- Email: [email protected]
Cutaneous infiltration with Waldenström macroglobulinemia
Leukemia Research 30 (2006) 1207–1210
Case report
Cutaneous infiltration with Waldenstr¨om macroglobulinemia T. Yokote a,∗ , T. Akioka a , S. Oka a , S. Hara a , K. Kobayashi a , Y. Hirata a , T. Yamano a , M. Tsuji b , T. Hanafusa a a
First Department of Intenal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka 569-8686, Japan b Division of Surgical Pathology, Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka 569-0801, Japan Received 5 November 2005; received in revised form 1 February 2006; accepted 1 February 2006 Available online 13 March 2006
Abstract A 59-year-old Japanese man was diagnosed as Waldenstr¨om macroglobulinema. With impaired general performance and a 2-year history of pruritic eruptions that were initially confined to the forearms, but later involved the face, limbs, and trunk. A skin biopsy that was performed on the forehead showed infiltration with abnormal cells of the dermis around the central vessels. PCR analysis of the skin biopsy showed immunoglobulin heavy chain rearrangement. As the rearrangement band occurred at the same site as that of the bone marrow aspiration, skin infiltration with abnormal cells was proven. © 2006 Elsevier Ltd. All rights reserved. Keywords: Waldenstr¨om macroglobulinema; Infiltration; Polymerase chain reaction
1. Introduction Waldenstr¨om macroglobulinema (WM) is a low-grade chronic lymphoplasmacytoid malignancy that is associated with IgM paraproteinemia [1]. Specific cutaneous manifestations include dermal lymphocytic infiltrates and cutaneous deposits of IgM paraprotein that are known as storage papules. The most common clinical features include anemia, lymphadenopathy, and hyperviscosity syndrome [2]. We report a patient diagnosed with WM who presented with several characteristic skin lesions and evaluated skin infiltrates of abnormal B cells by histochemistry and polymerase chain reaction.
2. Case report A 59-year-old Japanese man presented in April 2003, with impaired general performance and a 2-year history of pruritic eruptions that were initially confined to the forearms, ∗
Corresponding author. Tel.: +81 72 683 1221; fax: +81 72 684 6531. E-mail address: [email protected] (T. Yokote).
0145-2126/$ – see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2006.02.001
but later involved the face, limbs, and trunk. Skin fragility and occasional blisters were also noted. There was no family history of any similar disorder and the patient was not receiving concurrent medication. Examination revealed several pruritic eruptions and moderate skin fragility over the whole body (Fig. 1). There was no oral or ocular involvement, nail dystrophy or milia. Lymphadenopathy was present. The laboratory findings revealed low hemoglobin (82 g/l), although white blood cell counts and platelets were normal. The biochemical profile was normal apart from an increased total serum protein (129 g/l). Serum IgG and IgA were normal but a monoclonal paraprotein was noted (9660 mg/dl). Serum immunoelectrophoresis confirmed the presence of an IgM kappa paraprotein, but Bence-Johnes protein was absent. Bone marrow aspiration and biopsy showed about 55% infiltration with abnormal cells with lymphoplasmacytoid morphology, although no chromosomal aberrations were evident by Giemsa-band method. Abnormal cells showed the expression of surface CD19, surface CD20, surface CD22, surface CD38, and both surface and cytoplasmic IgM and light chain restriction with flow cytometric CD45/SCC-gating procedure. Polymerase chain reaction (PCR) analysis of bone marrow aspiration demonstrated immunoglobulin heavy chain
1208
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
rearrangement. These findings were consistent with Waldenstr¨om macroglobulinemia.
3. Material and method
CD45/SCC gating. The expression of CD38, CD20, kappa light chain, and lambda light chain in the positive cells by CD45/SCC gating was evaluated and the clonality of B cells was determined by quantitation of kappa and lambda light chain expression.
3.1. Sample preparation
3.3. Cytoplasmic labeling
For preparation of the cell suspension, the bone marrow aspiration sample was treated with heparin (as an anticoagulant) and processed using a lysed-whole blood technique with a FACS (fluorescence-activated cell sorting) lysing solution (Whole Blood Lysis Reagent, Coulter, Fullerton, CA). Samples were washed twice in phosphate buffered saline (PBS) and resuspended with PBS to a concentration of approximately 2 × 106 cells/mL. Samples were dually stained with fluorescein isothiocyanate (FITC)conjugated CD 20 (B-Ly1, Dako, Carpinteria, CA), IgM (Dako), kappa light chain (Coulter), lambda light chain (Coulter) and phycoerythrin–cyanin 5.1 (PC5)-conjugated CD45 (J.33, Coulter) for 30 min at 4 ◦ C. For negative controls, samples were stained with FITC-conjugated rat antihuman immunoglobulin (LODNP1, Coulter) for 30 min at 4 ◦ C. (Fig. 1) All samples were rinsed twice in PBS and were analyzed on an FACScan flow cytometer (EPICS XL, Coulter) using System IITM version 3.0 software (Coulter). A minimum of 10,000 total cells were analyzed.
Cells were stained with phycoerythrin–cyanin 5.1 (PC5)conjugated CD45 (Coulter). For fixation and permeabilization of the cells, IntraprepTM (Immunotech, Marseille, France) was used. Cells were first fixed with fixation reagent 1 for 15 min at room temperature. After being washed with phosphate-buffered saline (PBS), cells were resuspended in permeabilization reagent 2 and incubated for 5 min at room temperature, stained with fluorescein isothiocyanate (FITC)conjugated IgM, kappa light chain, and lambda light chain and incubated for 15 min at room temperature. After being washed with phosphate-buffered saline (PBS), cells were resuspended in PBS containing 0.5% formaldehyde and were analyzed in the flow cytometer.
3.2. FACS acquision and CD45/SCC-gating procedure All samples were collected in a side scatter versus CD45 histogram with gating on a B cell cluster and defined as
Fig. 1. Multiple pruritic eruption were observed on the face.
3.4. Immunohistochemistry Skin samples were obtained from tissue fixed with 10% buffered formalin and embedded in paraffin. Immunohistochemistry was performed with CD38 (AT13/5, MCA, Oxford, UK), CD20 (L26, Dako) and IgM (R1/69, Dako) monoclonal antibodies, using a modified avidin–biotin– peroxidase procedure with 3,3 -diaminobenzidine (Sigma Chemical Co., St. Louis, MO) as the chromogen. 3.5. PCR High molecular weight DNA was extracted from bone marrow aspiration and fresh skin samples. The two rounds of PCR was used for amplification of the immunoglobulin heavy chain gene using an Fr3 V-region primer in conjunction with nested primers directed to the J region, as described by Wan et al. [7]. The first-round of amplification used primer Fr3 (5 -ACACGGC[C/T][G/C]TGTATTACTGT-3 ) plus a down stream consensus primer directed to the joining region (LJH: 5 -TGAGGAGACGGTGACC-3 ). The second used the same upstream primer (Fr3) in conjunction with an inner downstream primer (VLJH: 5 -GTGACCAGGGTNCCTTGGCCCCAG-3 . The PCR mixture contained 10 mM Tris (pH 8.3), 50 mM KCL, 200 M of each dNTP, 250 ng of each primer, 0.001% gelatin, and 0.5 U of AmplitaqTM (I.L.S., U.K.) in a total volume of 50 l. The MgCl2 concentration was optimized for the PCR in each system. First-round reactions contained 100 ng of test DNA and the second-round contained 1 l of the first-round product. Thirty first-round and 20 second-round cycles of 93 ◦ C for 45 s, 50 ◦ C for 45 s, and 72 ◦ C for 110 s were carried out on a thermal cycler (Hybrid, U.K.). In each round, an initial denaturation step at 95 ◦ C for 7 min preceded the addition of enzyme and a
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
primer extension step at 72 ◦ C for 5 min concluded the reaction. Ten microliters of the PCR products were run for 1 h at 125 V on 10% (Fr3) polyacrylamide mini-gels, which were stained with ethidium bromide and viewed under UV light. Strict precautions were taken to minimize the possibility of sample cross-contamination, and product analysis was separated from PCR preparation area. Samples were amplified on at least two separate occasions to confirm the reproducibility of the method and to detect any sporadic false-positive results. Samples were run in parallel with a negative (no template DNA) and a polyclonal (reactive tonsil) control.
1209
4. Result A skin biopsy that was performed on the forehead showed infiltration with abnormal cells of the dermis around the central vessels. Abnormal cells also exhibited lymphoplasmacytoid morphology similar to the abnormal cells from the bone marrow biopsy and the expression of surface CD38, surface CD20, and surface and cytoplasmic IgM, with immunohistochemistry (Fig. 2). PCR analysis of the skin biopsy showed immunoglobulin heavy chain rearrangement. As the rearrangement band occurred at the same site as that of the bone
Fig. 2. (a) Biopsy specimen from the forehead showing infiltration with abnormal cells of the dermis around the central of the vessels. Hematoxylin-eosin stain, orginal × 32. (b) The infiltration of abnormal cells showing lymphoplasmacytoid morphology. Hematoxylin-eosin stain, original × 100. (c) Immnohistochemical staining showing abnormal cells positive for CD38. Original × 130. (d) Immnohistochemical staining showing abnormal cells positive for CD20. Original × 100. (e) Immnohistochemical staining showing abnormal cells positive for IgM. Original × 130.
1210
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
Fig. 3. Ethidium bromide-stained 10% polyacrylamide gel of Fr3 PCR products from DNA samples as follows. M:X174/Hinc II digest molecular weight markers (size in base pairs (bp); lane 1: reactive tonsillar DNA; lane 2: skin biopsy samples; lane 3: bone marrow aspiration samples. Lanes 2 and 3 showed a monoclonal pattern and the same site.
marrow aspiration, skin infiltration with abnormal cells was proven (Fig. 3). Oral cyclophosphamide monochemotherapy was begun, consisting of 500 mg/body on day 1–5 every 2 weeks, because the patient declined to undergo aggressive chemotherapy. Three months later the patient is alive and this therapy is ongoing. The pruritic eruptions have disappeared and moderate skin fragility has improved. Hemoglobin is normal and monoclonal paraprotein has decreased to 4000 mg/dl.
5. Discussion WM is a low-grade chronic B cell lymphoproliferative disorder characterized by bone marrow infiltration with small lymphocytes, lymphoplasmacytoid cells, and plasma cells that is associated with an elevated circulating levels of IgM paraprotein [3]. Skin signs in WM consist of either a non-neoplastic manifestation of the disease associated with hyperviscosity, [4] cryoglobulinemia, deposition of immunoglobulins, acral purpura, mucosal bleeds, urticaria, ulceration and storage papule disease, and rarely, direct neo-
plastic infiltration of the skin. To the best of our knowledge, eleven cases have been reported in the English literature [5,6]. However, confirming neoplastic infiltration of the skin can be difficult in WM because it is difficult to distinguish between reactive lymphoid cell infiltrations, chronic inflammatory lesions and low-grade B cell lymphomas. Significant background immunohistochemical staining may also hamper interpretation. Reactive lesions may also be present in the skin. Consequently, previously reported cases had to rely on cytomorphology, immunohistochemical findings, and immunohistochemical demonstration of immunoglobulin light chain restriction that can be misleading [5]. We confirmed the abnormal B lymphocytes to be a result of clonal proliferation by immunoglobulin heavy chain gene rearrangement analysis. Demonstration of clonality is a strong indicator in the diagnosis of lymphoma. PCR-based immunoglobulin heavy chain analysis is useful for establishing clonality of the cells, even if an extremely small amount of sample is analyzed [8]. In summary, we report a patient diagnosed with WM who presented with several characteristic skin lesions and evaluated skin infiltrates of abnormal B cells with histochemistry and PCR-based immunoglobulin heavy chain analysis.
Acknowledgments This work was not supported financial support and any conflicts of interest.
References [1] Duel TF. Waldenstr¨om macroglobulinaemia. Arch Internal Med 1983;143:986. [2] Ida Orengo F, et al. Cutaneous Waldenstr¨om macroglobulinaemia. Cancer 1987;60:1341–5. [3] Dimopoulous MA, Alexanian R. Wanderst¨orm’s macrogloburinemia. Blood 1994;83:1452–9. [4] Lowe I, Fitzpatrick JE. Cutaneous macroglobulinosis. A case report with unique ultrastractual findings. Arch Dermatol 1992;128:377–80. [5] Col Lester F, Libow. Cutaneous Waldenstr¨om macroglobulinaemia. J Am Acad Dermatol 2001;45:S202–6. [6] I Chan E. Cutaneous Waldenstr¨om macroglobulinaemia. Clin Exp Dermatol 2003;28:491–2. [7] Wan JH, Trainor KJ, Brisco MJ, Morley AA. Monoclonality in B cell lymphoma detected in paraffin wax embedded sections using the polymerase chain reaction. J Clin Pathol 1990;43:888–90. [8] Iijima T, Inadome Y, Noguchi M. Clonal proliferation of B lymphocytes in the germinal centers of human reactive lymph nodes: possibility of overdiagnosis of B cell clonal proliferation. Diagn Mol Pathol 2000 Sep;9(3):132–6.
Case report
Cutaneous infiltration with Waldenstr¨om macroglobulinemia T. Yokote a,∗ , T. Akioka a , S. Oka a , S. Hara a , K. Kobayashi a , Y. Hirata a , T. Yamano a , M. Tsuji b , T. Hanafusa a a
First Department of Intenal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka 569-8686, Japan b Division of Surgical Pathology, Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka 569-0801, Japan Received 5 November 2005; received in revised form 1 February 2006; accepted 1 February 2006 Available online 13 March 2006
Abstract A 59-year-old Japanese man was diagnosed as Waldenstr¨om macroglobulinema. With impaired general performance and a 2-year history of pruritic eruptions that were initially confined to the forearms, but later involved the face, limbs, and trunk. A skin biopsy that was performed on the forehead showed infiltration with abnormal cells of the dermis around the central vessels. PCR analysis of the skin biopsy showed immunoglobulin heavy chain rearrangement. As the rearrangement band occurred at the same site as that of the bone marrow aspiration, skin infiltration with abnormal cells was proven. © 2006 Elsevier Ltd. All rights reserved. Keywords: Waldenstr¨om macroglobulinema; Infiltration; Polymerase chain reaction
1. Introduction Waldenstr¨om macroglobulinema (WM) is a low-grade chronic lymphoplasmacytoid malignancy that is associated with IgM paraproteinemia [1]. Specific cutaneous manifestations include dermal lymphocytic infiltrates and cutaneous deposits of IgM paraprotein that are known as storage papules. The most common clinical features include anemia, lymphadenopathy, and hyperviscosity syndrome [2]. We report a patient diagnosed with WM who presented with several characteristic skin lesions and evaluated skin infiltrates of abnormal B cells by histochemistry and polymerase chain reaction.
2. Case report A 59-year-old Japanese man presented in April 2003, with impaired general performance and a 2-year history of pruritic eruptions that were initially confined to the forearms, ∗
Corresponding author. Tel.: +81 72 683 1221; fax: +81 72 684 6531. E-mail address: [email protected] (T. Yokote).
0145-2126/$ – see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2006.02.001
but later involved the face, limbs, and trunk. Skin fragility and occasional blisters were also noted. There was no family history of any similar disorder and the patient was not receiving concurrent medication. Examination revealed several pruritic eruptions and moderate skin fragility over the whole body (Fig. 1). There was no oral or ocular involvement, nail dystrophy or milia. Lymphadenopathy was present. The laboratory findings revealed low hemoglobin (82 g/l), although white blood cell counts and platelets were normal. The biochemical profile was normal apart from an increased total serum protein (129 g/l). Serum IgG and IgA were normal but a monoclonal paraprotein was noted (9660 mg/dl). Serum immunoelectrophoresis confirmed the presence of an IgM kappa paraprotein, but Bence-Johnes protein was absent. Bone marrow aspiration and biopsy showed about 55% infiltration with abnormal cells with lymphoplasmacytoid morphology, although no chromosomal aberrations were evident by Giemsa-band method. Abnormal cells showed the expression of surface CD19, surface CD20, surface CD22, surface CD38, and both surface and cytoplasmic IgM and light chain restriction with flow cytometric CD45/SCC-gating procedure. Polymerase chain reaction (PCR) analysis of bone marrow aspiration demonstrated immunoglobulin heavy chain
1208
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
rearrangement. These findings were consistent with Waldenstr¨om macroglobulinemia.
3. Material and method
CD45/SCC gating. The expression of CD38, CD20, kappa light chain, and lambda light chain in the positive cells by CD45/SCC gating was evaluated and the clonality of B cells was determined by quantitation of kappa and lambda light chain expression.
3.1. Sample preparation
3.3. Cytoplasmic labeling
For preparation of the cell suspension, the bone marrow aspiration sample was treated with heparin (as an anticoagulant) and processed using a lysed-whole blood technique with a FACS (fluorescence-activated cell sorting) lysing solution (Whole Blood Lysis Reagent, Coulter, Fullerton, CA). Samples were washed twice in phosphate buffered saline (PBS) and resuspended with PBS to a concentration of approximately 2 × 106 cells/mL. Samples were dually stained with fluorescein isothiocyanate (FITC)conjugated CD 20 (B-Ly1, Dako, Carpinteria, CA), IgM (Dako), kappa light chain (Coulter), lambda light chain (Coulter) and phycoerythrin–cyanin 5.1 (PC5)-conjugated CD45 (J.33, Coulter) for 30 min at 4 ◦ C. For negative controls, samples were stained with FITC-conjugated rat antihuman immunoglobulin (LODNP1, Coulter) for 30 min at 4 ◦ C. (Fig. 1) All samples were rinsed twice in PBS and were analyzed on an FACScan flow cytometer (EPICS XL, Coulter) using System IITM version 3.0 software (Coulter). A minimum of 10,000 total cells were analyzed.
Cells were stained with phycoerythrin–cyanin 5.1 (PC5)conjugated CD45 (Coulter). For fixation and permeabilization of the cells, IntraprepTM (Immunotech, Marseille, France) was used. Cells were first fixed with fixation reagent 1 for 15 min at room temperature. After being washed with phosphate-buffered saline (PBS), cells were resuspended in permeabilization reagent 2 and incubated for 5 min at room temperature, stained with fluorescein isothiocyanate (FITC)conjugated IgM, kappa light chain, and lambda light chain and incubated for 15 min at room temperature. After being washed with phosphate-buffered saline (PBS), cells were resuspended in PBS containing 0.5% formaldehyde and were analyzed in the flow cytometer.
3.2. FACS acquision and CD45/SCC-gating procedure All samples were collected in a side scatter versus CD45 histogram with gating on a B cell cluster and defined as
Fig. 1. Multiple pruritic eruption were observed on the face.
3.4. Immunohistochemistry Skin samples were obtained from tissue fixed with 10% buffered formalin and embedded in paraffin. Immunohistochemistry was performed with CD38 (AT13/5, MCA, Oxford, UK), CD20 (L26, Dako) and IgM (R1/69, Dako) monoclonal antibodies, using a modified avidin–biotin– peroxidase procedure with 3,3 -diaminobenzidine (Sigma Chemical Co., St. Louis, MO) as the chromogen. 3.5. PCR High molecular weight DNA was extracted from bone marrow aspiration and fresh skin samples. The two rounds of PCR was used for amplification of the immunoglobulin heavy chain gene using an Fr3 V-region primer in conjunction with nested primers directed to the J region, as described by Wan et al. [7]. The first-round of amplification used primer Fr3 (5 -ACACGGC[C/T][G/C]TGTATTACTGT-3 ) plus a down stream consensus primer directed to the joining region (LJH: 5 -TGAGGAGACGGTGACC-3 ). The second used the same upstream primer (Fr3) in conjunction with an inner downstream primer (VLJH: 5 -GTGACCAGGGTNCCTTGGCCCCAG-3 . The PCR mixture contained 10 mM Tris (pH 8.3), 50 mM KCL, 200 M of each dNTP, 250 ng of each primer, 0.001% gelatin, and 0.5 U of AmplitaqTM (I.L.S., U.K.) in a total volume of 50 l. The MgCl2 concentration was optimized for the PCR in each system. First-round reactions contained 100 ng of test DNA and the second-round contained 1 l of the first-round product. Thirty first-round and 20 second-round cycles of 93 ◦ C for 45 s, 50 ◦ C for 45 s, and 72 ◦ C for 110 s were carried out on a thermal cycler (Hybrid, U.K.). In each round, an initial denaturation step at 95 ◦ C for 7 min preceded the addition of enzyme and a
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
primer extension step at 72 ◦ C for 5 min concluded the reaction. Ten microliters of the PCR products were run for 1 h at 125 V on 10% (Fr3) polyacrylamide mini-gels, which were stained with ethidium bromide and viewed under UV light. Strict precautions were taken to minimize the possibility of sample cross-contamination, and product analysis was separated from PCR preparation area. Samples were amplified on at least two separate occasions to confirm the reproducibility of the method and to detect any sporadic false-positive results. Samples were run in parallel with a negative (no template DNA) and a polyclonal (reactive tonsil) control.
1209
4. Result A skin biopsy that was performed on the forehead showed infiltration with abnormal cells of the dermis around the central vessels. Abnormal cells also exhibited lymphoplasmacytoid morphology similar to the abnormal cells from the bone marrow biopsy and the expression of surface CD38, surface CD20, and surface and cytoplasmic IgM, with immunohistochemistry (Fig. 2). PCR analysis of the skin biopsy showed immunoglobulin heavy chain rearrangement. As the rearrangement band occurred at the same site as that of the bone
Fig. 2. (a) Biopsy specimen from the forehead showing infiltration with abnormal cells of the dermis around the central of the vessels. Hematoxylin-eosin stain, orginal × 32. (b) The infiltration of abnormal cells showing lymphoplasmacytoid morphology. Hematoxylin-eosin stain, original × 100. (c) Immnohistochemical staining showing abnormal cells positive for CD38. Original × 130. (d) Immnohistochemical staining showing abnormal cells positive for CD20. Original × 100. (e) Immnohistochemical staining showing abnormal cells positive for IgM. Original × 130.
1210
T. Yokote et al. / Leukemia Research 30 (2006) 1207–1210
Fig. 3. Ethidium bromide-stained 10% polyacrylamide gel of Fr3 PCR products from DNA samples as follows. M:X174/Hinc II digest molecular weight markers (size in base pairs (bp); lane 1: reactive tonsillar DNA; lane 2: skin biopsy samples; lane 3: bone marrow aspiration samples. Lanes 2 and 3 showed a monoclonal pattern and the same site.
marrow aspiration, skin infiltration with abnormal cells was proven (Fig. 3). Oral cyclophosphamide monochemotherapy was begun, consisting of 500 mg/body on day 1–5 every 2 weeks, because the patient declined to undergo aggressive chemotherapy. Three months later the patient is alive and this therapy is ongoing. The pruritic eruptions have disappeared and moderate skin fragility has improved. Hemoglobin is normal and monoclonal paraprotein has decreased to 4000 mg/dl.
5. Discussion WM is a low-grade chronic B cell lymphoproliferative disorder characterized by bone marrow infiltration with small lymphocytes, lymphoplasmacytoid cells, and plasma cells that is associated with an elevated circulating levels of IgM paraprotein [3]. Skin signs in WM consist of either a non-neoplastic manifestation of the disease associated with hyperviscosity, [4] cryoglobulinemia, deposition of immunoglobulins, acral purpura, mucosal bleeds, urticaria, ulceration and storage papule disease, and rarely, direct neo-
plastic infiltration of the skin. To the best of our knowledge, eleven cases have been reported in the English literature [5,6]. However, confirming neoplastic infiltration of the skin can be difficult in WM because it is difficult to distinguish between reactive lymphoid cell infiltrations, chronic inflammatory lesions and low-grade B cell lymphomas. Significant background immunohistochemical staining may also hamper interpretation. Reactive lesions may also be present in the skin. Consequently, previously reported cases had to rely on cytomorphology, immunohistochemical findings, and immunohistochemical demonstration of immunoglobulin light chain restriction that can be misleading [5]. We confirmed the abnormal B lymphocytes to be a result of clonal proliferation by immunoglobulin heavy chain gene rearrangement analysis. Demonstration of clonality is a strong indicator in the diagnosis of lymphoma. PCR-based immunoglobulin heavy chain analysis is useful for establishing clonality of the cells, even if an extremely small amount of sample is analyzed [8]. In summary, we report a patient diagnosed with WM who presented with several characteristic skin lesions and evaluated skin infiltrates of abnormal B cells with histochemistry and PCR-based immunoglobulin heavy chain analysis.
Acknowledgments This work was not supported financial support and any conflicts of interest.
References [1] Duel TF. Waldenstr¨om macroglobulinaemia. Arch Internal Med 1983;143:986. [2] Ida Orengo F, et al. Cutaneous Waldenstr¨om macroglobulinaemia. Cancer 1987;60:1341–5. [3] Dimopoulous MA, Alexanian R. Wanderst¨orm’s macrogloburinemia. Blood 1994;83:1452–9. [4] Lowe I, Fitzpatrick JE. Cutaneous macroglobulinosis. A case report with unique ultrastractual findings. Arch Dermatol 1992;128:377–80. [5] Col Lester F, Libow. Cutaneous Waldenstr¨om macroglobulinaemia. J Am Acad Dermatol 2001;45:S202–6. [6] I Chan E. Cutaneous Waldenstr¨om macroglobulinaemia. Clin Exp Dermatol 2003;28:491–2. [7] Wan JH, Trainor KJ, Brisco MJ, Morley AA. Monoclonality in B cell lymphoma detected in paraffin wax embedded sections using the polymerase chain reaction. J Clin Pathol 1990;43:888–90. [8] Iijima T, Inadome Y, Noguchi M. Clonal proliferation of B lymphocytes in the germinal centers of human reactive lymph nodes: possibility of overdiagnosis of B cell clonal proliferation. Diagn Mol Pathol 2000 Sep;9(3):132–6.