© 2009 The Authors. doi: 10.2340/00015555-0543
Journal Compilation © 2009 Acta Dermato-Venereologica. ISSN 0001-5555
Acta Derm Venereol 89
Acta Derm Venereol 2009; 89: 74–77
Solid organ transplant recipients are at risk of develop ing
a wide range of viral-associated malignancies, in cluding
skin tumours and lymphoproliferative disorders. The
risk of a post-transplant lymphoproliferative disorder
is 28–49 times the risk of a lymphoproliferative disor-
der in the normal population. Most cases are of B-cell
phenotype and are associated with Epstein-Barr virus
infection. Post-transplant lymphoproliferative disorders
presenting clinically in the skin are rare and usually of
B-cell phenotype. Only rare cases of cutaneous T-cell
post-transplant lymphoproliferative disorder have been
reported previously, mostly mycosis fungoides type. We
describe here a rare primary cutaneous T-cell lymphoma
CD30+ arising in a heart transplant patient who had a
nodule on the right leg, several years after heart trans-
plantation. The morphology and immunohistochemical
findings were consistent with a CD30+ anaplastic large
cell lymphoma with a T-cell phenotype. Excisional biop-
sy and radiotherapy of the affected area were performed.
In this patient, the presence of a solitary lesion and the
lack of systemic involvement represented the main fac-
tors taken into account in choosing the therapy and the
patient was therefore treated using a non-aggressive ap-
proach, although with systemic immunosuppression. In
conclusion, the diagnosis of a CD30+ anaplastic large cell
lymphoma in transplant recipients does not imply ag-
gressive clinical behaviour by the lymphoma. Key words:
CD30-positive; cutaneous T-cell lymphoma; transplanta-
tion; anaplastic large cell lymphoma.
(Accepted May 20, 2008.)
Acta Derm Venereol 2009; 89: 74–77.
Mauro Alaibac, Unit of Dermatology, University of Padua,
Via Cesare Battisti 206, IT-35121 Padova, Italy. E-mail:
After gastrointestinal localizations, skin is the most in-
volved site for non-Hodgkin’s lymphoma (1). Primary
cutaneous lymphomas are defined as cutaneous T-cell
lymphomas (CTCLs) and cutaneous B-cell lymphomas
(CBCLs) that present in the skin with no evidence of
extracutaneous disease at the time of diagnosis (2).
Among CTCLs, CD30-positive cutaneous T-cell lym-
phoma (CD30+CTCL) is the second most common
group; it represents approximately 30% of cutaneous
primary T-cell lymphoproliferative disorders (3). In the
World Health Organization – European Organisation for
Research and Treatment of Cancer (WHO-EORTC) clas-
sification of cutaneous lymphomas (2), the CD30+CTCL
group comprises primary cutaneous anaplastic large cell
lymphoma (ALCL) and lymphomatoid papulosis (LP).
ALCL presents large cells with an anaplastic, pleiomor-
phic or immunoblastic cytomorphology with a CD30
antigen expression in more of 75% of neoplastic cells;
it usually affects adults, with a male:female ratio of 3:1;
clinically, ALCL shows nodules or papules, often ulcer-
ated, in single or multiple lesions; these lesions could
have a spontaneous resolution but with possible recur-
rence; 10% of patients have local node involvement; the
10-year survival rate is greater than 90% for both solitary
and multifocal lesions (4).
LP is characterized by papular, papular-necrotic and
nodular skin lesions, usually localized in the trunk, arms
and legs; the lesions usually undergo spontaneous reso-
lution in 3–12 weeks but often reappear after a variable
period of time; 20% of patients with LP may present a
more aggressive lymphoproliferative disorder (5).
Hodgkin’s and non-Hodgkin’s lymphomas are a not
infrequent complication in transplant organ recipients
and they are usually aggressive diseases, with nodal
and extranodal localizations, generally B-cell lympho-
mas, often Epstein-Barr virus (EBV)-related (6, 7).
Possible regression after immunosuppressive regimen
reduction has been shown (8). Whereas skin is often
involved in transplant organ recipient carcinogenesis
(e.g. squamocellular carcinoma, basocellular carcinoma,
malignant melanoma and Kaposi’s sarcoma), cutaneous
lymphomas are extremely rare and their incidence has
not been established. Seventy percent of reported cases
are CBCL, whereas 30% are CTCL (9).
We describe here a case of cutaneous anaplastic
CD30+ T-cell lymphoma in a transplant organ recipient
and review the literature concerning CD30+ cutaneous
lymphomas in this group of patients.
In January 2005 a 68-year-old Caucasian man, heart-
transplanted in 1994, under immunosuppressive thera-
Primary Cutaneous CD30+ Anaplastic Large Cell Lymphoma in
a Heart Transplant Patient: Case Report and Literature Review
Anna BELLONI-FORTINA1, Maria Cristina MONTESCO2, Stefano PIASERICO1, Matteo BORDIgNON1, Francesco TONA3,
giuseppe FELTRIN3 and Mauro ALAIBAC1
Units of 1Dermatology, 2Pathology, and 3Cardiosurgery, University of Padua, Padua, Italy
Cutaneous lymphoma in a heart transplant patient
py with cyclosporin A (175 mg/day) and azathioprine
(100 mg/day) was referred to our unit. Skin examination
revealed a reddish oval nodule, about 2 cm in diameter
on the lateral side of the left leg (Fig. 1). An excisional
biopsy of the lesion was performed and histological
analysis showed an atypical, non-epidermotropic cel-
lular infiltrate of the entire dermal compartment; this
infiltrate was composed of large anaplastic cells with
eosinophilic cytoplasm and numerous and prominent
nucleoli (Fig. 2). Atypical mitosis were also identified.
The neoplastic cells were CD3+, CD4+ CD30+ (Fig. 3).
We observed also a weak positivity for CD5 molecule
(expressed in approximately 30% of the lymphoid infil-
trate) and a reduced expression of the CD1a molecule
in both the dermal and epidermal compartments. The
patient was properly staged (serum and instrumental
examinations, bone marrow biopsy) and no extracuta-
neous manifestation of disease was found. On the basis
of clinical, histological and immunophenotypical data
a diagnosis of primary cutaneous anaplastic CD30+ T-
cell lymphoma was made. After surgical removal, local
radiotherapy was performed. No variation was made in
the immunosuppressive drug regimen. After a 2-year
follow-up, complete remission persists.
Post-transplant cutaneous lymphoproliferative disor-
ders (PTCLDs) are a rare complication. To date, it has
not been demonstrated whether a major incidence of
primary cutaneous lymphoma does exist in immunosup-
pressed patients. Nevertheless, a role of immunosup-
pressive therapy in the development of PTCLDs could
be speculated. Reduction of immune surveillance,
chronic antigenic stimulation by the transplanted organ
and direct oncogenetic potential of immunosuppressive
drugs could be considered risk factors for PTCLDs in
Fig. 1. Appearance of the lesion: reddish, oval nodule, approximately 2 cm
in diameter, not ulcerated.
Fig. 2. Histological features of
the lesion. (A) Diffuse dermal
infiltration without epidermo-
tropism. Large anaplastic cells
with eosinophilic cytoplasm and
numerous and prominent nucleoli. (B)
Atypical mitosis was also observed.
Haematoxylin & eosin (H&E);
original magnifications: (A) ×10;
Fig. 3. Immunohistochemical
staining of most atypical cells with
monoclonal antibodies directed
against the CD3 and CD30 molecules.
Immunoperoxidase stain for (A) CD3
and (B) CD30. Original magnification
Acta Derm Venereol 89
A. Belloni-Fortina et al.
transplant recipients. To the best of our knowledge,
eight cases of ALCLs have been reported (Table I)
(10–17). The clinical behaviour of these cases seems
to be more aggressive compared with the non-immuno-
suppressed population. In most of these cases, multiple
lesions were present at the first observation and new
nodules were noticed a few months after diagnosis.
Systemic chemotherapy and variation of the original
immunosuppressive regimen were often necessary, with
a very poor prognosis in 50% of cases. The majority
of PTCLDs observed were found at least 5 years after
solid organ transplantation.
The clinical behaviour, histological and immunopheno-
typical features of our case were not different from
ALCLs of immunocompetent patients. The disease was
not aggressive and complete remission still persists after
2 years. The presence of a solitary lesion at the time of
diagnosis has represented the main prognostic factor
in our case, and for this reason we treated the patient
by means of a non-aggressive approach (surgical exci-
sion and local radiotherapy) without the necessity for
systemic chemotherapy or variation of the immunosup-
In conclusion, we present here a case of ALCL in a
heart transplant patient. This particular type of PTCLD
showed a not aggressive clinical behaviour that was
similar to other published cases with a solitary lesion at
the time of diagnosis. We conclude that the diagnosis of
ALCL in transplant recipients does not imply aggressive
clinical behaviour by the lymphoma and consequently
the therapeutic approach should be modulated according
to clinical presentation.
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Table I. Summary of cases of primary cutaneous anaplastic CD30+ T-cell lymphoma (CTCL) in organ transplant recipients reported in
(months) Skin examination Therapy and outcome
Ward HA, et al.
Seckin D, et al.
F/64 Kidney Pred, CyA, Aza56 Erythematous eruption on face and trunk,
with papules and hyperpigmented nodules
Reddish and rapidly growing nodule on the
Deceased after ECP and RT
F/51 KidneyPred, CyA, Aza10 Remission after 5 months
from RT (cumulative dose
Deceased after local RT
Deceased after CyA and
Aza reduction and Pred and
CR 10 months after 6 cycles
CR 49 months after therapy
with Igg, IFN-α and CHOP
Cooper SM, et
al. 2003 (12)
Coyne JD, et al.
M/60 Kidney M. mofetil, Pred, CyA66Asymptomatic and multiple nodules
localized on the left arm
Cutaneous nodules localized on abdomen,
thorax, right upper and lower extremities
F/33Kidney Pred, CyA, Aza 25
Kim HK, et al.
Lucioni M, et al.
M/56 KidneyPred, CyA, Aza192 Polypoid mass localized on the forehead
M/63Heart RATg, Aza, CyA, Pred 111 Nodules and multiple plaque, some
ulcero-necrotic, in the back side of lower
Multiple nodules localized on the left legSalama S, et al.
Denisi MC, et al.
M/59 Kidney– 72 Deceased
M/49Heart M. mofetil, tacrolimus,
60 Brownish, indolent, not ulcerated nodule
localized on the left cheek
Reddish, indolent, not ulcerated nodule
localized on the left lower extremity
CR, after surgical removal
CR, after surgical removal
*Time between transplant and CTCL.
CyA: cyclosporin A; Pred: prednisolone; Aza: azathioprine; CT: chemotherapy; RT: radiotherapy; CR: complete remission; ECP: extracorporeal
photopheresis; CHOP: cyclophosphamide, hydroxydaunorubicin, oncovin, predrisolone; RATg: rabbit anti-thymocyte globulins.
Acta Derm Venereol 89
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