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January 2020 Volume 4 Issue 1

BRIEF ARTICLES

Subcutaneous Panniculitis-Like T-cell Lymphoma: A Case Report

David D. Xiong, BA,1 Brandon T. Beal, MD,2 Manisha Manmohan, MD,2 M. Georgina Uberti,
MD,3 Kathryn Riley, MD,2 Anthony P. Fernandez, MD, PhD2

1Cleveland Clinic Lerner College of Medicine, Cleveland OH
2Cleveland Clinic Foundation, Department of Dermatology, Cleveland OH
3Cleveland Clinic Foundation, Departments of Anatomic Pathology and Dermatology, Cleveland OH

Subcutaneous panniculitis-like T-cell
lymphoma (SPTCL) is an unusual cutaneous
T-cell lymphoma (TCL) accounting for <1% of
non-Hodgkin lymphomas which typically
presents with subcutaneous nodules or deep
plaques. We present the case of a woman
diagnosed with SPTCL successfully treated
with oral corticosteroids and methotrexate.

A woman in her 60s presented with a 4-
month history of numerous painful 4-8cm
subcutaneous nodules on the cheeks, arms,
breasts, and buttocks (Figure 1a). Her past
medical history was unremarkable. Review of
symptoms was notable for fever, fatigue, and
a 60-pound unintentional weight loss.

Biopsy of a lesion demonstrated a dense
atypical lymphoid infiltrate in the subcutis
(Figure 2) that was CD3+, CD8+, CD56-,
reactive for TIA, perforin, granzyme B, and
BF1, with rare CD20+ cells. Tissue cultures
and stains were negative. Laboratory studies
were notable for elevated lactate
dehydrogenase (556 U/L), mildly elevated
transaminases, and mild pancytopenia. Flow
cytometry analysis of peripheral blood was
unrevealing. Positron Emission Tomography
demonstrated numerous subcutaneous
nodules in her cheeks, arms, neck, breasts,
back, mesentery, mediastinum, and
abdominal cavity without lymphadenopathy
or hepatosplenomegaly.

The patient was diagnosed with SPTCL and
started on oral methotrexate and a
prednisone taper with atrophy of her
subcutaneous nodules and resolution of her
elevated transaminases, cytopenias, and
symptomatic improvement. She was
continued on 15mg weekly methotrexate with

INTRODUCTION

REPORT OF A CASE

We present a case of a woman diagnosed with subcutaneous panniculitis-like T-cell lymphoma
treated with prednisone and methotrexate with sustained symptom remission, suggesting that
uncomplicated subcutaneous panniculitis-like T-cell lymphoma can be managed effectively
without multiagent chemotherapy or radiation.

ABSTRACT

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January 2020 Volume 4 Issue 1

sustained symptom remission 4 months after
diagnosis (Figure 1b).

Figure 1. (a) Subcutaneous nodules on the bilateral
breasts at presentation (b) and after four months of
treatment with methotrexate and a prednisone taper

Figure 2. A dense, lobular lymphocytic panniculitis
with rimming of the adipocytes by atypical T-cells.
The lymphocytes demonstrate nuclear atypia, there is
adipocyte membrane crowding and disruption, and
cellular fat necrosis. 40x magnification. Hematoxylin
and eosin staining.

SPTCL is an uncommon TCL characterized
by subcutaneous nodules that may be
scattered across the body. Cytologically, it is
defined by a T-cell infiltrate expressing an αβ
T-cell receptor phenotype and is typically
characterized by a CD4-, CD8+, CD56-, BF1-
lymphoid infiltrate. These lymphoid infiltrates
are typically confined to subcutaneous
tissue.1–3

SPTCL has been associated with underlying
autoimmune and rheumatologic disorders
such as lupus erythematosus or rheumatoid
arthritis in 20-40% of patients. Associated

symptoms may include fevers, chills, weight
loss, fatigue, and myalgia. Laboratory
findings may include cytopenias and elevated
liver function tests, and radiographic studies
may demonstrate lymphadenopathy and
hepatosplenomegaly. It may be
accompanied by hemophagocytic syndrome
(HPS) in approximately 20% of patients,
which portends a notably worse prognosis.3

Though traditional therapy for SPTCL has
centered on multiagent combination
chemotherapy, such as with CHOP (i.e.
Cyclophosphamide, Adriamycin, Vincristine,
and Prednisone) or CHOP-like regimens,4
these treatments are associated with
significant morbidity, often surpassing that of
the disease itself. Thus, there has been a
renewed push to induce disease remission
with less toxic and immunosuppressive
regimens such as systemic corticosteroids,
methotrexate, and other more common
immunosuppressive rather than
chemotherapy regimens.2 Response rates
are similar to that of traditional
chemotherapy, with the majority of patients
achieving complete disease remission with
immunosuppressive regimens such as
systemic corticosteroids, sparing patients the
cytotoxic side effects of traditional
chemotherapy.1,5 Multiagent chemotherapy
may be reserved for patients who do not
respond to systemic corticosteroids or
patients with HPS, with or without stem cell
transplantation. Radiotherapy may also be
considered in cases of solely local disease.4

Conflict of Interest Disclosures: None

Funding: None

Corresponding Author:
David D. Xiong, BA
Cleveland Clinic Lerner College of Medicine,
Cleveland Clinic Foundation.

DISCUSSION

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January 2020 Volume 4 Issue 1

9500 Euclid Avenue, NA2-90.
Cleveland OH, 44195.
Tel: (314) 435-7276
Email: xiongd@ccf.edu

References:
1. Willemze R, Jansen PM, Cerroni L, et al.

Subcutaneous panniculitis-like T-cell lymphoma:
definition, classification, and prognostic factors: an
EORTC Cutaneous Lymphoma Group Study of 83
cases. Blood. 2008;111(2):838-845.
doi:10.1182/blood-2007-04-087288

2. Parveen Z, Thompson K. Subcutaneous
Panniculitis-like T-Cell Lymphoma: Redefinition of
Diagnostic Criteria in the Recent World Health
Organization–European Organization for
Research and Treatment of Cancer Classification
for Cutaneous Lymphomas. Arch Pathol Lab Med.
2009;133(2):303-308. doi:10.1043/1543-2165-
133.2.303

3. Swerdlow S, Campo E, Harris N, Jaffe E, Pileri S,
Stein H. WHO Classification of Tumours of
Haematopoietic and Lymphoid Tissues, Fourth
Edition. Lyon, France: IARC; 2008.

4. Go RS, Wester SM. Immunophenotypic and
molecular features, clinical outcomes, treatments,
and prognostic factors associated with
subcutaneous panniculitis-like T-cell lymphoma.
Cancer. 2004;101(6):1404-1413.
doi:10.1002/cncr.20502

5. Guenova E, Schanz S, Hoetzenecker W, et al.
Systemic corticosteroids for subcutaneous
panniculitis-like T-cell lymphoma. Br J Dermatol.
2014;171(4):891-894. doi:10.1111/bjd.13053