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CASES FROM THE ACKERMAN ACADEMY
Year : 2014  |  Volume : 5  |  Issue : 4  |  Page : 508-509  

Initial presentation of acute myelogenous leukemia in the infiltrate underlying an actinic keratosis


1 Des Moines University, Iowa, USA
2 New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
3 Ackerman Academy of Dermatopathology, New York, USA

Date of Web Publication10-Oct-2014

Correspondence Address:
Dirk M Elston
Ackerman Academy of Dermatopathology, 145 East 32nd Street, 10th Floor, New York, NY 10016
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.142525

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   Abstract 

We report an 85-year-old female patient who presented with an erythematous keratotic lesion on her temple suspicious of squamous cell carcinoma. Histological evaluation revealed actinic keratosis, but the underlying atypical infiltrate contained atypical myeloid forms consistent with acute myelogenous leukemia (AML). Upon further questioning, it was determined that the patient had a history of myelodysplastic syndrome. Her skin biopsy provided the first evidence of progression to AML. This case serves as an important reminder of the role the dermatopathologist plays in identifying serious systemic disease.

Keywords: Actinic keratosis, acute myelogenous leukemia, leukemia cutis, squamous cell carcinoma


How to cite this article:
Blattner C, DeDonato A, Blochin E, Kazlouskaya V, Elston DM. Initial presentation of acute myelogenous leukemia in the infiltrate underlying an actinic keratosis . Indian Dermatol Online J 2014;5:508-9

How to cite this URL:
Blattner C, DeDonato A, Blochin E, Kazlouskaya V, Elston DM. Initial presentation of acute myelogenous leukemia in the infiltrate underlying an actinic keratosis . Indian Dermatol Online J [serial online] 2014 [cited 2019 Jun 24];5:508-9. Available from: http://www.idoj.in/text.asp?2014/5/4/508/142525


   Introduction Top


Myeloid leukemia cutis (LC) may be the presenting sign in patients with myeloid disorders, like acute myelogenous leukemia (AML). It occurs in approximately 13% of patients with AML [1] and classically presents later in the disease, when neoplastic leukocytes of myeloid lineage infiltrate the epidermis, dermis, or subcutis. [2] In some cases, however, the appearance of LC is the first evidence of leukemia and the atypical myeloid forms can be identified in the infiltrate underlying an unrelated skin lesion. The clinical appearance of the skin lesions is fairly non-specific and as in this case, the clinical appearance may reflect only the superficial cutaneous neoplasm, rather than the underlying leukemia. A high index of suspicion is required as correct interpretation of the biopsy leads to the correct diagnosis and allows early intervention. [3],[4] In our patient, the biopsy was performed for confirming a keratotic lesion; but the underlying leukemia proved to be the more important diagnosis.


   Clinical Top


An 85-year-old-female patient presented with skin lesions on her right temple and left nasal sidewall, suspicious for squamous cell carcinoma (SCC). Shave biopsies of the areas were performed.


   Dermatopathology Top


The lesion on right temple demonstrated an actinic keratosis (AK) with an underlying dermal infiltrate of immature myeloid cells [Figure 1] and [Figure 2]. Immunohistochemical staining for myeloperoxidase [Figure 3], CD68 and CD34 supported a diagnosis of myelogenous leukemia.
Figure 1: Actinic keratosis with underlying immature myeloid cells. Hematoxylin-eosin stained sections, ×100

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Figure 2: Underlying dermal infiltrate of immature myeloid cells. Hematoxylin-eosin stained sections, ×400

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Figure 3: Myeloperoxidase stain in cells of myeloid lineage, ×200

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   Discussion Top


AML may present as an isolated papule or nodule, but the manifestations may be as diverse as an erythematous, pruritic, morbilliform eruption or patches and plaques mimicking mycosis fungoides. [5] Leukemic cells may also be recruited to areas of inflammation. [6] A diagnosis of LC in the presence of AML is a poor prognostic indicator and strongly correlates with additional sites of extramedullary involvement. [7] This can alter the appropriate treatment regimen for a patient, making the diagnosis of particular importance.

The diagnosis rests on the recognition of immature myeloid cells within the cutaneous infiltrate. The cells commonly demonstrate hyperchromasia, amphophilic cytoplasm and a tendency toward single filing between collagen bundles. Nuclear molding may be noted. Any myeloid cell line may be represented, including immature neutrophils, eosinophils or basophils. Epidermal changes are usually minimal, but may be the most prominent finding in cases such as ours when the biopsy is performed because of the overlying unrelated skin lesion. Patients presenting with LC in association with non-melanoma skin cancer have including those with SCC and basal cell carcinomas. [8] In our patient, the overlying epidermal changes were diagnostic of AK and it might have been easy to overlook the more important diagnosis of leukemia. Dermatopathologists need to remain sensitive to the possibility of a critical diagnosis within the infiltrate underlying a common cutaneous lesion.



 
   References Top

1.
Baer MR, Barcos M, Farrell H, Raza A, Preisler HD. Acute myelogenous leukemia with leukemia cutis. Eighteen cases seen between 1969 and 1986. Cancer 1989;63:2192-200.  Back to cited text no. 1
    
2.
Rao AG, Danturty I. Leukemia cutis. Indian J Dermatol 2012;57:504.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Cibull TL, Thomas AB, O'Malley DP, Billings SD. Myeloid leukemia cutis: A histologic and immunohistochemical review. J Cutan Pathol 2008;35:180-5.  Back to cited text no. 3
    
4.
Misri R, Khopkar U, Kharkar V, Mahajan S. Different faces of leukemia cutis: Presenting as purpura fulminans and lupus like butterfly rash. Indian J Dermatol Venereol Leprol 2010;76:710-2.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Gibney MD, Penneys NS, Nelson-Adesokan P. Cutaneous eruption of lymphocyte recovery mimicking mycosis fungoides in a patient with acute myelocytic leukemia. J Cutan Pathol 1995;22:472-5.  Back to cited text no. 5
    
6.
Bakst RL, Tallman MS, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood 2011;118:3785-93.  Back to cited text no. 6
    
7.
Cho-Vega JH, Medeiros LJ, Prieto VG, Vega F. Leukemia cutis. Am J Clin Pathol 2008;129:130-42.  Back to cited text no. 7
    
8.
Ra S, Su A, Ellison D, Koperski J, Bonilla M, Robbins B. Leukemia cutis in association with cutaneous epidermal malignancies. J Cutan Pathol 2012;39:971-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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