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Table of Contents
CORRESPONDENCE
Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 254-255

Cutaneous adult T-cell leukemia/lymphoma mimicking primary cutaneous anaplastic large-cell lymphoma


1 Department of Dermatology, International University of Health and Welfare Mita Hospital, Minato-ku, Tokyo, Japan
2 Lymphoma/Hematology Center, International University of Health and Welfare Mita Hospital, Minato-ku, Tokyo, Japan
3 Department of Dermatology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Chiba, Japan

Date of Submission22-Feb-2020
Date of Decision20-May-2020
Date of Acceptance09-Jun-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
Dr. Makoto Sugaya
Department of Dermatology, International University of Health and Welfare Ichikawa Hospital, 6-1-14 Konodai, Ichikawa, Chiba 272-0827
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_29_20

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How to cite this article:
Takaoka M, Takekoshi T, Kobayashi M, Nakajima R, Asai H, Sugaya M. Cutaneous adult T-cell leukemia/lymphoma mimicking primary cutaneous anaplastic large-cell lymphoma. Dermatol Sin 2020;38:254-5

How to cite this URL:
Takaoka M, Takekoshi T, Kobayashi M, Nakajima R, Asai H, Sugaya M. Cutaneous adult T-cell leukemia/lymphoma mimicking primary cutaneous anaplastic large-cell lymphoma. Dermatol Sin [serial online] 2020 [cited 2021 Jan 16];38:254-5. Available from: https://www.dermsinica.org/text.asp?2020/38/4/254/303698



Dear Editor,

Tumor cells of adult T-cell leukemia/lymphoma (ATLL), which are likely derived from cells with the T-regulatory phenotype, sometimes express CD30 and such cases are clinically and pathologically almost indistinguishable from anaplastic large-cell lymphoma. Here, we report a case of ATLL mimicking primary cutaneous anaplastic large-cell lymphoma (pcALCL).

A 53-year-old Japanese male, who was born in the southwestern part of Japan, presented with indurated masses on the chest. He noticed erythema on the chest 2 months before and it grew rapidly over a period of 10 days. Physical examination showed three well-defined erythematous nodules with erosion on the left anterior chest [Figure 1]a. Laboratory study revealed abnormal lymphocytes in the peripheral blood (1.5%), lactate dehydrogenase level of 221 U/L, calcium level of 9.6 mg/dL, and soluble interleukin-2 receptor (sIL-2R) level of 1110 U/mL. No nodal or organ involvement was detected. All the nodules were excised. Histopathological examination revealed dense infiltrate of pleomorphic large atypical lymphocytes [Figure 1]b, which were CD30 positive [Figure 1]c and anaplastic lymphoma kinase negative, into subcutaneous tissues. The diagnosis in a pathology report was pcALCL. Clinical tumor, node, and metastasis classification was T2aN0M0.[1] However, there were also CD30 atypical small lymphocytes in the periphery of the lesions [Figure 1]d. The fact that the patient was from southwestern part of Japan, a human T-cell lymphotropic virus type I (HTLV-1) endemic area, and that both CD30+ large cells and CD30 small cells expressed CD25 [Figure 1]e raised the possibility of ATLL. Interestingly, CD30+ large cells were negative and a part of small atypical cells were positive for forkhead box P3 (Foxp3) [Figure 1]f. The patient turned out to be HTLV-1 seropositive and the monoclonal integration of HTLV-1 genomes was detected in the lesional skin by Southern blotting, leading to the diagnosis of ATLL (T2aN0M0).[1] Three months after the initial presentation, multiple erythematous papules appeared on the trunk and limbs [Figure 1]g. Histology showed dense infiltrate of atypical cells, some of which were CD30 positive, into the dermis [Figure 1]h. He also suffered from herpes zoster and oral candidiasis, suggesting immunodeficiency associated with HTLV-1 infection. Five months after the initial presentation, acute transformation occurred with sIL-2R level increasing to 19800 U/mL and chemotherapy was started.
Figure 1: (a) Initial clinical presentation. Three well-defined erythematous nodules with erosion on the left anterior chest. (b) Histology of the nodule. Dense infiltrates of pleomorphic large atypical lymphocytes in subcutaneous tissue (×400). (c) Larger tumor cells positive for CD30 (×400). (d) Scattered CD30+ large cells in the periphery of the lesion (×200). (e) Both CD30+ large cells and CD30- small cells positive for CD25 (×200). (f) CD30+ large cells negative for Foxp3. (g) Erythematous papules on the thigh. (h) Dense infiltrates of dysplastic cells in the dermis

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We reported a case of cutaneous ATLL mimicking pcALCL. Clinical presentation of ATLL is sometimes indistinguishable from other T-cell lymphomas such as mycosis fungoides/Sézary syndrome[2] and pcALCL. In our case, CD25, commonly expressed by ATLL tumor cells, was expressed not only by CD30+ large cells but also by CD30 small atypical lymphocytes, which was helpful for reaching a correct diagnosis. Foxp3 is reported to be expressed by pleomorphic small and medium cell types and be lost with large cell transformation.[3] Consistently, CD30+ large cells were negative and a part of small atypical cells were positive for Foxp3 in our case [Figure 1]f. Foxp3, a master control transcription factor for regulatory T cells, is a relatively specific maker for ATLL, although it can be expressed by other lymphomas.[4]

PcALCL has a favorable prognosis with 5-year survival rates between 76% and 96% and its initial treatment is surgical excision or radiotherapy,[5] whereas ATLL is associated with a poor prognosis; the mean survival time is 17.3 months for both nodulotumoral and multipapular types.[6] Although our case had only skin lesions at initial presentation, chemotherapy was needed due to the aggressive disease course.[7] If we had only focused on atypical large cells positive for CD30 and negative for Foxp3, we could not have reached the diagnosis. Our case reminds us of importance of ruling out ATLL even if the diagnosis in a pathology report is another type of lymphoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim YH, Willemze R, Pimpinelli N, Whittaker S, Olsen EA, Ranki A, et al. TNM classification system for primary cutaneous lymphomas other than mycosis fungoides and Sezary syndrome: A proposal of the International Society for Cutaneous Lymphomas (ISCL) and the Cutaneous Lymphoma Task Force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 2007;110:479-84.  Back to cited text no. 1
    
2.
Khanlari M, Ramos JC, Sanchez SP, Cho-Vega JH, Amador A, Campuzano-Zuluaga G, et al. Adult T-cell leukemia/lymphoma can be indistinguishable from other more common T-cell lymphomas. The University of Miami experience with a large cohort of cases. Mod Pathol 2018;31:1046-63.  Back to cited text no. 2
    
3.
Yao J, Gottesman SR, Ayalew G, Braverman AS, Axiotis CA. Loss of Foxp3 is associated with CD30 expression in the anaplastic large cell subtype of adult T-cell leukemia/lymphoma (ATLL) in US/Caribbean patients: potential therapeutic implications for CD30 antibody-mediated therapy. Am J Surg Pathol 2013;37:1407-12.  Back to cited text no. 3
    
4.
Ferreira CR, Zhao S, Sahoo MK, Pinsky B, Weber J, Lage LAPC, et al. FOXP3-positive T-cell lymphomas in non-HTLV1 carriers include ALK-negative anaplastic large cell lymphoma: expanding the spectrum of T-cell lymphomas with regulatory phenotype. Hum Pathol 2018;80:138-44.  Back to cited text no. 4
    
5.
Benner MF, Willemze R. Applicability and prognostic value of the new TNM classification system in 135 patients with primary cutaneous anaplastic large cell lymphoma. Arch Dermatol 2009;145:1399-404.  Back to cited text no. 5
    
6.
Sawada Y, Hino R, Hama K, Ohmori S, Fueki H, Yamada S, et al. Type of skin eruption is an independent prognostic indicator for adult T-cell leukemia/lymphoma. Blood 2011;117:3961-7.  Back to cited text no. 6
    
7.
Cook LB, Fuji S, Hermine O, Bazarbachi A, Ramos JC, Ratner L, et al. Revised adult t-cell leukemia-lymphoma international consensus meeting report. J Clin Oncol 2019;37:677-87.  Back to cited text no. 7
    


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