Primary Cutaneous Follicle Center Lymphoma

Observation of lymphadenopathy, systemic symptoms, and treatment in suspected indolent cutaneous B-cell lymphomas

BACKGROUND

Following the initial diagnosis of a marginal zone or follicle center lymphoma on skin biopsy, patients undergo staging to determine the extent of disease.

OBJECTIVE

We sought to characterize the frequency that these patients were found to have a systemic nodal disease upon work-up as well as the impact of imaging on disease management.

METHODS

We conducted a retrospective chart review of patients presenting with a working diagnosis of PCMZL or PCFCL treated at The Ohio State University from 1990 to 2022. Data collected included: patient history, progress notes, virtual encounters, laboratory results, presentation features, imaging, and pathology. Biomarkers included ANA, SSA/SSB, BCL6 and H. Pylori labs, bone marrow biopsies, positive imaging, and need of systemic medication and mortality.

RESULTS

71 patients with suspected PCMZL and PCFCL were identified. 66 of 71 patients underwent imaging. Of this group, 12 patients (9 with suspected PCFCL and 3 with suspected PCMZL) demonstrated lymphadenopathy on imaging. Of these 12 patients, 5 underwent biopsy of suspected lymph nodes, and 3 had biopsy-proven nodal involvement and received systemic therapy. Of the remaining 7 patients with evidence of lymphadenopathy on imaging, 4 were thought to have reactive lymph nodes, and 3 were treated empirically with systemic chemotherapy due to the extent or progression of their disease. Of patients with imaging negative for lymphadenopathy, 3 of 52 (5.8%) patients with received systemic treatment, while 49 of 52 patients (94.2%) received localized treatment.

LIMITATIONS

Most of the relationships between this data were correlational and patients selected for this study were limited to a single institution.

CONCLUSION

Prospective study of the role of imaging without subsequent lymph biopsy to direct treatment decisions is warranted.

An unusual case of B-cell lymphoma of the scalp

B-cell lymphoma is a lymphoproliferative non-Hodgkin lymphoma arising from B cells, a type of immune lymphocytes that produces antibodies in the follicles of lymph nodes. Primary cutaneous B-cell lymphoma (PCBCL), a subtype of B cell lymphoma, originates within cutaneous tissue without evidence of extracutaneous involvement. There are very few reports of PCBCLs originating in the scalp. The most common tumors of the scalp are usually benign with only 1%-2% being malignant, most being basal cell carcinoma, squamous cell carcinoma, or melanoma. Primary cutaneous follicular cell lymphoma (PCFCL) is regarded as the most common lymphoma of the skin with an indolent course and favorable prognosis due to the response rate to treatment methods such as surgical removal with local radiotherapy, topical drugs, and intralesional therapies. This report highlights a rare case of PCFCL originating in the scalp, to raise awareness of a topic that requires continued established management.

Spindle Cell Lipoma With Florid Primary Follicular Lymphocytic Hyperplasia: A Novel Association With Potential Diagnostic Pitfalls

ABSTRACT

Spindle cell lipoma (SCL) is a benign subcutaneous lipomatous neoplasm with a heterogeneous histologic appearance that varies greatly depending on the amount of fat, collagen, and myxoid stroma, which define the multiple subtypes of SCL, such as fat poor SCL, pseudoangiomatous SCL, and dendritic fibromyxolipoma. Cutaneous lymphoid hyperplasia is a spectrum of benign conditions characterized by reactive B-cell and T-cell cutaneous lymphocytic infiltrates. Cutaneous B-cell lymphoid hyperplasia is a heterogeneous group of non-neoplastic conditions that can be observed as reactive phenomena to infections, medications, allergens, or neoplasms and must be distinguished from cutaneous B-cell lymphomas. Here, we report a novel case of spindle cell lipoma, associated with B-cell primary lymphoid follicular hyperplasia, mixed within the tumor in a peculiar pattern, while discussing potential diagnostic pitfalls with low-grade B-cell lymphomas. This is the first report of such association in the literature.

Pseudolymphoma to Lymphoma: A Case of Chronic Reactive Lymphoid Hyperplasia Transforming to Primary Cutaneous Marginal Zone Lymphoma

ABSTRACT

Primary cutaneous marginal zone lymphoma (PCMZL) is a low-grade malignant B-cell lymphoma that originates from the skin. It often presents as erythematous solitary or multiple papules, nodules, and/or plaques. It is one of the 3 main subtypes of primary cutaneous B-cell lymphomas. PCMZLs are believed to develop from chronic antigenic stimulation such as from tick-borne bacteria, vaccines, tattoo pigment, or other foreign body. In addition, cutaneous lymphoid hyperplasia, a documented precursor to malignant PCMZL, often presents in response to areas of chronic inflammation. Cutaneous lymphoid hyperplasia and PCMZL share several clinical and histological similarities that require clinicopathologic suspicion, immunohistochemical ancillary studies, and histopathologic analysis to accurately differentiate the 2 entities. Although gene rearrangement studies have historically been of limited value in the diagnosis of PCMZL, recent studies investigating molecular markers have identified the presence of multiple genetic abnormalities that have helped to better characterize the disease and aid in diagnosis. In addition, newer studies have found associations between PCMZL and gastrointestinal disorders, including Helicobacter pylori and inflammatory bowel disorders. In this article, we describe a case of a 56-year-old patient with a history of ulcerative colitis presenting with chronic reactive lymphoid hyperplasia that transformed to primary cutaneous marginal zone lymphoma.

Primary Cutaneous Follicle Center Lymphoma Presenting as a Solitary Nodule on the Forearm of an Adolescent Girl: A Case Report and Literature Review

Primary cutaneous B-cell lymphomas (PCBCLs) are very rare to be seen in pediatric and adolescent age group, especially primary cutaneous follicle center lymphoma (PCFCL) which is considered the least occurring main subtype. Here, we describe a 16-year-old girl who developed a slowly growing solitary firm smooth surfaced erythematous nodule over her forearm. Histopathological examination showed a dense dermal nodular, periadnexal and perivascular lymphoid infiltrate extending deep to the subcutis. Immunohistochemical staining showed a B-cell population with positivity for CD20, variable staining for BCL6 and CD10 and uniquely staining for BCL2. Although a primary cutaneous marginal zone lymphoma (PCMZL) was considered but the presences of interfollicular BCL6 and CD10 positivity established the diagnosis of PCFCL. To our knowledge, only 12 cases of pediatric and adolescent PCFCL have been described in the literature.

Photodynamic Therapy as an Effective Treatment for Cutaneous Lymphomas

Topical photodynamic therapy (PDT) is a non-invasive treatment modality frequently used in dermatology to treat superficial skin cancers but also some inflammatory or infectious dermatoses. PDT appears a more and more promising therapeutic option also for cutaneous lymphomas, either of T- or B-cell origin. It is a well-tolerated treatment and has excellent cosmetic outcomes, less side effects compared to other therapies (steroids, surgery, radiotherapy, and so on), no particular contraindications, and is easily repeatable in case of relapses. However, how PDT works in the treatment of cutaneous lymphoproliferative diseases is poorly understood and the literature data are still controversial. Further randomized, controlled clinical trials involving a greater number of patients and centers with a long follow-up are necessary to assess the efficacy of PDT and establish a unique standardized treatment protocol in relation to the lymphomatous disease and the type, thickness, and location of the lesions.

Primary cutaneous follicle center lymphoma with aberrant CD8 expression

We report an unusual case of primary cutaneous follicle center lymphoma (PCFCL) with aberrant expression of the T-cell marker CD8. The patient is a 48-year-old male with no significant past medical history who presented with red indurated plaques on the abdomen. A punch biopsy showed abnormal lymphoid follicles in the dermis with reduced mantle zones and decreased tingible body macrophages. The epidermis was uninvolved. The follicles expressed CD20, PAX-5, and bcl-6 by immunohistochemistry. CD8, however, was strongly positive, highlighting neoplastic cells, which were negative for any additional T-cell markers. TIA and granzyme B were also negative. The patient underwent further staging workup, without evidence of nodal involvement. His course has been indolent thus far. In summary, we present a case of PCFCL with aberrant expression of the T-cell marker CD8, a finding not previously reported in the literature and a potential diagnostic pitfall.

Primary cutaneous follicle center lymphoma in a 16-year-old girl

In the pediatric and adolescent age group, primary cutaneous lymphomas are rare, especially cutaneous B-cell lymphomas. According to the World Health Organization, the three main subtypes of primary cutaneous B-cell lymphomas are primary cutaneous marginal zone B-cell lymphoma (PCMZL), primary cutaneous follicle center lymphoma (PCFCL), and primary cutaneous diffuse large B-cell lymphoma, leg type. We present an extraordinary case of PCFCL arising in a 16-year-old female, only the sixth case of PCFCL to be reported in the literature in a patient less than 20 years old. Although PCMZL was considered in this case, the finding of lambda light chain restriction in the BCL-6 and CD10 positive population of lymphocytes established the diagnosis of primary cutaneous follicle center lymphoma. Not many data currently exist on the prognosis of PCFCL in young individuals, but adult PCFCL has a good prognosis with an indolent course and 5-year survival rates over 95%. Because of its uncommon manifestation in young patients, the diagnosis of PCFCL is often delayed or missed. This case is presented to raise awareness of PCFCL in the pediatric/ adolescent population and to contribute to the ongoing research of this condition.

How we treat mature B-cell neoplasms (indolent B-cell lymphomas)

Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.

Primary cutaneous follicle center lymphoma of the breast: Management of an exceedingly rare malignancy

Primary cutaneous follicle center lymphoma (PCFCL) is defined as a low-grade B-cell non- Hodgkins lymphoma, which primarily occurs and remains confined to the skin, without evidence of extracutaneous or systemic involvement at the time of diagnosis. PCFCL affecting the breast skin is an exceedingly rare entity with only two cases reported in the English literature. We present a case of PCFCL affecting the periareolar breast skin and review the relevant literature. Our patient was a 64-year-old female who presented with an erythematous plaque in the periareolar region of the left breast. The diagnosis of PCFCL was confirmed by a biopsy performed with a seven-month delay, as the tumor had been initially misdiagnosed as a benign lesion. The patient was successfully treated with local radiation therapy. PCFCL is an indolent lymphoma associated with an excellent prognosis. For localized lesions, skin-directed therapies mainly consisting of radiation therapy or complete surgical excision are curative therapeutic approaches, while systemic chemotherapy should be reserved for patients with extensive disease. This case highlights the need to consider PCFCL as an important differential diagnosis in patients presenting with non-resolving erythematous breast skin lesions. A timely biopsy should be obtained to avoid delays in the initiation of appropriate treatment.

Follicular lymphoma

Follicular lymphoma (FL) is a systemic neoplasm of the lymphoid tissue displaying germinal centre (GC) B cell differentiation. FL represents ~5% of all haematological neoplasms and ~20-25% of all new non-Hodgkin lymphoma diagnoses in western countries. Tumorigenesis starts in precursor B cells and becomes full-blown tumour when the cells reach the GC maturation step. FL is preceded by an asymptomatic preclinical phase in which premalignant B cells carrying a t(14;18) chromosomal translocation accumulate additional genetic alterations, although not all of these cells progress to the tumour phase. FL is an indolent lymphoma with largely favourable outcomes, although a fraction of patients is at risk of disease progression and adverse outcomes. Outcomes for FL in the rituximab era are encouraging, with ~80% of patients having an overall survival of >10 years. Patients with relapsed FL have a wide range of treatment options, including several chemoimmunotherapy regimens, phosphoinositide 3-kinase inhibitors, and lenalidomide plus rituximab. Promising new treatment approaches include epigenetic therapeutics and immune approaches such as chimeric antigen receptor T cell therapy. The identification of patients at high risk who require alternative therapies to the current standard of care is a growing need that will help direct clinical trial research. This Primer discusses the epidemiology of FL, its molecular and cellular pathogenesis and its diagnosis, classification and treatment.

Unusual Clinical Presentation of a Primary Cutaneous Follicle Center Lymphoma on the Scalp of a Middle-Aged Female: Case Report and Review of the Literature

Primary cutaneous follicle center lymphoma (PCFCL) is a rare type of indolent, low-grade cutaneous B-cell lymphoma with an excellent prognosis. It usually presents with erythematous nodules and plaques on the head, neck, or back. The diagnosis is primarily based on histopathology, immunohistochemistry, and molecular studies. We describe a case of PCFCL causing a well-defined alopecic atrophic patch. The patch developed in the area of a large subcutaneous nodule that regressed after treatment with rituximab infusion. We hypothesize that the alopecia could have been caused by pressure.