Case Number : Case 2473 - 26 December 2019 Posted By: Saleem Taibjee

Anaplastic large T cell lymphoma will be my first thought.  Also secondary cutaneous involvement from Nodal Hodgkin disease should be considered. IHC is mandatory. 

ulcerating lesion in axilla with dense large atypical cells in the superficial, mid dermis and deep dermis and also extending into sub cutaneous fat. there is secondary epidermal changes. There is also anglocentric lesions down in dermis

CD 30 IHC, CD8, CD4, and other panel of cytotoxic markers. Also clinical information if it is single lesion or multiple lesions waxing and waning. considering the young age I would also consider lymphomatoid papulosis if the history is supportive

Also peripheral smear and EBNA in tumor cells.

Anything in axilla LCH to be considered but so atypical and mitosis LCH I am not considering 

On 27/12/2019 at 15:22, Dr. Mona Abdel-Halim said:

Anaplastic large T cell lymphoma will be my first thought.  Also secondary cutaneous involvement from Nodal Hodgkin disease should be considered. IHC is mandatory. 

AGREE!

Epidermal hyperplasia is a good clue for Anaplastic large cell lymphoma.

Secondary cutaneous is more likely from the underlying lymph node. Could be nodal ALCL. 

Great responses. Yes, this is CD30 positive anaplastic large cell lymphoma. As Richard correctly surmised, ALK was positive, and the patient was subsequently shown to have underlying axillary nodal disease, and referred to our regional young adult haemato-oncology team for further management.

The comment about overlying epidermal hyperplasia is also very pertinent.

Well done, guys.

Below are the images of the CD30 and ALK.

Happy New Year!

Saleem

Thanks for the update Dr Taibjee, could you (or Dr Carr) kindly explain why secondary cutaneous involvement from nodal/systemic ALCL was favoured on H&E rather than primary cutaneous ALCL even before the knowledge of further clinical features/staging and ALK status? aware the ALK is not definite for secondary cutaneous disease. 

Many thanks.  

I based it on the clinical image / location and probabilities (sALCL is known to affect "children/young adults" whereas I'd guess from my experience cALCL is more likely to affect older adults and not be located over a lymph node basin). It was not based on histology but a "lucky" guess. 

About 2000 years ago Confucius said: “The more you know, the more luck you will have.”

1937 December 19, Los Angeles Times, On the Side with E.V. Durling, Page A1, Los Angeles, California. (ProQuest Historical Newspapers)

Thanks very much Dr Carr for your explanation, honesty and sharing a useful wisdom from a Chinese philosopher/teacher stated ages ago.