PMC4349107_01
A 64-year-old man with a 3-month history of painful swelling and redness of the left upper arm. Cutaneous manifestation of primary cutaneous extranodal NK/T-cell lymphoma, nasal type. (A, B,) There was erythematous to violaceous swelling, nodules, and ulceration with a crust on the left arm.
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A 64-year-old man was referred to our hospital due to painful swelling and redness of the left upper arm for three months, which had persisted despite antibiotic treatment at a local clinic (Figure 1).
Magnetic resonance imaging and contrast-enhanced computed tomography findings of the left upper arm in a case of primary cutaneous extranodal NK/T-cell lymphoma, nasal type. Fat-suppressed T2-weighted (A) and contrast-enhanced fat suppressed T1-weighted (B) MRI images showed diffuse soft tissue infiltration and subcutaneous edema, with intermediate to subtle low-signal-intensity areas in the T2-weighted image (arrows in A) and heterogeneous enhancement (arrows in B) in the medial aspect of the left upper arm. Enhanced CT images (C, D, and E) of the left humerus (C-E) also showed diffuse soft tissue infiltration (arrows in C) and mixed subcutaneous nodules (arrowheads in D and E) with poorly enhancing peripheral rims and relatively radiolucent central areas.
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These findings were suggestive of cellulitis or fasciitis (Figure 2, A and B). Left humerus computed tomography (CT) scans at our hospital showed marked soft tissue thickening with edematous changes and ill-defined subcutaneous fatty infiltration in the cutaneous and the subcutaneous layer of the left upper medial arm (Figure 2, C-E).
Left axillary lymphadenopathies and cutaneous involvement in a case of primary cutaneous extranodal NK/T-cell lymphoma, nasal type. A and B, Axial contrast-enhanced CT images showed small discrete subcutaneous nodules with poorly enhanced peripheral rims and relatively radiolucent central areas (arrowheads) in the left anterior chest wall, and multiple conglomerated lymphadenopathies in the left axilla (arrows). C and D, These nodules and axillary lymphadenopathies showed high fludeoxyglucose (FDG) uptake in PET-CT images. E, Coronal maximum-intensity-projection PET image showing multiple 18 F-FDG-avid lesions. F, Follow-up PET image after seven months showing regression of multiple 18 F-FDG-avid lesions. The remaining high-FDG-uptake lesion in the left upper lung (arrow) was caused by pneumonic infiltration.
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A-E). To assess the disease status, positron emission tomography (PET)-CT scans were obtained and revealed multiple nodular lesions in the left axillary area, chest and abdominal walls, upper and lower extremities, and cervical space that showed high fludeoxyglucose (FDG) uptake (Figure 3, C and D). After salvage L-asparagine chemotherapy, all lesions were remarkably improved.
Pathological specimens. A, Atypical lymphoid cell infiltration in the dermis and subcutaneous deep fat layer, with extensive necrosis (H and E staining, magnification x 10). B, Angiodestruction by tumor cells (H and E staining, magnification x 200). C, Immunohistochemical staining showing that lymphoma cells were positive for CD56. D, Granzyme B. E, Epstein-Barr virus in situ.
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