Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(3):e2022132 1 Lymphoma Developing in a Patient With Long-term Antitumor Necrosis Factor Therapy Giovana Serrão Fensterseifer1, André Carvalho2, Ana Letícia Boff3, Joel Schwartz4 1 Dermatologist at Private Practice, Dermatologist at Dermatology Department at Hospital São Lucas da PUCRS, Porto Alegre- Brazil 2 Dermatologist at Private Practice, Dermatologist at Hospital Moinhos de Vento, Porto Alegre- Brazil 3 Pathologist at Private Practice, Pathologist at Dermatology Department at Santa Casa de Misericórdia de Porto Alegre, Porto Alegre- Brazil 4 Dermatologist at Private Practice, Porto Alegre- Brazil Key words: lymphoma, antiTNF, adalimumab, psoriasis Citation: Fensterseifer GS, Carvalho A, Boff AL, Schwartz J. Lymphoma developing in a patient with long-term antitumor necrosis factor therapy. Dermatol Pract Concept. 2022;12(3):e2022132. DOI: https://doi.org/10.5826/dpc.1203a132 Accepted: December 6, 2021; Published: July 2022 Copyright: ©2022 Fensterseifer et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/ which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Giovana Serrão Fensterseifer, MD, Rua Professor Langendonck, 117. Porto Alegre- Brazil, +55 51 99240-4660, E-mail: gfensterseifer@gmail.com Dermatology Practical & Conceptual Introduction Some studies have shown that tumor necrosis factor (TNF) alfa inhibitor therapy may increase the risk of lymphomas [1]. It is historically known that psoriasis can also increase the risk of cutaneous lymphomas. Here we present a case of a primary cutaneous anaplastic large cell lymphoma in a patient under treatment with adalimumab for psoriasis and psoriatic arthritis. Case Presentation Patient presented to the clinic with a shallow one-month ulcerative lesion, with infiltrated borders on the buttock. The patient had been on adalimumab for, approximately, the last 10 years due to psoriasis and psoriatic arthritis (Figure 1). A biopsy was performed for histopathology and immuno- histochemistry analysis. The report showed cohesive sheets of large CD30-positive anaplastic cells confirming the Figure 1. Ulcer on the buttock. 2 Research Letter | Dermatol Pract Concept. 2022;12(3):e2022132 diagnosis of CD30+ anaplastic T-cell lymphoma. Staging determined a cutaneous primary lymphoma with no other organs involved. The patient is currently under treatment for the disease (Figure 2). Conclusions Studies have shown that the most common lymphoma subtype associated with anti-TNF therapy is non-Hodgkin B-cell lymphoma [1]. In the other hand, it is known that pso- riasis itself can increase the risk of cutaneous lymphoma. In this case, T-cell lymphoma is the most associated lymphoma subtype, mainly mycosis fungoides. Our patient presented a primary cutaneous anaplastic large cell lymphoma. This subtype of cutaneous T-cell lymphoma usually presents as a solitary nodule that often develops ulceration, as presented in this case. The prognosis is usually favorable with extracu- taneous dissemination occurring in approximately 10% of the patients. Radiotherapy is usually the initial choice of treatment, but chemotherapy could also be considered. More recently, a study by Langley et al stated that longer-term (≥ 12 months) treatment with a TNF alfa inhibitor, but not shorter-term treatment, was associated with increased risk Figure 2. (A) Histopathology shows (x10) an acanthotic epidermis and a diffuse infiltrate of lymphocytes and some neutrophils on the dermis. (B) Histopathology shows (x40) a diffuse lymphocyte infiltrate with irregularly shaped nuclei, prominent nucleoli and abundant cytoplasm. (C) Immunohistochemistry shows CD3 positive lymphocytes. (D) Immunohistochemistry shows diffuse and strong positivity for CD30 on neoplastic cells. for malignancy [2]. The patient presented here had been un- der treatment for, approximately, 10 years. In conclusion, studies are controversial regarding if there is an increased risk of malignancy due to anti-TNF alfa therapy, with a tendency of relating it to the duration of the treatment. We presented a case of a patient with a long- term treatment with adalimumab for psoriasis and psoriatic arthritis who developed a cutaneous lymphoma. Further studies are needed to determine the risk of lymphomas in patients with long term anti-TNF therapy, but physicians should remain aware of this possibility when following patients under this treatment. References 1. Wong AK, Kerkoutian S, Said J, Rashidi H, Pullarkat ST. Risk of lymphoma in patients receiving antitumor necrosis factor therapy: a meta-analysis of published randomized controlled studies. Clin Rheumatol. 2012;31(4):631-636. DOI: 10.1007/ s10067-011-1895-y. PMID: 22147207.2. Fiorentino D, Ho V, Lebwohl MG, et at. Risk of malignancy with systemic psoria- sis treatment in the Psoriasis Longitudinal Assessment Registry. J Am Acad Dermatol. 2017;77(5):845-854. DOI: 10.1016/j. jaad.2017.07.013. PMID: 28893407.