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The Alphabet Soup of CD30+ Lymphoproliferative Disorders
Uma Sundram, MD, PhDProfessor of Pathology
Oakland University William Beaumont School of MedicineBeaumont Health Systems, Royal Oak, MI
September 27, 2019
Disclosures
• I have nothing relevant to disclose.
10/1/2019 2
Outline
• CD30 + Lymphoproliferative Disorders• Lymphomatoid papulosis• Primary cutaneous anaplastic large cell
lymphoma• Transformed mycosis fungoides
DD of Dense Dermal Lymphoid Infiltrates
CD20, CD3
CD20+, CD3- CD20-, CD3+CD20-, CD3-
Cutaneous B-celllymphoma
CTCLNK/T- cell lymphoma
Important Antibodies to Employ
• CD30• CD56• CD4, CD8• TIA-1• Ki-67• β-F1, TCR gamma
• EBV in situ• PD-1, CXCL-13• Other pan T cell
antigens, i.e., CD5, CD2, CD7
CD30
• First known as Ki-1 antigen• Seen in reactive B- and T-cells exposed to
virus, such as EBV or HTLV• CD30 coupled with CD30 ligand can institute
both apoptotic and proliferative effects
CD30+, CD56-, CD3+CD30+ Lymphoproliferative Disorder• More than 75% of large cells CD30 positive
– Lymphomatoid papulosis-Lyp– Primary cutaneous anaplastic large cell lymphoma-PC
ALCL– Systemic anaplastic large cell lymphoma,
alk-negative– Systemic anaplastic large cell lymphoma,
alk-positive– (Transformed mycosis fungoides)
CD30+ Lymphoproliferative Disorders
• Next most common outside of MF, 30% of primary CTCL
• Lyp and pcALCL overlap A LOT• Lyp also overlaps a lot with reactive entities• Definitive diagnosis requires clinicopathologic
correlation
CD30+ Lymphoproliferative Disorders
• Other pc lymphomas express CD30• Secondary cutaneous lymphomas express
CD30 (outside of ALCL)• If TRULY pc CD30+ LPD, great prognosis
(except for MF and some rare cases) (Kempf 2017)
What is Lymphomatoid papulosis (LyP)?• Hyperplasia: benign
– Chronic stimulation may lead to “second hit” and malignancy
• Lymphoma: malignant– Low grade lymphoma, controlled by host– Indolent end of spectrum of CD30+ LPD
• Heterogeneous entity• Don’t know, yet (still true, today)
Lymphomatoid Papulosis
• Pathologists uniformly called this lesion malignant-carcinoma, melanoma, undifferentiated malignant neoplasm, reticulum cell sarcoma
“Hence, it appears that there exists a dermatologic disorder, the clinical and histologic features of which are variable within limits….Is this condition a bona fide malignancy, self healing, or an entity to stand beside keratoacanthoma, benign juvenile melanoma, and other pseudocancers?” (Macaulay1968)
Follow-up• Patient was still alive and well 25 years later• No treatment• Eruption continued but diminished (Macauley
1968)
Lyp: Clinical Features
• Peak incidence: 4th and 5th decade– All ages
• Predilection for trunk and extremities– No area spared
• Asymptomatic• Protracted course (>20 years) more common than
self-limited
Morphology• Red-brown papules and nodules
– Central hemorrhage and necrosis• Lesions < 3cm• Involute in 3-8 weeks
– Hypo- or hyperpigmented macules– Superficial scars
• Number variable (few - >100)• Lesions in different stages of evolution
Associated Neoplasia
• 10% -20% associated with lymphoma (Kempf 2011)• Most associated lymphomas occur subsequently
– Lymphoma may precede Lyp or present simultaneously• Most common: MF, Hodgkin lymphoma, CD30+ ALCL
(de la Garza Bravo 2015)• Lyp with and without associated lymphoma
indistinguishable (Cieza-Diaz 2019)
Treatment• “Watchful waiting”• No staging necessary for Lyp (Shinohara 2019)• No curative therapy available• Therapies often tried: topical
mechlorethamine, topical carmustine, topical steroids, low dose oral methotrexate, Psoralen-UV-A
Histology• Type A• Type B• Type C• Type D• Type E• Variant with DUSP22
rearrangement• Different types can
coexist in same patient
Type A Lyp (>75%)• Variable epidermal changes• Perivascular and interstitial infiltrate• Wedge shaped• May extend into SQ• Large atypical cells in mixed background composed
of neutrophils, eosinophils, histiocytes, and small lymphocytes
CD30
CD30
Type B Lyp (<10%)
• Resembles plaque stage MF• Superficial perivascular to bandlike infiltrate with
epidermotropism• Small to medium sized cerebriform cells• Few if any CD30+ large cells• Eosinophils and neutrophils infrequent compared to
type A
CD30
Type C Lyp (approx. 10%)
• Monotonous population of large CD30+ cells• Few admixed inflammatory cells• Indistinguishable from CD30+ ALCL
CD30
Type D (Rare)
• Introduced more recently (Saggini, 2010)• Examplified by epidermotropic infiltrates of CD8 and
CD30+ infiltrates of small-medium sized cells• May have deep dermal infiltrate• Mimic of PC CD8+ aggressive epidermotropic
cytotoxic TCL
Type E (Rare)
• Angiocentric and angiodestructive lesions (Kempf 2013)• Medium sized, cytologically atypical cells• Can have hemorrhagic, necrotic and ulcerative lesions• Can be clinically large lesions (up to 4 cm) with eschars• Resolve within a few weeks• Complete resolution in half of patients studied
Histology Subtypes
• Histologic subtypes clinically and prognostically irrelevant (true of newer and more rare variants as well)
• CD30+ large cells may be absent in very early lesions, resolving lesions, type B Lyp and (sometimes) type D Lyp
• Multiple biopsies will increase diagnostic yield
Other Histopathologic Variations
• Pseudoepitheliomatous hyperplasia• Follicular; Acneiform and pustular; with follicular
mucinosis• Syringotropic; with syringosquamous metaplasia• Myxoid• Granulomatous• Spindled
Immunophenotype
• Large cells– CD30+, CD25+– CD4+ (<5% of cases CD8+)– Cytotoxic protein expression (TIA-1, granzyme B, perforins)– Variable loss of CD2, CD3, or CD5– Alk-1 -– CD15 –
• CD8 expression in types D and E, and pediatric Lyp
Immunophenotype
• Majority express TCR beta on surface; rarely TCR gamma (Rodriguez-Pinilla 2013)
• CD95 (Fas) +, Fas ligand +• Jun-B+• Occasional coexpression of CD56• c-kit -• EBV-
Pathogenesis
• Comparing Lyp, c-ALCL,s-ALCL has provided attractive model for tumorigenesis
• Much research has focused on proliferation, apoptosis and definition of specific pathways
• Jun-B• Fascin• Fas/FasL(CD95/CD95L)• TGF-beta• CD30/CD30L• Bcl-2• Granzyme B
• CD44/CD44v6• CD134• p21• Stat3• CD27• CD40• CCR3
Short (and Incomplete) List of Candidate Molecules
Fascin
• Study of fascin expression in CD30+ LPD• 11/17 (64%) ALCL• 11/45 (24%) Lyp• 6/10 (60%) Lyp associated with lymphoma (Kempf
2002)
Fas (CD95) and Fas Ligand (CD95L)
• CD95L = transmembrane protein of TNF family• Expressed by activated T-cells, NK cells and various
tumors• Binding of CD95L to CD95 induces apoptosis• CD95/CD95L plays important role in modulating
immune responses and self-tolerance
Fas (CD95) and Fas Ligand (CD95L)
• Fas expressed in majority of tumor cells in primary cutaneous CD30+ LPD, but loss of expression documented in tumor stage MF and CD30- lymphomas
• FasL expression was seen in all CD30+ LPD studied
• Fas-FasL interactions important for localized disease (Zoi-Toli 2000)
CD30 and CD30L
• CD30-CD30L interaction can lead to cell death or proliferation
• CD30L found at higher level in regressing than in growing Lyp lesions by RT-PCR and Southern blot
• CD30L appears to be colocalized with CD30 in large cells
• Postulated to be one of the mechanisms leading to regression of Lyp lesions (Mori 1999)
TGF-beta/TGF-beta Receptor
• Transforming growth factor (TGF)-beta is a potent inhibitor of proliferation
• Mutations in the TGF-beta signaling pathway lead to resistance to growth inhibition
• TGF-beta is expressed in some regressing lesions of Lyp
Molecular Data
• t(2;5) and 6p25.3 rearrangements are absent or present in very small minority of Lyp
• Approx. 70% of Lyp have detectable clone (Comfere 2018)
• Same clone when anatomically or temporally distinct lesions are examined, as well as lesions of different histologies
• Clonality does not seem to have prognostic implications for Lyp
Molecular Data
• t(2;5) and 6p25.3 rearrangements are absent or present in very small minority
• 6p25.3 rearrangement reported in 1/32 cases of Lyp (Wada 2011)
• 11 patients reported by Karai to have typical clinical course of Lyp but with 6p25.3 rearrangement (involving DUSP22) (Karai 2013)
Molecular Data
• Same clone in Lyp and associated MF (Cieza-Diaz 2019; de la Garza Bravo 2015)
• Same clone in Lyp and associated HD and ALCL (Zackheim 2003; Chott 1996)
• Hodgkin lymphoma• ALCL (systemic and
primary cutaneous)• Large cell transformed
MF• CD30+ B-cell lymphoma• PLEVA• NK/T cell lymphoma
• Viral infection• Activated cells in
reactive infiltrates• Mycosis fungoides• CD8+ epidermotropic
CTCL• Pagetoid reticulosis• Gamma delta TCL
Differential Diagnosis of Lyp
CD30+ Cutaneous Lymphoid Proliferations• Arthropod bites• Tuberculosis• Molluscum contagiosum• Orf• Herpes simplex/zoster• Scabies (more likely in older than in fresh lesions)• Drug eruption
DRUG ERUPTION
DRUG ERUPTION
DRUG ERUPTION, CD30
Lyp vs PLEVA
• Both can be clonal and contain CD30+ cells• PLEVA: younger patients, more limited time
course• PLEVA: CD8+• Lyp: CD4+ (some are CD8+ and may overlap
with PLEVA)
Diagnosis/Clinical Work up-Lyp
• Based on CPC• Overlap between cases of type B Lyp and
papular MF (Saggini 2019)– Helps to biopsy more than 1 lesion
• Borderline/indeterminate cases
Diagnosis/Clinical Work up
• No need for extensive clinical staging if initial evaluation suggests Lyp (Shinohara 2019)
• If clinical suspicion of extracutaneous disease, staging should be pursued
• Prognosis=Can develop second lymphoid neoplasm• Life long surveillance
Lyp=Arguments for Benign Disease
• Excellent prognosis• Self-regressing• Sometimes self-limited
Lyp=Arguments for Malignant Disease
• Distressing with sometimes >50 lesions• May require MTX• Morphologically malignant• Clonal• Loss of pan T-cell antigens• Association/development into lymphoma• Same clone in associated lymphoma
What is Lymphomatoid papulosis (LyP)?• Hyperplasia: benign
– Chronic stimulation may lead to “second hit” and malignancy
• Lymphoma: malignant– Low grade lymphoma, controlled by host– Indolent end of spectrum of CD30+ LPD
• Heterogeneous entity• Don’t know, yet
SPRING IN MARQUETTE, UPPER PENINSULA OF MICHIGAN
Primary Cutaneous ALCL
• Presents as an asymptomatic solitary firm nodule that persists rather than regresses
• On histology, large atypical lymphocytes with expression of CD30 in more than 75% of cells
• Favorable prognosis
Primary Cutaneous ALCL
• Mainly affects adults• Can happen in HIV+ individuals• Large ulcerated lesions• Head and neck, limbs favored• Can have spontaneous regression
Primary Cutaneous ALCL
• Histology: sheets of large atypical cells with anaplastic morphology
• Can have neutrophil or eosinophil rich versions (Kong 2009)
• More common in immunodeficient patients, resembling pyoderma
Primary Cutaneous ALCL
• Angiocentric versions• Keratoacanthomatous version (Lin 2004)• Can be intralymphatic (Ferrara 2015)• CD30+, alk-, EMA variably positive• CD4+ with expression of cytotoxic markers• CD45RO+ with loss of CD5
Primary Cutaneous ALCL
• Clonal rearrangement in 90% of cases (Macgrogan 1996)
• t(2;5) found rarely (DeCouteau 1996; Oschlies 2013)
• FISH for 6p25.3 (IRF4-DUSP22 rearrangement) highly specific for pcALCL (Wada 2011) but present in a minority of cases
Primary Cutaneous ALCL
• Important DDX=Transformed MF– difficult when the lesion is CD30 rich– Favor tMF when lesion is present in a plaque– DUSP22 rearrangement has not been reported in
tMF
Primary Cutaneous ALCL
• Important DDX=Systemic ALCL– ALK+ favors systemic ALCL over pcALCL– CLA expression favors pcALCL over systemic ALCL
CD30
TULIPS ON THE CAMPUS OF THE UNIV OF MICHIGAN
Transformed Mycosis Fungoides
• Transformed MF (tMF, MF in LCT) associated with more aggressive clinical course (median time from tranformation to death 18-36 mo)
• Important to remember that plaques, tumors, and lesional skin of patients with Sézary syndrome can all fulfill histologic criteria for LCT
Definition of Large Cell Transformation• Greater than 25% of infiltrate is composed of
large cells and/or such large cells are present in microscopic nodules
• Large cells are lymphocytes more than 4x the size of ‘regular’ lymphocytes
• Histiocytes must be discounted (Vergier 2000)
CD30
• CD30 + transformed MF do better than CD30-transformed MF
• Some studies may have included Lyp/ALCL• However, extreme variability in expression of
CD30 in clinically documented lesions of tMF
CD30
CD30
Summary
• The most important aspect of CD30 + lymphoproliferative disorders=– Know your clinical diagnosis!
• Reactive entities can look malignant, and malignant entities can look reactive
• Undercall, rather than overcall, lesions; when in doubt, revert to “atypical lymphoid infiltrate”
Summary
• Time can sort out diagnoses• Look for lesions arising in patches of mycosis
fungoides; tumors in patients with MF are always tricky
• Expression of CD30 in mycosis fungoides does not equal transformation
SAULT STE. MARIE, MICHIGAN, CONNECTS L SUPERIOR AND L HURON