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lymphomatoid papulosis, type A (5394)
lymphomatoid papulosis, type Aclosed
Subtitle: Skin lesion in a-67-year old male
Type:
skin
Sender:
semir
2008-04-10 16:41
INCTR - EBMWG Hematopathology Online
We present here a new case of the skin lesion, located on the palmar side of the right upper arm in a-67-old Bosnian male. The lesion has persisted for seven months and was composed of a small papullar lesions followed by very severe pruritus.  
Histopathology: A dense dermal infiltration of moderately large lymphoid cells with scant cytoplasm and large hyperchromatic nuclei.  
Tumor cells exhibited the following immunophenotype: CD3(+), CD4(+), CD8(positive single cells), CD20 (positive single cells), and CD30 (sporadically positive).  
Clinical diagnosis: Chronic parapsoriasis or Peripheral T-cell lymphoma  
Histopathological diagnosis: Peripheral T-cell lymphoma  
Looking foward to hearing your opinions!
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diane.c.farhi
2008-04-10 22:34
I see a predominantly perivascular and periadnexal infiltrate of mixed CD4+ and CD8+ T cells, with scattered CD30+ larger cells. I am not able to see mitoses or cellular atypia; possibly they are present under the microscope. Was CD20 done? I would predict it would be positive. You might want to stain for mast cells, since the lesion is pruritic, but it is not strictly necessary. So far, I am not convinced of malignancy, but would suggest the possibility of an insect-bite-like reactive process, pending a CD20 stain. That said, this is a difficult area in dermatopathology, and I cannot claim to be an expert at it.
semir
2008-04-10 22:43
CD20 was not performed, but can easily be done. There is neither significant atypia nor mitoses.
semir
2008-04-11 09:03
Sorry for not attaching figure with CD20 staining. It was certainly done and the picture is now added.
diane.c.farhi
2008-04-11 18:00
CD20+ cells are there, but not as many as I expected. I am still not comfortable with calling this lymphoma, especially without mitoses, atypia, or epidermal involvement (although some cutaneous T cell lymphomas do not involve epidermis). The lesion doesn't seem destructive to me. TCR clonality might help, if one single clonal band is found. If it is oligoclonal or a single clonal band on a background of polyclonality, I don't think I would take it as a criterion of malignancy. In fact, I would probably not do TCR studies at all, since they will end up being confusing. I would diagnose this as atypical lymphoid infiltrate, with a wait-and-watch approach, local treatment, and rebiopsy if needed for expanding or worsening disease. Maybe that's what the dermatologists mean by chronic parapsoriasis; I'm not familiar with this term.
schulze
2008-04-14 20:39
Do you know the size of the skin lesion and whether it was solitary or multiple?  
Histology is suggestive for tumor stage of mycosis fungoides with secondary CD30-expression or for CD30-positive large anaplastic T cell lymphoma of the skin (ask for history to differentiate as described above), however, you have to rule out extracutaneous involvement to confirm one of these diagnoses.
semir
2008-04-14 20:47
It is a solitary lesion and it was slightly reduced in its size. According to our dermatologist, it is now a small cutaneous reddish infiltrate.
semir
2008-04-14 23:03
Sorry for my last comment. The patient got diffuse infiltrations (up to 5 mm), particularly on his back followed by pruritus.  
Laboratory findings:  
nalazi su mu bez ostupanja  
SE 23, L 7,92; Ly 1,53-19,3%, Ne 5,4-68,1%  
Eo 0,187-2,36%, Mo 0,748-9,44%, Ba 0,06-0,76%
schulze
2008-04-16 09:15
Thank you for the additional information.  
Short history (7 months) of solitary papules (up to 5 mm) rules out mycosis fungoides. With respect to papular and not nodular skin lesions, histology fits well with lymphomatoid papulosis, type A.
tzankov
2008-04-16 10:20
considering all the information, I would also agree with Dr. Schulze, that the lesion most probably represents lymphomatoid papulosis.
hurwitz
2008-04-16 19:40
Please do consider Dr.Schulzes comment as the final one.  
According to his comment the case can be closed with the diagnosis of:  
 
Lymphomatoid papulosis type A.  
 
Thanks for submitting the case and the discussion, in particular Dr.Schulze for his support in dermatopathologic cases
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Last modified: 2008-04-10 16:41:16