- Email: [email protected]
Primary cutaneous apocrine carcinoma treated with radiotherapy
5197
5565
Prevalence and clinical correlation of superficial fungal foot infection in Thai naval rating cadets Punyawee Ongsri, MD, Naval Medical Department, Royal Thai Navy; Sumanas Bunyaratavej, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University; Penvadee Pattanprichakul, MD, Department of Dermatology, Faculty of Medicine Siriraj hospital, Mahidol University; Charussri Leeyaphun, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University; Pattachee Ongmahutmongkol, MD, Naval Medical Department, Royal Thai Navy; Nattaporn Ariyatanasuporn, MD, Naval Medical Department, Royal Thai Navy; Kanokwalai Kulthanan, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University
Primary cutaneous anaplastic large cell lymphoma treated with low dose methotrexate Stefanie Grewe, BS, University of South Florida Morsani College of Medicine; Brooke Baldwin, MD, James A. Haley Veterans Hospital Primary cutaneous anaplastic CD30-positive large cell lymphoma is a rare type of non-Hodgkin’s lymphoma that is defined by a predominance of large clusters of CD30+ blast cells on histology. Considered a part of the spectrum of CD30+ lymphoproliferative cutaneous processes, this neoplasm often presents clinically in two forms: systemic and primary cutaneous. The diagnosis is confirmed with histologic examination, radiologic imaging, and supportive immunohistochemistry. The primary cutaneous form occurs in the skin with no evidence of disease elsewhere after a thorough workup. It is more likely to be negative for anaplastic lymphoma kinase (ALK1). It more commonly occurs in men in their sixth decade of life and presents as single or multifocal nodules that can regress and recur. We present a case of an 82 -year-old patient with a past medical history significant for prostate cancer and multiple nonmelanoma skin cancers, as well as six previous PCALCL lesions all on his left chest treated conservatively with excisions. Five years after his initial diagnosis a new lesion appeared as a 2cm perirectal erythematous, ulcerated plaque. He denied any fevers, night sweats, chills, unexpected weight loss, fatigue, nausea, or vomiting. He presented to clinic with concerns that the lesion was not resolving and had been enlarging over a 5 month period of time. A shave biopsy was performed on a representative area to help confirm the diagnosis. Histologic examination revealed an atypical lymphoid infiltrate with lesional cells expressing CD2, CD3, and CD30, with a predominate CD4 phenotype by CD4/8 staining. Lesional cells lacked expression of CD15, CD20, and EMA, with at least partial loss of CD5 and CD7. Given negative ALK-1 immunohistochemical staining, primary cutaneous anaplastic large cell lymphoma was favored. A CT scan of the thorax, abdomen, and pelvis was performed for staging and did not reveal any adenopathy or other sites of lymphoma involvement. With a second body site involved, the patient was now considered to have multifocal PC-ALCL. Surgical excision of the perirectal lesion was not considered given the size and location of the lesion. Patient consulted with radiation oncology for treatment of the new lesion however was not interested in pursuing radiation treatment. Given patient preference as well as the desire to attempt a remission, systemic treatment with low dose methotrexate was initiated. He was started on 15mg po BID once weekly with folic acid on other days of the week. The patient had a good response with clinical resolution of the perirectal lesion and no further lesions appearing in any other locations. At 12 months he remained disease free and plan is to taper methotrexate to lowest effective dose. We present this case to review this rare diagnosis and remind clinicians to consider methotrexate as a treatment option for patients who present with multifocal disease.
Background: Superficial fungal foot infections are common dermatologic diseases affecting military personnel. Many Thai naval rating cadets are found to suffer from superficial fungal foot infections and their sequelae. Objective: To investigate prevalence, potential risk factors, causative organisms and clinical correlation of superficial fungal foot infection in Thai naval rating cadets training in Naval rating school, Sattahip, Thailand. Materials and Methods: This cross-sectional study of 788 Thai naval rating cadets using validated structured questionnaire asking information about behaviors and clinical symptoms, Dermatology Quality of Life Index (DLQI) questionnaire, clinical presentation demonstrated by Athlete’s foot severity score (AFSS, ranging 0-4), and laboratory investigations including direct microscopic examination and fungal culture was performed in August 2015. Results: Age of Thai naval rating cadets was 18-19. Of all 788 participants, 363 (46.1%) were suspected of skin fungal infection from questionnaire screening. After clinical examination, 288 participants (79.3%) were found to have foot lesions (AFSS $1). Superficial fungal foot infection was diagnosed in 57 participants, giving a point prevalence of 7.2 %. The pathogens were T mentagrophytes (52.8 %), E floccosum (13.9 %), S dimidiatum (11.1 %), T rubrum (11.1 %), T tonsurans (2.8 %) and Candida spp. (8.3 %). Tinea pedis was diagnosed in 54 participants and cutaneous candidiasis was diagnosed in 3 participants, respectively. Only one participant (1.8 %) was diagnosed with both tinea pedis and tinea ungium and another one (1.8 %) with both tinea pedis and tinea cruris. The participants who took a shower at least twice a day were found to have tinea pedis more than those who did not. Most participants noticed abnormal skin lesions of their feet (P ¼.01). Skin maceration and scales were detected in most of the cases (P ¼.07). Mean DLQI in tinea pedis cases was 3.35. Participants who had foot lesions (AFSS$1), concerned of their foot odors and felt troublesome demonstrated mean DLQI of 3.81 (P \.01). Conclusion: Tinea pedis is commonly found among naval rating cadets who presented with foot lesions. Early self-recognition and prompt treatment should be encouraged. Despite skin rash, feet malodors also impact on patients’ quality of life.
Commercial support: None identified.
Commercial support: None identified.
5409 Primary cutaneous anaplastic large cell lymphoma Ana Paula Schwarzbach, MD, Santa Casa de Misericordia de Porto Alegre; Giovana Fensterseifer, MD, Universidade Federal de Ci^encias da Sa ude de Porto Alegre; Fernanda Bonkevitch, MD, Santa Casa de Misericordia de Porto Alegre; Ana Letıcia Boff, MD, Santa Casa de Misericordia de Porto Alegre; Andr e Vicente Esteves de Carvalho, MD, Santa Casa de Misericordia de Porto Alegre
4943
CD30 -positive lymphoproliferative skin diseases are the second most common form of cutaneous T cell lymphoma and have an excellent prognosis. We present a case of a primary cutaneous anaplastic large cell lymphoma. A 76-year-old man presented with an asymptomatic and recurring lesion on the anterior aspect of the left arm and forearm. On examination, confluent, infiltrated erythematous papules with superficial lichenification were seen. Histologic examination showed extensive lichenoid infiltrate without epidermotropism and immunohistochemical study showed great amount (more than 75%) of CD30+ lymphocytes confirming the diagnosis of primary cutaneous anaplastic large cell lymphoma (PCALCL). CD30-positive lymphoproliferative skin diseases correspond to a spectrum of diseases including lymphomatoid papulosis (LP) and primary cutaneous anaplastic large cell lymphoma (PCALCL). Histologic and immunophenotype of PCALCL and lymphomatoid papulosis features may overlap. In this context, the clinical features are very important to confirm the diagnosis. PCALCL presents as nodules or plaques that may ulcerate and have rapid growth. It occurs predominantly as solitary and localized tumors, however multifocal or generalized lesions are seen in approximately 20 % of patients. Extracutaneous involvement is seen in 5% to 10 % of patients and most often occurs in regional lymph nodes. LP is characterized by papules and nodules that may develop central necrosis and hemorrhage, which disappear spontaneously within three to eight weeks. During this period, hypo or hyperpigmented macules and atrophic varicella-like scars are observed. Lesions at different stages can coexist. Diagnosis is made by skin biopsy . Histologic analysis shows dermal infiltrate with neoplastic cells which are large and cohesive, have abundant cytoplasm, bulky and irregular nuclei and single, central prominent nucleoli. Immunohistochemistry shows a pattern of CD3+ CD4+ CD8+ and CD30+. By definition CD30 is expressed in at least 75 % of the malignant cells. There is no curative therapy for this group of lymphomas. However they have an excellent prognosis with a survival rate at 5 years of 90% (76-96%). An average of 25-44 % of patients will have spontaneous regression of lesions. The therapeutic modalities include observation, surgical excision or local radiotherapy . Low dose methotrexate (10-25 mg weekly) is considered by some authors the therapy of choice for multifocal lesions of PCALCL.
Primary cutaneous apocrine carcinoma is a rare adnexal carcinoma arising from normal or modified (Moll and ceruminous) apocrine glands. Most studies of cutaneous apocrine carcinoma consist of single case reports or small case series. Because it is such a rare entity, limited data exist regarding epidemiology, prognosis, and optimal treatment strategies. Wide local excision is the most commonly reported treatment strategy and is considered standard therapy at this time, but optimal surgical margins have not been determined. Mohs micrographic surgery offers therapeutic advantages including evaluation of 100% of the surgical margins, minimizing the amount of healthy tissue lost, and maximizing the functional and cosmetic outcomes. Adjuvant radiotherapy can be considered for large or poorly differentiated tumors or when margins of resection are positive, but there are no reports of using this as a primary treatment modality. We present a case of a 73-yearold white man with a large erythematous indurated plaque in the left axilla and multiple satellite papules and nodules on the left flank. A thorough workup was negative for metastasis or contiguous spread of an underlying adenocarcinoma so a diagnosis of primary cutaneous apocrine carcinoma was made. Due to the presence of regional cutaneous metastases, he was not an optimal surgical candidate. After discussion with a multidisciplinary tumor board, the patient was treated with primary radiotherapy. There was clinical improvement with decreased tumor burden after radiation treatment with 66 Gy in 33 fractions via 3D technique. This case supports the use of radiotherapy as a primary modality in the treatment of primary cutaneous apocrine carcinoma. Although rare, primary cutaneous apocrine carcinoma is an important entity for dermatologic surgeons to recognize and understand. Wide local excision currently considered standard therapy but there are implications for primary radiotherapy, as illustrated by this case.
Commercial support: None identified.
JUNE 2017
Primary cutaneous apocrine carcinoma treated with radiotherapy Jennifer Vermeesch, DO, St. Joseph Mercy Hospital; Jessica Schweitzer, DO, St. Joseph Mercy Hospital; Jenny Cotton, MD, St. Joseph Mercy Hospital; Kent Krach, MD, St. Joseph Mercy Hospital; Theresa Zaleski, DO, St. Joseph Mercy Hospital
Commercial support: None identified.
J AM ACAD DERMATOL
AB203
5565
Prevalence and clinical correlation of superficial fungal foot infection in Thai naval rating cadets Punyawee Ongsri, MD, Naval Medical Department, Royal Thai Navy; Sumanas Bunyaratavej, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University; Penvadee Pattanprichakul, MD, Department of Dermatology, Faculty of Medicine Siriraj hospital, Mahidol University; Charussri Leeyaphun, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University; Pattachee Ongmahutmongkol, MD, Naval Medical Department, Royal Thai Navy; Nattaporn Ariyatanasuporn, MD, Naval Medical Department, Royal Thai Navy; Kanokwalai Kulthanan, MD, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University
Primary cutaneous anaplastic large cell lymphoma treated with low dose methotrexate Stefanie Grewe, BS, University of South Florida Morsani College of Medicine; Brooke Baldwin, MD, James A. Haley Veterans Hospital Primary cutaneous anaplastic CD30-positive large cell lymphoma is a rare type of non-Hodgkin’s lymphoma that is defined by a predominance of large clusters of CD30+ blast cells on histology. Considered a part of the spectrum of CD30+ lymphoproliferative cutaneous processes, this neoplasm often presents clinically in two forms: systemic and primary cutaneous. The diagnosis is confirmed with histologic examination, radiologic imaging, and supportive immunohistochemistry. The primary cutaneous form occurs in the skin with no evidence of disease elsewhere after a thorough workup. It is more likely to be negative for anaplastic lymphoma kinase (ALK1). It more commonly occurs in men in their sixth decade of life and presents as single or multifocal nodules that can regress and recur. We present a case of an 82 -year-old patient with a past medical history significant for prostate cancer and multiple nonmelanoma skin cancers, as well as six previous PCALCL lesions all on his left chest treated conservatively with excisions. Five years after his initial diagnosis a new lesion appeared as a 2cm perirectal erythematous, ulcerated plaque. He denied any fevers, night sweats, chills, unexpected weight loss, fatigue, nausea, or vomiting. He presented to clinic with concerns that the lesion was not resolving and had been enlarging over a 5 month period of time. A shave biopsy was performed on a representative area to help confirm the diagnosis. Histologic examination revealed an atypical lymphoid infiltrate with lesional cells expressing CD2, CD3, and CD30, with a predominate CD4 phenotype by CD4/8 staining. Lesional cells lacked expression of CD15, CD20, and EMA, with at least partial loss of CD5 and CD7. Given negative ALK-1 immunohistochemical staining, primary cutaneous anaplastic large cell lymphoma was favored. A CT scan of the thorax, abdomen, and pelvis was performed for staging and did not reveal any adenopathy or other sites of lymphoma involvement. With a second body site involved, the patient was now considered to have multifocal PC-ALCL. Surgical excision of the perirectal lesion was not considered given the size and location of the lesion. Patient consulted with radiation oncology for treatment of the new lesion however was not interested in pursuing radiation treatment. Given patient preference as well as the desire to attempt a remission, systemic treatment with low dose methotrexate was initiated. He was started on 15mg po BID once weekly with folic acid on other days of the week. The patient had a good response with clinical resolution of the perirectal lesion and no further lesions appearing in any other locations. At 12 months he remained disease free and plan is to taper methotrexate to lowest effective dose. We present this case to review this rare diagnosis and remind clinicians to consider methotrexate as a treatment option for patients who present with multifocal disease.
Background: Superficial fungal foot infections are common dermatologic diseases affecting military personnel. Many Thai naval rating cadets are found to suffer from superficial fungal foot infections and their sequelae. Objective: To investigate prevalence, potential risk factors, causative organisms and clinical correlation of superficial fungal foot infection in Thai naval rating cadets training in Naval rating school, Sattahip, Thailand. Materials and Methods: This cross-sectional study of 788 Thai naval rating cadets using validated structured questionnaire asking information about behaviors and clinical symptoms, Dermatology Quality of Life Index (DLQI) questionnaire, clinical presentation demonstrated by Athlete’s foot severity score (AFSS, ranging 0-4), and laboratory investigations including direct microscopic examination and fungal culture was performed in August 2015. Results: Age of Thai naval rating cadets was 18-19. Of all 788 participants, 363 (46.1%) were suspected of skin fungal infection from questionnaire screening. After clinical examination, 288 participants (79.3%) were found to have foot lesions (AFSS $1). Superficial fungal foot infection was diagnosed in 57 participants, giving a point prevalence of 7.2 %. The pathogens were T mentagrophytes (52.8 %), E floccosum (13.9 %), S dimidiatum (11.1 %), T rubrum (11.1 %), T tonsurans (2.8 %) and Candida spp. (8.3 %). Tinea pedis was diagnosed in 54 participants and cutaneous candidiasis was diagnosed in 3 participants, respectively. Only one participant (1.8 %) was diagnosed with both tinea pedis and tinea ungium and another one (1.8 %) with both tinea pedis and tinea cruris. The participants who took a shower at least twice a day were found to have tinea pedis more than those who did not. Most participants noticed abnormal skin lesions of their feet (P ¼.01). Skin maceration and scales were detected in most of the cases (P ¼.07). Mean DLQI in tinea pedis cases was 3.35. Participants who had foot lesions (AFSS$1), concerned of their foot odors and felt troublesome demonstrated mean DLQI of 3.81 (P \.01). Conclusion: Tinea pedis is commonly found among naval rating cadets who presented with foot lesions. Early self-recognition and prompt treatment should be encouraged. Despite skin rash, feet malodors also impact on patients’ quality of life.
Commercial support: None identified.
Commercial support: None identified.
5409 Primary cutaneous anaplastic large cell lymphoma Ana Paula Schwarzbach, MD, Santa Casa de Misericordia de Porto Alegre; Giovana Fensterseifer, MD, Universidade Federal de Ci^encias da Sa ude de Porto Alegre; Fernanda Bonkevitch, MD, Santa Casa de Misericordia de Porto Alegre; Ana Letıcia Boff, MD, Santa Casa de Misericordia de Porto Alegre; Andr e Vicente Esteves de Carvalho, MD, Santa Casa de Misericordia de Porto Alegre
4943
CD30 -positive lymphoproliferative skin diseases are the second most common form of cutaneous T cell lymphoma and have an excellent prognosis. We present a case of a primary cutaneous anaplastic large cell lymphoma. A 76-year-old man presented with an asymptomatic and recurring lesion on the anterior aspect of the left arm and forearm. On examination, confluent, infiltrated erythematous papules with superficial lichenification were seen. Histologic examination showed extensive lichenoid infiltrate without epidermotropism and immunohistochemical study showed great amount (more than 75%) of CD30+ lymphocytes confirming the diagnosis of primary cutaneous anaplastic large cell lymphoma (PCALCL). CD30-positive lymphoproliferative skin diseases correspond to a spectrum of diseases including lymphomatoid papulosis (LP) and primary cutaneous anaplastic large cell lymphoma (PCALCL). Histologic and immunophenotype of PCALCL and lymphomatoid papulosis features may overlap. In this context, the clinical features are very important to confirm the diagnosis. PCALCL presents as nodules or plaques that may ulcerate and have rapid growth. It occurs predominantly as solitary and localized tumors, however multifocal or generalized lesions are seen in approximately 20 % of patients. Extracutaneous involvement is seen in 5% to 10 % of patients and most often occurs in regional lymph nodes. LP is characterized by papules and nodules that may develop central necrosis and hemorrhage, which disappear spontaneously within three to eight weeks. During this period, hypo or hyperpigmented macules and atrophic varicella-like scars are observed. Lesions at different stages can coexist. Diagnosis is made by skin biopsy . Histologic analysis shows dermal infiltrate with neoplastic cells which are large and cohesive, have abundant cytoplasm, bulky and irregular nuclei and single, central prominent nucleoli. Immunohistochemistry shows a pattern of CD3+ CD4+ CD8+ and CD30+. By definition CD30 is expressed in at least 75 % of the malignant cells. There is no curative therapy for this group of lymphomas. However they have an excellent prognosis with a survival rate at 5 years of 90% (76-96%). An average of 25-44 % of patients will have spontaneous regression of lesions. The therapeutic modalities include observation, surgical excision or local radiotherapy . Low dose methotrexate (10-25 mg weekly) is considered by some authors the therapy of choice for multifocal lesions of PCALCL.
Primary cutaneous apocrine carcinoma is a rare adnexal carcinoma arising from normal or modified (Moll and ceruminous) apocrine glands. Most studies of cutaneous apocrine carcinoma consist of single case reports or small case series. Because it is such a rare entity, limited data exist regarding epidemiology, prognosis, and optimal treatment strategies. Wide local excision is the most commonly reported treatment strategy and is considered standard therapy at this time, but optimal surgical margins have not been determined. Mohs micrographic surgery offers therapeutic advantages including evaluation of 100% of the surgical margins, minimizing the amount of healthy tissue lost, and maximizing the functional and cosmetic outcomes. Adjuvant radiotherapy can be considered for large or poorly differentiated tumors or when margins of resection are positive, but there are no reports of using this as a primary treatment modality. We present a case of a 73-yearold white man with a large erythematous indurated plaque in the left axilla and multiple satellite papules and nodules on the left flank. A thorough workup was negative for metastasis or contiguous spread of an underlying adenocarcinoma so a diagnosis of primary cutaneous apocrine carcinoma was made. Due to the presence of regional cutaneous metastases, he was not an optimal surgical candidate. After discussion with a multidisciplinary tumor board, the patient was treated with primary radiotherapy. There was clinical improvement with decreased tumor burden after radiation treatment with 66 Gy in 33 fractions via 3D technique. This case supports the use of radiotherapy as a primary modality in the treatment of primary cutaneous apocrine carcinoma. Although rare, primary cutaneous apocrine carcinoma is an important entity for dermatologic surgeons to recognize and understand. Wide local excision currently considered standard therapy but there are implications for primary radiotherapy, as illustrated by this case.
Commercial support: None identified.
JUNE 2017
Primary cutaneous apocrine carcinoma treated with radiotherapy Jennifer Vermeesch, DO, St. Joseph Mercy Hospital; Jessica Schweitzer, DO, St. Joseph Mercy Hospital; Jenny Cotton, MD, St. Joseph Mercy Hospital; Kent Krach, MD, St. Joseph Mercy Hospital; Theresa Zaleski, DO, St. Joseph Mercy Hospital
Commercial support: None identified.
J AM ACAD DERMATOL
AB203