Diffuse large B cell lymphoma: cutaneous manifestation

Abstract

DESCRIPTIONA 47-year-old gentleman was diagnosed with diffuse B cell lymphoma. His initial presentation was skin lesions. He was then referred for patch test with a diagnosis of periorbital eczema. Later, patient developed varicose veins and skin lesions in the right leg which was operated upon with poor healing and subsequent skin biopsy of the lesions demonstrated diffuse large B cell lymphoma (DLBCL). The bone marrow biopsy proved marrow involvement. He had no B symptoms. His past medical history includes brain abscess aged 9 months which was operated upon and left him with some weakness on the left side. He is married with two children. No signifi cant illnesses in the family. Patient had six to eight cycles of R-CHOP chemotherapy, however he had progression of lymphoma within 2 months of R-CHOP chemotherapy. He then represented with extensive skin lesions. He was referred for positron emission tomography (PET) scan which was performed using radioisotope 18FDG which confi rmed extensive involvement of skin. The pictures show the skin lesions ( fi gure 1 ) at the time patient was referred for PET and a corresponding picture of PET image ( fi gure 2 ). The patient had further chemotherapy with oral CCEP (Cytoxan, CCNU, Etoposide and Prednisone) which resulted in complete remission. Currently, he is awaiting peripheral blood stem cell autograft. DLBCL is the most common histological subtype of non-Hodgkin's lymphoma (NHL) accounting for approximately 30-58% of adult NHL cases. 1 It is aggressive form of NHL and sixth most common cancer in the UK. 2 Most frequently, diffuse large cell lymphomas appear in lymphoreticuloendothelial tissues, which include the lymph nodes, spleen, liver and bone marrow. However, any extra nodal site may be primarily or secondarily involved. Skin biopsy from the plaques in such patients showed dense infi ltrates of large lymphocytes with irregularly shaped nuclei and prominent nucleoli in the dermis and subcutaneous tissue. 3 FDG-PET/CT after the fi rst cycles of chemotherapy is useful to monitor treatment due to its high negative predictive value (87.5%),