82 yrs old Lady with resected breast tumor. Clin. diagnosis: "adenocarcinoma vs lymphocytoma cutis".  
MACRO: 3,5x2,5x1,5 cm skin/subcutaneous tissue with yelowish nodule 3,1x2,5 cm with 0,1 cm distance from lateral resection margin.  
HISTO: On the slides.  
IH: CD21/CD23(-)(FDC network absent); CD20(+++)(40% population; large tumor cells 100%), CD3/CD43(+++)(60% population; reactive T cells); CD10(-)(except stroma); Bcl2(++)(40% tumor population); Ki67 in tumor cells 80%; Bcl6(+/++)60% in tumor cells; Mum1 (++) 70% in tumor cells; CD138(-)(plasma cells absent); CyclinD1(-); IgM (++) 90% >> IgD(++)10% in tumor cells; Ig kappa slightly > Ig lambda (unsatisfactory?).  
IMMUNOPHENOTYPE ACTIVATED/MIXED: Bcl6+ CD10- Bcl2+ IgM+, Mum1+. Ki67 80%.  
PROPOSED DIAGNOSIS: DLBCL of the skin vs Follicular cell lymphoma (grade II) of the skin.  
QUESTION: Bcl2+ and IgM+ value in decission making in this case?  
 
PLEASE FIND a link to another breast skin B lymhoma case from our archives below.  
Your participation is HIGHLY appreciated.

kunze 2007-10-29 12:05	I share your opinion of a cutaneous B-cell lymphoma and support the diagnosis of a DLBCL (with numerous reactive T-cells). The immunoreactivity of the large B-cells for Bcl-2 is rather an argument against a cutaneous follicular lymphoma. I have no much experience with IgM/IgD in skin lymphomas.
anpo 2007-10-31 02:49	I agree that morphology and immunophenotype are in favor of cutaneous DLBCL.
tzankov 2007-10-31 07:18	Considering the hige amount of reactive T-cells, the nodular apperance at scanning magnification with some paler areas, the expression of IgM, the displacement of bcl-6+ cells by lymphoma and the presence of "deep nodules" with lower proliferative activity, my favorite diegnosis would be a blast-rich (cutaneous? exclude other organs) marginal zone lymphoma with a high grade component/transformation (DLBCL). cutaneous follicular lymphoma could be practiaclly excluded considering your immunostains.
ugnius 2007-10-31 08:18	Thank you. The prominent T cell reaction and relativelly small caliber of the cells with some nodularity WITHOUT IH results evoke an idea of low grade B lymphoma.   After IH the diagosis of DLBCL becomming the single choice. I will append the last IH stains soon.
ugnius 2007-10-31 11:09	1 question left: variant of DLBDL in the skin. We cannot call it "leg type".
ugnius 2007-10-31 11:14	Please find Mum1+ 70%
anpo 2007-11-09 00:02	DLCB leg type are rare in other localizations but one case primary in breats was described in a recent study (see attached). Whether you call it leg type or not - high MUM-1 expression is a bad prognostic sign (see attached second paper)
anpo 2007-11-09 00:03	I do not see the files - try again attachment: DLCB_leg.pdf
anpo 2007-11-09 00:04	and the other one
anpo 2007-11-09 00:05	one more try...
anpo 2007-11-09 00:10	Unfortunately it appeared that the pdf file was too large (over 5MB).   The reference is J.Cutan Path 2005,32, 227-234. Sundram U et al.
ugnius 2007-11-09 09:50	Thank you for a comment and pdf's. I get it.
ugnius 2007-11-25 20:31	Thank you from my side.
schulze 2007-12-17 16:58	I agree with the comments and diagnoses of Drs. Kunze, Porwit and Tzankov: DLBCL. However, I recommend to rule out involvement of other organs.
hurwitz 2007-12-29 20:20	The consensus diagnosis is     Diffuse large B-cell lymphoma involving skin of the breast.   Involvement of other sites remains to be excluded.
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