque-type T-/B-cell primary cutaneous lymphomas (PCLs) is available.

OBJECTIVE

To describe dermatoscopic features of nodular/plaque-type PCLs, comparing them with those of clinical mimickers (pseudolymphomas, tumors, and inflammatory lesions) and investigating possible differences according to histologic subtypes.

METHODS

Participants were invited to join this retrospective, multicenter case-control study by submitting histologically/immunohistochemically confirmed instances of nodular/plaque-type PCLs and controls. Standardized assessments of the dermatoscopic images and comparative analyses were performed.

RESULTS

A total of 261 lesions were included (121 PCLs and 140 controls). Orange structureless areas were the strongest PCL dermatoscopic predictor on multivariate analysis compared with tumors and noninfiltrative inflammatory dermatoses. On the other hand, a positive association was found between PCLs and either unfocused linear vessels with branches or focal white structureless areas compared with infiltrative inflammatory dermatoses, whereas white lines were predictive of PCLs over pseudolymphomas. Differences in the vascular pattern were also seen between B- and T-cell PCLs and among B-cell PCL subtypes.

LIMITATIONS

Retrospective design and the lack of a dermatoscopic-pathologic correlation analysis.

CONCLUSION

Nodular/plaque-type PCLs display dermatoscopic clues, which may partially vary according to histologic subtype and whose diagnostic relevance depends on the considered clinical differential diagnoses.

Dermoscopic and trichoscopic features of primary cutaneous lymphomas - systematic review

Dermoscopy and trichoscopy are non-invasive methods used as auxiliary tools in diagnostics of different dermatoses. To date, no systematic review concerning the utility of dermoscopy and trichoscopy in the diagnostics of primary cutaneous lymphomas has been published. The aim of this study was to summarize the current state of knowledge on this topic based on systematic search of PubMed database and related references published before 8th of August 2020. Besides dermoscopic features, type of dermoscope, polarization mode, magnification, number of cases and histopathological correlation were analysed. A total of 34 records were included into the final analysis, evaluating 141 patients diagnosed with primary cutaneous T-cell lymphomas and 70 patients with primary cutaneous B-cell lymphomas. Most of the analysed records evaluated dermoscopic features (n = 206); trichoscopy was analysed in only 5 cases. Structures most commonly observed in classical mycosis fungoides (n = 108) were fine short linear vessels/linear vessels, spermatozoa-like vessels and orange-yellow patchy areas. In folliculotropic mycosis fungoides (n = 12), most frequently observed were comedonal lesions/comedo openings/central keratotic plugs and white halo around hair follicles/perifollicular accentuation. Primary cutaneous marginal zone B-cell lymphoma (n = 42) and primary cutaneous follicle centre lymphoma (n = 20) most commonly presented with salmon-coloured background and fine short/linear irregular/serpentine vessels. For other PCL, with less than 10 cases reported in the analysed records, details have been provided in the article. Most observations analysed in this systematic review rely on findings from case reports/case series (with the level of evidence V) and lack a control group. A few studies provided information concerning technical aspects of dermoscopic/trichoscopic examination. The role of dermoscopy/trichoscopy in diagnostics of cutaneous lymphomas requires further studies, especially in entities where dermoscopic features have been described in only single or a few cases. However, it seems that this practical, accessory tool in future may provide additional clues during clinical assessment.

Borrelia burgdorferi in primary cutaneous lymphomas: a systematic review and meta-analysis

BACKGROUND

The association between Borrelia burgdorferi and primary cutaneous lymphoma is still unclear. This systematic review and meta-analysis aims to define the association of Borrelia burgdorferi with primary cutaneous lymphoma and its different entities.

METHODS

Electronic databases were searched for all studies that assessed the presence of Borrelia burgdorferi DNA in specimens of primary cutaneous lymphoma. The association between Borrelia and primary cutaneous lymphomas was assessed with an odds ratio (significant p < 0.05); cutaneous specimens with no lymphoproliferative disorders were used as controls. A secondary analysis was performed to assess the prevalence of Borrelia infection in different lymphoma entities.

RESULTS

Ten studies with 506 primary cutaneous lymphomas and 201 controls were included. The prevalence of Borrelia DNA positivity was highly heterogeneous among studies from different regions. Borrelia DNA positivity was significantly associated with primary cutaneous lymphomas (odds ratio = 10.88; p < 0.00001). The prevalence of Borrelia DNA positivity was similar among different entities (marginal zone: 7.3 %; follicular: 8.1 %; diffuse large B-cell: 7.5 %; mycosis fungoides: 8 %).

CONCLUSIONS

Borrelia burgdorferi is significantly associated with primary cutaneous lymphomas, with no differences among the several lymphoma entities (both B-cell and T-cell), but with strong geographical differences. Molecular testing for Borrelia would be justified in patients with primary cutaneous lymphoma from endemic areas.

Primary cutaneous anaplastic large-cell lymphoma of the eyelid: report of two cases and review of the literature

PURPOSE

Two new cases of primary cutaneous CD30+ anaplastic large-cell lymphoma (cALCL) of the eyelid are reported; these are analysed alongside existing cases to identify challenges relating to the diagnosis and management of such rare lesions.

MATERIAL AND METHODS

A review of existing literature on the PubMed database is conducted using the keywords: 'eyelid lymphoid proliferations', 'lymphoma of the eyelid', and 'primary cutaneous CD30+, ALK-anaplastic large-cell lymphoma of the eyelid'. Two new cases of cALCL are reported. Cases where patients present solely with a nodular periocular lesion are analysed for recurrence and survival rate.

RESULTS

Two new patients with a painless ulcerated nodule on the upper eyelid receive a confirmed diagnosis of cALCL after undergoing an excisional biopsy. The first, elderly patient has spontaneous remission; the second patient, with a concomitant chronic infection of hepatitis C virus (HCV), presents a more diffuse disease at the onset and requires radiotherapy. Together with 13 patients a primary cALCL identified from 11 previous studies, this constitutes a cohort of 15 patients. Of these, 10 present with an exclusively nodular lesion of the eyelid and four experience disease recurrence; no deaths from cALCL are reported.

CONCLUSION

Differential diagnosis between primary cALCL and lymphomatoid papulosis is essential and requires careful consideration of clinical and pathologic features. Radiologic staging examination is crucial in order to exclude systemic ALCL, particularly for patients with comorbidity. Though cALCL has the pathological features of a malignant lesion, the prognosis seems favourable for patients; a relatively high percentage even experience spontaneous resolution.

Dermoscopic follow-up of therapeutic response in mantle cell lymphoma with secondary involvement of the scalp

The scalp is a potential location for both benign and malignant tumors. Lymphoproliferative diseases can involve the skin as a primary or secondary manifestation. Dermoscopy is a noninvasive diagnostic tool for rapid diagnosis, screening, and follow-up of the majority of skin tumors. Mantle cell lymphoma (MCL), a rare type of aggressive systemic lymphoma, usually occurs as a generalized lymphadenopathy, commonly with infiltration of the bone marrow, spleen, gastrointestinal tract, and Waldeyer's ring. In rare cases, it can also involve other structures, such as the lungs, central nervous system, liver, or skin. We report the case of a 74-year-old male patient suffering from MCL since 2015. Complete remission was obtained after R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) treatment. During maintenance therapy with rituximab, a solitary tumor occurred on the scalp. Dermoscopy of the lesion suggested relapse because of the presence of multiple chaotically distributed short linear vessels with multiple red dots within the hair follicles. Histological examination confirmed the diagnosis of MCL. After second-line therapy with rituximab and bendamustine (R-B), the tumor of the scalp completely disappeared and dermoscopy showed no abnormalities.

Cutaneous localization of plasmablastic multiple myeloma with heterotopic expression of CD3 and CD4: Skin involvement revealing systemic disease

Plasmablastic multiple myeloma is an uncommon morphological variant of multiple myeloma with aggressive clinical course and poor outcome. Its differential diagnosis includes plasmablastic lymphoma, a variant of diffuse large B-cell lymphoma with frequent extranodal presentation, which usually affects immunosuppressed patients and is virtually indistinguishable from plasmablastic multiple myeloma on the basis of histology solely. Differential diagnosis relies on close clinical-pathological correlation. Herein, the authors report a case of aggressive multiple myeloma occurring in a 48-year-old patient with pure plasmablastic morphology, expression of T-cell markers CD3 and CD4, and cutaneous involvement as first presenting sign. Heterotopic expression of T-cell markers has been described in literature for both plasmablastic multiple myeloma and plasmablastic lymphoma. The causative mechanisms underlying this aberrant phenotype have not yet been elucidated; nevertheless the possibility of this rare finding should be considered to avoid misinterpretations. Remarkably, despite occurring rarely, cutaneous involvement could be observed at an early stage or even be the first manifestation of disease in particularly aggressive forms of myeloma. As a consequence, the presence of cutaneous lesions should not favor a straightforward diagnosis of plasmablastic lymphoma. The importance of a correct differential diagnosis lies in its therapeutical implications.

Dermoscopy in the Diagnosis of Cutaneous Leishmaniasis

Background

Cutaneous leishmaniasis (CL) is a protozoan infectious disease. Dermoscopy is a noninvasive diagnostic tool that has been applied to several skin diseases, including infestations.

Objectives

To determine the dermoscopic patterns of CL lesions and to investigate whether a relationship exists between dermoscopic characteristics and the disease duration, localization, and type of CL lesions.

Methods

Seventy-nine patients (48 male, 31 female) from Hatay, Turkey, were enrolled in the study and a dermoscopic evaluation was performed on 139 lesions. Images of CL lesions were taken via polarized light contact dermoscopy. Chi-square and Fisher exact tests were used for statistical analyses and P values <0.05 were considered significant.

Results

Generalized erythema was seen in all CL lesions. Vascular structures (94.2%), yellow tears (75.5%), and a white starburst-like pattern (58.3%) were the other most common dermoscopic features. Hyperkeratosis (P = 0.001) and white starburst-like pattern (P < 0.001) were more prevalent in the extremities than elsewhere. Among vascular structures, linear irregular (45.8%), hairpin (43.5%), and comma-shaped (25.9%) patterns were the most common dermoscopic findings. Linear irregular (P = 0.023) and arborizing vessels (P = 0.001) were observed in the head-neck region. Dotted (P = 0.009), hairpin (P < 0.001), and glomerular-like (P = 0.016) morphological findings were more prevalent in the extremities. Statistical significances in disease duration were detected in microarborizing (P = 0.027) and arborizing (P = 0.004) vessels and were most prevalent with a disease duration of >6 months. Hairpin vessels were prevalent in the plaque and nodulo-ulcerative type of lesions. Dotted vessels were most commonly seen in the plaque type (47.4%) of lesions.

Conclusions

Generalized erythema, yellow tears, and starburst-like patterns, as well as linear irregular, hairpin, comma-shaped, and arborizing vessels, were the most commonly detected dermoscopic features of CL lesions. We suggest that the presence of these features can be helpful when diagnosing CL lesions by dermoscopy.

Dermoscopy of the Month: Dermoscopy of Primary Cutaneous B-Cell Lymphoma

Primary cutaneous B- cell lymphomas (PCBLs) are B-cell malignant neoplasms that originate in the skin, and have no extracutaneous manifestations of disease at the time of diagnosis. PCBLs are classified into three main types: primary cutaneous marginal zone lymphoma (PCMZL), primary cutaneous follicle center lymphoma (PCFCL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL- LT). Dermoscopic characterization of PCBLs has been limited and dermoscopy may help to augment the clinical recognition of PCBLs with the most common dermoscopic findings of salmon colored areas and serpentine vessels. Recognition of dermoscopic features of primary cutaneous B- cell lymphomas can improve the early diagnosis of these tumors and their proper management.

Dermoscopic features of idiopathic facial aseptic granuloma

Idiopathic facial aseptic granuloma is a recently described condition with defined clinical features, natural history, and underlying histopathologic findings. Several reports have recently described the potential diagnostic usefulness of ultrasound findings in idiopathic facial aseptic granuloma. We describe herein the dermoscopic features of idiopathic facial aseptic granuloma.

Dermoscopy of Lymphomas and Pseudolymphomas

Primary cutaneous lymphomas are a heterogeneous group that includes 2 main groups of primary T- and B-cell lymphomas, which can involve the skin with distinct variability in clinical presentation, histopathology, immunophenotypes, molecular signature, and prognosis. The authors describe the most frequent clinical forms of cutaneous lymphomas and their dermoscopic features. Even if the diagnosis of these entities is still based on a cellular level and the literature on dermoscopy in cutaneous lymphomas is limited and, for several entities it is based only on single case reports/case series, we think that know how they appear also in dermoscopy can be useful for helping in the clinical diagnosis.

Dermatoscopy of Vascular Lesions

Cutaneous vascular lesions (VLs) represent a very common reason for dermatologic consultation for patients. In most cases, VLs are benign and self-limiting. However, because they often mimic malignant skin tumors, their correct and prompt identification is very important in daily practice. Dermoscopy may play a key role in achieving that purpose. This article reviews current knowledge of dermoscopic features of the most frequent VLs.

Alternative uses of dermoscopy in daily clinical practice: An update

Dermoscopy is a noninvasive diagnostic tool that is currently being used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermoscopy beyond pigmented lesions are constantly increasing, the aim of this article is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermoscopy features so as to enhance the diagnosis and avoid (in selected cases) unnecessary histologic confirmation. In other cases, dermoscopy features may be shared with other conditions, with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermoscopic presentation.

Dermoscopy and the diagnosis of primary cutaneous B-cell lymphoma

BACKGROUND

Primary cutaneous B-cell lymphomas (PCBCLs) are frequently misdiagnosed, and a biopsy is needed to attain the correct diagnosis.

OBJECTIVE

To characterize the dermoscopic features of PCBCL.

METHODS

In this retrospective observational study, we analysed the pathology reports of 172 newly diagnosed PCBCL for the initial clinical differential diagnosis. The dermoscopic images of 58 PCBCL were evaluated for dermoscopic features. Two dermoscopy experts, who were blinded to the diagnosis and the study objective, evaluated images from 17 cases for a dermoscopic differential diagnosis.

RESULTS

Of 172 biopsy-proven PCBCL lesions, cutaneous lymphoma was suspected by the clinician in 16.3%; the leading diagnosis was basal cell carcinoma in 17.4%, and other skin neoplasms in 21%. Studying 58 PCBCL dermoscopic images, we most frequently identified salmon-coloured background/area (79.3%) and prominent blood vessels (77.6%), mostly of serpentine (linear-irregular) morphology (67.2%). Dermoscopic features did not differ significantly by subtype or location. Blinded evaluation by dermoscopy experts raised a wide differential diagnosis including PCBCL, arthropod bite, basal cell carcinoma, amelanotic melanoma and scar/keloid.

CONCLUSIONS

Two dermoscopic features, salmon-coloured area/background and serpentine vessels, are frequently seen in PCBCL lesions. These characteristic dermoscopic features, although not specific, can suggest a possible diagnosis of PCBCL.

Dermoscopy of Malignant Skin Tumours: What's New?

Dermoscopy represents a new and effective tool that assists dermatologists in improving the accuracy of clinical diagnosis in onco-dermatology. The aim of this article is to provide an overview of the latest and important dermoscopic progress and observations in this ever-evolving field of dermatology.

Primary cutaneous CD 30 (+) ALK (-) anaplastic large cell lymphoma with dermoscopic findings: a case report

Primary cutaneous CD 30 (+) anaplastic large cell lymphoma (PCALCL) is a rare and indolent type of cutaneous T cell lymphoma, which usually presents as an asymptomatic solitary firm nodule that rapidly grows and often ulcerates without any systemic involvement.

A 64-year-old female presented to our outpatient clinic with a one-year history of multiple pink nodular lesions on the chest, back and gluteal regions. Dermoscopic examination of the nodular lesions revealed pink-to-yellow structureless areas and arborizing-to-polymorphous vessels. Histopathologic examination was consistent with CD30 (+) anaplastic large cell lymphoma. Systemic involvement was not detected. Local radiotherapy for large nodules and surgical excision for small nodules were performed. The large nodules had totally regressed after 10 sessions of radiotherapy.