Solitary Lymphocytic Tumor: Benign or Malignant?

A healthy 80-year-old  Chinese man presented with a 2-month history of a 6 x 6 cm erythematous plaque on the right forearm that had gradually increased in size. He saw a dermatologist 2 months ago, had a biopsy and was told it was an insect bite reaction. However, he did not recall any insect bite reaction.  I repeated his skin biopsy as it was not responding to treatment..

 

Clinical and Histopatological Photos

Pathology: Section shows epidermis with mild spongiosis. The dermis shows dense, superficial and deep perivascular infiltration of lymphocytes and plasma cells. There is no significant increase of eosinophils. The infiltrate extends along the sweat ducts, hair follicles and sebaceous glands. The superficial subcutaneous fat shows lymphocytes and plasma cells infiltration. The deeper dermis shows marked increased in eosinophils. There is no granulomatous lesion or atypical bizzare lymphocytes seen. The deeper dermis and subcutaneous fat are normal.  No granuloma or nerve hypertrophy seen.

INTERPRETATION
Reactive lymphoid proliferative disorder or lymphocytoma cutis.
No granuloma seen to suggest leprosy or cutaneous TB. 

Follow up with IHC stains.
CD3: CD20 showed mixed populations of the lymphoid cells.
CD10: positive weak for genimal centre
BCL2: negative for geminal centre
BCL6: positive for geminal centre
CD30 negative
EBER: negative
cMYC negative
EMA negative
Ki67 no marked increase in mitosis

Discussion: The pathologists concluded reactive lymphoid proliferative disorder or lymphocytoma cutis.

Questions: Is this benign or does it have a malignant potential?  Does he warrant further work up or perhaps follow up closely to watch his progression? Thanks for your input!

Keratinocyte Skin Cancer in a Centenarian

The patient is a 100 year-old widow who lives independently in an apartment complex.  She’s been on supplemental oxygen for almost 20 years.  She has friends who visit regularly, but no close relatives nearby.  She enjoys life and is a great sports fan.

 

She has a biopsy proven nodular basal cell on the left second toe and a biopsy proven superficial squamous cell carcinoma involving most of the dorsum of left middle finger.  The closest Mohs surgeon is an hour away.

 

Clinical Photos

Discussion: Optimal treatment of these lesions would be micrographic surgery, but this may be too aggressive for this relatively frail woman and wound care at home would be difficult. Individuals of this age may not live long enough to benefit from “gold standard” therapy, however, unchecked tumor progression can worsen their quality of life if treatment is withheld.  Radiotherapy would also be difficult as many trips for fractionated care would be taxing for her.

 

There are few therapeutic guidelines for patients like this.  We would appreciate your suggestions as we plan to address the patient and her tumors.

 

References:

1. A J G Leus, et. al. Treatment of keratinocyte carcinoma in elderly patients - a review of the current literature. J Eur Acad Dermatol Venereol. 2020 Sep;34(9):1932-1943.  Free PMC article

 

2. Christopher McLaughlin, Mark A Russell. Single-fraction high-dose palliative radiotherapy for facial cutaneous squamous cell carcinoma: a case report. Ann Palliat Med. 2022 Oct;11(10):3337-3340.