1
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Tavberidze N, Bennett DD, Matson DR. Diffuse Large B-Cell Lymphoma, Not Otherwise Specified (DLBCL NOS) Presenting as Multiple Subcutaneous Nodules: An Unusual Cutaneous Presentation of Systemic Disease. Case Rep Pathol 2023; 2023:2960965. [PMID: 37822715 PMCID: PMC10564572 DOI: 10.1155/2023/2960965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
Diffuse large B-cell lymphoma, not otherwise specified (DLBCL NOS) is the most common lymphoid malignancy in the Western world and classically presents as a rapidly enlarging nodal or extranodal mass. Cutaneous involvement by systemic DLBCL NOS is an infrequent clinical presentation, encountered in only 1.5-3.5% of cases, while disseminated cutaneous disease with multiple subcutaneous nodules at the time of diagnosis is unusual and can present a diagnostic challenge. The differential diagnosis when encountering a high-grade B-cell malignancy at a cutaneous site is broad and includes primary cutaneous follicle center lymphoma (PCFCL), primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT), high-grade B-cell lymphoma with MYC and BCL2 rearrangements (HGBCL-MYC/BCL2), and other potential entities which must all be carefully considered before rendering a final diagnosis. In this report, we describe the case of a 69-year-old man who was seen at our hospital due to generalized weakness and was found to have multiple subcutaneous nodules representing disseminated DLBCL NOS. The case was complicated by concurrent monoclonal B-cell lymphocytosis involving the bone marrow.
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Affiliation(s)
- Nika Tavberidze
- Departement of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Daniel D. Bennett
- Department of Dermatology, University of Wisconsin-Madison, Madison, WI, USA
| | - Daniel R. Matson
- Departement of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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2
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous B-cell lymphomas: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1326-1332. [PMID: 37434388 DOI: 10.1002/ajh.26968] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 07/13/2023]
Abstract
DISEASE OVERVIEW Approximately one-fourth of primary cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL, LT). DIAGNOSIS Diagnosis and disease classification is based on histopathologic review and immunohistochemical staining of an appropriate skin biopsy. Pathologic review and an appropriate staging evaluation are necessary to distinguish primary cutaneous B-cell lymphomas from systemic B-cell lymphomas with secondary skin involvement. RISK-STRATIFICATION Disease histopathology remains the most important prognostic determinant in primary cutaneous B-cell lymphomas. Both PCFCL and PCMZL are indolent lymphomas that infrequently disseminate to extracutaneous sites and are associated with 5-year survival rates that exceed 95%. In contrast, PCDLBCL, LT is an aggressive lymphoma with an inferior prognosis. RISK-ADAPTED THERAPY PCFCL and PCMZL patients with solitary or relatively few skin lesions may be effectively managed with local radiation therapy. While single-agent rituximab may be employed for patients with more widespread skin involvement, multiagent chemotherapy is rarely appropriate. In contrast, management of patients with PCDLBCL, LT is comparable to the management of patients with systemic DLBCL.
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Affiliation(s)
- Alexandra C Hristov
- Departments of Pathology and Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Trilokraj Tejasvi
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan A Wilcox
- Division of Hematology/Oncology, University of Michigan Cancer Center, Ann Arbor, Michigan, USA
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3
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Louissaint A. Navigating the Heterogeneity of Follicular Lymphoma and its Many Variants: An Updated Approach to Diagnosis and Classification. Surg Pathol Clin 2023; 16:233-247. [PMID: 37149358 DOI: 10.1016/j.path.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Follicular lymphoma (FL) is a lymphoid neoplasm composed of follicle center (germinal center) B cells, with varying proportions of centrocytes and centroblasts, that usually has a predominantly follicular architectural pattern. Over the past decade, our understanding of FL has evolved significantly, with new recognition of several recently defined FL variants characterized by distinct clinical presentations, behaviors, genetic alterations, and biology. This manuscript aims to review the heterogeneity of FL and its variants, to provide an updated guide on their diagnosis and classification, and to describe how approaches to the histologic subclassification of classic FL have evolved in current classification schemes.
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Affiliation(s)
- Abner Louissaint
- Department of Pathology, Massachusetts General Hospital, 149 13th St, Charlestown, MA 02114, USA.
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4
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Saksena A, Jain A, Pack SD, Kim J, Lee I, Tyagi M, Xi L, Pittaluga S, Raffeld M, Jaffe ES. Follicle Center Lymphoma (FCL) of the Lower Female Genital Tract (LFGT): A Novel Variant of Primary Cutaneous Follicle Center Lymphoma (PCFCL). Am J Surg Pathol 2023; 47:409-419. [PMID: 36461146 PMCID: PMC9974907 DOI: 10.1097/pas.0000000000002003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Primary cutaneous follicle center lymphoma has been distinguished from nodal follicular lymphoma (FL) based on genomic and clinical features. The nature of other extranodal FLs is not well defined. We report 15 cases of follicle center lymphoma involving the lower female genital tract. Cases were evaluated using an immunohistochemical panel for B-cell lymphoma, B-cell clonality, fluorescence in situ hybridization for BCL2 gene rearrangement, and next-generation sequencing. All patients had localized disease with no evidence of bone marrow involvement. Most cases (12/15, 80%) had a follicular pattern, at least focally. Large centrocytes were a prominent feature leading to concern for diffuse large B-cell lymphoma by referring pathologists. Neoplastic cells were positive for CD20 and BCL-6, while BCL-2 was positive in 2/15 (13%) cases. Fluorescence in situ hybridization for BCL2 gene rearrangement was negative in 10/11 (91%) cases. Next-generation sequencing performed in 10 cases revealed TNFRSF14 as the most frequently mutated gene in 6/10 (60%) cases. No case had CREBBP or KMT2D mutations as seen in nodal FL. None of the patients had progressive disease with durable complete remission achieved in 10/12 (83%) cases. The median follow-up period was 7.8 years (range: 0.2 to 20.5 y) with a 5-year overall survival of 100%. We conclude that follicle center lymphoma of the lower female genital tract is a novel variant of primary cutaneous follicle center lymphoma. Despite a frequent component of large cells, it is characterized by localized disease and low risk for dissemination. Awareness and recognition are important to distinguish these lesions from aggressive B-cell lymphomas.
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Affiliation(s)
- Annapurna Saksena
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Ashish Jain
- CCR Collaborative Bioinformatics Resource (CCBR), CCR, NCI, Bethesda, MD
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Svetlana D. Pack
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Jung Kim
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Ina Lee
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Manoj Tyagi
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Liqiang Xi
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Mark Raffeld
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
| | - Elaine S. Jaffe
- Laboratory of Pathology, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
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5
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Goodlad JR, Cerroni L, Swerdlow SH. Recent advances in cutaneous lymphoma-implications for current and future classifications. Virchows Arch 2023; 482:281-298. [PMID: 36278991 PMCID: PMC9852132 DOI: 10.1007/s00428-022-03421-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/27/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023]
Abstract
The Revised European-American Classification of mature lymphoid neoplasms published in 1994 and the 2001, 2008 and 2016 WHO classifications that followed, were the product of international collaboration and consensus amongst haematopathologists, geneticists, molecular scientists and clinicians. Primary cutaneous lymphomas were fully incorporated into this process following the publication of the WHO-EORTC classification of cutaneous lymphomas in 2005. The definition, diagnostic criteria and recommended studies for primary cutaneous lymphoma continue to be refined. The 2022 International Consensus Classification represents the most recent update and an overview of all the main entities presenting primarily in the skin, together with the major changes in classification, are summarized herein. Primary cutaneous marginal zone lymphoma is segregated from other extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT lymphoma) and downgraded to a lymphoproliferative disorder in line with its markedly indolent behaviour. In addition, two subtypes are recognised, based largely but not exclusively on whether they are heavy chain class-switched or IgM positive. Similarly, in keeping with a trend to greater conservatism, primary cutaneous acral CD8 positive T cell lymphoma is now also classified as a lymphoproliferative disorder. In addition, significant new insights into the biology of primary cutaneous lymphoma have also recently been forthcoming and will be presented. These studies have enhanced our knowledge of genetic, epigenetic and transcriptional changes in this group of diseases. They not only identify potential targets for novel therapies, but also raise as yet unanswered questions as to how we categorise cutaneous lymphomas, particularly with respect to relationships with similar lymphomas at extracutaneous sites.
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Affiliation(s)
- JR Goodlad
- Department of Pathology, NHS Greater Glasgow and Clyde, Level 3 Laboratory Medicine Building Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF UK
| | - L Cerroni
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - SH Swerdlow
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
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6
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A 47-Year-Old Patient With Multiple Desquamative Patches and Subsequent Onset of Papular Lesions: Answer. Am J Dermatopathol 2021; 42:791-792. [PMID: 32956083 DOI: 10.1097/dad.0000000000001486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Skala SL, Harms PW, Fullen DR, Brown NA, Tejasvi T, Wilcox RA, Boyer DF, Hristov AC. Cutaneous follicle center lymphomas with plasmacytic differentiation. J Cutan Pathol 2020; 48:632-636. [PMID: 33184902 DOI: 10.1111/cup.13917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/11/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
Follicle center lymphomas, including primary cutaneous follicle center lymphoma (PCFCL), may rarely show plasmacytic differentiation. Such cases can pose a diagnostic challenge and can be mistaken for other lymphomas that more commonly include plasma cells. Here, we report four cases of PCFCL and one case of systemic follicular lymphoma involving the skin with associated monotypic plasma cells, including the clinical, morphologic and immunophenotypic features.
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Affiliation(s)
- Stephanie L Skala
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Paul W Harms
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Douglas R Fullen
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Noah A Brown
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Trilokraj Tejasvi
- Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Ryan A Wilcox
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Daniel F Boyer
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Alexandra C Hristov
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan, USA
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8
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous B-cell lymphomas: 2021 update on diagnosis, risk-stratification, and management. Am J Hematol 2020; 95:1209-1213. [PMID: 32815650 DOI: 10.1002/ajh.25970] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 11/12/2022]
Abstract
DISEASE OVERVIEW Approximately one-fourth of primary cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL, LT). DIAGNOSIS Diagnosis and disease classification is based on histopathologic review and immunohistochemical staining of an appropriate skin biopsy. Pathologic review and an appropriate staging evaluation are necessary to distinguish primary cutaneous B-cell lymphomas from systemic B-cell lymphomas with secondary skin involvement. RISK-STRATIFICATION Disease histopathology remains the most important prognostic determinant in primary cutaneous B-cell lymphomas. Both PCFCL and PCMZL are indolent lymphomas that infrequently disseminate to extracutaneous sites and are associated with 5-year survival rates that exceed 95%. In contrast, PCDLBCL, LT is an aggressive lymphoma with an inferior prognosis. RISK-ADAPTED THERAPY Both PCFCL and PCMZL patients with solitary or relatively few skin lesions may be effectively managed with local radiation therapy. While single-agent rituximab may be employed for patients with more widespread skin involvement, multi-agent chemotherapy is rarely appropriate. In contrast, management of patients with PCDLBCL, LT is comparable to the management of patients with systemic DLBCL.
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Affiliation(s)
- Alexandra C Hristov
- Departments of Pathology and Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Trilokraj Tejasvi
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan A Wilcox
- Departments of Pathology and Dermatology, University of Michigan, Ann Arbor, Michigan, USA
- Division of Hematology/Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
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9
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Abstract
CONTEXT.— Primary cutaneous follicle center lymphoma is a low-grade B-cell lymphoma that is limited to the skin at diagnosis. It has a differential diagnosis that includes systemic/nodal follicular lymphoma secondarily involving the skin; primary cutaneous diffuse large B-cell lymphoma leg type; reactive lymphoid hyperplasia; and primary cutaneous marginal zone lymphoma. OBJECTIVE.— To review the clinical, morphologic, immunophenotypic, and genetic features of primary cutaneous follicle center lymphoma; its differential diagnosis; and the evidence that supports use of immunohistochemistry and genetic testing in the diagnosis and prognosis of this entity. DATA SOURCES.— Pertinent literature regarding cutaneous B-cell lymphomas is summarized and University of Michigan cases are used to highlight characteristics of primary cutaneous follicle center lymphoma. CONCLUSIONS.— Primary cutaneous follicle center lymphoma is a low-grade B-cell lymphoma with distinctive features, although some cases may have elements that overlap with other lymphomas, complicating interpretation.
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Affiliation(s)
| | | | - Alexandra C Hristov
- From the Department of Pathology, University of Michigan Medical Center, Ann Arbor (Drs Skala and A. C. Hristov); the Department of Internal Medicine, Section of Radiation Oncology, Wright Patterson Air Force Base (Dr B. Hristov); and the Department of Dermatology, University of Michigan Medical Center (Dr A. C. Hristov)
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10
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Servitje O, Climent F, Colomo L, Ruiz N, García‐Herrera A, Gallardo F, Mercadal S, Pomares H, Muniesa C, Martin‐Callizo C, Marcoval J, Rovira R, Estrach T, Pujol RM. Primary cutaneous vs secondary cutaneous follicular lymphomas: A comparative study focused on BCL2, CD10, and t(14;18) expression. J Cutan Pathol 2018; 46:182-189. [DOI: 10.1111/cup.13399] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 11/07/2018] [Accepted: 11/26/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Octavio Servitje
- Department of DermatologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Fina Climent
- Department of PathologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Lluis Colomo
- Department of PathologyHospital del Mar. Parc de Salut Mar. IMIM Barcelona Spain
| | - Nuria Ruiz
- Department of PathologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Adriana García‐Herrera
- Department of PathologyHospital Clínic. IDIBAPS. Universitat de Barcelona Barcelona Spain
| | - Fernando Gallardo
- Department of DermatologyHospital del Mar. Parc de Salut Mar. IMIM Barcelona Spain
| | - Santiago Mercadal
- Department of Hematology, Catalan Institute of Oncology. Hospital Duran i Reynals. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Helena Pomares
- Department of Hematology, Catalan Institute of Oncology. Hospital Duran i Reynals. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Cristina Muniesa
- Department of DermatologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Clara Martin‐Callizo
- Department of DermatologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Joaquim Marcoval
- Department of DermatologyHospital Universitari de Bellvitge. IDIBELL. Universitat de Barcelona Barcelona Spain
| | - Roger Rovira
- Department of DermatologyHospital del Mar. Parc de Salut Mar. IMIM Barcelona Spain
| | - Teresa Estrach
- Department of DermatologyHospital Clínic. IDIBAPS. Universitat de Barcelona Barcelona Spain
| | - Ramon M. Pujol
- Department of DermatologyHospital del Mar. Parc de Salut Mar. IMIM Barcelona Spain
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11
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Abstract
This article focuses on cutaneous hematopoietic neoplasms that are more likely to be encountered in the pediatric age-group and includes both lymphoproliferative and histiocytic disorders. The cutaneous hematologic disorders in children have a different epidemiologic profile to what is seen during adulthood. Although mycosis fungoides is the most frequent form of cutaneous lymphoma in adults, it is very rare in children. Because lymphoblastic leukemias and lymphomas are more frequent in the pediatric setting, cutaneous leukemic infiltrates are relatively common in this age-group. Similarly, histiocytic disorders are more common in children, particularly Langerhans cell histiocytosis and juvenile xanthogranuloma. Notably, the histiocytic disorders have undergone significant modifications on their nomenclature in the basis of the molecular characteristics that are present in them. A summary of the most frequent cutaneous hematopoietic disorders in children will be discussed further in this review.
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Affiliation(s)
- Alejandro A Gru
- 1 Department of Pathology, University of Virginia, Charlottesville, Virginia
| | - Louis P Dehner
- 2 Lauren V. Ackerman Laboratory of Surgical Pathology, St. Louis Children's Hospital and Dermatopathology, Washington University Medical Center, St. Louis, Missouri
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12
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Abstract
B-cell lymphomas represent approximately 20% to 25% of primary cutaneous lymphomas. Within this group, most cases (>99%) are encompassed by 3 diagnostic entities: primary cutaneous marginal zone lymphoma, primary cutaneous follicle center lymphoma, and primary cutaneous diffuse large B-cell lymphoma, leg type. In this article, the authors present clinical, histopathologic, immunophenotypic, and molecular features of each of these entities and briefly discuss the rarer intravascular large B-cell lymphoma.
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Affiliation(s)
- Charity B Hope
- Department of Pathology, UCSF Dermatopathology Section, University of California, San Francisco, 1701 Divisidero Street, Room 280, San Francisco, CA 94115, USA
| | - Laura B Pincus
- Department of Pathology, UCSF Dermatopathology Section, University of California, San Francisco, 1701 Divisidero Street, Room 280, San Francisco, CA 94115, USA; Department of Dermatology, UCSF Dermatopathology Section, University of California, San Francisco, 1701 Divisidero Street, Room 280, San Francisco, CA 94115, USA.
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13
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Primary Cutaneous Follicle Centre Lymphoma with Hodgkin and Reed-Sternberg Like Cells: A Case Report and Review of the Literature. Case Rep Hematol 2017; 2017:9549428. [PMID: 29082051 PMCID: PMC5634621 DOI: 10.1155/2017/9549428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/20/2017] [Indexed: 01/30/2023] Open
Abstract
An elderly woman with a complex medical history presented with a left forearm mass that slowly developed for several months. The excisional biopsy of this skin mass was remarkable for involvement by a follicle centre cell derived lymphoma with a nodular and diffuse pattern associated with a subset of scattered Hodgkin and Reed-Sternberg like cells. Fluorescence in situ hybridization studies did not detect the presence of IgH-bcl2 fusion transcript, and molecular studies were negative for immunoglobulin heavy chain gene rearrangements and EBV DNA sequences. Hodgkin and Reed-Sternberg like cells are rarely reported in FLs, and the association with primary cutaneous follicle centre lymphoma is extremely rarely seen. To our knowledge, our case is the second case of primary cutaneous follicle centre lymphoma with Hodgkin and Reed-Sternberg like cells.
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14
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Kheterpal M, Mehta-Shah N, Virmani P, Myskowski PL, Moskowitz A, Horwitz SM. Managing Patients with Cutaneous B-Cell and T-Cell Lymphomas Other Than Mycosis Fungoides. Curr Hematol Malig Rep 2017; 11:224-33. [PMID: 27101016 DOI: 10.1007/s11899-016-0322-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cutaneous lymphomas (CL) are a heterogeneous group of neoplasms characterized with clinical and histopathological variation, as well as overlap with benign dermatoses. Diagnosis and treatment of CLs is challenging and often requires a multidisciplinary approach. However, prognostic knowledge of these conditions and awareness of treatment options can help optimize appropriate use of available regimens, thereby improving care for patients. Here, we review the most recent literature and outline treatment themes for managing patients with cutaneous B-cell and T-cell lymphomas other than mycosis fungoides.
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Affiliation(s)
- Meenal Kheterpal
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, 500 Westchester Ave, West Harrison, NY, 10604, USA
| | - Neha Mehta-Shah
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, 1233 York Avenue, New York, NY, 10065, USA
| | - Pooja Virmani
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,, 16 E60th Street, New York, NY, 10022, USA
| | - Patricia L Myskowski
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,, 16 E60th Street, New York, NY, 10022, USA
| | - Alison Moskowitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,, 1275 York Avenue, New York, NY, 10065, USA
| | - Steven M Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Memorial Sloan Kettering Cancer Center, 1233 York Avenue, New York, NY, 10065, USA.
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15
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An Aggressive Primary Cutaneous Follicle Center Lymphoma With c-MYC Translocation and CDKN2A (9p21) Deletion: A Case Report and Review of the Literature. Am J Dermatopathol 2017; 39:e44-e49. [DOI: 10.1097/dad.0000000000000738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Hope CB, Pincus LB. Primary cutaneous B-cell lymphomas with large cell predominance-primary cutaneous follicle center lymphoma, diffuse large B-cell lymphoma, leg type and intravascular large B-cell lymphoma. Semin Diagn Pathol 2016; 34:85-98. [PMID: 28065463 DOI: 10.1053/j.semdp.2016.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In this review, we present clinical features and detailed histopathologic, immunologic, and molecular information regarding primary cutaneous follicle center lymphoma and primary cutaneous diffuse large B-cell lymphoma, leg type which together represent two of the three most common types of primary cutaneous B-cell lymphoma recognized in the current WHO classification system.1,2 Overall, B-cell lymphomas represent 19-27% of primary cutaneous lymphomas in most large European and American studies3-6 and together, primary cutaneous follicle center lymphoma and primary cutaneous diffuse large B-cell lymphoma, leg type account for approximately 2/3 to ¾ of these cases.5,7-11 Both subtypes can contain a high content of large B-lymphocytes, although most cases of primary cutaneous follicle center lymphomas exhibit a range in cell size and cytology. Intravascular large B-cell lymphoma, a less commonly-encountered EBV-negative primary cutaneous B-cell lymphoma composed of large cells, will be more briefly discussed in this report as well.
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Affiliation(s)
- Charity B Hope
- Department of Pathology, University of California San Francisco, USA
| | - Laura B Pincus
- Department of Pathology, University of California San Francisco, USA; Department of Dermatology, University of California San Francisco, USA.
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17
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Ceppi F, Pope E, Ngan B, Abla O. Primary Cutaneous Lymphomas in Children and Adolescents. Pediatr Blood Cancer 2016; 63:1886-94. [PMID: 27229270 DOI: 10.1002/pbc.26076] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/28/2016] [Accepted: 04/28/2016] [Indexed: 12/22/2022]
Abstract
Primary cutaneous lymphomas are rare in children and mostly represented by mycosis fungoides and CD30(+) lymphoproliferative disorders. Most pediatric cutaneous lymphomas have similar clinical/pathological features as their adult counterparts, particularly the T-cell subtypes. With regard to outcome, adult cutaneous mature T-cell lymphomas have a tendency to progression, while this appears to be relatively infrequent in children. The outcome of cutaneous B-cell lymphomas depends on subtype, with the B-lymphoblastic entity being associated with similar outcomes to precursor B acute lymphoblastic leukemia, while there are insufficient data on other entities. The diagnosis and treatment of these patients require a close collaboration between experienced pediatric pathologists, dermatologists, and oncologists. Prospective collection of longitudinal clinical and biological data from children with these rare lymphomas is needed to better understand their biological and clinical behavior and to ultimately discover the best therapeutic strategies.
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Affiliation(s)
- Francesco Ceppi
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, Ontario, Toronto, Canada
| | - Elena Pope
- Division of Dermatology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bo Ngan
- Division of Pathology, Department of Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Oussama Abla
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, Ontario, Toronto, Canada.
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Wilcox RA. Cutaneous B-cell lymphomas: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:1052-5. [PMID: 27650702 DOI: 10.1002/ajh.24462] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/09/2022]
Abstract
DISEASE OVERVIEW Approximately one-fourth of cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL, LT). DIAGNOSIS Diagnosis and disease classification is based on histologic review and immunohistochemical staining of an appropriate skin biopsy. Pathologic review and an appropriate staging evaluation are necessary to distinguish primary cutaneous B-cell lymphomas from systemic B-cell lymphomas with secondary skin involvement. RISK-STRATIFICATION Disease histology remains the most important prognostic determinant. Both PCFCL and PCMZL are indolent lymphomas that infrequently disseminate to extracutaneous sites and are associated with 5-year survival rates that exceed 95%. In contrast, PCDLBCL, LT is an aggressive lymphoma with an inferior prognosis. RISK-ADAPTED THERAPY PCFCL and PCMZL patients with solitary or relatively few skin lesions may be affectively managed with local radiation therapy. While single-agent rituximab may be employed for patients with more widespread skin involvement, multiagent chemotherapy is rarely appropriate. In contrast, management of patients with PCDLBCL, LT is comparable to the management of patients with systemic DLBCL. Am. J. Hematol. 91:1052-1055, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology University of Michigan Cancer Center; 1500 E. Medical Center Drive Room 4310 CC Ann Arbor Michigan 48109-5948
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19
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Lucioni M, Berti E, Arcaini L, Croci GA, Maffi A, Klersy C, Goteri G, Tomasini C, Quaglino P, Riboni R, Arra M, Dallera E, Grandi V, Alaibac M, Ramponi A, Rattotti S, Cabras MG, Franceschetti S, Fraternali-Orcioni G, Zerbinati N, Onida F, Ascani S, Fierro MT, Rupoli S, Gambacorta M, Zinzani PL, Pimpinelli N, Santucci M, Paulli M. Primary cutaneous B-cell lymphoma other than marginal zone: clinicopathologic analysis of 161 cases: Comparison with current classification and definition of prognostic markers. Cancer Med 2016; 5:2740-2755. [PMID: 27665744 PMCID: PMC5083727 DOI: 10.1002/cam4.865] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/30/2016] [Accepted: 07/16/2016] [Indexed: 11/21/2022] Open
Abstract
Categorization of primary cutaneous B‐cell lymphomas (PCBCL) other than marginal zone (MZL) represents a diagnostic challenge with relevant prognostic implications. The 2008 WHO lymphoma classification recognizes only primary cutaneous follicular center cell lymphoma (PCFCCL) and primary cutaneous diffuse large B‐cell lymphoma, leg type (PCDLBCL‐LT), whereas the previous 2005 WHO/EORTC classification also included an intermediate form, namely PCDLBCL, other. We conducted a retrospective, multicentric, consensus‐based revision of the clinicopathologic characteristics of 161 cases of PCBCL other than MZL. Upon the histologic features that are listed in the WHO classification, 96 cases were classified as PCFCCL and 25 as PCDLBCL‐LT; 40 further cases did not fit in the former subgroups in terms of cytology and/or architecture, thus were classified as PCDLBCL, not otherwise specified (PCDLBCL‐NOS). We assigned all the cases a histogenetic profile, based on the immunohistochemical detection of CD10, BCL6, and MUM1, and a “double hit score” upon positivity for BCL2 and MYC. PCDLBCL‐NOS had a clinical presentation more similar to PCFCCL, whereas the histology was more consistent with the picture of a diffuse large B‐cell lymphoma, as predominantly composed of centroblasts but with intermixed a reactive infiltrate of small lymphocytes. Its behavior was intermediate between the other two forms, particularly when considering only cases with a “non‐germinal B‐cell” profile, whereas “germinal center” cases resembled PCFCCL. Our data confirmed the aggressive behavior of PCDLBC‐LT, which often coexpressed MYC and BCL2. The impact of single factors on 5‐year survival was documented, particularly histogenetic profile in PCDLBCL and BCL2 translocation in PCFCCL. Our study confirms that a further group—PCDLBCL‐NOS—exists, which can be recognized through a careful combination of histopathologic criteria coupled with adequate clinical information.
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Affiliation(s)
- Marco Lucioni
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Emilio Berti
- Department of Dermatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico and Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Luca Arcaini
- Section of Hematology-Oncology, Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giorgio A Croci
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aldo Maffi
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Scientific Direction, Biometry and Statistics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gaia Goteri
- Pathologic Anatomy and Histopathology, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region, United Ancona Hospitals, Torrette, Ancona, Italy
| | - Carlo Tomasini
- Pathology Unit, Department of Laboratory Medicine, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Quaglino
- Dermatologic Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberta Riboni
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariarosa Arra
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elena Dallera
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vieri Grandi
- Division of Dermatology, University of Florence Medical School, Florence, Italy
| | - Mauro Alaibac
- Dermatologic Clinic, University of Padova, Padova, Italy
| | - Antonio Ramponi
- Division of Pathology, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Sara Rattotti
- Department of Hematology and Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Silvia Franceschetti
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | | | - Nicola Zerbinati
- Department of Surgical and Morphological Sciences, Faculty of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francesco Onida
- Hematology and Bone Marrow Transplantation Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milano, Italy
| | - Stefano Ascani
- Institute of Pathology, Ospedale S. Maria di Terni and University of Perugia, Perugia, Italy
| | - Maria Teresa Fierro
- Dermatologic Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Serena Rupoli
- Clinic of Hematology, United Ancona Hospitals, Torrette, Ancona, Italy
| | | | - Pier Luigi Zinzani
- Institute of Hematology "Seràgnoli", University of Bologna, Bologna, Italy
| | - Nicola Pimpinelli
- Division of Dermatology, University of Florence Medical School, Florence, Italy
| | - Marco Santucci
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence School of Human Health Sciences, Firenze, Italy
| | - Marco Paulli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Elwan NM, Abdel Salam S, Radwan NS. Spindle B-cell lymphoma: a rare variant of follicle center lymphoma. J Cutan Pathol 2016; 43:451-5. [DOI: 10.1111/cup.12686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 05/03/2015] [Accepted: 09/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Nagwa M. Elwan
- Dermatology and Venereology Department, Faculty of Medicine; Tanta University; Tanta Egypt
| | - Shady Abdel Salam
- Dermatology and Venereology Department, Faculty of Medicine; Tanta University; Tanta Egypt
| | - Nesrin S. Radwan
- Dermatology and Venereology Department, Faculty of Medicine; Tanta University; Tanta Egypt
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21
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Lima M. Cutaneous primary B-cell lymphomas: from diagnosis to treatment. An Bras Dermatol 2016; 90:687-706. [PMID: 26560215 PMCID: PMC4631235 DOI: 10.1590/abd1806-4841.20153638] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 06/05/2014] [Indexed: 12/19/2022] Open
Abstract
Primary cutaneous B-cell lymphomas are a heterogeneous group of mature B-cells neoplasms with tropism for the skin, whose biology and clinical course differ significantly from the equivalent nodal lymphomas. The most indolent forms comprise the primary cutaneous marginal zone and follicle center B-cell lymphomas that despite the excellent prognosis have cutaneous recurrences very commonly. The most aggressive forms include the primary cutaneous large B-cell lymphomas, consisting in two major groups: the leg type, with poor prognosis, and others, the latter representing a heterogeneous group of lymphomas from which specific entities are supposed to be individualized over time, such as intravascular large B-cell lymphomas. Treatment may include surgical excision, radiotherapy, antibiotics, corticosteroids, interferon, monoclonal antibodies and chemotherapy, depending on the type of lymphoma and on the type and location of the skin lesions. In subtypes with good prognosis is contraindicated overtreatment and in those associated with a worse prognosis the recommended therapy relies on CHOP-like regimens associated with rituximab, assisted or not with local radiotherapy. We review the primary cutaneous B-cell lymphomas, remembering the diagnostic criteria, differential diagnosis, classification, and prognostic factors and presenting the available therapies.
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Affiliation(s)
- Margarida Lima
- Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
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22
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Akhtari M, Reddy JP, Pinnix CC, Allen PK, Osborne EM, Gunther JR, Milgrom SA, Smith GL, Wogan CF, Fowler N, Rodriguez MA, Dabaja B. Primary cutaneous B-cell lymphoma (non-leg type) has excellent outcomes even after very low dose radiation as single-modality therapy. Leuk Lymphoma 2016; 57:34-8. [PMID: 25860237 PMCID: PMC9746263 DOI: 10.3109/10428194.2015.1040012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Primary cutaneous B cell lymphomas (PCBCL) are rare; although data on outcomes and treatment are limited, traditionally they have been treated with radiation doses in excess of 24 Gy. We retrospectively identified and reviewed all cases of PCBCL treated at our institution from 2002-2014. Thirty-nine patients with PCBCL (42 lesions) were identified. Radiation was the only treatment for most patients. All lesions had a complete response and none had in-field failures; seven patients had out-of-field relapses, three of which were salvaged with radiation therapy. No differences in PFS or OS were found for patients given low-dose (≤ 12 Gy) versus high-dose (> 12 Gy) radiation. PCBCL is an indolent entity with a long clinical course and excellent response to radiation therapy and successful salvage of recurrent disease, even when doses are as low as 4 Gy. Given the above findings, we recommend the initial use of low-dose irradiation for PCBCL.
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Affiliation(s)
- Mani Akhtari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX,Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Jay Paul Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chelsea C. Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela K. Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eleanor M. Osborne
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jillian R. Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah A. Milgrom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christine F. Wogan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nathan Fowler
- Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Alma Rodriguez
- Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bouthaina Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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23
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Wilcox RA. Cutaneous B-cell lymphomas: 2015 update on diagnosis, risk-stratification, and management. Am J Hematol 2015; 90:73-6. [PMID: 25535037 DOI: 10.1002/ajh.23863] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 09/30/2014] [Indexed: 11/10/2022]
Abstract
DISEASE OVERVIEW Approximately one-fourth of cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL, LT). DIAGNOSIS DIAGNOSIS and disease classification is based on histologic review and immunohistochemical staining of an appropriate skin biopsy. Pathologic review and an appropriate staging evaluation are necessary to distinguish primary cutaneous B-cell lymphomas from systemic B-cell lymphomas with secondary skin involvement. Risk-stratification: Disease histology remains the most important prognostic determinant. Both PCFCL and PCMZL are indolent lymphomas that infrequently disseminate to extracutaneous sites and are associated with 5-year survival rates that exceed 95%. In contrast, PCDLBCL, LT is an aggressive lymphoma with an inferior prognosis. RISK-ADAPTED THERAPY PCFCL and PCMZL patients with solitary or relatively few skin lesions may be affectively managed with local radiation therapy. While single-agent rituximab may be employed for patients with more widespread skin involvement, multiagent chemotherapy is rarely appropriate. In contrast, management of patients with PCDLBCL, LT is comparable to the management of patients with systemic DLBCL.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology; University of Michigan Cancer Center; Ann Arbor Michigan
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24
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Kempf W, Kazakov DV, Rütten A, Rupec RA, Talarcik P, Ballová V, Kerl K, Dummer R, Lautenschlager S, Zimmermann DR, Tinguely M. Primary cutaneous follicle center lymphoma with diffuse CD30 expression: A report of 4 cases of a rare variant. J Am Acad Dermatol 2014; 71:548-54. [DOI: 10.1016/j.jaad.2014.03.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 11/24/2022]
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25
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Chromosomal anomalies in primary cutaneous follicle center cell lymphoma do not portend a poor prognosis. J Am Acad Dermatol 2014; 70:1010-20. [DOI: 10.1016/j.jaad.2014.01.862] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 12/16/2013] [Accepted: 01/09/2014] [Indexed: 12/22/2022]
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26
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Can Cutaneous Low-Grade B-cell Lymphoma Transform Into Primary Cutaneous Diffuse Large B-cell Lymphoma? An Immunohistochemical Study of 82 cases. Am J Dermatopathol 2014; 36:478-82. [DOI: 10.1097/dad.0000000000000009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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28
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Ceovic R, Jovanovic I, Kostovic K, Rados J, Dotlic S, Radman I, Kulisic SM, Loncaric D. Radiotherapy of primary cutaneous follicle center lymphoma: case report and review of literature. Radiat Oncol 2013; 8:147. [PMID: 23786884 PMCID: PMC3702489 DOI: 10.1186/1748-717x-8-147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 06/17/2013] [Indexed: 11/10/2022] Open
Abstract
Primary cutaneous follicle center lymphoma is an indolent primary cutaneous B-cell lymphoma originating from the follicle center cells, composed of a combination of centrocytes (small and large cleaved cells) and centroblasts (large noncleaved cells) with a follicular, follicular/diffuse, or diffuse growth pattern. Lesions are mostly located on the head, neck and trunk. A case is presented of a 56-year-old male patient with primary cutaneous follicle center lymphoma, with lesions involving the skin of the back, shoulders, presternal area and right forearm. As the patient presented a disseminated cutaneous form of the disease that involved several anatomical regions, complete work-up was followed by superficial fractionated radiotherapy of eight fields in VI expositions, with total irradiation dose of 1400 cGy upon the following fields: right and left pectoral region, left and right shoulders, right suprascapular region, and proximal third of the right forearm. Total irradiation dose applied upon each field for the lesions located on the left and right side of the back was 1500 cGy. This therapy resulted in significant reduction of visible tumor. The patient was regularly followed up on outpatient basis for 12 months of radiotherapy, being free from local recurrence and systemic spread of the disease.
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29
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Honda R, Cerroni L, Tanikawa A, Ebihara T, Amagai M, Ishiko A. Cutaneous plasmacytosis: Report of 6 cases with or without systemic involvement. J Am Acad Dermatol 2013; 68:978-85. [DOI: 10.1016/j.jaad.2012.11.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 10/12/2012] [Accepted: 11/10/2012] [Indexed: 12/12/2022]
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30
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Clonal Identity and Differences in Primary Cutaneous B-Cell Lymphoma Occurring at Different Sites or Time Points in the Same Patient. Am J Dermatopathol 2013; 35:11-8. [DOI: 10.1097/dad.0b013e318255dbae] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Monsálvez V, Montes-Moreno S, Artiga MJ, Rodríguez ME, Sanchez-Espiridion B, Espiridión BS, Lozano M, Fernández-de-Misa R, Rodríguez-Peralto JL, Piris MA, Ortíz-Romero PL. MicroRNAs as prognostic markers in indolent primary cutaneous B-cell lymphoma. Mod Pathol 2013; 26:171-81. [PMID: 22936066 DOI: 10.1038/modpathol.2012.149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Indolent primary cutaneous B-cell lymphoma is a group of malignant lymphomas comprising marginal zone B-cell lymphoma and centrofollicular B-cell lymphoma. Relapse rate of these tumors is close to 40%, and identifying those patients who are likely to progress remains a challenge. The aim of this study was to characterize the microRNA (miRNA) expression profile of a series of primary cutaneous B-cell lymphomas and correlate with histological and clinical findings. We studied a series of 68 patients with primary cutaneous B-cell lymphomas (30 cutaneous marginal-zone B-cell lymphomas and 38 primary cutaneous centrofollicular lymphomas). A set of 11 miRNAs associated with the differentiation stage of B cells was quantified by real-time PCR, using RNA extracted from formalin-fixed, paraffin-embedded tissue diagnostic samples. Relevant clinical variables were retrieved in a subset of 57 patients (28 cutaneous marginal zone B-cell lymphomas and 29 primary cutaneous centrofollicular lymphomas). miR-150 was upregulated in cutaneous marginal zone B-cell lymphomas relative to primary cutaneous centrofollicular lymphoma samples (false discovery rate <0.05). miR-155 and miR-150 expression levels were associated with progression-free survival in a univariate Cox regression analysis (P<0.1). After stratification by histological subtype, low-expression levels of miR-155 and miR-150 were both associated with shorter progression-free survival only in primary cutaneous marginal zone B-cell lymphomas cases (log-rank test, P<0.05). In summary, miRNA expression analysis can be used as a tool for diagnosis and outcome prognosis in indolent primary cutaneous B-cell lymphoma.
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Affiliation(s)
- Veronica Monsálvez
- Department of Dermatology, Hospital Universitario 12 de Octubre, Madrid, Spain
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32
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Wilcox RA. Cutaneous B-cell lymphomas: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol 2013; 88:73-6. [PMID: 23379008 DOI: 10.1002/ajh.23360] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
DISEASE OVERVIEW Approximately one-fourth of cutaneous lymphomas are B-cell derived and are generally classified into three distinct subgroups: primary cutaneous follicle-center lymphoma (PCFCL), primary cutaneous marginal zone lymphoma (PCMZL), and primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL, LT). DIAGNOSIS Diagnosis and disease classification is based on histologic review and immunohistochemical staining of an appropriate skin biopsy. Pathologic review and an appropriate staging evaluation are necessary to distinguish primary cutaneous B-cell lymphomas from systemic B-cell lymphomas with secondary skin involvement. RISK-STRATIFICATION: Disease histology remains the most important prognostic determinant. Both PCFCL and PCMZL are indolent lymphomas that infrequently disseminate to extracutaneous sites and are associated with an excellent long-term prognosis. In contrast, PCLBCL, LT is an aggressive lymphoma with an inferior prognosis. RISK-ADAPTED THERAPY PCFCL and PCMZL patients with solitary or relatively few skin lesions may be affectively managed with local radiation therapy. Although single-agent rituximab may be employed for patients with more widespread skin involvement, multiagent chemotherapy is rarely appropriate. In contrast, management of patients with PCLBCL, LT is comparable to the management of patients with systemic DLBCL.
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MESH Headings
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/therapeutic use
- Humans
- Lymphoma, B-Cell, Marginal Zone/diagnosis
- Lymphoma, B-Cell, Marginal Zone/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/therapy
- Practice Guidelines as Topic
- Radiotherapy/methods
- Risk Assessment
- Rituximab
- Skin Neoplasms/diagnosis
- Skin Neoplasms/therapy
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Affiliation(s)
- Ryan A Wilcox
- Division of Hematology/Oncology, University of Michigan Cancer Center, Ann Arbor, 48109-5948, USA.
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33
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Rozati S, Kerl K, Kempf W, Tinguely M, Zimmermann DR, Dummer R, Cozzio A. Spindle-cell variant of primary cutaneous follicle center lymphoma spreading to the hepatobiliary tree, mimicking Klatskin tumor. J Cutan Pathol 2012; 40:56-60. [DOI: 10.1111/cup.12017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 05/16/2012] [Accepted: 06/03/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Sima Rozati
- Department of Dermatology; University Hospital of Zurich; Zurich; Switzerland
| | - Katrin Kerl
- Department of Dermatology; University Hospital of Zurich; Zurich; Switzerland
| | - Werner Kempf
- Department of Dermatology; University Hospital of Zurich; Zurich; Switzerland
| | - Marianne Tinguely
- Institute of Surgical Pathology; University Hospital of Zurich; Zurich; Switzerland
| | - Dieter R. Zimmermann
- Institute of Surgical Pathology; University Hospital of Zurich; Zurich; Switzerland
| | - Reinhard Dummer
- Department of Dermatology; University Hospital of Zurich; Zurich; Switzerland
| | - Antonio Cozzio
- Department of Dermatology; University Hospital of Zurich; Zurich; Switzerland
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Boiocchi L, Witter RE, He B, Subramaniyam S, Mathew S, Nie K, Cerutti A, Coleman M, Knowles DM, Orazi A, Tam W. Composite chronic lymphocytic leukemia/small lymphocytic lymphoma and follicular lymphoma are biclonal lymphomas: a report of two cases. Am J Clin Pathol 2012; 137:647-59. [PMID: 22431543 DOI: 10.1309/ajcphxo5ugw2oela] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Composite lymphomas (CLs) consisting of 2 indolent B-cell lymphomas are rare. We present 2 CL cases composed of chronic lymphocytic leukemia (CLL) and follicular lymphoma (FL), each with unique clinicopathologic features. In the first case, the FL was negative for IGH-BCL2 and harbored a novel IGH-associated translocation; in the second case, the CL manifested in the skin. The individual components in both CLs were derived from different B-cell clones. This is the first complete characterization, including molecular analysis, of CLs composed of leukemic CLL and FL and the first report of a cutaneous CL derived from 2 low-grade B cell lymphomas. Our results provide additional supporting evidence that CLs of indolent B-cell lymphomas are biclonal and suggest that they are pathogenetically different from CLs composed of a low-grade B-cell lymphoma and an aggressive B-cell lymphoma or Hodgkin lymphoma, which are usually clonally related.
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35
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Sproul AM, Goodlad JR. Clonality testing of cutaneous lymphoid infiltrates: practicalities, pitfalls and potential uses. J Hematop 2012. [DOI: 10.1007/s12308-012-0145-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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36
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Aigner F, Korol D, Schmitt AM, Kurrer MO. Extranodal diffuse large B cell lymphoma of cutaneous follicle centre lymphoma type: a study of 24 patients with non-cutaneous primary limited stage extranodal diffuse large B cell lymphoma in support of a new concept. Histopathology 2012; 60:774-84. [PMID: 22304695 DOI: 10.1111/j.1365-2559.2011.04122.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Follicle centre cell lymphoma of small cell type showing either a follicular or diffuse growth pattern similar to cutaneous follicle centre lymphoma (cFCL) has been recognized in extranodal non-cutaneous sites. Our aim was (i) to investigate whether diffuse large B cell lymphoma (DLBCL) of cFCL type could be identified in extranodal non-cutaneous sites and (ii) whether clinical characteristics similar to primary cFCL could be recognized. METHODS AND RESULTS Of 24 extranodal non-cutaneous DLBCLs, nine (38%) had large centrocytoid morphology and 15 (62%) were either 'centrocytoid and centroblastic' or 'centroblastic and immunoblastic'. Six centrocytoid cases were Irf-4 negative, Bcl-6 positive and at most weakly CD10- or Bcl-2-positive by immunohistochemistry, consistent with DLBCL of cFCL type. All patients with cFCL type were stage IE and were significantly younger than other patients. Recurrences occurred in two patients and were exclusively extranodal. CONCLUSION Our results suggest that DLBCL of cFCL type can be identified in extranodal non-cutaneous sites and shows clinical characteristics similar to genuine cFCL. We propose to expand the concept of cFCL to encompass large cell lymphomas in extranodal sites.
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Affiliation(s)
- Fabian Aigner
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
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Fernandez-Flores A. Comments on cutaneous lymphomas: since the WHO-2008 classification to present. Am J Dermatopathol 2011; 34:274-84. [PMID: 22126841 DOI: 10.1097/dad.0b013e31821b8bfe] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The last classification of lymphomas of the World Health Organization in 2008 made a few changes from the preceding classification. Although useful, at the same time, it has posed new questions, concerns, and dilemmas which have been raised in the literature. The current report highlights some of these controversies, of each of these primary cutaneous entities, going through cutaneous mature T-cell and NK-cell neoplasms, mature B-cell neoplasms, precursor neoplasms, and other entities, which for several reasons do not fit in the previous categories. It also reviews some advances on many of these lymphomas published in the last 2 years.
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Clinicopathologic and Genetic Characterization of Follicular Lymphomas Presenting in the Ovary Reveals 2 Distinct Subgroups. Am J Surg Pathol 2011; 35:1691-9. [DOI: 10.1097/pas.0b013e31822bd8a8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Gulia A, Saggini A, Wiesner T, Fink-Puches R, Argenyi Z, Ferrara G, Müller CS, Vale E, Cerroni L. Clinicopathologic features of early lesions of primary cutaneous follicle center lymphoma, diffuse type: Implications for early diagnosis and treatment. J Am Acad Dermatol 2011; 65:991-1000. [DOI: 10.1016/j.jaad.2010.06.059] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/17/2010] [Accepted: 06/18/2010] [Indexed: 12/17/2022]
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Acneiform presentation of primary cutaneous follicle center lymphoma. J Am Acad Dermatol 2011; 65:887-889. [DOI: 10.1016/j.jaad.2010.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 10/18/2010] [Accepted: 10/24/2010] [Indexed: 01/09/2023]
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Pileri A, Patrizi A, Agostinelli C, Neri I, Sabattini E, Bacci F, Piccaluga PP, Pimpinelli N, Pileri SA. Primary cutaneous lymphomas: a reprisal. Semin Diagn Pathol 2011; 28:214-33. [PMID: 21850987 DOI: 10.1053/j.semdp.2011.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary cutaneous lymphomas (PCLs) are a group of lymphoid neoplasms provided with heterogeneous clinical, histological, immunohistochemical and molecular features. They can be classified in two groups: cutaneous T-cell lymphomas (CTCLs) and cutaneous B-cell lymphomas (CBCLs). Recent studies show an increase of the incidence of PCLs over the last three decades. Our aim is to evaluate the commonest types of PCL analysing the clinical characteristics, histology, phenotype, molecular biology, prognosis and therapy.
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Miliary and agminated-type primary cutaneous follicle center lymphoma: report of 18 cases. J Am Acad Dermatol 2011; 65:749-755. [PMID: 21601947 DOI: 10.1016/j.jaad.2010.07.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 07/03/2010] [Accepted: 07/20/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary cutaneous follicle center lymphoma (PCFCL) presents usually with reddish nodules, plaques, and tumors on the head and neck area, particularly the scalp, and on the back. OBJECTIVE We sought to describe a peculiar clinical variant of PCFCL. METHODS We report a series of 18 patients (male:female = 7:11; median age 52 years; mean age 50.8 years; age range 27-75 years) with a clinical variant of PCFCL characterized clinically by multiple, miliary, or agminated papules predominantly on the head and neck. RESULTS All patients presented with multiple erythematous, firm papules arranged in a manner that resembled millet seeds or collected together in small clusters. Lesions were located on the entire face in one patient (5.6%), the forehead in 8 (44.4%), the cheeks in 3 (16.7%), the preauricular region in two (11.1%), and multiple regions on the head and neck area in 3 (16.7%). The last patient had miliary papules on the entire face, back, upper aspect of arms, and scattered on the front of the chest. The initial diagnosis was never cutaneous lymphoma, and all patients had been treated unsuccessfully for different skin conditions including mainly rosacea, lupus miliaris disseminatus faciei, and persistent arthropod bite reaction. Microscopic examination confirmed the diagnosis of PCFCL in all patients. LIMITATIONS Small number of cases and retrospective study are limitations. CONCLUSIONS This peculiar clinical presentation of PCFCL is unusual and represents a pitfall in the clinical diagnosis. Dermatologists should be aware of this variant of PCFCL so as to treat patients timely and properly.
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Abstract
An increasing number of neoplasms are associated with variably specific genetic abnormalities. This is best exemplified by hematological malignancies, in which there is a growing list of entities that are defined by their genetic lesion(s); this is not (yet) the case in mature B-cell lymphomas. However, enhanced insights into the pathogenesis of this large and diverse group of lymphomas have emerged with the ongoing unraveling of a plethora of fascinating genetic abnormalities. The purpose of this review is to synthesize well-recognized data and nascent discoveries in our understanding of the genetic basis of a spectrum of mature B-cell lymphomas, and how this may be applied to contemporary clinical practice. Despite the explosion of new and exciting knowledge in this arena, with the potential for enhanced diagnostic and prognostic strategies, it is essential to remain cognizant of the limitations (and complexity) of genetic investigations, so that assays can be developed and used both judiciously and rationally.
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Yamamoto S, Nakase H, Yamashita K, Matsuura M, Takada M, Kawanami C, Chiba T. Gastrointestinal follicular lymphoma: review of the literature. J Gastroenterol 2010; 45:370-88. [PMID: 20084529 DOI: 10.1007/s00535-009-0182-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Accepted: 11/23/2009] [Indexed: 02/04/2023]
Abstract
Gastrointestinal follicular lymphoma (GI-FL) is a relatively rare disease, accounting for only 1%-3.6% of gastrointestinal non-Hodgkin's lymphoma. Although the duodenum and terminal ileum are considered to be the most common sites of origin, the development of wireless capsule endoscopy and double-balloon enteroscopy has increased the detection of GI-FL in every part of the small intestine. Approximately 70% of patients with GI-FL are estimated to have multiple lesions throughout the entire gastrointestinal tract. FL is a low-grade lymphoma that usually develops very slowly. If the lymphoma causes no symptoms, immediate treatment may not be necessary. Standard therapy has not yet been established for GI-FL, but chemotherapy, radiotherapy, monoclonal antibody therapy, or a combination of these therapies, is sometimes performed based on the therapeutic regimens for nodal FL. Regimens including conventional chemotherapy with rituximab, which achieve high response rates in nodal FL, are commonly used for GI-FL. The long-term clinical outcome of GI-FL is unclear. The results of a few series on the long-term outcomes of patients with GI-FL treated with conventional therapy indicate a median relapse-free time ranging from 31 to 45 months. On the other hand, in patients with GI-FL who were followed without treatment, the median time to disease progression was 37.5 months. Thus, whether to initiate aggressive therapy or whether to continue watchful waiting in patients with GI-FL is a critically important decision. Ongoing research on biomarkers to guide individualized GI-FL therapy may provide invaluable information that will lead to the establishment of a standard therapeutic regimen.
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Affiliation(s)
- Shuji Yamamoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Abstract
Cutaneous lymphoid infiltrates may pose some of the most difficult diagnostic problems in dermatopathology. Immunocytochemistry is often employed in an effort to determine whether an infiltrate is neoplastic or, in the case of clearly malignant infiltrates, to provide a specific diagnosis. The rarity of these disorders and the variant immunocytochemical profiles they may present further thwart understanding and sometimes prevent an accurate diagnosis. In this review the common immunocytochemical profiles of various cutaneous lymphomas are presented and potential pitfalls and problems considered. Immunocytochemistry is not a diagnostic test but, as in other areas of histopathology, is a highly valuable tool that requires critical interpretation within a context: so applied, it is an indispensable part of the pathologist's arsenal in evaluating lymphoid infiltrates and defining different lymphomas.
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Affiliation(s)
- Alistair Robson
- Department of Dermatopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK.
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Cerroni L, Wiesner T. Cutaneous Lymphomas: from Morphology to Chip Technology. ACTAS DERMO-SIFILIOGRAFICAS 2009; 100 Suppl 1:3-17. [DOI: 10.1016/s0001-7310(09)73164-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Golling P, Cozzio A, Dummer R, French L, Kempf W. Primary cutaneous B-cell lymphomas – Clinicopathological, prognostic and therapeutic characterisation of 54 cases according to the WHO-EORTC classification and the ISCL/EORTC TNM classification system for primary cutaneous lymphomas other than mycosis fungoides and Sézary syndrome. Leuk Lymphoma 2009; 49:1094-103. [DOI: 10.1080/10428190802064925] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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