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JAMA Oncology Clinical Challenge
September 2018

Disseminated Cutaneous Lesions in a Patient With a Medical History of Myelodysplastic Syndrome

Author Affiliations
  • 1Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
  • 2Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
JAMA Oncol. 2018;4(9):1281-1282. doi:10.1001/jamaoncol.2018.0488

A white man in his 50s with a medical history of myelodysplastic syndrome (MDS) refractory anemia with excess blasts, type 2 (RAEB-2) or MDS with excess blasts, type 2 (MDS-EB-2) RAEB-2 reported a 2-month history of nonpruritic infiltrative skin lesions on the left upper chest, which disseminated to the entire chest, back, and right facial areas (Figure, A). The patient was initially diagnosed with MDS 3 years ago and treated with azacitidine followed by CLAG (cladribine, cytarabine, granulocyte-colony stimulating factor). Posttreatment bone marrow biopsy findings at that time showed no evidence of disease. His physical examination on this presentation showed multiple dark brown cutaneous papules measuring at 3.0 to 5.0 cm (Figure, A), but the rest of the examination results were negative for hepatosplenomegaly or lymphadenopathy. Complete blood cell count showed a white blood cell count of 3.3 × 109/L with absolute neutrophil count of 1.0 × 109/L, Hb 12.7g/dL, platelet counts 118 × 109/L and differential counts showed no evidence of circulating blasts. In addition, results of laboratory workup including peripheral blood culture, methicillin-resistant Staphylococcus aureus (MRSA) swab, human immunodeficiency virus test, and flow cytometry performed on his peripheral blood were all negative. Pathologic sampling from the skin lesion showed the presence of monomorphous small to medium cells extending through the dermis and into the subcutaneous fat (Figure, B). Immunohistochemical staining demonstrated CD4-, CD33-, CD43-, CD56-, CD123-, and TCL1-positive neoplastic cells with Ki-67 of 85%, but staining results for TdT, MUM1, CD3, CD20, Bcl-6, CyclinD1, and CD8 were negative (Figure, C). Results of bone marrow biopsy showed normocellular marrow maturing trilineage hematopoiesis with no increase of blasts or other abnormal populations. Cytogenetics results were abnormal, showing del(20)(q11.2q13.3)[8]/46,XY[12].

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