74 DIFFUSE LARGE B-CELL LYMPHOMA MIMICKING ADVANCED BASAL CELL CARCINOMA.

Introduction Primary cutaneous B-cell lymphomas (PCBCLs) are made up of a heterogeneous group of B-cell lymphoproliferative diseases confined to the skin at the time of diagnosis with no evidence of extracutaneous involvement. With early diagnosis and adequate treatment, PCBCLs as a group have an excellent prognosis, with about a 95% survival rate at 5 years. There is no universally acceptable method of treatment and classification. Diagnosis can be made with the use of immunohistochemical staining and histologic appearance. We report a case of diffuse large B-cell lymphoma (DLBCL) in a 52-year-old woman presenting as a fungating skin ulcer mimicking advanced basal cell carcinoma. Case Report A 52-year-old female originally from Ukraine presented to our emergency room with a 7-month history of circumscribed, reddish ulcerations and nodules over the left scapular region with extension into the left axillary region. According to the patient, the lesion started as a small dark pigmented spot 7 years prior to admission into our service and began to grow rapidly 9 months ago. The lesion was slow-growing, nontender, and nonpruritic. There was no history of fever, weight loss, or night sweats. Past medical history was noncontributory except that she lived close to the Chernobyl nuclear disaster of 1986. Physical examination revealed a 15 × 15 cm ulcer over the serratus anterior muscle with elevated borders and another 6 × 6 cm ulcer in the left axilla. The ulcers had central areas of necrosis with malodorous greenish discharge. No evidence of peripheral lymphadenopathy was found. Routine laboratory tests such as hemogram, serum chemistry, and chest radiography were within normal limits. Computed tomographic scans of the chest, abdomen, and pelvis showed no evidence of lymphadenopathy or systemic involvement, and a nuclear bone scan failed to reveal any evidence of metastatic bone disease, thus ruling out extracutaneous involvement. Biopsy of the ulcer showed dermis filled with sheets of large cells with vesicular nuclei and prominent nucleoli. Mitotic admixtures were numerous with areas of necrosis. The epidermis was free. Immunohistochemical stains favored the diagnosis of DLBCL. Therapy was initiated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and radiotherapy. After three cycles of chemotherapy, the lesion became smaller, with a flat border and dry and healing skin, with disappearance of the axillary nodules. Discussion PCBCL is a rare group of lymphoproliferative disorders. It is a distinct subclass of non-Hodgkin9s lymphoma that originates in the skin and comprises the second largest group of extranodal B-cell lymphomas (after gastrointestinal). It is estimated to be about 20 to 25% of all cutaneous lymphomas. Extracutaneous dissemination is rare, with most disease having a favorable prognosis. Various treatment options are available and depend on the histologic subtype and number of lesions. CHOP with and without radiotherapy has been used extensively. Remission has been achieved in 92% of cases studied, with a median follow-up of 28 months and only one patient with DLBCL of the leg dying from progressive cutaneous disease. PCBCLs are highly radiosensitive. Radiation therapy can be used as an adjunct with chemotherapy at presentation or relapse. It is frequently used for localized disease. Treatment of PCBCL with anti-CD20 monoclonal antibody (rituximab) was recently introduced. It is usually combined with cytotoxic therapy and has shown mixed results.