Primary Cutaneous Small/Medium CD4+ T-CELL Lymphoproliferative Disorder Occurring in a Patient With Metastatic Melanoma

Therapeutic agents designed to stimulate the immune system are now cornerstones in the treatment of metastatic melanoma. These drugs promote lymphocyte growth and survival, which could plausibly result in clinical lymphoproliferative disorders. We report the case of a 62-year-old female with metastatic melanoma who developed primary cutaneous small/medium CD4 T-cell lymphoproliferative disorder (PC-SMTCL) after treatment with vemurafenib and recombinant high-dose interleukin-2 (IL-2). The patient developed a painless red papule behind the ear. A biopsy showed a dense population of CD4 lymphocytes with a T-follicular helper cell phenotype. Molecular studies confirmed the presence of a clonal population of T cells, and the process was classified as PC-SMTCL. The patient was diagnosed with metastatic melanoma approximately 3 years before the development of the cutaneous lymphoma and had been treated with vemurafenib followed by 2 courses of IL-2. The patient's last course of IL-2 was completed in April of 2013. She developed the cutaneous lymphoma behind her ear in December of 2015. An association between PC-SMTCL and vemurafenib treatment for advanced melanoma has been reported previously in one patient; however, an association between PC-SMTCL and IL-2 treatment has not been documented. The immunostimulatory properties of IL-2 or vemurafenib may be responsible for the development of PC-SMTCL in our patient. Additionally, antigenic stimulation of the immune system by melanoma itself could contribute to clonal selection of lymphocytes.

Cutaneous lymphoproliferative disorders in organ transplant recipients: update 2014

Post-transplant lymphoproliferative disorders (PTLD) are lymphoid or plasmacytic proliferations that develop after solid organ, bone marrow or stem cell transplantation. PTLD are the leading cause of cancer-related mortality and graft loss in both pediatric and adult solid organ transplant recipients (ORT). These disorders comprise a spectrum ranging from usually EBV-driven, mostly B-cell polyclonal proliferations to B- and T-cell lymphomas indistinguishable from their counterparts occurring in immunocompetent individuals. PTLD usually present in extranodal sites; isolated skin involvement of PTLD is rare. A recent multicenter European case series showed that primary cutaneous T-cell PTLD are more common than primary cutaneous B-cell PTLD, and along with its folliculotropic variant, mycosis fungoides (MF) is the most frequent form of posttransplant primary cutaneous T-cell lymphoma (CTCL). This case series also disclosed that primary cutaneous CD30+ lymphoproliferative disorders is the second most common posttransplant CTCL subtype, indicating that the spectrum of primary CTCL in OTR is similar to that in the general population. However, in contrast with the immunocompetent individuals, the prognosis of primary cutaneous CD30+ anaplastic large T-cell lymphoma is worse than posttransplant MF and than its counterpart in the general population which has an excellent prognosis. The recent case series indicated that the spectrum of primary cutaneous B-cell PTLD differs significantly from cutaneous B-cell lymphoma in the general population, with a predominance of EBV-associated forms. Currently, the best therapeutic intervention(s) for primary cutaneous PTLD remains unknown.

Sudden onset of an aggressive cutaneous lymphoma in a young patient with psoriasis: role of immunosuppressants

Psoriasis is thought to be associated with an increased risk of lymphoma. We report here the first case of an aggressive primary cutaneous pleomorphic T-cell lymphoma in a patient with psoriasis. The 36-year-old patient, who had previously been treated successively with methotrexate, ciclosporin and etanercept, presented with rapidly growing nodules on the leg. A biopsy confirmed a stage IVa primary cutaneous pleomorphic T-cell lymphoma. Despite treatment with pegylated liposomal doxorubicin, the disease progressed and the patient died 5 months later. This case of pleomorphic T-cell lymphoma was remarkable in both its extremely rapid onset and the aggressive nature of the disease. The onset of this disease in a patient with psoriasis who had been previously treated with immunosuppressive drugs and a tumour necrosis factor (TNF)-α blocker is of major interest. Only eight cases of cutaneous lymphomas associated with treatment with TNF-α blockers have been published previously. Most of these eight cases related to anti-TNFα antibodies; only two were linked to etanercept.

Aggressive CD30 large cell lymphoma after cyclosporine given for putative atopic dermatitis

Atopic dermatitis (AD) is not regarded as a predisposing condition for cutaneous T cell lymphoma. Cyclosporine (CsA) is an efficient therapy in AD, and its side effects, including lymphocytic proliferation, are rare at the low dose used in such cases. So far 3 cases of patients who developed cutaneous T cell lymphoma under CsA treatment for atopy have been described. An adult patient with a history of AD received CsA therapy because of an atypical flare-up of his eruption. He rapidly developed papular atypical lesions, then followed by the onset of a voluminous cutaneous tumor leading to the diagnosis of mycosis fungoides (MF) transformed in CD30+ large cell lymphoma with nodal and blood involvement. No improvement occurred after withdrawing of CsA, and he required a polychemotherapy and an allograft. This case illustrates the dramatic evolution of an MF under CsA given in the hypothesis of AD. It stresses the fact that skin biopsies should be taken in case of atypical AD to rule out MF and avoid such an aggressive evolution under immunosuppressive therapy.

A case of subcutaneous panniculitis-like T-cell lymphoma with haemophagocytosis developing secondary to chemotherapy

A 45-year-old woman presented with fever, generalized skin lesions and multiple lymphadenopathies. In her past history she had had six courses of cyclophosphamide and cisplatin combination chemotherapy 7 years ago because of an ovarian carcinoma. We found pancytopenia in the peripheral blood examination. Skin biopsy showed diffuse subcutaneous infiltration reminiscent of panniculitis but composed of malignant lymphoid cells that were of T lineage. Bone marrow biopsy showed normocellular myeloid tissue with abundant haemophagocytic macrophages. Subcutaneous panniculitis-like T-cell lymphoma with haemophagocytic syndrome was diagnosed. This is the first case reported of subcutaneous panniculitis-like lymphoma occurring secondary to chemotherapy.

Primary cutaneous CD30+ large T-cell lymphoma in a patient with psoriasis treated with cyclosporine

We report the case of a 61-year-old woman who developed an anaplastic CD30+ cutaneous T-cell lymphoma during oral cyclosporine (CsA) therapy for recalcitrant psoriasis. Two months after CsA discontinuation, clinical and histological resolution of the lymphoma was observed. However, 3 years later extracutaneous involvement of the lymphoma could be detected. The association between CsA administration and the occurrence of the lymphoma may be casual, but a relationship with immunosuppression may also be hypothesized. We have reviewed all relevant data in the literature. To our knowledge, this is the first case of primary cutaneous CD30+ anaplastic large T-cell lymphoma in a patient treated with CsA for psoriasis.

Cutaneous T-cell lymphoma developing in a patient on cyclosporin therapy

The use of cyclosporin in the transplant setting is associated with a small but significantly increased risk of the development of lymphoproliferative disorders. These are predominantly but not always related to Epstein-Barr virus (EBV) infection. We report a cutaneous CD30(+) T-cell lymphoma in a patient with atopic eczema during low-dose cyclosporin monotherapy. There was no evidence of EBV DNA transcripts in the tumor tissue as assessed by in situ hybridization. The tumors resolved when cyclosporin therapy was stopped and have not recurred. There are a few reports of primary cutaneous lymphoma in transplant patients. This is the first report to our knowledge of cutaneous lymphoma in a patient treated with low-dose cyclosporin monotherapy. Although this finding may be coincidental, we believe this case highlights the small lymphoproliferative risk associated with cyclosporin.

[Persistent inflammatory reaction at the injection site of Il-2 with lymphoma-like inflammatory infiltrates]

Interleukin-2 (Il-2) is widely used for treatment of carcinomas, leukemia, and melanoma. Adverse drug effects of Il-2 include various systemic and generalized cutaneous drug reactions. In the following we report on a persistent inflammatory reaction at the injection site of Il-2. A patient received chemoimmuno-therapy for treatment of metastasizing melanoma, including subcutaneous application of recombinant interleukin-2 (Proleukin((R))). Within a few days reddish nodules developed at the injection sites that persisted after cessation of Il-2 injections for two years until final lethal outcome. Histologic examination revealed a lobular panniculitis expressing atypical lymphocytes and multinucleated histiocytes.

Incidence of CTCL in Vietnam veterans

The causative factors of cutaneous T-cell lymphoma (CTCL) are unclear. Exposure to herbicides has been linked to the development of other lymphomas. Three Vietnam Veterans with CTCL treated at a photopheresis unit in New Jersey report positive histories of exposure to Agent Orange, a herbicide used during the war.

Generalized nodular cutaneous pseudolymphoma associated with phenytoin therapy. Use of T-cell receptor gene rearrangement in diagnosis and clinical review of cutaneous reactions to phenytoin

The first reported case of phenytoin-induced generalized nodular cutaneous pseudolymphoma without symptoms of the phenytoin hypersensitivity syndrome is presented. Despite the malignant histologic appearance of the dermal infiltrate, T-cell receptor gene rearrangement studies did not demonstrate monoclonality. The cutaneous nodules resolved within 2 weeks after discontinuation of phenytoin therapy. The literature is reviewed with regard to the spectrum of cutaneous reactions to phenytoin and particularly with regard to the occurrence of lymphoma, pseudolymphoma, and phenytoin hypersensitivity syndrome. We suggest the use of T-cell receptor gene rearrangement studies in similar situations of phenytoin hypersensitivity syndrome and lymphadenopathy. A brief period of discontinuation of the drug will demonstrate the regression associated with benign lymphoproliferation and will forestall needless treatment.

Cutaneous pseudo-T-cell lymphomas. A clinicopathologic study of 20 patients

The histologic features of 20 patients with cutaneous pseudo-T-cell lymphomas other than actinic reticuloid and lymphomatoid papulosis were investigated. Two histologic types of cutaneous pseudo-T-cell lymphomas were designated. The band-like (MF-like) pattern that simulated mycosis fungoides (MF) and a nodular pattern that mimicked cutaneous T-cell lymphomas (CTCL) other than MF. Both patterns showed histologic features that generally are not found in CTCL and thus may be helpful in the differential diagnosis from CTCL. However, at present the differential diagnosis between pseudo-T-cell lymphomas and CTCL should be based on a combination of clinical and histologic data.