Diagnostic Approaches for Hematologic Malignancies With Skin Symptoms

Uma Borate, MBBS

Associate Professor – Clinical

The James – The Ohio State University Comprehensive Cancer Center

Columbus, OH

DISCUSSION QUESTIONS

• If a patient presented to an oncologist with particular skin manifestations such as dark-colored plaques or nodules, how would you approach workup? ​
• What possible hematologic malignancies come to mind?
  • Initial clinical differential diagnosis includes:
    • Common traumatic ecchymoses,
    • Purpuric disorders​
    • Angiosarcoma​
    • Kaposi sarcoma​
    • Neuroblastoma​
    • Vascular metastases​
    • Extramedullary hematopoiesis​
    • Skin involvement due to other nonneoplastic/neoplastic etiologies

UMA BORATE, MBBS: If you saw a patient with these skin manifestations, what malignancies come to mind? All of us see different [malignancies] and I’m lucky in that I see a very small subset of patients. But for many of you, maybe the patient has immune thrombocytopenia because they have all these lesions that look like ecchymoses, or maybe it's some sort of [unusual] angiosarcoma. Maybe it's Kaposi sarcoma, [or] maybe it's another metastatic disease. There are all these options that can be on the differential. It's hard to say, "Of course this is BPDCN [blastic plasmacytoid dendritic cell neoplasm]." Is there anything else that you have thoughts about, any patients that you've seen that come to mind, [or] any patient journeys you want to share your experience with the group?

MADAN ARORA, MD: I've seen a patient with advanced multiple myeloma with plasma cell leukemia with these purplish skin lesions, almost looking like Kaposi sarcoma.

BORATE: That's a good point. I never thought about multiple myeloma looking like that, but I'm sure I can see that.

BAIDEHI MAITI, MD: I had a patient who presented with this diffuse [large B-cell lymphoma], very similar purpuric appearance and ulceration all along his lower extremities and, initially, I was very suspicious that this was Kaposi sarcoma. I sent him to a dermatologist to get a biopsy and long story short, it turns out these were essentially diffuse large B-cell skin lesions. I've never heard anything like that. This patient had an [ejection fraction of approximately] 30%, so he was an anthracycline candidate, and I ended up giving him rituximab (Rituxan), cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone, and all these lesions disappeared in a couple of cycles. That was pretty remarkable.

BORATE: All of us have such a different experience of seeing weird skin lesions that can be myeloma, lymphoma, etc. Anybody else have anything to share?

ARORA: Let me add one more point. That patient with myeloma had these skin lesions were seen on…the cubital fossa where we would draw blood. It clearly looks like contamination of the sites by the plasma cells.

BORATE: That's interesting. That's some aggressive disease.

ARUN KUMAR, MD: I had a patient yesterday [with] a skin rash and worsening anemia. I did a bone marrow biopsy. I'm just hoping it won't turn out to be BPDCN.

BORATE: Yes, and a pathologist, unless you give them some very specific history, is not going to routinely do CD123 staining. They're not going to routinely [test] CD4 and CD56; it's just not part of their practice. Unless you specifically say, “By the way, this patient also has skin lesions,” or you already have a skin pathology report with suspicion for BPDCN, they don't do it. I think the onus is on us, because we have the full clinical picture to think about it, to let the pathologist know, and then they do all this confirmatory testing.

KUMAR: The dermatologist gave prednisone and then [the patient] got a little bit better and then I said, OK, I'll send her back to the dermatologist for the biopsy.

BORATE: Yes, that'll be interesting, Dr Kumar, to see what it turns out to be.