April 2010 – Case of the Month #9

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Dermatology Case of the Month #9

Clinical history

A 68 year old woman with a history of AML presented with a five month history of progressive eruption of violaceous firm nodules in the umbilicus, groin, trunk and scalp.

A left breast punch biopsy was performed.

Micro images:

Stains:

CD45                           CD43

CD117                         CD68

What is your diagnosis? 

(scroll down to continue)

Diagnosis:

Leukemia cutis

Discussion

The dermis and superficial subcutaneous fat are diffusely infiltrated by a monotonous population of large cells with a high nuclear to cytoplasmic ratio, round to slightly irregular nuclear contours, finely dispersed chromatin and prominent nucleoli.  The tumor cells are diffusely immunoreactive for CD45, CD117 and CD43, with focal expression of CD68.  Myeloperoxidase (not shown) highlights a small subset of tumor cells.  The cells are negative for CD34, TdT, CD20, bcl-1, and CD56.  CD3 and CD4 (not shown) highlight scant, admixed T-lymphocytes.

Overall, the morphologic and immunophenotypic findings are consistent with tissue infiltration by acute myelogenous leukemia.  The prior AML subtype is unknown.

Leukemia cutis includes cutaneous manifestations of any type of leukemia.  It can be difficult to clinically distinguish from other skin lesions.  Patients usually have preexisting systemic leukemia, but occasionally skin involvement precedes bone marrow or peripheral blood involvement (Am J Clin Pathol 2008;129:130)

Myeloid leukemia with monocytic differentiation more commonly involves the skin than other types of myeloid leukemia.  It may also have an accompanying vasculitis (Am J Clin Pathol 1997;107:637).

Leukemia cutis is associated with aggressive behavior and short survival (J Am Acad Dermatol 1999;40:966).  Treatment is systemic chemotherapy directed at eradicating the leukemic clone.

Additional references: eMedicine

Nat Pernick, M.D., President

and Kara Hamilton, M.S., Associate Medical Editor
DermatologyOutlines.com, LLC
30100 Telegraph Road, Suite 404
Bingham Farms, Michigan (USA) 48025

Telephone: 248/646-0325
Fax: 248/646-1736
Email: NatPernick@hotmail.com