Beruflich Dokumente
Kultur Dokumente
Shriniwas b Rushi MD
A variety of T and B-cell neoplasms can involve
skin, either primarily or secondarily.
Secondary
cutaneous lymphomas : systemic
lymphomas that secondarily involve the skin.
After the gastrointestinal tract, the skin is the second most common site of
extranodal non-Hodgkin lymphoma.
For that reason, the European Organization for Research and Treatment of
Cancer (EORTC) classification for primary cutaneous lymphomas and the World
Health Organization (WHO) classification for tumors of hematopoietic and
lymphoid tissues included primary cutaneous lymphomas as separate entities. A
consensus classification was developed in 2005 referred to as ―WHO-EORTC
Classification of Cutaneous Lymphomas‖.
Hoppe RT, Kim YH,Clinical features, staging, and prognosis of mycosis fungoides and Sezary syndrome, Uptodate.com, 11/06
INVESTIGATION PATHOLOGY
SKIN BIOPSY -Atypical SMALL to MEDIUM sized mononuclear cells with cerebriform
nuclei infiltrating the upper dermis among epidermal keratinocytes
(epidermotropism) or forming intraepidermal aggregates (Pautrier
microabscesses).
- Pautrier's abscesses – pathognomonic but present only in 38 % cases of
MF
- Hyperconvoluted intraepidermal lymphocytes
- Lymphocytes aligned within the basal layer
Basic
1. Persistent and/or progressive patches/thin plaques
Additional:
1. Non-sun exposed location
2. Size/shape variation
3. Poikiloderma
Histopathologic 2 points for basic criteria and two additional criteria
BASIC
1. Superficial lymphoid infiltrate
Additional:
1. Epidermotropism without spongiosis
Mycosis fungoides and Sézary Syndrome. Semin Oncol 1999; 26:276. figure 1, page 279.
1: 543 patients with disease apparently limited to the skin (clinical stages
I/II/III); 2: 57 patients with extracutaneous disease (clinical stage IV) at the
time of presentation.
Kim, YH, Hoppe, RT. Mycosis fungoides and Sézary Syndrome. Semin Oncol
.
1999; 26:276. figure 2, page 280.
Good-Risk:
Patch/Plaque only
Survival >12 years
Intermediate-risk:
Tumors/erythroderma
Plaque + node/blood
Survival 5 years
Poor-risk:
Visceral involvement
Survival 2.5 years
MYCOSIS FUNGOIDES
Cures generally unattainable
Goals of treatment are symptom relief and cosmetic improvement (palliation)
Early aggressive therapy results in high complete remission rates but no
significant difference in DFS or OS.
Patients are susceptible to infections with skin flora; immune suppression is
undesirable
Skin Directed
Phototherapy : UVB (Ultraviolet B) or PUVA ( Psoralen + UVA photochemotherapy)
Topical chemotherapy :- Nitrogen Mustard (HN2) or Carmustine (BCNU)
Radiation therapy ( Electron Beam Therapy, TSEBT – Total Skin Electron Beam Therapy)
Topical Retinoids ( Baexarotene)
Topical Corticosteroids
Systemic
Photopheresis
Biologic Therapies : ( IFN alfa, Denileukin diftitox)
Retinoids/Rexinoids ( Oral Bexarotene or Isotretinoin)
HDAC ( Histone Deacetylase inhibitors) - Vorinostat
Chemotherapy ( Single agent chemotherapy – Methotrexate, Doxil, Gemcitabine,
Chlorambucil, Cyclophosphamide)
TYPE TREATMENT MODALITY
Hypertriglyceridemia 63%
Most patients require drugs to reduce hypertriglyceridemia
such as statin or fibrates. Diet should include Vitamin E and
dietary consultation, especially for monotherapy patients.
Hypothyroidism 43%
These patients need synthroid supplements.
Leukopenia 7%
Dose adjustments control leukopenia
Teratogenic
Oral HDAC (Histone Deacetylase) inhibitor
Partial response rates in MF of 30 percent
Approved by the FDA for the treatment of
cutaneous T-cell lymphoma (CTCL) in patients
with progressive, persistent, or recurrent disease
on or following two systemic therapies.
Common Side effects :
Gastrointestinal symptoms
(diarrhea, nausea, anorexia, weight
decrease, vomiting, constipation)
Constitutional symptoms (fatigue, chills)
Hematologic abnormalities (thrombocytopenia, anemia)
Taste disorders (dysgeusia, dry mouth)
Abnormal laboratory values include high
glucose, abnormal EKGs
Hoppe RT, Kim YH,Clinical features, staging, and prognosis of mycosis fungoides and Sezary syndrome, Uptodate.com,
11/06
Likelyrepresents leukemic phase of mycosis
fungoides.
Sezary Syndrome:
Generalized erythroderma + intense Pruritis
Lymphadenopathy
Atypical T- cells (Sezary cells) in the peripheral blood ( An
absolute count ≥1000 Sezary cells/cubic mm is a
diagnostic criterion for Sezary syndrome equivalent to
the B2 designation in the TNMB classification syndrome).
Low levels of Sezary-like cells can be detected
in the peripheral blood of patients with benign
skin conditions. Hence, diagnostic criteria of
Sezary syndrome uses an absolute Sezary cell
count of >1000/microL with positive clones
Diagnosis is made when there is a clonal
rearrangement of the T-cell receptor (TCR) in
the blood (identified by PCR or southern blot
analysis) plus
either
an absolute Sezary cell count of at least 1000
cells/microL
or one of the following two criteria
Increased CD4+ or CD3+ cells with a CD4 to CD8
ratio of 10 or more.
Increased CD4+ cells with an abnormal
phenotype (such as a CD4+ to CD7- ratio ≥40
percent or a CD4+ to CD26- ratio ≥30 percen
Treatment includes Extracorporeal Photopheresis
( ECP) alone or in combination with other
therapies ( IFNα) OR 30-80% and CR 15-25%.
The clinical appearance and course are used as decisive criteria for
the definite diagnosis and choice of treatment.
Frequently misdiagnosed.
Despite modern techniques, cannot be definitively
diagnosed by pathologists without pertinent clinical
information.
Clinically benign.
Excellent prognosis.
Chronic ATLL
skin lesions only ( closely resemble MF)
Circulating atypical cells are few or absent
Indolent clinical course and better survival, however this may
transform into an acute phase with an aggressive course.
Rx: Skin targeted therapies similar to MF in chronic cases.
Acute ATLL requires systemic chemotherapy.
More common in males. Seen in Asia, South
America and Central America.
EBV associated Lymphoma.
Multiple plaques and tumors on the trunk/
extremities and in the Nose/ Nasopharynx.
Systemic symptoms such as fever and weight
loss. An associated hemophagocytic syndrome
may be seen
The malignant cells are usually CD2 and CD56
positive (NK cell phenotype) - Epstein-Barr
virus (EBV) are commonly positive. Rarely, cells
may have a true cytotoxic T-cell phenotype.
Very aggressive disease, Rx with Systemic
Chemotherapy, Median survival < 1yr .
characterized by a proliferation of
epidermotropic CD8 cytotoxic T-cells and an
aggressive clinical behavior.
presents with eruptive papules, nodules, and
tumors with central ulceration. Visceral
involvement (CNS, Lung, Testes ) can be seen
but LN are usually spared.
Rx: anthracycline-based systemic
chemotherapy
Median survival : 32 months
Heterogeneous group which includes all T-cell
neoplasms that do not fit into any of the better
defined subtypes of T-cell lymphoma/leukemia.
Out of this group, primary cutaneous aggressive
epidermotropic CD8 cytotoxic T-cell
lymphoma, cutaneous gamma-delta T-cell
lymphoma, and primary cutaneous smallmedium
CD4 T-cell lymphoma can be separated out as
provisional entities.
Remaining diseases that do not fit into either of
these provisional entities must be the designated
as PTL, unspecified.
In all these cases a diagnosis of MF must be ruled
out by complete clinical examination and an
accurate clinical history.
•CLASSIFICATION
•CLINICAL
FEATURES
•TREATMENT
Primary
cutaneous marginal zone B-cell
lymphoma
Primary
cutaneous follicle center
lymphoma
Primary
cutaneous diffuse large B-cell
lymphoma, leg type
Primary
cutaneous diffuse large B-cell
lymphoma, other
Histologically, dilated blood vessels in the dermis and subcutis are filled
and extended by a proliferation of large neoplastic B cells.
Usually,
a reactive process, though a number
of these can be difficult to distinguish from a
lymphoma
• Drug induced
Anticonvulsants; phenytoin, carbamazepine
ACE inhibitors
Miscellaneous; atenolol, allopurinol, mexilitine,
cyclosporine, antihistamines, griseofulvin
2. Idiopathic
2. Nodular pattern
• Many small round T-cells
• Scattered T-blasts & medium/large cerebriform cells
• Histiocytes usually numerous +/- plasma cells, eosinophils
Seen in
• Drug induced CTCPL
• Persistent arthropod bite reactions
• Idiopathic CTCPL
Features which strongly suggest MF
1. Pautrier‘s microabscesses
2. Medium/large cerebriform cells in epidermis
3. Linear epidermotropism
4. Disproportionate epidermotropism
5. ‗Haloed‘ lymphocytes in epidermis
ACTINIC RETICULOID vs MYCOSIS FUNGOIDES
• CD8+ T-cells, MF usually CD4+
• Multinucleate giant cells – fibroblasts,
histiocytes
• Vertically orientated collagen in papillary
dermis
ABERRANT PHENOTYPE
1.Loss of pan-T-cell antigens
CD2, CD3, CD5, CD7
BUT also lost in some benign conditions (esp CD7)
2. Ratio of CD4:CD8
vast excess
dual expression
no expression
CD7 T, NK Prothymocyte
CD 8 T subset, NK Suppressor
CD25 Active T, B, M IL-2R (Tac)
CD30 Active T, B Ki-1
CD45 T subset CLA
CD56 NK NCAM
CD20-B-cell
marker
Cd138 and
CD79a– plasma
cell markers 9
usually CD20 –
VE)
Immunophenotyping in anaplastic large cell lymphoma (ALCL) exhibits consistently strong
CD30 expression in all clinical and pathologic subtypes – Most tumor cells are T Cell
Phenotype ( frequent CD3 expression, clonal T-cell receptor gene rearrangements and lack
of B-cell – associated markers) or null cell phenotype. In ALCL, B-cell antigenic expression is
rare and is commonly observed in the HIV-related clinical form. In fact, these B-cell cases
of ALCL are classified separately in the World Health Organization classification under
diffuse, large, B-cell lymphoma
Primary systemic anaplastic large cell lymphoma (ALCL) is typically in an advanced stage at
patient presentation, and the disease is rapidly progressive. These patients demonstrate an
increased frequency of bone marrow involvement (30%) and extranodal involvement,
including skin (21%), bone (17%), soft tissues (17%), lung (11%), liver (8%), and, rarely, the
gastrointestinal tract and central nervous system. Systemic symptoms are observed in 75%
of patients, with fever the most common symptom. The primary systemic form, unlike the
primary cutaneous form, generally stains positive for EMA and usually displays the t(2;5)
translocation and the chimeric p80 protein ( NPM-ALK fusion protein – NPM on
chromosome 5 joined with ALK on chromosome 2) with PCR and antibody studies.
Primary cutaneous anaplastic large cell lymphoma (ALCL) usually manifests as a single or
localized cluster of erythematous skin nodules, some of which may demonstrate superficial
ulcerations. As many as 25% of patients have some degree of spontaneous regression of
these lesions. Although most cases present with local involvement, patients may rarely
present with disseminated cutaneous disease and are at higher risk of developing spread to
other organs.
Most cases of HIV-related anaplastic large cell lymphoma
(ALCL) are actually of B-cell origin and seem instead to be
related to the anaplastic variant of diffuse large B-cell
lymphoma. Many patients demonstrate infection with
the Epstein-Barr virus, which is absent in those with the T-cell or
null-cell types of anaplastic large cell lymphoma (ALCL).
Secondary anaplastic large cell lymphoma (ALCL) evolves from
other lymphomas, most frequently from peripheral T-cell
lymphomas, mycosis fungoides, Hodgkin disease, or
lymphomatoid papulosis. This form of anaplastic large cell
lymphoma (ALCL) tends to arise in older adults, is commonly ALK
negative (chr 2, 5 translocation), and carries a poor prognosis.
Patients with anaplastic large cell lymphoma (ALCL) present with
either a primary cutaneous form or a systemic form of the illness.
Patients may present with isolated lymphadenopathy or with
extranodal disease at any site, including the gastrointestinal
tract and bone. Patients with infiltration into musculoskeletal
tissues (eg, psoas muscle) can present with backache.