Large T-Cell Lymphoma

An ulcerated lesion that measured approximately 2 cm in diameter had developed on an 80-year-old woman's scalp. The lesion featured a dark eschar that covered a slightly elevated, erythematous border. According to the patient's husband, a different lesion had been at the site 2 weeks earlier. He described the original as a "ball" that ulcerated, had no drainage, and formed a scab. Another practitioner prescribed oral and topical antibiotics and performed an incisional biopsy that revealed mycosis fungoides, a cutaneous T-cell lymphoma. The lesion ulcerated, flattened, formed an eschar, and regressed. The patient's history included a mastectomy and postoperative radiation therapy for breast cancer 6 years earlier. At age 79 years, she had a severe, constant, and progressive sore throat with bilateral exudative tonsillitis and bilateral cervical adenopathy; a tonsillectomy and excisional biopsy of a right jugular lymph node were performed. Pathologic examination of the tissue was confounding; the findings suggested lymphoma and an atypical mycobacterial infection. Clarithromycin was given for several months; the condition improved. Large-cell anaplastic lymphoma is a distinct variant of lymphoma that is usually of T-cell lineage. The 3 clinical variants of this type of tumor are:

• Painful cutaneous lesions that occasionally ulcerate; they arise in children and adolescents.

• Cutaneous lesions in elderly persons are violaceous to deep red with a tense, shiny surface; they may ulcerate.

• Lesions that develop as a complication of mycosis fungoides or other T-cell lymphoma or antecedent lymph node infiltration.

Cutaneous lesions are usually solitary or localized. Relapses and remissions are frequent. Radiation therapy may be useful for persistent lesions.