CORRECT DIAGNOSIS:

Diffuse large B-cell non-Hodgkin’s lymphoma, high grade

DISCUSSION:

Primary cutaneous B-cell lymphomas are rare, making up the minority of primary cutaneous lymphomas. Classification schemes for cutaneous lymphomas have been controversial and continue to be disputed. Multiple classification schemes have been proposed, and have led to confusion in the terminology of cutaneous lymphomas.

Cutaneous lymphomas typically present with erythematous to violaceous plaques and nodules on the skin. Primary versus secondary disease must be distinguished. Physical exam, laboratory workup, and imaging help to exclude systemic involvement. Patients may complain of fever, weight loss, night sweats, and fatigue. Lymphadenopathy, as well as hepatosplenomegaly, may be present, and an exam should also include lymph nodes and palpation of the liver and spleen.

Laboratory workup should include CBC, chemistries to evaluate liver and renal function, and LDH. Evaluation of systemic involvement should include a peripheral blood smear, bone marrow evaluation, CT or PET scan, and a lymph node biopsy if lymphadenopathy is found on the exam. Histology will reveal large, atypical lymphoid cells in a diffuse pattern of growth. These cells have hyperchromatic nuclei with prominent nucleoli. Mitoses may be abundant. Immunophenotype will stain positively for lymphoid markers, such as LCA (CD45), and B lymphocyte markers, such as CD20 and CD79a.

Low-grade, indolent B cell lymphomas do not require aggressive chemotherapy, and may be observed, and localized lesions may benefit from radiation therapy. Rituximab, an anti-CD20 antibody that targets CD20 on B cells, is generally used for low or high-grade B-cell lymphomas. The standard treatment for aggressive, high-grade B-cell lymphomas includes multiple-agent chemotherapy (CHOP) in combination with rituximab (CHOP-R), which may be followed by radiation.

TREATMENT:

CHOP chemotherapy with rituximab, followed by radiation.

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