Eosinophils in Mycosis Fungoides: An Uncommon Finding in the Patch and Plaque Stages
Department of Dermatology, Geisinger Medical Center, Danville, PA 17821, USA.The American Journal of dermatopathology (Impact Factor: 1.39). 08/2012; 34(6):586-91. DOI: 10.1097/DAD.0b013e31823d921b
Early diagnosis of mycosis fungoides (MF) is one of the most challenging problems in dermatopathology, as the histopathologic features of inflammatory dermatoses and MF may show significant overlap. One criterion used to distinguish early MF (patch stage) from dermatitis, which may be currently underutilized, is the presence of eosinophils. A search was performed for cases with a preoperative diagnosis of MF, cutaneous T-cell lymphoma, or dermatitis, which included 29 cases "diagnostic" for MF, 25 cases "suspicious" for MF, and 55 cases of spongiotic dermatitis. We examined tissue sections blinded to diagnosis to obtain an exact eosinophil count. Twenty-nine cases were diagnostic for MF (12 patch, 9 plaque, and 8 tumor stage). The average eosinophil count for cases diagnostic for patch stage MF was 1 eosinophil in 10 (0.11) sections examined. For plaque MF, there was 1 eosinophil in 5 (0.24) sections examined. All tumor stage MF cases showed abundant eosinophils within each section. Twenty-five cases were suspicious for MF (15 patches, 9 plaques, and 1 folliculotropic). The average eosinophil count for the patch lesions was 1 eosinophil in 4 (0.25) sections examined and 2 eosinophils per section for plaque lesions. Forty-five of 55 cases of spongiotic dermatitis had at least scattered eosinophils (>3) in each section. Twenty-three (47%) had eosinophils around most postcapillary venules. Only 3 of 45 patients (6.6%) with biopsies diagnostic or suspicious for patch or plaque stage MF showed >3 eosinophils per tissue section, whereas 45 of 55 (81.8%) biopsies of spongiotic dermatitis had >3. The presence of eosinophils (>3 per tissue section) is statistically significant in differentiating cases diagnostic or suspicious for patch or plaque stage MF from dermatitis (P < 0.0001). Our data indicate that eosinophils are uncommon in cases of patch and plaque MF. When a pathologist is faced with evaluating a biopsy that lacks some of the criteria used to make the diagnosis of patch stage MF, yet demonstrates >3 eosinophils per tissue section, dermatitis is the likely diagnosis. However, in cases where fewer than 3 eosinophils are present in sections, patch stage MF cannot be excluded.
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ABSTRACT: Die Mycosis fungoides ist ein häufiges kutanes T-Zell-Lymphom und verläuft in verschiedenen Stadien mit zunehmender klinischer Aggressivität. Die frühe Patch- und Plaque-Phase ist sowohl klinisch als auch histopathologisch schwierig von entzündlichen Dermatosen abzugrenzen. Eine zuverlässige Diagnostik in diesem Stadium erfordert die Integration von klinischen, histopathologischen und molekularen Befunden, wobei kein Einzelkriterium für sich alleine als krankheitsspezifisch gewertet werden kann. Hilfreichste Merkmale der Mycosis fungoides sind der Nachweis atypischer epidermotroper meist CD4-positiver reifer T-Zellen bei geringen Veränderungen der Epidermis, die Ausbildung von Pautrier-Abszessen und das sog. basale Aufreihungsphänomen. Ein aberranter Immunphänotyp der intradermalen T-Zellen sowie der molekulare Nachweis einer klonalen T-Zell-Population sind wichtige weitere Faktoren, die eine sichere diagnostische Zuordnung ermöglichen können. Zumindest in der Abgrenzung der frühen Mycosis fungoides zur Parapsoriasis besteht dennoch eine diagnostische, möglicherweise auch biologische, Grauzone zwischen entzündlicher Dermatose und Lymphom.
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ABSTRACT: Mycosis fungoides is a cutaneous T-cell lymphoma with protracted clinical course and progression in different stages with increasing aggressiveness. The clinical picture as well as the histopathology of mycosis fungoides within the early patch and plaque phase is difficult to delineate from some inflammatory skin diseases. Thus, the diagnosis of these early stages of the lymphoma is only possible when clinical, histopathological, and molecular features are integrated into the diagnosis, especially as none of the individual disease criteria is specific. Important clues towards the diagnosis of mycosis fungoides are cytologically abnormal epidermotropic CD4-positive T-cells causing only minor epidermal alterations, the formation of Pautrier-abscesses and basal alignment of the epidermotropic T-cells. The findings of an aberrant T-cell immunophenotype of the intraepidermal lymphoid component as well as the molecular proof of T-cell clonality are important further features. In the differential diagnosis between early stage mycosis fungoides and parapsoriasis, there remains nevertheless a diagnostic and maybe also a true biological grey zone.
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ABSTRACT: Mycosis fungoides (MF) is a relatively rare cutaneous T-cell malignancy. Only two cases of MF with marked eosinophilia have been reported. In addition, MF with concomitant squamous cell carcinoma (SCC) occurring in the site of MF has not been reported. The author reports herein a very rare case of MF in the plaque stage showing pronounced eosinophilic infiltration, folliculotropic pattern, and in situ development of poorly differentiated squamous cell carcinoma (SCC). A 75-year-old man was found to show high prostate specific antigen (PSA, 13 hg/ml) and prostatic biopsy showed well differentiated prostatic adenocarcinoma of Gleason score 6. Imaging techniques showed no metastatic lesions. He was treated by estrogen therapy. At 80 years, he consulted our hospital because of erythematous patch in the trunk. Biopsy showed mild infiltrations of lymphocyte and eosinophils. The lesion disappeared spontaneously. At 82 years, he consulted our hospital of because of erythematous patch at the back, and biopsy showed mildly atypical lymphocytes positive for CD20 and CD45, but negative for CD30, CD45RO, S100 protein, and cytokeratin (CK). Lymphoma was suspected but not definite. The lesions spontaneously disappeared. At 86 ages, he also consulted our hospital because of plaques in the face. Biopsy showed proliferation of atypical lymphocytes, marked infiltration of mature eosinophils, marked infiltration of these cells in the fair follicles (folliculotropism), and poorly differentiated invasive SCC arising from follicular cells. An immunohistochemical analysis showed that the atypical lymphocytes are T-lymphoma cells with T-cell markers, cyclinD1, p53, and high Ki67 labeling (50%) but without B-cell markers, NK-cell markers and plasma cell markers. The eosinophils were mature, and lacked p53 and showed low Ki67 labeling (4%). The carcinoma was positive for CK, p53, cyclinD1, and high Ki67 labeling (35%). A diagnosis of MF in the plaque stage with marked non-neoplastic eosinophilic infiltration, marked folliculotropism, and coexistent poorly differentiated invasive SCC was made by the author. Post-biopsy imaging techniques showed no metastasis or lymphadenopathy in the body. The patient was now treated by chemotherapy.
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