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A Lesion on the Scalp

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 67-year-old man presented with a rapidly enlarging scalp lesion (Figure 1A) first noticed 3 months earlier as a pimple. The lesion was itchy but without generalized pruritus. The patient reported a weight loss of 10 pounds over the preceding 3 months. In addition, he reported a longer history of vague, nonspecific, intermittent abdominal pain without nausea, vomiting, or fever starting about 3 years prior to presentation. Previous work-up had revealed minimal abdominal adenopathy, but the patient declined further workup. On examination, he had no other cutaneous lesions, but he did have cervical lymphadenopathy. All other physical findings were within normal limits. Laboratory findings were unremarkable, save for a mild normochromic normocytic anemia and a mildly elevated levels of lactate dehydrogenase. A biopsy specimen from the skin lesion is shown in Figure 1B.

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B. Follicular lymphoma

Scalp lesion, lymph node, and bone marrow biopsy demonstrated involvement by CD10-positive, low-grade B-cell non-Hodgkin lymphoma (NHL), consistent with follicular lymphoma. A positron emission tomography (PET) scan revealed extensive hypermetabolic activity in the scalp soft tissue (standardized uptake value [SUV], 7.0) (Figure 2) and in the cervical (SUV, 9.1), axillary, upper thoracic, and abdominal lymph nodes (SUV, 3.9) compatible with lymphoma with a FLIPI score (Follicular Lymphoma International Prognostic Index) of 5. The patient underwent 6 cycles of R-CHOP chemotherapy (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) and achieved a complete response verified by PET scan after cycle 4.

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Article Information

Corresponding Author: Haythem Ali, MD, Division of Hematology/Oncology, Department of Internal Medicine, Henry Ford Hospital, 2799 W Grand Blvd, CFP-5, Detroit, MI 48202 (HALI1@hfhs.org).

Published Online: September 13, 2018. doi:10.1001/jamaoncol.2018.3685

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Kim  BK, Surti  U, Pandya  A, Cohen  J, Rabkin  MS, Swerdlow  SH.  Clinicopathologic, immunophenotypic, and molecular cytogenetic fluorescence in situ hybridization analysis of primary and secondary cutaneous follicular lymphomas.  Am J Surg Pathol. 2005;29(1):69-82. doi:10.1097/01.pas.0000146015.22624.c7PubMedGoogle ScholarCrossref
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Xerri  L, Dirnhofer  S, Quintanilla-Martinez  L,  et al.  The heterogeneity of follicular lymphomas: from early development to transformation.  Virchows Arch. 2016;468(2):127-139. doi:10.1007/s00428-015-1864-yPubMedGoogle ScholarCrossref
3.
Chiu  A, Frizzera  G, Mathew  S,  et al.  Diffuse blastoid B-cell lymphoma: a histologically aggressive variant of t(14;18)-negative follicular lymphoma.  Mod Pathol. 2009;22(11):1507-1517. doi:10.1038/modpathol.2009.106PubMedGoogle ScholarCrossref
4.
Natkunam  Y, Warnke  RA, Zehnder  JL, Jones  CD, Milatovich-Cherry  A, Cornbleet  PJ.  Blastic/blastoid transformation of follicular lymphoma: immunohistologic and molecular analyses of five cases.  Am J Surg Pathol. 2000;24(4):525-534. doi:10.1097/00000478-200004000-00006PubMedGoogle ScholarCrossref
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