Epidemiological changes in cutaneous lymphomas: an analysis of 8593 patients from the French Cutaneous Lymphoma Registry

BACKGROUND

Primary cutaneous lymphomas (PCLs) are a heterogeneous group of T-cell (CTCL) and B-cell (CBCL) malignancies. Little is known about their epidemiology at initial presentation in Europe and about potential changes over time.

OBJECTIVES

The aim of this retrospective study was to analyse the frequency of PCLs in the French Cutaneous Lymphoma Registry (GFELC) and to describe the demography of patients.

METHODS

Patients with a centrally validated diagnosis of primary PCL, diagnosed between 2005 and 2019, were included.

RESULTS

The calculated incidence was unprecedently high at 1·06 per 100 000 person-years. The number of included patients increased yearly. Most PCL subtypes were more frequent in male patients, diagnosed at a median age of 60 years. The relative frequency of rare CTCL remained stable, the proportion of classical mycosis fungoides (MF) decreased, and the frequency of its variants (e.g. folliculotropic MF) increased. Similar patterns were observed for CBCL; for example, the proportion of marginal-zone CBCL increased over time.

CONCLUSIONS

Changes in PCL frequencies may be explained by the emergence of new diagnostic criteria and better description of the entities in the most recent PCL classification. Moreover, we propose that an algorithm should be developed to confirm the diagnosis of PCL by central validation of the cases.

Cutaneous presentation of adult T-cell leukemia/lymphoma (ATLL). Single-center study on 37 patients in metropolitan France between 1996 and 2016

INTRODUCTION

Adult T-cell leukemia/lymphoma (ATLL) is a hematological malignancy associated with chronic HTLV-1 infection.

AIM

To describe skin lesions in ATLL.

METHODS

A descriptive, retrospective study between 1996 and 2016, including all patients diagnosed with ATLL at Saint-Louis Hospital (Paris, France).

RESULTS

Thirty-seven ATLL patients were included. Fifteen patients (41%) had a cutaneous localization of the disease, which was present from the beginning of the disease for two thirds of them. ATLL types in patients with cutaneous localization of the disease were as follows: lymphoma, n=5, chronic, n=4, smoldering, n=4, acute, n=2. Half the patients had 2 or more cutaneous manifestations. The cutaneous localizations observed were as follows: nodulotumoral (n=8), plaques (n=7), multipapular (n=6), macular (n=4), purpuric (n=2). Among the 15 patients with cutaneous localization, median overall survival was significantly shorter in the acute and lymphoma types compared to the smoldering and chronic types (8.7 months vs. 79 months, P=0.003).

DISCUSSION

ATLL is a hematologic malignancy with variable expression that is diagnosed only very rarely in metropolitan France, but that should be sought in patients from countries with high HTLV-1 prevalence in the event of a chronic eruption with patches, papules, plaques and/or tumors. The chronic and smoldering types are relatively indolent, whereas the acute and lymphoma forms have a poor prognosis.

[Post-radiation atypical vascular lesions and angiosarcoma: 11 cases]

BACKGROUND

Post-radiation atypical vascular lesions of the skin display clinical and morphological overlap with well-differentiated angiosarcomas, and correct diagnosis may be difficult.

PATIENTS AND METHODS

We studied clinical, histological and immuno-histochemical aspects (CD31, CD34, D2-40 and VEGFR-3) of eight post-radiation atypical vascular lesions comparatively with three post-radiation angiosarcomas.

RESULTS

All patients were female and received radiation therapy for breast carcinoma. On average, atypical vascular lesions occurred 4.3 years after radiation therapy and presented as small papulonodules or erythematous plaques. The clinical course after simple excision was benign. Histologically, they were relatively circumscribed lesions and showed slit-like vessels dissecting dermal collagen in all cases. On average, angiosarcomas occurred 5 years after radiation therapy and presented as more extensive lesions with a more aggressive clinical course. The lesions showed histological overlap with atypical vascular lesions, but were poorly circumscribed, with deeper invasion, cytological atypia and mitosis. Although the immuno-histochemical profiles were similar, expression of VEGFR-3 was greater in two cases of angiosarcoma.

CONCLUSION

Post-radiation atypical vascular lesions are benign lesions that display clinical, histological and immuno-phenotypic overlap with well-differentiated angiosarcoma, and diagnosis requires good clinicopathological correlation. VEGFR-3 may be useful for differential diagnosis, as well as amplification of the MYC gene.

[Multiple cutaneous osteomas of the face in a setting of chronic acne]

BACKGROUND

Multiple cutaneous osteomas are a rare complication of chronic inflammatory acne that often goes unrecognized. We report a case concerning a 35-year-old woman.

PATIENTS AND METHODS

A 35-year-old woman had been treated for acne since the age of 22 years, as part of which she received two courses of oral isotretinoin. We noted the secondary appearance of several microcysts on the face for which the excision was very difficult. Curiously, these small formations did not contain keratin but were very callous. Histological examination revealed foci of osseous metaplasia, probably of postinflammatory origin. Treatment consisted solely of excision of the lesions.

DISCUSSION

Osteoma cutis comprises two distinct groups (primary and secondary). In our case, there were multiple cutaneous osteomas of the face resulting from chronic acne. The differential diagnosis was idiopathic miliary osteomatosis of the face, but this was ruled out by the young age of the patient, the improvement of the acneiform lesions under isotretinoin (confirming the initial diagnosis of acne) and the subsequent appearance of microcysts. Although there are as yet no codified treatments, excision appears to yield good results.

Cutis laxa acquise généralisée associée à un myélome : découverte de grandes cellules vacuolisées dermiques

INTRODUCTION

Cutis laxa is a rare disorder characterized by loss of elastic tissue. Several organs are often involved such as the skin, lungs, heart, digestive system or genitourinary tract. It may be inherited or acquired, generalized or localized. Its pathogenesis is unclear. Association of acquired cutis laxa with myeloma or plasma cell dyscrasia is very rare. We report a case of acquired cutis laxa associated with a myeloma.

CASE REPORT

A 59 year-old woman was admitted for skin hyperlaxity present for a number of years. Light microscopic examination of a skin sample revealed fragmented elastic fibers. Electron microscopic examination of the elastic network demonstrated numerous large vacuolated cells with the appearance of macrophages around abnormal elastic and collagen fibers of the reticular dermis. In addition, a stage-1 IgG lambda myeloma was detected. The patient was treated by thalidomide for one year. After this treatment, electron microscopy examination did not reveal any large vacuolated cells in the dermis, and elastic and collagen fibers were not modified and skin laxity seemed to be stabilized.

DISCUSSION

Acquired cutis laxa may be associated with many systemic diseases or can appear after inflammatory skin diseases. Seven cases of generalized cutis laxa associated with myeloma and four cases associated with plasma cell dyscrasia have been reported in the literature. In our case, as in 2 previously described cases, large vacuolated cells resembling macrophages were seen in the dermis. They were thought to play a role in cutis laxa.

Sézary syndrome in a patient receiving infliximab for ankylosing spondylitis

Infliximab, a tumour necrosis factor (TNF)-alpha antagonist, has shown striking efficacy in the treatment of chronic inflammatory rheumatological diseases such as rheumatoid arthritis and ankylosing spondylitis. However, long-term follow-up studies support that treatment with infliximab is associated with an increased risk of non-Hodgkin lymphoma. So far, few cases of cutaneous lymphoma have been reported in patients receiving TNF-alpha-blocking agents. We report a patient who developed Sézary syndrome 17 months after the onset of infliximab therapy for ankylosing spondylitis. Cutaneous lesions partially remitted following infliximab withdrawal and methotrexate treatment. Although the causal link between infliximab and the emergence of Sézary syndrome is uncertain, the present case raises the need for exhaustive long-term registries of malignancies, including primary cutaneous lymphomas, in patients receiving TNF-alpha-blocking agents.

Blépharites du lupus érythémateux chronique

BACKGROUND

Discoid lupus erythematosus is a chronic skin disease frequently involving the face, scalp and ears. Palpebral lesions are rare. We report 4 cases of this uncommon localization. In one case, palpebral lesions were the sole manifestation of the discoid lupus erythematosus.

CASE REPORTS

Four patients aged between 26 and 45 Years had lesions of the lower eyelid as erythematous, infiltrated and scaly plaques. One patient, without diagnosis despite 2 skin biopsies of lesion, presented with a 2-Year history of blepharitis in the absence of any other cutaneous abnormality. In one case, chronic blepharitis has been present for 4 Years and associated with inflammatory arthralgia. Alopecia occurred 4 Years after the onset of blepharitis and led to the diagnosis of discoid lupus erythematosus. In 2 cases, blepharitis was associated with typical cutaneous lesions of discoid lupus erythematosus. Antimalaria drugs were very effective in 3 cases. In one patient the antimalaria drug failed, but thalidomide was effective.

DISCUSSION

The location of lesions on the eyelids in the absence of any other cutaneous abnormality is rare and can easily lead to the misdiagnosis of discoid lupus erythematosus. Most Authors mention a predilection of the lesions to the inferior portion of the eyelid, more specifically to the external third. The involvement of the eyelids with permanent scarring and severe eye impairment is explained by the long duration of the disease without diagnostic and appropriate treatment. Clinical examination is highly consistent with discoid lupus erythematosus: the lesions typically present as well-circumscribed, erythematous plaques with telangiectasia and scales and atrophy in long-standing disease. Antimalaria drugs are remarkably effective.

Germline and somatic mutations of the INK4a-ARF gene in a xeroderma pigmentosum group C patient

Xeroderma pigmentosum is an inheritable autosomal recessive DNA repair deficient syndrome characterized by a high predisposition to skin cancers. An elevated proportion of tumors from xeroderma pigmentosum patients harbor ultraviolet-induced mutations (CC:GG > TT:AA tandem transitions) of the p53 and/or the INK4a-ARF genes. Here, we report the clinical and molecular features of a 12 y old xeroderma pigmentosum patient who, in addition to severe cutaneous clinical symptoms, also had three unusual tumors, a mediastinal lymphoblastic lymphoma, an atypical fibroxanthoma, and an epithelioid hemangioma. Single strand conformation polymorphism and sequencing analysis of the p53 and INK4a-ARF genes were carried out in DNA from normal skin and different tumors (four actinic keratosis, two microinvasive squamous cell carcinomas, one basal cell carcinoma, and one atypical fibroxanthoma) from the patient. After characterization of the xeroderma pigmentosum C complementation group, we found unexpectedly that this patient also carried a germline mutation of the INK4a-ARF locus affecting the p16INK4A reading frame. Three different somatic mutations that all harbor the signature of ultraviolet light (two of p16INK4A and one of p53) were also detected in the basal cell carcinoma. We hypothesize that the germline mutation of p16INK4A, in association with the nucleotide excision repair defect, could explain the patient's unusual phenotype. Furthermore, this study confirms that concomitant somatic mutations of INK4a-ARF and p53 occur in some xeroderma pigmentosum associated tumors, and seem to accumulate during tumor progression rather than the initiation step.

[Cutaneous B-cell lymphoma treatment with rituximab: two cases]

INTRODUCTION

Anti-CD20 monoclonal antibodies have been successfully used in patients affected with B-cell lymphomas - mostly of the centrofollicular variety - showing relapse after treatment with antineoplastic chemotherapy. We report herein two patients with cutaneous B-cell lymphomas showing complete remission after treatment with rituximab.

CASE REPORTS

A 70 year-old man with a cutaneous large cell lymphoma of the legs relapsing despite chemotherapy, and a 38 year-old woman with a cutaneous and lymph node centrofollicular lymphoma were treated with rituximab 375 mg/m(2) weekly for 4 weeks, leading to complete remission, persisting 15 months after the end of treatment in one case, while remission lasted 10 months in the first case. In this latter case, relapsing lesions responded following treatment with a rituximab/cytotoxic polychemotherapy combination.

DISCUSSION

Rituximab is a monoclonal chimeric antibody targeting CD20, a surface antigen which is expressed by cells belonging to the B-lymphocytic lineage and by most B cell malignancies. Sixteen other patients with cutaneous B-cell lymphomas treated with rituximab have been previously reported in the literature, with a complete remission rate of 25 p. 100 and a partial remission rate of 56 p. 100. The presently reported cases support the use of rituximab in cases of cutaneous B-cell lymphoma showing resistance or relapse after antineoplastic chemotherapy, either alone or in combination with cytotoxic drugs.

Topical use of cidofovir induced acute renal failure

BACKGROUND

Cidofovir has antiviral activity against a wide spectrum of DNA viruses. Several small studies have focused on the efficacy of topical cidofovir in various viral-induced diseases. We report a systemic complication of such therapy.

CASE REPORT

A bone marrow transplant recipient with chronic renal failure developed genital condylomas resistant to standard therapy. After topical cidofovir application (1% once daily for 5 days, then 4% for 12 days), the lesions improved while local erosions appeared. Acute renal failure with features of tubular acidosis occurred at day 19. Spontaneous recovery was observed after cidofovir withdrawal.

CONCLUSION

We describe for the first time acute renal failure after topical cidofovir in an immunosuppressed patient with prior renal insufficiency. This method of administration should be avoided on abraded skin and should be carefully monitored.

Trichoepithelioma with "monster" stromal cells

Trichoepithelioma is a benign tumor of trichogenic origin which appears predominantly in childhood or in young adults. Different forms have been described according to clinical and histological features. The authors report a unique variant of trichoepithelioma arising on the limb of a 27-year-old man. The tumor was characterized by the mixture of an atypical fibroxanthomatous proliferation and basaloid epithelial strands of trichoepithelioma. Such histological features have not been previously reported. It raises the question of an additional variant of hair follicle tumor with a mixed epithelial and mesenchymal proliferation.

[Resin polymerizing at low temperatures: II. Histochemistry, electron microscopy and immunomarkers]

For pathologists, tissu processing and analysis require good preservation of both the shape (morphology) and the content of the cells (antigens, nucleic acids). Low temperature embedding resins are the only inclusion substrate which allows both a fine morphological analysis and good preservation of antigens and nucleic acids. Automatic the technical processes and simplified protocols now allow the introduction of low temperature embedding resins in diagnostic procedures.

Human papillomavirus infection and anogenital condyloma in bone marrow transplant recipients

BACKGROUND

Secondary malignant diseases are late complications after allogeneic bone marrow transplantation (BMT). Anogenital lesions associated with human papillomavirus (HPV) infection have been described in renal transplant recipients but not after BMT. HPV types 16 and 18 are strongly linked to the malignant transformation.

METHODS

In a series of 238 patients with allogeneic BMT, three had anogenital lesions. We looked for HPV in DNA extracted from embedded tissue to study HPV genotypes, p53 expression, and ploidy.

RESULTS

In two patients, HPV sequences were detected. One of them, with giant condyloma, had HPV type 18 and two aneuploid clones, but p53 expression was not found.

CONCLUSION

As in solid organ transplant recipients, anogenital condyloma may develop after BMT. Because the oncoprotein of HPV is able to bind and to degrade p53, it may lead to genetic instability, and subsequently to malignant transformation.

[Resins polymerizing at low temperatures. I. Different families and principle technics]

For pathologists, tissue processing and analysis require good preservation of both the shape (morphology) and the content of the cells (antigens, nucleic acids). Low temperature embedding resins are the only inclusion substrate which allows both a fine morphological analysis and good preservation of antigens and nucleic acids. Automatic the technical processes and simplified protocols now allow the introduction of low temperature embedding resins in diagnostic procedures.

[Gorlin-Goltz syndrome. Apropos of a maxillary cyst]

We report a case of Gorlin-Goltz syndrome and recall the principle features of this uncommon disease. The syndrome associates multiple skeletal malformations, skin tumors and epidermoid maxillary cyst. We discuss the differential diagnosis of maxillary cysts.

[Atypical cellular blue nevus. Apropos of 1 case]

We report a new case of a cellular blue nevus with clinicopathologic atypia. It was a large lesion presenting clinically as a vascular tumor located in the middle of the back. It grew for 2 years without skin ulceration. The pathological study suggested a cellular blue nevus with moderate nuclear atypia, without any atypical mitosis and necrosis. The differential diagnosis such as malignant blue nevus and melanoma are discussed in search of a better definition of these rare lesions.